Basic Sciences, Miscellaneus : Coloproctology

Inflammatory bowel disease: epidemiology, pathogenesis, and therapeutic opportunities.
Hanauer SB
Inflamm Bowel Dis. 2006 Jan;12 Suppl 1:S3-9.

ABSTRACT: Ulcerative colitis (UC) and Crohn's disease (CD), the primary constituents of inflammatory bowel disease (IBD), are precipitated by a complex interaction of environmental, genetic, and immunoregulatory factors. Higher rates of IBD are seen in northern, industrialized countries, with greater prevalence among Caucasians and Ashkenazic Jews. Racial gaps are closing, indicating that environmental factors may play a role. IBD is multigenic, with the most clearly established genetic link between certain NOD2 variants and CD. Regardless of the underlying genetic predisposition, a growing body of data implicates a dysfunctional mucosal immune response to commensal bacteria in the pathogenesis of IBD, especially CD. Possible triggers include a chronic inflammatory response precipitated by infection with a particular pathogen or virus or a defective mucosal barrier. The characteristic inflammatory response begins with an infiltration of neutrophils and macrophages, which then release chemokines and cytokines. These in turn exacerbate the dysfunctional immune response and activate either TH1 or TH2 cells in the gut mucosa, respectively associated with CD and, less conclusively, with UC. Elucidation of immunological and genetic factors indicate multiple points at which the inflammatory cascade may be interrupted, yielding the possibility of precise, targeted therapies for IBD.

Midterm follow-up study of high-type imperforate anus after laparoscopically assisted anorectoplasty.
Kudou S, Iwanaka T, Kawashima H, Uchida H, Nishi A, Yotsumoto K, Kaneko M
J Pediatr Surg. 2005 Dec;40(12):1923-6.

PURPOSE: The aim of this study was to evaluate postoperative anal function of high-type imperforate anus after laparoscopically assisted anorectoplasty (LAARP). METHODS: Between 2000 and 2002, LAARP was performed in 13 patients with high-type imperforate anus. Clinical data of the LAARP group were compared with the posterior sagittal anorectoplasty (PSARP) group (n = 7) operated before 2000. All patients were treated with initial colostomy in the newborn period. After anorectoplasty, daily glycerin enemas were given for postoperative bowel management. Anorectal function of these patients was evaluated using the Kelly score and manometry at the age of 3 to 5 years (LAARP) and 5 to 6 years (PSARP). RESULTS: Age at evaluation in the LAARP group was younger than that in the PSARP group (51 +/- 10 vs 73 +/- 12 months, P < .01). Kelly score was 3.8 +/- 1.3 vs 3.4 +/- 0.8, respectively. Resting pressure of internal sphincter was 31 +/- 11 vs 33 +/- 10 cm H(2)O, respectively. Relaxation reflex of the internal anal sphincter was observed in 62% (8/13) and 29% (2/7), respectively. CONCLUSIONS: Midterm follow-up study revealed that satisfactory fecal continence can be achieved in patients with high-type imperforate anus after LAARP. Laparoscopically assisted anorectoplasty may be a good alternative in this patient population. However, long-term follow-up is necessary to compare the benefits of LAARP against PSARP.

Retrograde hydrostatic irrigation enema-induced perforation of the sigmoid colon in a chronic renal failure patient before colonoscopy.
Nakamura H, Iyoda M, Sato K, Kitazawa K
J Int Med Res. 2005 Nov-Dec;33(6):707-10.

We present a rare case of colon perforation caused by hydrostatic irrigation enema in a patient with chronic renal failure. A 76-year-old woman was admitted to our hospital because of an exacerbation of lumbar pain and increased difficulty in walking. She had a medical history of traumatic neck pain and chronic lower back pain, which had been treated with non-steroidal anti-inflammatory drugs (NSAIDs) for 8 years. On admission, the C-reactive protein level was 6.8 mg/dl, so we planned to do a colonoscopy to determine the cause of inflammation. The patient developed abdominal pain approximately 3.5 h after a pre-procedural enema was administered. An emergency operation was performed and a small perforation was found in the sigmoid colon. We conclude that the cause of the colon perforation was a combination of the use of a hydrostatic retrograde irrigation enema in a patient with chronic renal failure who had been treated with long-term NSAIDs.

Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information.
Esposito TJ, Ingraham A, Luchette FA, Sears BW, Santaniello JM, Davis KA, Poulakidas SJ, Gamelli RL
J Trauma. 2005 Dec;59(6):1314-9.

BACKGROUND: Performance of digital rectal examination (DRE) on all trauma patients during the secondary survey has been advocated by the Advanced Trauma Life Support course. However, there is no clear evidence of its efficacy as a diagnostic test for traumatic injury. The purpose of this study is to analyze the value of a policy mandating DRE on all trauma patients as part of the initial evaluation process and to discern whether it can routinely be omitted. METHODS: Prospective study of patients treated at a Level I trauma center. Clinical indicators other than DRE (OCI) denoting gastrointestinal bleeding (GIB), urethral disruption (UD), or spinal cord injury (SCI) were sought and correlated with DRE findings suggesting the same. Impression of the examining physician as to the need and value of DRE was also studied. Patients with a Glasgow Coma Scale Score (GCS) of 3 and pharmacologically paralyzed were excluded from the SCI analyses. UD analysis included only males. RESULTS: In all, 512 cases were studied (72% male, 28% female) ranging in age from 2 months to 102 years. Thirty index injuries were identified in 29 patients (6%), 17 SCI (3%), 11 GIB (2%), and 2 UD (0.4%). DRE findings agreed positively or negatively with one or more OCI of index injuries in 93% of all cases (92% seeking SCI, 90% seeking GIB, 96% seeking UD). Overall, negative predictive value of DRE was the same as that of OCI, 99% (SCI 98% versus 99%, GIB, 97% versus 99%, UD both 100%). Positive predictive value for DRE was 27% and for OCI 24% (SCI 47% versus 44%, GIB 15% versus 18%, UD 33% versus 6%). Efficiency of DRE was 94% and OCI was 93%. For confirmed index injuries, indicative DRE findings were associated with 41% and OCI 73% (SCI 36% versus 79%, GIB 36% versus 73%, UD 50% versus 100%). OCIs were present in 81% of index injury cases. In all index injury cases where OCIs were absent, positive DRE findings were also absent. DRE was felt to give additional information in 5% of all cases and change management in 4%. In cases where the clinician felt DRE was definitely indicated (29%) it reportedly gave no additional information in 85% and changed management in 11%. CONCLUSION: DRE is equivalent to OCI for confirming or excluding the presence of index injuries. When index injuries are demonstrated, OCI is more likely to be associated with their presence. DRE rarely provides additional accurate or useful information that changes management. Omission of DRE in virtually all trauma patients appears permissible, safe, and advantageous. Elimination of routine DRE from the secondary survey will presumably conserve time and resources, minimize unpleasant encounters, and protect patients and staff from the potential for further harm without any significant negative impact on care and outcome.

Preliminary data on the use of apheresis in inflammatory bowel disease.
Sandborn WJ
Inflamm Bowel Dis. 2006 Jan;12 Suppl 1:S15-21.

In patients with inflammatory bowel disease (IBD), centrifugation has been attempted to remove leukocyte components from whole blood; however, the use of selective filters has proved to result in more active modification of cellular immunity in that 4 times as many white blood cells are removed, which may result in a greater therapeutic effect. Selective apheresis for treatment of IBD, in particular ulcerative colitis (UC), has been used in Japan and some European countries for several years; pilot studies with Adacolumn, a selective therapeutic granulocyte/monocyte apheresis device, in patients with IBD have recently been completed in the United States with favorable results. Unlike conventional pharmacological treatments, selective apheresis may be associated with a relatively low rate of adverse events. Multiple studies have suggested that selective apheresis may be of benefit as a steroid-sparing treatment. In an unblinded randomized trial in 69 steroid-dependent patients with active UC randomized to selective apheresis with Adacolumn or an increased dose of prednisolone, 83% of patients receiving Adacolumn achieved remission compared with 65% of those receiving an increased dose of prednisolone. In another uncontrolled study of 60 patients with active UC, treatment with Adacolumn selective apheresis enabled nearly 70% of steroid-dependent patients to discontinue prednisolone. An unblinded randomized controlled trial of a different selective apheresis device (Cellsorba) versus high-dose prednisolone in patients with active UC showed a greater therapeutic effect (74%) than high-dose prednisolone (38%) and lower frequency of adverse effects (24% versus 68%).

Pelvic drainage should be a routine for TME with or without radiation.
Konishi T, Watanabe T, Nagawa H
Ann Surg. 2006 Jan;243(1):141-2; author reply 142.

Drainage and other risk factors for leakage after anterior resection in rectal cancer patients: a prospective study of 978 patients.
Bozzetti F
Ann Surg. 2006 Jan;243(1):140-1; author reply 141.

Transanal endoscopic repair of rectal anastomotic defect.
Machado GR, Bojalian MO, Reeves ME
Arch Surg. 2005 Dec;140(12):1219-22.

Surgeons often encounter difficulty when constructing a colorectal anastomosis in the "hostile pelvis." Examples include performing low anterior resection or colostomy takedown in the setting of prior radiation, severe inflammation, or a narrow pelvis. Circular staplers have made low anastomosis a viable alternative to permanent colostomy in these situations. However, the surgeon may occasionally be faced with the difficult decision of how to manage a gross disruption of a stapled anastomosis in a pelvis that will not permit anastomotic redo. The traditional approach to this would be creating a permanent colostomy. We describe an alternate approach: endoscopic suturing with protecting ileostomy. We have successfully applied this technique to 4 patients with gross anastomotic disruption in a hostile pelvis. All patients tolerated the procedure well and have maintained normal bowel function without the need for a permanent colostomy.

Ineffectiveness of Lactobacillus johnsonii LA1 for prophylaxis of postoperative recurrence in Crohn's disease: a randomised, double-blind, placebo-controlled GETAID trial.
Marteau P, Lemann M, Seksik P, Laharie D, Colombel JF, Bouhnik Y, Cadiot G, Soule JC, Boureille A, Metman E, Lerebours E, Carbonnel F, Dupas JL, Veyrac M, Coffin B, Moreau J, Abitbol V, Blum-Sperisen S, Mary JY
Gut. 2005 Dec 23;.

BACKGROUD AND AIMS: Early endoscopic recurrence is frequent after intestinal resection for Crohn's disease. Bacteria are involved, and probiotics might modulate immune responses to the intestinal flora. Here we tested the probiotic strain Lactobacillus johnsonii LA1 in this setting. PATIENTS AND METHODS: This was a randomized double- blind, placebo-controlled study. Patients were eligible if they had undergone surgical resection <1 m removing all macroscopic lesions within the past 21 days. Patients were randomized to receive two packets per day of lyophilized LA1 (2 x 109 cfu) or placebo for 6 months; no other treatment was allowed. The primary endpoint was endoscopic recurrence at 6 months, with grade >1 in Rutgeerts' classification or an adapted classification for colonic lesions. Endoscopic score was the maximal grade of ileal and colonic lesions. Analyses were performed primarily on an intent-to-treat basis. RESULTS: Ninety-eight patients were enrolled (48 in the LA1 group). At 6 months, endoscopic recurrence was observed in 30/47 patients (64%) in the placebo group, and 21/43 (49%) in the LA1 group (p=0.15). Per protocol analysis confirmed this result. Endoscopic score distribution did not differ significantly between the LA1 and placebo groups. There were four clinical recurrences in the LA1 group and three in the placebo group. CONCLUSION: L. johnsonii LA1 (4 x 109 cfu/day) did not have a sufficient effect, if any, to prevent endoscopic recurrence of Crohn's disease.

What is in Store for Your Crohn's Patient?
Weitzman G, Maltz C
J Clin Gastroenterol. 2006 Feb;40(2):93-5.

Adenocarcinoma of the ileoanal pouch for ulcerative colitis-a complication of severe chronic atrophic pouchitis?
Knupper N, Straub E, Terpe HJ, Vestweber KH
Int J Colorectal Dis. 2005 Dec 20;:1-5.

BACKGROUND: The appearance of a carcinoma in the ileal pouch after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative proctocolitis is rare. Most of these adenocarcinomas previously described in literature develop from residual viable rectal mucosa. We report a case of an adenocarcinoma arising in all probability from the ileal pouch after malignant transformation of the ileal pouch mucosa based on a chronic atrophic pouchitis. PATIENT AND METHODS: A 34-year-old man developed an adenocarcinoma after a double-stapled ileorectal J-pouch for ulcerative colitis (UC) proceeded from malignant ileal transformation. Before surgery, he had a 20-year history of UC refractory to medical therapy, but no occurrence of backwash ileitis, dysplasia or colitis-associated illness. He experienced severe pouchitis after IPAA since the ileostomy closure. Carcinoma was ensured by endoscopy, and the patient underwent an abdominoperineal pouch extirpation combined with excision of perirectal tissues and anal canal. Histology after surgery showed a pT4,pN2(4/16)pM0,G3 adenocarcinoma with global severe chronic atrophic pouchitis (CAP), villous atrophy and malignant ileal transformation. No metaplasia of the rectal mucosa was found, not even malignant epithelial transformation of the anal canal. CONCLUSION: This case suggests that a malignant transformation of the ileal pouch mucosa may occur as a pure complication of severe CAP, even in the absence of backwash ileitis or a previous history of cancer. The absence of metaplasia of the rectal mucosa revealed the passage from CAP to dysplastic epithelium and to cancer. A multifactorial development of carcinogenesis is supposed, but we emphasize the importance of severe CAP, and that careful surveillance is needed in patients after IPAA. We must submit that this is just a case report and cannot stand for general cancer development in ulcerative colitis, but it may point out the risk factor of chronic inflammation and leads the surgeon to skillful working when building the pouch.

New pieces of the pathogenetic mosaic in inflammatory bowel disease.
Vieth M, Tannapfel A
Eur J Gastroenterol Hepatol. 2006 Feb;18(2):123-4.

Ulcerative colitis is a lifelong disease with an elevated risk of colorectal neoplasiaNew hypotheses such as the defensin concept are available concerning the ongoing inflammatory reactionIt is known that telomere length is related to neoplasiaIn this issue of EJGH it is speculated as to whether the telomere length of fibroblasts is related to the age of onset of chronic inflammatory bowel diseaseIt is questionable whether the length of telomeres in fibroblasts is related directly to neoplasia but indirectly via variable age of onset and duration of diseaseUlcerative colitis (UC) is a lifelong disease. Patients with UC have an approximately 20% risk of developing colorectal cancer. The risk of neoplasia increases with the duration of the disease. Why some patients develop colorectal cancer and others do not is still poorly understood. UC patients who develop cancer have an underlying process of genetic and epigenetic instability in the inflamed mucosa, as indicated previously using several experimental techniques. Rapid cell turnover and oxidative injury observed in UC mucosa is associated with accelerated telomere shortening, followed by an increased potential for the chromosomal ends to fuse, ending in chromatin damage and chromosomal instability. It has been reported that chromosomal losses are greater and telomeres are shorter in the biopsies of patients with long-standing UC. Telomere length is correlated with chromosomal instability in a variety of epithelial preneoplastic lesions. In the case of an inflammatory context for UC mucosa, this genetic (and also epigenetic) damage may be associated with cellular transformation and tumour progression. However, almost all studies have focussed on the hypothesis that the epithelial cells are the primary target in this scenario, leading to epithelial types of cancer. The elongated lifespan of fibroblasts, as reported in the paper by Getliffe et al. in this issue of European Journal of Gastroenterology and Hepatology, is probably indirectly connected to a lesser frequency of colorectal neoplasia in UC as part of a different immune response in these patients compared with individuals with early-onset UC.

Transanal Endoscopic Microsurgical Resection of pT1 Rectal Tumors.
Floyd ND, Saclarides TJ
Dis Colon Rectum. 2005 Dec 20;.

PURPOSE: Transanal endoscopic microsurgery has emerged as an improved method of transanal excision of neoplasms because its enhanced visibility, superior optics, and longer reach permit a more complete excision and precise closure. This study will show that transanal endoscopic microsurgical treatment of pT1 rectal cancers is safe and achieves low local recurrence and high survival rates. METHODS: Retrospective review performed of all pT1 rectal cancers treated by a single surgeon (TS) using transanal endoscopic microsurgery between 1991 and 2003. Patient age, gender, tumor distance from the anal verge, lesion size, operative time, blood loss, complications, recurrence, and survival rates were prospectively recorded. RESULTS: Fifty-three patients (average age, 65.6 (range, 31-89) years) were studied. Forty-nine percent were male. Average tumor distance from the anal verge was 7 (range, 0-13) cm; average size was 2.4 (range, 1-10) cm. Radiation and/or chemotherapy were not administered. Sixteen patients had pT1 lesions removed piecemeal during colonoscopy; there was no residual tumor after transanal endoscopic microsurgical resection of the polyp site. Mean follow-up was 2.84 years. Fifty-one percent had longer than two-year follow-up. For the entire group, there were four recurrences (7.5 percent) occurring at 9 months, 15 months, 16 months, and 11 years. Two were treated with abdominoperineal resection, one with low anterior resection, and one with fulguration alone. There were no recurrences in the 16 patients who had excision of the polypectomy site. If excluded, recurrence was 11 percent (4/37). Patients were examined at three-month intervals for the first two years and every six months thereafter. There have been no cancer-related deaths. CONCLUSIONS: Transanal endoscopic microsurgical resection of pT1 rectal cancers yields low recurrence rates. Close follow-up permits curative salvage for those that do recur. Transanal excision remains a viable option.

Calcium plus vitamin D alters preneoplastic features of colorectal adenomas and rectal mucosa.
Holt PR, Bresalier RS, Ma CK, Liu KF, Lipkin M, Byrd JC, Yang K
Cancer. 2005 Dec 13;106(2):287-296.

BACKGROUND: Calcium and vitamin D are chemopreventive agents for colorectal neoplasia...The administration of a calcium plus vitamin D chemopreventive regimen resulted in several changes in adenomatous tissue that may have contributed to reduced polyp formation.

T4 rectal cancer: analysis of patient outcome after surgical excision.
Amshel C, Avital S, Miller A, Sands L, Marchetti F, Hellinger M
Am Surg. 2005 Nov;71(11):901-3; discussion 904.

Locally advanced rectal cancer dictates a major surgical undertaking, which includes en bloc resection of the rectum and all involved organs. The aim of this study was to evaluate patient outcome and compare multimodality treatment options after various surgical approaches from one institution for T4 rectal cancer. A retrospective chart review identified 24 patients who were operated on for advanced primary rectal cancer invading adjacent structures (T4) over a 5(1/2)-year period. The types of treatment and outcome were analyzed. From these 24 patients, the most frequently involved organ was the bladder (33%). A total of 16 patients underwent chemoradiotherapy. There were 12 complications (50%), the most common being wound infection (33% of complications, 17% overall). Nine patients had nodal disease. Disease-free survival was 54 per cent, and overall survival was 75 per cent. However, disease-free survival in node-negative patients was 67 per cent versus 33 per cent in node-positive individuals. Out of the six patients who died in this review, five (83%) received chemoradiotherapy. Operations for advanced primary rectal cancer with involvement of adjacent organs are major procedures associated with high morbidity. Patients without nodal disease may have long-term survival despite the locally advanced tumor. Interestingly, neoadjuvant therapy, adjuvant, or both, did not increase survival.

Fat, fiber, meat and the risk of colorectal adenomas.
Robertson DJ, Sandler RS, Haile R, Tosteson TD, Greenberg ER, Grau M, Baron JA
Am J Gastroenterol. 2005 Dec;100(12):2789-95.

OBJECTIVE: The aim of this study was to determine the relationship between fat, fiber, and meat intake, and risk of colorectal adenoma recurrence. METHODS: We determined adenoma recurrence and dietary intake for 1,520 participants in two randomized trials: The Antioxidant Polyp Prevention Study and Calcium Polyp Prevention Study. Subjects underwent baseline colonoscopy with removal of all adenomas, and dietary intake was estimated with a validated semiquantitative food frequency questionnaire. Follow-up colonoscopy was performed 1 and 4 yr later. Pooled risk ratios for adenoma recurrence were obtained by generalized linear regression, with adjustment for age, sex, clinical center, treatment category, study, and duration of observation. RESULTS: In the total colorectum, fiber intake was weakly and nonsignificantly associated with a risk for all adenomas (RR quartile 4 vs quartile 1 = 0.85, 95% CI 0.69-1.05) and advanced adenomas (RR = 0.88, 95% CI 0.54-1.44). Associations were stronger for adenomas in the proximal colon (RR = 0.73, 95% CI 0.56-0.97) and some fiber subtypes (fruit and vegetable, grain). There was no association between fat or total red meat intake and risk of adenoma or advanced adenoma recurrence. However, when considering other meats, risk (quartile 4 vs quartile 1) for advanced adenoma was increased for processed meat (RR = 1.75, 95% CI 1.02-2.99) and decreased for chicken (RR = 0.61, 95% CI 0.38-0.98). CONCLUSION: The inverse associations between fiber intake and risk of adenoma recurrence we observed are weak, and not statistically significant. Our data indicate that intake of specific meats may have different effects on risk.

Acute colorectal obstruction treated by means of transanal drainage tube: effectiveness before surgery and stenting.
Horiuchi A, Nakayama Y, Tanaka N, Kajiyama M, Fujii H, Yokoyama T, Hayashi K
Am J Gastroenterol. 2005 Dec;100(12):2765-70.

OBJECTIVES: The aim of this study was to clarify the usefulness of the management of acute colorectal obstruction using a transanal drainage tube before surgery or stenting. METHODS: Fifty-four patients (34 males and 20 females, aged 46-94 yr, mean = 69.7) treated between May 1998 and March 2004 for acute colorectal obstruction were identified in a colorectal obstruction database, and their clinical and radiological features were reviewed. Based on abdominal computed tomography findings, urgent colonoscopy was performed. Subsequently, endoscopic decompression using a Dennis((R)) Colorectal Tube (DCT) was attempted. RESULTS: Endoscopic decompression using the DCT was technically successful in 52 of 54 patients (96.3%). The site of obstruction was the cecum in 4, the ascending colon in 2, the transverse colon in 7, the descending colon in 11, the sigmoid colon in 18, and the rectum in 12. The etiology of obstruction was primary colorectal carcinoma in 45, non-colonic metastatic carcinoma in 4, postoperative obstruction in 4, and retrograde intussusception in 1. Following adequate cleansing of the colon, 44 patients underwent a one-stage surgery after 7 +/- 3 days (SD; range, 4-10 days). Stenting was successfully used as the final palliative treatment in 4. The use of the DCT alone relieved postoperative stenosis (3 patients) and retrograde intussusception (Prognosis in patients with obstructing colorectal carcinoma. Am J Surg 1982;143:742-7). During these treatments, perforation occurred in one patient with postoperative stenosis of the cecum. CONCLUSIONS: Management of acute colorectal obstruction using the DCT was found to be effective and safe, irrespective of the site or etiology of the obstruction. Therefore, this procedure should be considered as a primary method for decompression of the obstructed colon before considering surgery or stenting.

Relevance of the phenotypic characteristics of Crohn's disease in patient perception of health-related quality of life.
Casellas F, Vivancos JL, Sampedro M, Malagelada JR
Am J Gastroenterol. 2005 Dec;100(12):2737-42.

BACKGROUND: Crohn's disease (CD) has a negative impact on patients' perception of health. Several factors, such as disease activity, influence HRQOL impairment. However, the effect of the phenotypic CD characteristics recognized in the Vienna classification on health-related quality of life (HRQoL) remains unknown. METHODS: HRQOL was measured in CD patients using three questionnaires: the Spanish version of the Inflammatory Bowel Disease Questionnaire (IBDQ-36), the Psychological General Well-Being Index (PGWBI), and the EuroQol. RESULTS: One hundred ninety-eight CD patients were included. Scores for the IBDQ-36, PGWBI, and EuroQol dimensions did not differ according to age at diagnosis (177 patients under 40 yr and 21 over 40 yr), disease location (53 in terminal ileum, 62 in colon, 72 in ileocolon, and 11 in upper gastrointestinal tract) or disease behavior (99 nonstricturing-nonpenetrating, 32 stricturing, and 67 penetrating). Multivariate analysis identified as significant independent variables for worse HRQoL: female sex (t: -3.70), higher number of relapses per year (t: -2.71), and worse clinical disease activity (t: -7.82). None of the three Vienna variables reached statistical significance. CONCLUSIONS: HRQoL impairment in CD patients is independent of the clinical variables established in the Vienna classification for phenotypic type of disease.

Inflammatory bowel disease: dysfunction of GALT and gut bacterial flora (I).
Chandran P, Satthaporn S, Robins A, Eremin O
Surgeon. 2003 Apr;1(2):63-75.

Gut-associated lymphoid tissue (GALT) is the largest lymphoid organ in the body. This is not surprising considering the huge load of antigens (Ags) from food and commensal bacteria with which it interacts on a daily basis. Gut-associated lymphoid tissue has to recognise and allow the transfer of beneficial Ags whilst concurrently dealing with and successfully removing putative and overtly harmful Ags. This distinctive biological feature of GALT is believed to be crucial to good health. Deregulation or dysfunction of GALT is thought to predispose to inflammatory bowel diseases (IBD) such as ulcerative colitis and Crohn's disease. The exact mechanism(s) underlying the pathogenesis of IBD is (are) poorly understood and the immunological defects in GALT are poorly documented. Advances in immunology have highlighted the importance of dendritic cells (DCs), which are the key Ag presenting cells in tissues and lymphoid compartments. Their crucial role in GALT, in health and disease is discussed in this review. Interaction of DCs with T cells in the gut produces a subset of T lymphocytes, which have immunosuppressive function. Inappropriate Ag uptake and presentation to naive T cells in mesenteric lymph nodes may lead to T cell tolerance in GALT. These various complex factors in the gut are discussed and their possible relevance to IBD evaluated.

Loop ileostomy: modification of technique.
Nunoo-Mensah JW, Chatterjee A, Khanwalkar D, Nasmyth DG
Surgeon. 2004 Oct;2(5):287-91.

INTRODUCTION: A loop ileostomy is a suitable procedure for faecal diversion. A number of technical improvements and advancement in stoma management have made its creation a suitable alternative to a loop colostomy. We describe an alternative technique for securing a loop ileostomy and perform a retrospective review of this technique. PATIENTS & METHOD: 40 patients who had a loop ileostomy performed as part of an abdominal procedure were reviewed. The loop of ileum was secured to the stoma site with a novel 'suture bridge' technique. RESULTS: 32 patients had the stoma formed to protect a distal anastomosis, 6 to palliate bowel obstruction, 1 to control faecal incontinence and another for colonic Crohn's disease. There were no incidences of paralytic ileus, mechanical obstruction, prolapse, retraction or bleeding after the loop ileostomies were formed. Thirty patients had their ileostomies closed. In 27 patients this was performed by excising the muco-cutaneous edge and anterior closure. Three patients had their stomas resected and an end-to-end bowel anastomoses. Following closure there were two complications in separate patients--self-limiting paralytic ileus and small bowel obstruction at the site of the stomal closure that required a second operation. There were no incidences of anastomotic leaks or bleeding in patients who had their ileostomy closed. No mortalities were attributed to either stoma formation or closure. CONCLUSION: We have described a safe alternative technique for securing a loop ileostomy with negligible complications in construction and closure as demonstrated in our results.

Elevated anal squamous cancer risk associated with benign inflammatory anal lesions.
Nordenvall C, Nyren O, Ye W
Gut 2005 Nov 18;.

BACKGROUND: The role of benign anal lesions, including fissures, fistulas, perianal abscesses, and hemorrhoids, remains undefined. Few data from large cohort studies are available. METHODS: We conducted a register-based retrospective cohort study including 45,186 patients hospitalized for inflammatory anal lesions (anal fissures, fistulas, and perianal abscesses), as well as 79,808 hemorrhoid patients from 1965 through 2002. Multiple record linkages identified all incident anal (squamous-cell carcinoma only) and colorectal cancers through 2002. Relative risk was estimated by standardized incidence ratios (SIRs), the ratio of observed number of cases divided by that expected in the age-, sex- and calendar-year-matched general Swedish population. RESULTS: There was a distinct incidence peak in the first 3 years of follow-up among patients with inflammatory lesions. SIR then leveled off at around 3 and remained on this level throughout follow-up (SIR during year 3-37 of follow-up was 3.3; 95% confidence interval, 1.8 to 5.7). A similar initial incidence peak was observed among hemorrhoid patients, but it was confined to the first year. SIR was 2.8 in the second year, and then it further dropped and was close to unity in the following years (SIR during year 3-37 was 1.3; 95% confidence interval, 0.7 to 2.1). Among either inflammatory lesion or hemorrhoid patients, significantly increased risk for colorectal cancer was observed only in the first year after hospitalization. CONCLUSIONS: Inflammatory benign anal lesions are associated with a significantly increased long-term risk for anal cancer. By contrast, hemorrhoids appear not to be a risk factor for this malignancy.

Preliminary Observations of Oral Nicotine Therapy for Inflammatory Bowel Disease: An Open-label Phase I-II Study of Tolerance.
Ingram JR, Rhodes J, Evans BK, Thomas GA
Inflamm Bowel Dis 2005 Dec;11(12):1092-1096.

BACKGROUND: Transdermal nicotine provides benefit in active ulcerative colitis but is often associated with adverse events (AEs). An oral formulation has been developed to minimize AEs. This study was undertaken to make initial observations on the safety and tolerance of oral nicotine therapy in inflammatory bowel disease; the effect on disease activity was also noted. METHODS: Twenty-six patients with ulcerative colitis, 11 with active disease, and 5 patients with Crohn's colitis (2 with active disease) were given oral nicotine in 3-mg capsules, gradually increasing the dose to the maximum tolerated. AEs were recorded, concomitant prednisolone and/or azathioprine were reduced where possible, and disease activity was reassessed at the end of nicotine treatment. RESULTS: Patients were followed for up to 12 months. Twenty-nine of 31 could tolerate at least 6 mg of nicotine each day, and 5 patients tolerated at least 18 mg daily. Twenty-four patients had nicotine-related nonserious AEs; over one half occurred during the period of dose escalation, but 7 discontinued treatment because of them. Six of the 13 patients with active disease became asymptomatic, whereas 3 patients in remission developed active symptoms; 11 patients reduced their concomitant medication. CONCLUSIONS: Oral nicotine is a safe potential treatment of inflammatory bowel disease, but there is considerable variation in tolerance.

Comparison of 4 Neutrophil-derived Proteins in Feces as Indicators of Disease Activity in Ulcerative Colitis.
Langhorst J, Elsenbruch S, Mueller T, Rueffer A, Spahn G, Michalsen A, Dobos GJ
Inflamm Bowel Dis 2005 Dec;11(12):1085-1091.

BACKGROUND: To evaluate the diagnostic use of fecal concentrations of lactoferrin (Lf), calprotectin (Cal), polymorphonuclear neutrophil-elastase (PMN-e), and lysozyme (Lys) as indicators of disease activity in patients with active and inactive ulcerative colitis (UC). METHODS: A total of 76 fecal specimens were collected from 31 patients with UC in times of active and inactive status of disease. Disease activity was determined with the colitis activity index (CAI; Rachmilewitz index), which includes a combination of laboratory parameters and clinical symptoms, with a score of at least 6 indicating active disease. Fecal Lf, Cal, PMN-e, and Lys were measured and reported as micrograms per milliliter feces. Levels of more than 7.25, more than 6.00, at least 0.062, and at least 0.6 for Lf, Cal, PMN-e, and Lys, respectively, were considered elevated as specified by the manufacturers. RESULTS: Based on the CAI classification, 25 of the samples were from patients with active disease status and 51 were from patients with inactive status. Lf, PMN-e, and Cal but not Lys showed increased levels in samples from patients in active disease compared with those in remission (median for Lf: 28.12 +/- 110.86 versus 179.54 +/- 334.09, P < 0.001; median for Cal: 15.13 +/- 30.27 versus 116.23 +/- 182.29, P < 0.001; median for PMN-e: 0.21 +/- 0.44 versus 1.02 +/- 0.89, P < 0.001; median for Lys: 1.54 +/- 2.39 versus 3.75 +/- 5.39, P > 0.05). All 4 parameters correlated with the CAI (Lf: r = 0.441, P < 0.001; Cal: r = 0.505, P < 0.001; PMN-e: r = 0.604, P < 0.001; Lys: r = 0.295, P < 0.05). Introducing a composite index based on Lf, Cal, and PMN-e, the specificity was 72.5% and the sensitivity 88% compared with the CAI. CONCLUSIONS: Among the neutrophil-derived proteins in feces, PMN-e, Cal, and Lf represent useful markers of disease activity in patients with UC. Using all 3 markers in a composite index may be an additional noninvasive tool for the management of ambulant patients with UC.

CT colonography in the detection of colorectal polyps and cancer: systematic review, meta-analysis, and proposed minimum data set for study level reporting.
Halligan S, Altman DG, Taylor SA, Mallett S, Deeks JJ, Bartram CI, Atkin W
Radiology 2005 Dec;237(3):893-904.

PURPOSE: To assess the methodologic quality of available data in published reports of computed tomographic (CT) colonography by performing systematic review and meta-analysis. MATERIALS AND METHODS: The MEDLINE database was searched for colonography reports published between 1994 and 2003, without language restriction. The terms colonography, colography, CT colonoscopy, CT pneumocolon, virtual colonoscopy, and virtual endoscopy were used. Studies were selected if the focus was detection of colorectal polyps verified with within-subject reference colonoscopy by using key methodologic criteria based on information presented at the Fourth International Symposium on Virtual Colonoscopy (Boston, Mass). Two reviewers independently abstracted methodologic characteristics. Per-patient and per-polyp detection rates were extracted, and authors were contacted, when necessary. Per-patient sensitivity and specificity were calculated for different lesion size categories, and Forest plots were produced. Meta-analysis of paired sensitivity and specificity was conducted by using a hierarchical model that enabled estimation of summary receiver operating characteristic curves allowing for variation in diagnostic threshold, and the average operating point was calculated. Per-polyp sensitivity was also calculated. RESULTS: Of 1398 studies considered for inclusion, 24 met our criteria. There were 4181 patients with a study prevalence of abnormality of 15%-72%. Meta-analysis of 2610 patients, 206 of whom had large polyps, showed high per-patient average sensitivity (93%; 95% confidence interval [CI]: 73%, 98%) and specificity (97%; 95% CI: 95%, 99%) for colonography; sensitivity and specificity decreased to 86% (95% CI: 75%, 93%) and 86% (95% CI: 76%, 93%), respectively, when the threshold was lowered to include medium polyps. When polyps of all sizes were included, studies were too heterogeneous in sensitivity (range, 45%-97%) and specificity (range, 26%-97%) to allow meaningful meta-analysis. Of 150 cancers, 144 were detected (sensitivity, 95.9%; 95% CI: 91.4%, 98.5%). Data reporting was frequently incomplete, with no generally accepted format. CONCLUSION: CT colonography seems sufficiently sensitive and specific in the detection of large and medium polyps; it is especially sensitive in the detection of symptomatic cancer. Studies are poorly reported, however, and the authors propose a minimum data set for study reporting.

Gender Differences in Quality of Life of Patients with Rectal Cancer. A Five-Year Prospective Study.
Schmidt CE, Bestmann B, Kuchler T, Longo WE, Rohde V, Kremer B
World J Surg 2005 Nov 26;.

To determine how quality of life changes over time and to assess gender-related differences in quality of life of rectal cancer patients we conducted a 5-year study. Little is known about how quality of life (QoL) changes over time in patients after surgery for rectal cancer, and whether gender of the patients is associated with a different perception of QoL. The aim of this study was to assess prospectively, changes in quality of life after surgery for rectal cancer, with a focus on gender related differences. Over a 5-year period, the EORTC-QLQ-C-30 and a tumor-specific module were prospectively administered to patients before surgery, at discharge, 3, 6, 12, and 24 months postoperatively. Comparisons were made between female and male patients. A total of 519 patients participated in the study, 264 men and 255 women. The two groups were comparable in terms of surgical procedures, adjuvant treatment, tumor stage, and histology. Most QoL scores dropped significantly below baseline in the early postoperative period. From the third month onward, global health, emotional and physical functioning, improved. Female gender was associated with significantly worse global health and physical functioning and with higher scores on treatment strain and fatigue. Men reported difficulties with sexual enjoyment; furthermore, over time, sexual problems created high levels of strain in men, worse than baseline levels in the early postoperative period. These problems tended to continue over the course of time. The findings in this study confirm that QoL changes after surgery and differs between men and women. Women appear to be affected by impaired physical functioning and global health. Female gender is associated with significantly higher fatigue levels and increased strain values after surgery. Through impaired sexual enjoyment, men are put more under strain than woman.

Association between colonic screening, subject characteristics, and stage of colorectal cancer.
Fazio L, Cotterchio M, Manno M, McLaughlin J, Gallinger S
Am J Gastroenterol 2005 Nov;100(11):2531-9.

OBJECTIVES: Colorectal cancer remains a significant cause of mortality and morbidity in North America. Colorectal cancer survival is highly dependent on stage at diagnosis, therefore it is important to identify factors related to stage. This study evaluated the association between subject factors (e.g., colonic screening, family history) and stage of colorectal cancer at diagnosis. METHODS: Population-based colorectal cancer cases recruited by the Ontario Familial Colon Cancer Registry between 1997 and 1999 were staged according to the tumor-nodal-metastasis (TNM) staging system and classified as early (TNM I/II) or late (TNM III/IV) stage. Epidemiologic information and stage was available for 768 cases. Multivariate logistic regression was used to obtain odds ratios (OR) estimates. RESULTS: Having had screening endoscopy reduced the risk of late stage diagnosis (OR = 0.46, 95% CI 0.22-0.98). Being older (>45 yr) was associated with a reduced risk of late stage cancer (OR = 0.36, 95% CI 0.18-0.74), as was having a first degree relative with colorectal cancer (OR =0.66, 95% CI 0.46-0.95). Rural residence (OR = 1.48, 95% CI 1.01-2.17) and non-white ethnicity (OR = 3.34, 95% CI 1.20-9.36) were associated with an increased risk of late stage cancer. CONCLUSIONS: Several factors are independently associated with late stage colorectal cancer. Colorectal cancer screening awareness and education programs need to consider targeting persons most likely to present with late stage colorectal cancer.

Inappropriate colorectal cancer screening: findings and implications.
Fisher DA, Judd L, Sanford NS
Am J Gastroenterol 2005 Nov;100(11):2526-30.

OBJECTIVES: Inclusion of colorectal cancer screening as a performance measure in the Veterans Health Administration (VHA) health system appears to have improved screening rates but may have also increased inappropriate screening. Our aim was to ascertain whether the fecal occult blood test (FOBT) was being ordered appropriately. METHODS: We examined records of 500 consecutive primary care patients at a single VHA facility for whom FOBT had been ordered to determine whether the FOBT was appropriate and, if not, the reason why. RESULTS: We found that 18% of the sample had severe comorbid illness, 13% had signs or symptoms of gastrointestinal blood loss, 7% had a history of colorectal neoplasia or inflammatory bowel disease (high risk), 5% had undergone colonoscopy within prior 5 yr, and 3% were younger than 50 yr of age. Overall, 35% of the patients had at least one reason that the FOBT was inappropriate and at least 19% of the patients should not have undergone any colorectal cancer test for screening or diagnosis. CONCLUSIONS: The FOBT order was inappropriate in a third of the sample, most commonly because of a documented life-limiting comorbidity. In addition, data suggested that FOBT was being used for diagnosis instead of screening. Screening patients unlikely to live long enough to develop and die from colorectal cancer provides no benefit and places these individuals at unjustifiable risk. Additionally, inappropriate screening utilizes resources that could be used to improve screening and follow-up for eligible individuals.

A prospective comparison study of MRI versus small bowel follow-through in recurrent Crohn's disease.
Bernstein CN, Greenberg H, Boult I, Chubey S, Leblanc C, Ryner L
Am J Gastroenterol 2005 Nov;100(11):2493-502.

BACKGROUND: We aimed to determine the utility of magnetic resonance imaging (MRI) compared with small bowel follow-through (SBFT) in the assessment of known Crohn's disease. METHODS: Subjects, over age 18 yr who were to undergo SBFT investigations to assess for complications or extent of Crohn's disease were eligible. SBFT was performed by a single radiologist (IB), and within 4 wk MRI was performed by a single radiologist (HG) who was blinded to the SBFT results. For MRI, oral contrast was 2% barium sulfate (1,350 mL). After unenhanced T1 weighted images and single shot fast spin echo T2 imaging, intravenous (IV) glucagon and gadolinium were given. Fast multiplanar spoiled-gradient recalled T1 coronal sequences were obtained followed by abdominal and pelvic axial images. MRI and SBFT were compared for extent of disease, presence of complications, and for identification of extraintestinal disease. RESULTS: Paired studies were undertaken within a mean of 22 days in 30 subjects. Ten studies were normal by both modalities and 8 studies showed similar extent of Crohn's disease. SBFT revealed additional information in 4, including a stricture in 1 and ileosigmoid fistulas in 2. MRI provided enhanced information in 8, including identifying active inflammation in strictured areas based on wall enhancement patterns, vasa recta changes, and lymphadenopathy. CONCLUSIONS: On the basis of cost and accessibility, SBFT may still be a first line procedure of choice in some centers without MRI, but MRI's advantages of no radiation and the potential to identify active inflammation in strictured areas, extraintestinal, and colorectal disease make it an attractive alternative.

Basaloid Squamous Carcinoma of the Anal Canal With an Adenoid Cystic Pattern: Histologic and Immunohistochemical Reappraisal of an Unusual Variant.
Chetty R, Serra S, Hsieh E
Am J Surg Pathol 2005 Dec;29(12):1668-1672.

Two cases of a distinctive variety of basaloid squamous carcinoma (BSC) of the anal canal are described. Both occurred in female patients who presented with bleeding per rectum. Histologic evaluation of the tumors showed lobules and aggregates of medium-sized basaloid cells with distinctive peripheral palisading and focal areas of central, comedo-necrosis. Accompanying dysplasia of the overlying squamous mucosa was absent. However, the microscopic pattern was dominated by the presence of eosinophilic, hyaline, paucicellular basement membrane-like material around and within tumor nests. This appearance together with microcystic spaces simulated that of an adenoid cystic carcinoma. Immunohistochemistry of the tumors revealed the following profile: CK7, CK5/CK6, 34betaE12 positive, CK14 focally positive but CK20 negative. The following were all negative: EMA, CEA, smooth muscle and muscle-specific actin, calponin, and S-100. The tumor cells exhibited diffuse nuclear positivity with p63. The eosinophilic basement membrane hyaline material was positive for collagen type IV and also for laminin. BSC of the anal canal with an adenoid cystic pattern is an infrequently encountered and reported variant, although it is seen more often in the aerodigestive tract. There may be an increased propensity for BSC with an adenoid cystic pattern to metastasize to the liver, but the number of cases encountered are too small to be definitive. The histologic differential diagnosis is true salivary gland-type adenoid cystic carcinoma and basal cell adenocarcinoma. Immunohistochemistry and awareness of this unusual pattern of BSC will facilitate the correct diagnosis being reached.

Local recurrence after curative resection for rectal cancer is associated with anterior position of the tumour.
Chan CL, Bokey EL, Chapuis PH, Renwick AA, Dent OF
Br J Surg 2005 Nov 21;.

BACKGROUND: Mobilization of rectal cancer can be difficult if the tumour is located anteriorly and may result in a higher incidence of local recurrence. The aim of this study was to determine whether local recurrence and survival following curative resection of rectal cancer were associated with the position of the tumour. METHODS: Data were drawn from a comprehensive, prospective hospital registry of all resections for rectal cancer from January 1990 to December 1998, with follow-up to December 2003. RESULTS: The 5-year local recurrence rate was 15.9 (95 per cent confidence interval (c.i.) 11.0 to 22.8) per cent in 176 patients with tumours that had an anterior component compared with 5.8 (95 per cent c.i. 2.8 to 11.9) per cent in 132 patients with tumours without an anterior component (P = 0.009). This association persisted after adjustment for other factors linked to local recurrence (hazard ratio (HR) 2.4 (95 per cent c.i. 1.1 to 5.4)). Similarly, anterior position had a significant negative independent association with survival (HR 1.4 (95 per cent c.i. 1.0 to 2.00)). CONCLUSION: Anterior position is an independent negative prognostic factor for both local recurrence and survival after curative resection of rectal cancer. Copyright (c) 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Evaluation of outcome of laparoscopic colorectal resection with POSSUM, Portsmouth POSSUM and colorectal POSSUM.
Law WL, Lam CM, Lee YM
Br J Surg 2005 Nov 15;.

BACKGROUND: This study evaluated the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM), Portsmouth (P) POSSUM and colorectal (CR) POSSUM in laparoscopic colorectal resection. METHODS: Observed mortality and morbidity rates in 400 patients who underwent laparoscopic colorectal resection were compared with those predicted by POSSUM, P-POSSUM and CR-POSSUM. RESULTS: Observed mortality and morbidity rates were 0.5 and 19.0 per cent respectively. Mortality rates predicted by POSSUM, P-POSSUM and CR-POSSUM were 10.8, 4.0 and 5.6 per cent respectively, and the morbidity rate predicted by POSSUM was 43.0 per cent. The predicted and observed mortality and morbidity rates showed significant lack of fit. The conversion rate to open surgery was 11.5 per cent. The mortality rate for patients having conversion was 2 per cent and was not significantly different to that predicted by P-POSSUM (4 per cent; P = 0.493) or CR-POSSUM (5 per cent; P = 0.370). In this group, the observed and POSSUM-predicted morbidity rates were also similar (43 versus 48 per cent respectively; P = 0.104). CONCLUSION: POSSUM, P-POSSUM and CR-POSSUM overestimated mortality and morbidity in patients who underwent laparoscopic colorectal resection. However, the mortality rate in patients who required conversion fitted the models of P-POSSUM and CR-POSSUM, and the morbidity rate was comparable to that predicted by POSSUM. Copyright (c) 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Causes and outcomes of pouch excision after restorative proctocolectomy.
Prudhomme M, Dehni N, Dozois RR, Tiret E, Parc R
Br J Surg 2005 Nov 15;.

BACKGROUND: Pouch failure occurs in up to 10 per cent of patients after ileal pouch-anal anastomosis (IPAA). The aims of this study were to determine the reasons for pouch excision and to evaluate the outcome of the perineal wound after pouch excision. METHODS: Between 1984 and 2002, 91 patients with severe ileal pouch dysfunction were treated. This was a retrospective analysis of data collected prospectively from 24 patients who underwent pouch excision. RESULTS: Patients were grouped according to the final histological diagnosis. Fourteen patients with Crohn's disease developed extensive fistulous disease and/or recurrent abscesses, of whom six had a persistent perineal sinus after pouch excision. Five patients had familial adenomatous polyposis, in three of whom desmoid tumours were the cause of failure. Three patients had chronic ulcerative colitis and developed recurrent pelvic sepsis. Finally, two patients with multiple colorectal adenocarcinoma developed recurrent cancer (one) or sepsis (one). CONCLUSION: Sepsis was the principal reason for pouch excision and was usually associated with recrudescent Crohn's disease in the pouch. Perineal wound healing was problematic after pouch excision for Crohn's disease. Copyright (c) 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Radiofrequencies and Proctology: A Difficult Marriage.
Filingeri V, Gravante G
Digestion 2005 Nov 25;72(4):261.

Seasonal Patterns of Hospital Treatment for Inflammatory Bowel Disease in Italy.
Soncini M, Triossi O, Leo P, Magni G, Giglio LA, Mosca PG, Bertele AM, Pompeo F, Pietrini L, Muratori R, Marone GP, Belfiori V, Sciampa G, Tanzilli A, Azzola E, Ferraris L, Grasso T, Caruso S, Bonecco S, Casanova B, Brambilla G, Frulloni L, D'Offizi V
Digestion 2005 Dec 1;73(1):1-8.

Aim: It is still debated whether clinical flare-ups of chronic inflammatory bowel disease follow a seasonal pattern, and the various reports are based on general practitioners' records or hospital discharge charts. There are, however, no specific figures for treatment in hospital gastroenterology units, which serve as a reference point for these disorders. This study was therefore designed to investigate whether there is a seasonal pattern in admissions for inflammatory intestinal disease in Italy, differing from what is generally known about gastrointestinal pathologies, since there are no nation-wide figures on the subject. Methods: The RING (Ricerca Informatizzata in Gastroenterologia) project is an observational study collecting hospital discharge forms from 22 centers in Italy. Results: From winter 2000 to autumn 2003, the 22 gastroenterology units participating in the RING project discharged 32,357 patients following ordinary hospital admissions. Of these, 2,856 (8.8%) had a main diagnosis of inflammatory bowel disease: 1,541 Crohn's disease, and 1,315 ulcerative colitis. No seasonal patterns were detected for either category, or when the analysis was done by age, sex and site of disease. Conclusions: The most serious flare-ups of inflammatory bowel disease, i.e. those requiring routine hospital treatment, do not appear to follow any seasonal pattern, regardless of the site of the disease or the patient's age or sex. Copyright (c) 2006 S. Karger AG, Basel.

Risk Factors regarding the Need for a Second Operation in Patients with Crohn's Disease.
Avidan B, Sakhnini E, Lahat A, Lang A, Koler M, Zmora O, Bar-Meir S, Chowers Y
Digestion 2005 Nov 25;72(4):248-253.

Background/Aims: The majority of Crohn's disease patients undergo surgery. However, the factors that predict post-operative recurrence remain controversial. The aim of the present study was to shed light on the potential predictors of such recurrence. Methods: 86 patients who underwent operative procedures for Crohn's disease were retrospectively studied. Recurrence was defined as the need for a second operation. Life table and multivariate analysis were performed to find the predictors of recurrence. Results: In 26/86 (30%) of the patients, post-operative recurrence was diagnosed within a mean of 42 months of the follow-up. Logistic regression analysis revealed that smoking (OR 3.69, 95% CI 2.06-11.52) and perforating disease (OR 4.09, 95% CI 1.31-12.65) were associated with a risk of recurrence. However, survival analysis showed that only perforating disease was associated with an early post-operative recurrence (log-rank test, p < 0.001). Neither resected surgical specimen characteristics, nor the duration and the location of the disease were found to predict the need for a second operation. Conclusion: The risk for Crohn's disease patients who undergo surgery is related to the presence of perforating disease and smoking, which predict the need for a second operation. The former is associated with an even earlier recurrence. Copyright (c) 2005 S. Karger AG, Basel.

Is There Any Difference in Recurrence Rates in Laparoscopic Ileocolic Resection for Crohn's Disease Compared With Conventional Surgery? A Long-Term, Follow-Up Study.
Lowney JK, Dietz DW, Birnbaum EH, Kodner IJ, Mutch MG, Fleshman JW
Dis Colon Rectum 2005 Nov 23;.

PURPOSE: The long-term outcome of laparoscopic ileocolic resection in patients with Crohn's disease is not well defined. This study was designed to define the surgical recurrence rate after laparoscopic ileocolic resection for Crohn's disease and to compare it with that seen after open ileocolic resection. METHODS: A retrospective review of 113 records of patients who underwent index ileocolic resection for terminal ileal Crohn's disease was performed (1987-2003). Recurrence was defined as development of new preanastomotic Crohn's disease requiring surgical intervention. Details of recurrence and use of chemoprophylaxis was determined by phone interview andchart review. RESULTS: Sixty-three patients (26 males; mean age, 35.2 years) underwent laparoscopic ileocolic resection and 50 had open ileocolic resection (17 males; mean age, 37.1 years). Surgical recurrence developed in 6of 63 patients (9.5 percent) in the laparoscopic ileocolic resection group (mean follow-up, 62.9 months) and in 12of 50 patients (24 percent) in the open ileocolic resection group (mean follow-up, 81.8 months). Rates of chemoprophylaxis were similar between groups (laparoscopic ileocolic resection, 39 percent; open ileocolic resection, 54 percent; P = not significant). Median times to recurrence after laparoscopic ileocolic resection and open ileocolic resection were 60 (range, 36-72) months and 62 (range, 12-180) months, respectively. Fifty percent of the recurrences in the laparoscopic ileocolic resection group and 4 of 12 in the open ileocolic resection group were able to be retreated laparoscopically. Re-recurrence occurred in 4 of 12 open ileocolic resection patients (33 percent) at a mean of 63.6 months, and one patient had a third recurrence at 28 months. CONCLUSIONS: In this study, the long-term outcome after laparoscopic ileocolic resection was not shown to be statistically different from that of open ileocolic resection. The relatively low recurrence rates in both groups may be explained by our aggressive use of chemoprophylaxis.

Consequences of Conversion in Laparoscopic Colorectal Surgery.
Gonzalez R, Smith CD, Mason E, Duncan T, Wilson R, Miller J, Ramshaw BJ
Dis Colon Rectum 2005 Dec 4;.

Laparoscopic colorectal resections has a relatively high conversion rate; however, the converted cases have outcomes similar to open colorectal resections. In fact, the converted group required fewer blood transfusions than the open group. Experience and good judgment are fundamental for timely conversion of a laparoscopic procedure to open to decrease complication rates. Despite a high conversion rate, surgeons should consider laparoscopic colorectal resections, because even when necessary, conversion does not result in poorer outcomes than laparoscopic colorectal resections or open colorectal resections.

Total Mesorectal Excision: The Unrecognized Pelvic Plane.
Koh PK, Seow-Choen F, Kwek BH
Dis Colon Rectum 2005 Dec 8;.

Total mesorectal excision for low rectal cancers has been shown to reduce local recurrence rate after curative operation to < 5 percent. The lack of anatomic appreciation of the mesorectum is an important cause of intersurgeon variability in the outcome of rectal cancer surgery. Surgical illustrations depicting the mesorectal anatomy, however, are less than accurate. Basic surgical concepts must be illustrated correctly to be learned correctly. True-to-life illustration is the only way the learner can appreciate the actual situation and improve his/her surgical results. We describe the mesorectal anatomy with correlation to computerized tomography scans of the in vivo rectum to further illustrate the technique of total mesorectal excision in rectal cancer surgery.

Experience of Endoscopic Transanal Resections With a Urologic Resectoscope in 131 Patients.
Tsai JA, Hedlund M, Sjoqvist U, Lindforss U, Torkvist L, Furstenberg S
Dis Colon Rectum 2005 Dec 8;.

PURPOSE: Endoscopic transanal resection of rectal adenomas and other presumably benign lesions is not widespread. The purpose of this study was to evaluate the efficacy and the safety of endoscopic transanal resection. METHODS: Patients who underwent endoscopic transanal resection at three Stockholm hospitals between 1993 and 2004 were studied retrospectively with respect to patient and lesion characteristics, complications, follow-up time, and recurrence rates. RESULTS: One hundred eighty endoscopic transanal resection procedures were performed in 131 patients. The tissue diagnosis was adenoma in 160 operative cases, cancer in 12 operative cases, and hyperplasia, fibrosis, or normal mucosa in the remaining 8 operative cases. Among the patients with rectal adenomas, one endoscopic transanal resection was sufficient in 77 cases and in 16 cases the surgery was performed in more than one session because of the large size of the adenoma. In 27 cases there were recurrences that needed additional endoscopic transanal resection or other surgery. The median time until recurrence was seven months, but there were no recurrent rectal carcinomas. In 16 operative cases there were complications. Two patients had to undergo a Hartman's procedure as a result of a bowel perforation, and one patient had to be reoperated on because of bleeding. There were no perioperative deaths. The median follow-up time without recurrence was 32 (range, 0-67) months. CONCLUSIONS: Endoscopic transanal resection is a feasible and oncologically safe option for treatment of rectal adenomas, especially in cases where conventional transanal resection or transanal endoscopic microsurgery are unavailable or unsuitable because of the characteristics and localization of the lesion.

Preoperative Chemoradiation for Rectal Cancer Causes Prolonged Pudendal Nerve Terminal Motor Latency.
Lim JF, Tjandra JJ, Hiscock R, Chao MW, Gibbs P
Dis Colon Rectum 2005 Nov 16;.

PURPOSE: A worsened anorectal function after chemoradiation for high-risk rectal cancer is often attributed to radiation damage of the anorectum and pelvic floor. Its impact on pudendal nerve function is unclear. This prospective study evaluated the short-term effect of preoperative combined chemoradiation on anorectal physiologic and pudendal nerve function. METHODS: Sixty-six patients (39 men, 27 women) with localized resectable (T3, T4, or N1) rectal cancer were included in the study. All patients received 45 Gy (1.8 Gy/day in 25 fractions) over five weeks, plus 5-fluorouracil (350 mg/m(2)/day) and leucovorin (20 mg/m(2)/day) concurrently on days 1 to 5 and 29 to 33. Patients who had rectal cancer with a distal margin within 6 cm of the anal verge had the anus included in the field of radiotherapy (Group A, n = 26). Patients who had rectal cancer with a distal margin 6 to 12 cm from the anal verge had shielding of the anus during radiotherapy (Group B, n = 40). The Wexner continence score, anorectal manometry and pudendal nerve terminal motor latency were assessed at baseline and four weeks after completion of chemoradiation. RESULTS: The median Wexner score deteriorated significantly (P < 0.0001) from 0 to 2.5 for both Groups A (range, 0-8) and B (range, 0-14). The maximum resting anal pressures were unchanged after chemoradiation. The maximum squeeze anal pressures were reduced (mean = 166.5-157.5 mmHg) after chemoradiation. This change was similar in both Groups A and B. Eighteen patients (Group A = 7, Group B = 11) developed prolonged pudendal nerve terminal motor latency after chemoradiation. These 18 patients similarly had a worsened median Wexner continence score (range, 0-3) and maximum squeeze anal pressures (mean = 165.5-144 mmHg). The results obtained were independent of tumor response to chemoradiation. CONCLUSIONS: Preoperative chemoradiation for rectal cancer carries a significant risk of pudendal neuropathy, which might contribute to the incidence of fecal incontinence after restorative proctectomy for rectal cancer.

Outcomes for Abdominoperineal Resections Are Not Worse Than Those of Anterior Resections.
Chuwa EW, Seow-Choen F
Dis Colon Rectum 2005 Nov 16;.

Both abdominoperineal resections and sphincter-preserving anterior resections can be performed safely with low morbidity and mortality in a specialized high-volume hospital unit without compromising oncologic outcomes. With appreciation of the anatomic relations in total mesorectal excision and standardized consistent surgical technique, the oncologic outcomes of patients treated by abdominoperineal resections are not worse than those treated by sphincter-preserving anterior resections.

Expectant Management of Anal Squamous Dysplasia in Patients With HIV.
Devaraj B, Cosman BC
Dis Colon Rectum 2005 Nov 16;.

PURPOSE: Anal squamous dysplasia is commonly found in patients with HIV infection. There is no satisfactory treatment that eradicates this premalignant lesion with low morbidity and low recurrence. This study reviews a series of patients with HIV and an abnormal anal examination who had squamous dysplasia and who have been followed with physical examination alone and with repeat biopsies as necessary for new or suspicious lesions. METHODS: We reviewed the charts of 40 HIV-positive men who had squamous dysplasia of the anal canal and anal margin, focusing on history, physical findings, histologic diagnosis, and the occurrence of invasive squamous-cell carcinoma. RESULTS: Forty HIV-positive men (mean age, 39 years) were followed for anal squamous dysplasia. Biopsies revealed dysplasia, which was usually multifocal. The grade of dysplasia varied, but 28 of 40 patients had at least one area of severe dysplasia. All patients had a follow-up period greater than one year (mean, 32 months; range, 13-130 months). Three patients developed invasive carcinoma while under surveillance, and these were completely excised or cured with chemoradiation. CONCLUSIONS: Extensive excision for dysplasia in the context of HIV confers high morbidity and questionable benefit, and other treatments are of uncertain value. In a group of patients followed expectantly, most did not develop invasive cancer, and in those who did, early cancers could be identified and cured. Physical examination surveillance for invasive carcinoma may be acceptable for following patients with HIV and biopsy-proven squamous dysplasia.

Biopsy of colorectal polyps is not adequate for grading of neoplasia.
Gondal G, Grotmol T, Hofstad B, Bretthauer M, Eide TJ, Hoff G
Endoscopy 2005 Dec;37(12):1193-7.

BACKGROUND AND STUDY AIM: Valid tissue sampling of colorectal adenomas is crucial for their management in terms of treatment and follow-up. The aim of this study was to assess the validity of a cold biopsy sample as representative for the whole polypectomy specimen, with regard to histopathological features. PATIENTS AND METHODS: As part of the Norwegian Colorectal Cancer Prevention trial, 442 participants (60 % men) who fulfilled the criterion of colonoscopic recovery of adenoma that had been biopsied at flexible sigmoidoscopy, had their adenomas subsequently removed by polypectomy (snare resection) at colonoscopy. Logistic regression analysis was used to determine which variables contributed to the histopathological discrepancy between cold biopsy and polypectomy specimens. RESULTS: Among the 532 colorectal adenomas biopsied at flexible sigmoidoscopy and removed by colonoscopy, the assessment of intraepithelial neoplasia (dysplasia) status was changed in 51 adenomas (10 %), and 38 (7 %) of them had been underestimated at biopsy compared with polypectomy. Likewise, the assessment of villousness was changed in 45 adenomas (9 %), being upgraded in 26 (6 %) at polypectomy compared with biopsy. In a multivariate model, the diameter of neoplasia at polypectomy was positively associated with increased risk of the underestimation of intraepithelial neoplasia and/or villousness influencing a diagnosis of advanced colorectal neoplasia, when cold biopsy and polypectomy specimens were compared ( P(trend) = 0.01). Among 56 cases of advanced neoplasia, 35 (63 %) showed only low-grade intraepithelial neoplasia on biopsy. CONCLUSIONS: Biopsy-based diagnosis underestimated histopathological diagnosis in about 10 % of colorectal adenomas detected by flexible sigmoidoscopy screening, but advanced neoplasia was underestimated in more than 60 %. Efforts must be made to obtain polypectomy specimens to secure precise diagnosis.

Is an ileal pouch an alternative for patients requiring surgery for Crohn's proctocolitis?
Delaini GG, Scaglia M, Lindholm E, Colucci G, Hulten L
Tech Coloproctol 2005 Nov 21;.

BACKGROUND: Most surgeons consider Crohn's colitis to be an absolute contraindication for a continent ileostomy, due to high complication and failure rates. This opinion may, however, be erroneous. The results may appear poor when compared with those after pouch surgery in patients with ulcerative colitis (UC), but the matter may well appear in a different light if the pouch patients are compared with Crohn's colitis patients who have had a proctocolectomy and a conventional ileostomy.METHODS: We assessed the long-term outcomes in a series of patients with Crohn's colitis who had a proctocolectomy and a continent ileostomy (59 patients) or a conventional ileostomy (57 patients). The median follow-up time was 24 years for the first group and 27 years for the second group.RESULTS: The outcomes in the two groups of patients were largely similar regarding both mortality and morbidity; the rates of recurrent disease and reoperation with loss of small bowel were also similar between groups.CONCLUSIONS: The possibility of having a continent ileostomy, thereby avoiding a conventional ileostomy - even if only for a limited number of years - may be an attractive option for young, highly motivated patients.

Anal localization as first manifestation of metastatic ductal breast carcinoma.
Haberstich R, Tuech JJ, Wilt M, Rodier JF
Tech Coloproctol 2005 Nov 21;.

The incidence of extrahepatic gastrointestinal metastases from breast cancer is reported in the literature only as necroscopy studies (6-18%); they usually originate from lobular or a mixed ductal-lobular subtype. Nonspecific presenting symptoms, death of the patients caused by other more frequent metastases, and variable radiographic features mimicking primary neoplasms cause a clinical underestimation of this pathology. We report here a case of rectal metastasis from an invasive ductal carcinoma (IDC). This is to our knowledge, the first recorded instance of an anal metastasis from IDC.

Advances in short bowel syndrome: an updated review.
Sukhotnik I, Coran AG, Kramer A, Shiloni E, Mogilner JG
Pediatr Surg Int 2005 Nov 3;:1-7.

Short bowel syndrome (SBS) continues to be an important clinical problem due to its high mortality and morbidity as well as its devastating socioeconomic effects. The past 3 years have witnessed many advances in the investigation of this condition, with the aim of elucidating the cellular and molecular mechanisms of intestinal adaptation. Such information may provide opportunities to exploit various factors that act as growth agents for the remaining bowel mucosa and may suggest new therapeutic strategies to maintain gut integrity, eliminate dependence on total parenteral nutrition, and avoid the need for intestinal transplantation. This review summarizes current research on SBS over the last few years.

T1 Adenocarcinoma of the Rectum: Transanal Excision or Radical Surgery?
Bentrem DJ, Okabe S, Wong WD, Guillem JG, Weiser MR, Temple LK, Ben-Porat LS, Minsky BD, Cohen AM, Paty PB
Ann Surg 2005 Oct;242(4):472-479.

BACKGROUND: Recent studies suggest local excision may be acceptable treatment of T1 adenocarcinoma of the rectum, but there is little comparative data with radical surgery to assess outcomes and quantify risk. We performed a retrospective evaluation of patients with T1 rectal cancers treated by either transanal excision or radical resection at our institution to assess patient selection, cancer recurrence, and survival. METHODS: All patients who underwent surgery for T1 adenocarcinomas of the rectum (0-15 cm from anal verge) by either transanal excision (TAE) or radical resection (RAD) between January 1987 and January 2004 were identified from a prospective database. Data were analyzed using Fisher exact test, Kaplan-Meier method, and log-rank test. RESULTS: Three hundred nineteen consecutive patients with T1 lesions were treated by transanal excision (n = 151) or radical surgery (n = 168) over the 17-year period. RAD surgery was associated with higher tumor location in the rectum, slightly larger tumor size, a similar rate of adverse histology, and a lymph node metastasis rate of 18%. Despite these features, patients who underwent RAD surgery had fewer local recurrences, fewer distant recurrences, and significantly better recurrence-free survival (P = 0.0001). Overall and disease-specific survival was similar for RAD and TAE groups. CONCLUSION: Despite a similar risk profile in the 2 surgical groups, patients with T1 rectal cancer treated by local excision were observed to have a 3- to 5-fold higher risk of tumor recurrence compared with patients treated by radical surgery. Local excision should be reserved for low-risk cancers in patients who will accept an increased risk of tumor recurrence, prolonged surveillance, and possible need for aggressive salvage surgery. Radical resection is the more definitive surgical treatment of T1 rectal cancers.

Crohn's disease: increased mortality 10 years after diagnosis in a Europe-wide population based cohort.
Wolters FL, Russel MG, Sijbrandij J, Schouten L, Odes S, Riis L, Munkholm P, Bodini P, O'morain C, Mouzas IA, Tsianos E, Vermeire S, Monteiro E, Limonard C, Vatn M, Fornaciari G, Pereira S, Moum B, Stockbrugger RW
Gut 2005 Sep 8;.

BACKGROUND: No previous correlation has been performed of phenotype at diagnosis of Crohn's disease (CD) patients and mortality. We assessed the predictive value of phenotype at diagnosis on overall and disease related mortality in a European cohort of CD patients. METHODS: Overall and disease related mortality were recorded ten years after diagnosis in a prospectively assembled, uniformly diagnosed European population based inception cohort of 380 CD patients diagnosed between 1991 and 1993. Standardized Mortality Ratios (SMRs) were calculated for geographic and phenotypic subgroups at diagnosis. RESULTS: Thirty-seven deaths were observed in the entire cohort, whereas 21.5 deaths were expected (SMR 1.85 , 95 % CI: 1.30-2.55). Mortality risk was significantly increased in both females (SMR 1.93, 95% CI: 1.10-3.14) and males (SMR 1.79, 95% CI: 1.11-2.73). Patients from North European centres had a significant overall increased mortality risk (SMR 2.04, 95% CI: 1.32- 3.01), whereas a tendency towards increased overall mortality risk was also observed in the South (SMR 1.55, 95% CI: 0.80-2.70). Mortality risk was increased in patients with colonic disease location and with inflammatory disease behaviour at diagnosis. Mortality risk was also increased in the age group above 40 years at diagnosis for both total and CD related causes. Excess mortality was mainly due to gastrointestinal causes that were related to CD. CONCLUSIONS: This European multinational population-based study revealed an increased overall mortality risk in CD patients ten years after diagnosis and age above 40 years at diagnosis to be the sole factor associated with increased mortality risk.

Infliximab for Ulcerative Colitis.
Chey WY, Shah A
J Clin Gastroenterol 2005 November/December;39(10):920.

Infliximab for ulcerative colitis.
Shen E, Das K
J Clin Gastroenterol 2005 Nov-Dec;39(10):920.

Feasibility of autonomic nerve-preserving surgery for advanced rectal cancer based on analysis of micrometastases.
Matsumoto T, Ohue M, Sekimoto M, Yamamoto H, Ikeda M, Monden M
Br J Surg 2005 Sep 26;.

BACKGROUND: Autonomic nerve preservation has been advocated as a means of preserving urinary and sexual function after surgery for rectal cancer, but may compromise tumour clearance. The aim of this study was to determine the incidence of micrometastasis in the connective tissues surrounding the pelvic plexus. METHODS: The study included 20 consecutive patients who underwent rectal surgery with bilateral lymph node dissection for advanced cancer. A total of 78 connective tissues medial and lateral to the pelvic plexus and 387 lymph nodes were sampled during surgery. All connective tissue samples and 260 lymph nodes were examined for micrometastases by reverse transcriptase-polymerase chain reaction (RT-PCR) after operation. All patients were followed prospectively for a median of 36.0 months. RESULTS: Of 245 histologically negative lymph nodes, 38 (15.5 per cent) were shown by RT-PCR to harbour micrometastases. However, micrometastases to tissues surrounding the pelvic plexus were detected in only two (3 per cent) of 78 tissues, that is in two of 20 patients. Clinical follow-up showed that the two patients had a poor prognosis owing to distant metastases. CONCLUSION: Autonomic nerve-preserving surgery may be feasible for advanced rectal cancer, but study of more patients positive for micrometastases is required. Copyright (c) 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Molecular pathogenesis of colorectal cancer.
Arnold CN, Goel A, Blum HE, Richard Boland C
Cancer 2005 Oct 4;.

Colorectal cancer is the third leading cause of cancer-related death in both men and woman in industrialized countries. Major advances have been made in our understanding of molecular events leading to formation of adenomatous polyps and cancer. Most colorectal cancers are sporadic, but a significant proportion (5-6%) has a clear genetic background. It is now widely accepted that colorectal carcinogenesis is a multistep process involving the inactivation of a variety of tumor-suppressor and DNA-repair genes and simultaneous activation of certain oncogenes. In addition, epigenetic alterations through aberrant promoter methylation and histone modification have been found to play a major role in the evolution and progression of a large proportion of sporadic colon cancers. Consequently, it is now apparent that individual colorectal cancers may evolve through diverse molecular pathways. In this article, the authors have summarized the current knowledge of molecular pathogenesis in common hereditary syndromes and sporadic forms of colorectal cancer. Novel molecular diagnostic tools for the early diagnosis and prevention of colorectal cancer that have emerged from these insights are discussed. Cancer 2005. (c) 2005 American Cancer Society.

Impact of race and ethnicity on inflammatory bowel disease.
Basu D, Lopez I, Kulkarni A, Sellin JH
Am J Gastroenterol 2005 Oct;100(10):2254-61.

INTRODUCTION: Inflammatory bowel disease (IBD) is now increasingly recognized in diverse ethnic populations. In the United States, IBD among the minority populations, especially Mexican Americans, has not been extensively studied. Apart from the known genetic influences that differ among the IBD subtypes [ulcerative colitis (UC) vs. Crohn's disease (CD)], serologic markers may differentiate UC and CD, including perinuclear antineutrophilic cytoplasmic antibody (p-ANCA) and anti-Saccharomyces cerevisiae antibody (ASCA) in UC and CD. METHODS: One hundred forty-eight patients with IBD seen in a university gastroenterology practice in Houston, Texas, between June 1999 and November 2003 were analyzed to determine whether there were significant differences among racial/ethnic groups. Whites comprised 40%, African Americans 37%, Mexican Americans 20%, and Asians 3% of the total IBD patients. RESULTS: We found that African Americans and whites predominantly had CD, whereas Mexican Americans predominantly had UC. There was no difference between African Americans and Mexican Americans when separately compared to whites in terms of intestinal manifestations of CD and UC, respectively. However, African Americans with CD had a significantly higher incidence of IBD-associated arthritis (p= 0.004) and ophthalmological manifestations, notably uveitis (p= 0.028), compared to whites with CD. Among UC patients, in comparison to the Mexican Americans, whites had significantly higher incidences of joint symptoms (p < 0.0001) and osteoporosis (p= 0.001). Whites had a stronger family history of IBD and colorectal carcinoma compared to the other ethnic groups. p-ANCA served as a sensitive marker for UC among Mexican Americans. All the Mexican Americans with UC tested had positive p-ANCA compared to only 40% of whites (p= 0.033). CONCLUSION: There are significant differences in IBD subtypes and serologic markers among racial/ ethnic groups with IBD in the United States. (Am J Gastroenterol 2005;100:1-8).

A cost-effectiveness analysis of alternative disease management strategies in patients with Crohn's disease treated with azathioprine or 6-mercaptopurine.
Dubinsky MC, Reyes E, Ofman J, Chiou CF, Wade S, Sandborn WJ
Am J Gastroenterol 2005 Oct;100(10):2239-47.

BACKGROUND: Azathioprine (AZA) is effective for the maintenance of a steroid free remission in Crohn's disease (CD). Thiopurine methyltransferase (TPMT) is important for the metabolism of AZA and influences the production of active AZA metabolites. AZA dose selection based on pharmacogenetic testing of TPMT and metabolite monitoring (MM) may offer a safety and efficacy advantage over traditional dosing strategies. We performed a decision analysis to estimate the potential costs and effectiveness of TPMT screening and MM as disease management strategies for CD. METHODS: Strategies applying TPMT and/or MM to influence treatment decisions were compared to community care (CC). The impact on toxicity minimization and improved time to initial and sustained response was evaluated. A 1-yr model was developed from the third-party payer perspective for mild to moderately chronically active, steroid-treated CD patients. Effectiveness and toxicity defined by time to response CD activity index (CDAI <150, +/- steroids) or time to sustained response (CDAI <150, off steroids x 8 wk) and reduction in leukopenic events, respectively. One- and two-way sensitivity analyses were conducted to determine the effect of varying individual estimates from those used in the base-case analysis. RESULTS: MM, TPMT, and TPMT + MM strategies as compared to CC achieved an earlier time to initial response (18.66, 18.96, and 19.10 vs. 22.41 wk, respectively) and sustained response (39.83, 42.91, and 39.8 vs. 45.36 wk, respectively). The least costly strategy at 1 yr was TPMT ($3,861) and the most costly strategy was CC ($7,142). Each alternative strategy was shown to dominate CC (i.e., less costs and faster time to response or sustained response). The cost-effectiveness rankings were robust to sensitivity analyses on key variables. CONCLUSION: The addition of alternative strategies to CC may improve AZA outcomes and reduce the total cost of care for steroid treated chronically active CD patients, with TPMT being more beneficial for initial response to treatment and MM being more beneficial for sustained response to treatment. (Am J Gastroenterol 2005;100:1-9).

Lack of seasonal variation in the endoscopic diagnoses of Crohn's disease and ulcerative colitis.
Auslander JN, Lieberman DA, Sonnenberg A
Am J Gastroenterol 2005 Oct;100(10):2233-8.

BACKGROUND: Conflicting data have been reported about the seasonal variation of inflammatory bowel diseases (IBD). The purpose of the present analysis was to assess the occurrence of seasonal variations in the endoscopic diagnosis of Crohn's disease (CD) and ulcerative colitis (UC). METHODS: The Clinical Outcomes Research Initiative (CORI) uses a computerized endoscopic report generator to collect endoscopic data from 73 diverse practice sites throughout the United States. We utilized the CORI database to analyze the date-specific occurrence of colonoscopy, as well as the colonoscopic diagnoses of CD and UC. Time trends were analyzed by autocorrelation, linear, and nonlinear regression. RESULTS: Between January 2000 and December 2003, the number of colonoscopies increased 4.1-fold. The proportion of colonoscopies with a CD diagnosis fell by 28%, and the proportion of colonoscopies with a UC diagnosis fell by 50%. The occurrence of neither CD nor UC was shaped by any clear-cut seasonal periodicity. However, the trends of the two diseases revealed strikingly similar patterns with four resembling peaks superimposed on their monthly fluctuations. CONCLUSIONS: Endoscopic diagnosis of IBD is unaffected by any seasonal variation. The decline in the diagnostic rate of colonic IBD may reflect a relative increase in the utilization of colonoscopy for colon cancer screening. The similarity in the monthly fluctuations of both IBD suggests that their incidence or flare-ups may be influenced by identical exogenous risk factors. (Am J Gastroenterol 2005;100:1-6).

Increased Prevalence of Colorectal Adenomas in Women with Breast Cancer.
Ochsenkuhn T, Bayerdorffer E, Meining A, Spath L, Mannes GA, Wiebecke B, Eiermann W, Sackmann M, Goke B
Digestion 2005 Sep 16;72(2-3):150-155.

Background: The frequency of colorectal adenomas and carcinomas was investigated in a large cohort of women with breast cancer in comparison with matched controls, since data on the occurrence of second tumors in women with breast cancer is controversial. Design: In a cohort study, 188 consecutive women (median age 57 years) with primary breast cancer and 376 age-matched women who served as controls were examined by total colonoscopy. Breast cancer patients and controls were compared for the frequency of colorectal adenomas and carcinomas. Results: Women with breast cancer showed a higher risk of colorectal adenomas than controls (14.9 vs. 9.3%, p = 0.047, OR 1.7, 95% CI 1.0-2.9). This increased prevalence resulted primarily from an increased prevalence in the age group 65-85 (31 vs. 10%, p = 0.004, OR 3.8, 95% CI 1.6-9.3). Colorectal carcinomas were found infrequently in both groups (2 in each group). Women with breast cancer receiving anti-estrogen therapy showed a trend towards a lower risk of adenomas compared to women without anti-estrogen therapy (3.7 vs. 17.2%, p = 0.053, OR 0.16, 95% CI 0.0-1.1). Conclusions: Women with breast cancer above the age of 65 years have an increased risk of colorectal adenomas compared to women without breast cancer. Women with a diagnosis of breast cancer should especially be encouraged to participate in colorectal cancer-screening programs which, in most countries, call for screening of all average-risk individuals over the age of 50 years. Copyright (c) 2005 S. Karger AG, Basel.

Ileitis in Ulcerative Colitis: Is It a Backwash?
Abdelrazeq AS, Wilson TR, Leitch DL, Lund JN, Leveson SH
Dis Colon Rectum 2005 Aug 29;.

PURPOSE: This study aims to determine the incidence, demography, pathologic nature, and clinical significance of ileitis in ulcerative colitis patients who underwent restorative proctocolectomy. METHODS: A prospectively collected pouch database and the case notes of 100 consecutive patients who underwent restorative proctocolectomy for ulcerative colitis, under the care of a single surgeon, between 1988 and 2003 were reviewed. The original proctocolectomy specimens and pouch biopsies were reexamined and regraded blind, using the current diagnostic criteria. Patients were divided into two groups, those who had ileitis and those who had not. The demographic, clinical, and pathologic characteristics and the incidence of pouchitis of both groups were compared. RESULTS: Twenty-two patients had ileitis (22 percent). Compared with those with noninflamed ileum, patients with ileitis had a significantly shorter disease duration (P < 0.005), many of them presented or progressed to a fulminant state requiring acute surgical intervention (P < 0.01), had strong association with pancolitis and primary sclerosing cholangitis (P < 0.001), and had a higher incidence of subsequent development of pouchitis (P < 0.001). There was no correlation between the presence of ileitis and colitis severity. CONCLUSIONS: Ileitis in ulcerative colitis is not rare and does influence the prognosis, and the term "backwash" is a misnomer. Ulcerative colitis with ileitis represents a distinct disease-specific subset of patients. Its true incidence and clinical significance can be determined only if detailed microscopic characterization of the terminal ileum is performed routinely in every patient with ulcerative colitis and the clinical outcome of these patients is audited prospectively.

Gingival hyperplasia as a first manifestation of Crohn's disease.
Mergulhao P, Magro F, Pereira P, Correia R, Lopes JM, Magalhaes J, Dias JM, Carneiro F, Tavarela-Veloso F
Dig Dis Sci 2005 Oct;50(10):1946-9.

The Impact of Diagnosis and Treatment of Rectal Cancer on Paid and Unpaid Labor.
van den Brink M, van den Hout WB, Kievit J, Marijnen CA, Putter H, van de Velde CJ, Stiggelbout AM
Dis Colon Rectum 2005 Sep 7;.

PURPOSE: This study was designed to describe the consequences of diagnosis and treatment of rectal cancer for paid and unpaid labor over time and to identify sociodemographic-related factors, treatment-related factors, and quality of life-related factors associated with paid and unpaid labor. METHODS: Data were assessed prospectively in two samples of patients with primary rectal cancer, participating in a multicenter clinical trial, who were randomized to receive surgery with or without 5 x 5-Gy preoperative radiotherapy. For paid labor, 292 patients who indicated paid labor before treatment filled out quality of life questionnaires, which included questions on paid labor at 3, 6, 12, 18, and 24 months after surgery. For unpaid labor, another sample of 92 patients also filled out the Health and Labor questionnaire, which included questions on unpaid labor, before treatment, and at 3 and 12 months after treatment. RESULTS: From 3 to 18 months after surgery, paid labor resumption increased from 19 to 63 percent (P < 0.001). At 24 months after surgery, paid labor resumption was 61 percent. In a multivariate analysis, age older than 55 years (P </= 0.001), lower education level (P </= 0.003), shorter time since surgery (P < 0.001), preoperative radiotherapy (P = 0.02), lower valuation of overall health (P < 0.01), more physical symptom distress (P < 0.001), and more limitations in daily activities (P < 0.001) were all associated with less or later resumption of paid labor. The average amount of unpaid labor increased from 17.3 hours per week at 3 months to 21 hours per week at 12 months after surgery. In a multivariate analysis, only shorter time since surgery (P = 0.03) and male gender (P < 0.001) were related to less unpaid labor. CONCLUSIONS: Diagnosis and treatment of rectal cancer affect paid and unpaid labor. The impact on paid labor is most pronounced. Multiple other sociodemographic and quality of life-related variables also were associated with paid labor. Patient information and decision making on preoperative radiotherapy should include the effects on paid labor, and interventions focused on promoting paid labor participation in patients with rectal cancer should be tailored to the specific characteristics and needs of those patients.

Narcotic use in patients with Crohn's disease.
Cross RK, Wilson KT, Binion DG
Am J Gastroenterol 2005 Oct;100(10):2225-9.

OBJECTIVES: Despite advances in treatment for Crohn's disease (CD), some patients suffer from chronic pain. We sought to characterize the prevalence of narcotic use and contributing factors in CD patients at a referral center. METHODS: A retrospective analysis of 291 CD patients followed over a 5-yr period was performed. Clinical status was evaluated with the Harvey-Bradshaw index (HBI) of disease activity and the short inflammatory bowel disease questionnaire (SIBDQ). RESULTS: Narcotic use was identified in 13.1% of patients. Narcotic users were more likely to be female, 72%versus 49% (p= 0.01), had higher rates of disability, 15.4%versus 3.6% (p= 0.001), and a longer duration of disease, 17.0 versus 12.9 yr (p= 0.03). In addition, they took more medications 6.97 versus 4.7 (p < 0.001) and had a higher prevalence of neuropsychiatric drug use, 37%versus 19% (p= 0.01). CD patients receiving narcotics had worse disease activity (HBI 9.1 vs 5.0, p < 0.001) and diminished quality of life (SIBDQ 44.2 vs 51.6 (p= 0.04)). However, logistic regression analysis found that active disease [HBI score of >/= 4 (OR 3.9)], polypharmacy [use of >/= 5 drugs (OR 5.5)], and smoking (OR 2.8) were associated with narcotic use. CONCLUSIONS: Narcotic use may be an indicator of more severe disease since it is associated with increased disease activity and decreased quality of life. Factors correlating with narcotic use include smoking and PP. Our data emphasize the need for further work to characterize chronic pain in CD patients. (Am J Gastroenterol 2005;100:1-5).

A survey of Canadian gastroenterologists about the use of methotrexate in patients with Crohn's disease.
Chande N, Ponich T, Gregor J
Can J Gastroenterol 2005 Sep;19(9):553-8.

BACKGROUND: Methotrexate (MTX) is effective in remission induction and maintenance in steroid-dependent Crohn's disease (CD), but is often considered to be a second-line immunosuppressive agent, to be used in cases of failure or intolerance to azathioprine (AZA) or 6-mercaptopurine (6-MP). This may be related to concerns about hepatotoxicity, but this adverse effect is rare in monitored CD patients taking MTX. Still, there are no guidelines for monitoring patients with CD on MTX, and physicians must decide based on rheumatological literature about how to monitor their patients. PURPOSE: To determine the patterns of MTX use in patients with CD by Canadian gastroenterologists, examining the reasons for choosing MTX versus AZA/6-MP, the doses and routes of administration of MTX, and how patients on MTX are monitored, including the use of liver biopsy. METHODS: A self-report survey was sent to physician members of the Canadian Association of Gastroenterology, with a second mailing three months later to increase response rate. RESULTS: Of 490 surveys mailed, a 54.9% response rate was achieved. Of adult gastroenterologists, 60.7% stated they never use MTX as a first-line immunosuppressive agent, and 33.3% never use MTX at all. The most common reasons for choosing MTX were a contraindication to the use of AZA/6-MP (43.7%) and patient preference (22.5%). MTX is used intramuscularly in 41.5%, subcutaneously in 31.8%, and orally in 26.7% of patients. The most common dose used for remission induction was 25 mg/week (84.2%; range 7.5 mg/week to 50 mg/week; three responders used more frequent dosing than weekly) and for remission maintenance was 15 mg/week (55.4%; range 7.5 mg/week to 50 mg/week; three responders used more frequent dosing than weekly). Most responders checked a liver profile and complete blood count at baseline and serially. Of those who used MTX, 26.5% routinely performed liver biopsy after an accumulated dose of MTX had been taken (usually 1 g to 2 g), 57.7% sometimes performed liver biopsy, and 16.8% never performed liver biopsy. Of pediatric gastroenterologists, 17.6% never used MTX, but those who used it prescribed it subcutaneously (80.0%) more often than intramuscularly (17.5%) or orally (2.5%). CONCLUSIONS: MTX was used as a first-line immunosuppressive agent in patients with CD by a minority of Canadian gastroenterologists. When used, there is variability in how MTX is prescribed and monitored. Although hepatotoxicity is rare, liver biopsy was performed frequently and probably often unnecessarily.

Change of nitric oxide in experimental colitis and its inhibition by melatonin in vivo and in vitro.
Mei Q, Xu JM, Xiang L, Hu YM, Hu XP, Xu ZW
Postgrad Med J 2005 Oct;81(960):667-72.

AIM: To investigate the change of nitric oxide (NO) in rat colitis and its inhibition by melatonin in vivo and in vitro. METHODS: In vivo, rat colitis was established intracolonically with trinitrobenzenesulphonic acid (TNBS) and ethanol. The animals were randomised into five groups: control group, model group, melatonin group (2.5, 5.0, 10.0 mg/kg), and treated intracolonically with saline, saline and melatonin respectively (once a day, from day 7 after colitis was established to day 28). After the end of the experiment, the mucosal damage index (CMDI) and histology score (HS) were evaluated and the level of myeloperoxidase (MPO) and malondiadehyde (MDA) and NO in the colon tissue were measured. In vitro, the co-culture model of the inflamed colon mucosa (from the colitis) with lipopolysaccharide (LPS), and the colonocytes oxidative injury model by hydroxyl radical, were designed respectively to elucidate the inhibition of NO by melatonin. RESULTS: After treated with TNBS/ethanol, the extent of CMDI and HS, the levels of MPO, MDA, and NO in the model group, were higher than that in the control group; melatonin ameliorated these parameters effectively. The stimulation of LPS increased the level of NO and MPO and MDA in the co-culture model of inflamed colon mucosa, and melatonin significantly reduced the level of MPO, MDA, and NO. In the coloncyte oxidative injury model by hydroxyl radical, the contents of LDH, MDA, and NO were increased; melatonin reversed this oxidative injury considerably. CONCLUSION: This study showed that TNBS/ethanol induced colitis was pharmacologically controlled by melatonin in vivo and in vitro.

Increased risk for demyelinating diseases in patients with inflammatory bowel disease.
Gupta G, Gelfand JM, Lewis JD
Gastroenterology 2005 Sep;129(3):819-26.

Background & Aims: Reports of multiple sclerosis (MS), demyelination, and optic neuritis (ON) associated with anti-tumor necrosis factor alpha therapy resulted in warnings on prescribing instructions for infliximab, etanercept, and adalimumab. However, the underlying relationship between IBD and these neurologic conditions has not been established. Methods: We performed a retrospective cohort study and a retrospective cross-sectional study using 1988 to 1997 data from the General Practice Research Database. A total of 7988 Crohn's disease and 12,185 ulcerative colitis patients were matched for age, sex, and primary care practice to 80,666 randomly selected controls. In the cohort study, incident cases of MS, demyelination, and/or ON (MS/D/ON) had to occur at least 1 year after registration with the physician and after the diagnosis of IBD. In the cross-sectional study, the diagnosis of MS/D/ON could either precede or follow the IBD diagnosis. Results: In the cohort study, the incidence of MS/D/ON was higher in patients with Crohn's disease and ulcerative colitis compared with their matched controls, reaching statistical significance for ulcerative colitis (ulcerative colitis incidence rate ratio [IRR], 2.63; 95% confidence interval, 1.29-5.15; Crohn's disease IRR, 2.12; 95% confidence interval, .94-4.50). In the cross-sectional study, MS/D/ON was more prevalent in patients with Crohn's disease and ulcerative colitis compared with their matched controls (Crohn's disease odds ratio, 1.54; 95% confidence interval, 1.03-2.32; ulcerative colitis odds ratio, 1.75; 95% confidence interval, 1.28-2.39). Conclusions: Demyelinating diseases occur more commonly among patients with IBD than among non-IBD patients. Future studies should clarify whether treatment with tumor necrosis factor alpha blockers results in further increased incidence of MS/D/ON among IBD patients.

A Randomized, Placebo-Controlled Trial of Certolizumab Pegol (CDP870) for Treatment of Crohn's Disease.
Schreiber S, Rutgeerts P, Fedorak RN, Khaliq-Kareemi M, Kamm MA, Boivin M, Bernstein CN, Staun M, Thomsen OO, Innes A
Gastroenterology 2005 Sep;129(3):807-818.

Background & Aims: To investigate the efficacy and safety of certolizumab pegol (a polyethylene-glycolated Fab' fragment of anti-tumor necrosis factor, CDP870) in Crohn's disease. Methods: In a placebo-controlled, phase II study, 292 patients with moderate to severe Crohn's disease received subcutaneous certolizumab 100, 200, or 400 mg or placebo at weeks 0, 4, and 8. The primary end point was the percentage of patients with a clinical response at week 12 (a Crohn's Disease Activity Index decrease of >/= 100 points or remission [Crohn's Disease Activity Index </= 150 points]) in the intent-to-treat population. Results: All certolizumab doses produced significant clinical benefit over placebo at week 2 (placebo, 15.1%; certolizumab 100 mg, 29.7% [P = .033]; 200 mg, 30.6% [P = .026]; 400 mg, 33.3% [P = .010]). At all time points, the clinical response rates were highest for certolizumab 400 mg, greatest at week 10 (certolizumab 400 mg, 52.8%; placebo, 30.1%; P = .006) but not significant at week 12 (certolizumab 400 mg, 44.4%; placebo, 35.6%; P = .278). Patients with baseline C-reactive protein levels of 10 mg/L or greater (n = 119) showed clearer separation between active treatment and placebo (week 12 clinical response: certolizumab 400 mg, 53.1%; placebo, 17.9%; P = .005; post hoc analysis) owing to a lower placebo response rate than patients with C-reactive protein levels of less than 10 mg/L. Adverse events were similar among groups. Conclusions: Certolizumab 400 mg may be effective and is well tolerated in patients with active Crohn's disease. High placebo response rates in the large patient subgroup with low C-reactive protein levels may have obscured statistical separation between certolizumab and placebo. Ongoing phase III trials are necessary to establish the clinical efficacy of certolizumab.

Colon Cancer Screening Guidelines 2005: the fecal occult blood test option has become a better FIT.
Allison JE
Gastroenterology 2005 Aug;129(2):745-8.

Colorectal cancer prognosis: is it all mutation, mutation, mutation?
Hassan AB, Paraskeva C
Gut 2005 Sep;54(9):1209-11.

For the 500,000 new cases of colorectal cancer in the world each year, identification of patients with a worse prognosis and those who are more likely to respond to treatment is a challenge. There is an increasing body of evidence correlating genetic mutations with outcome in tumours derived from human colorectal cancer cohorts. K-ras, but not p53 or APC, mutations appear to be associated with poorer overall survival in colorectal cancer patients.

Biphasic development of an intraperitoneal rectum perforation: a rare but serious complication after barium enema.
de Feiter PW, Soeters PB, Dejong CH
Int J Colorectal Dis 2005 Aug 10;.

Anorectal malignant melanoma: preoperative usefulness of magnetic resonance imaging.
Matsuoka H, Nakamura A, Iwamoto K, Sugiyama M, Hachiya J, Atomi Y, Masaki T
J Gastroenterol 2005 Aug;40(8):836-42.

Magnetic resonance imaging (MRI) findings in three patients with primary anorectal malignant melanoma are described. Two patients had melanotic and one had amelanotic anorectal melanoma. The findings of MRI with a pelvic coil and an endorectal coil were consistent with pathologic findings. MRI with a pelvic coil demonstrated the melanotic component as high signal intensity on T1-weighted imaging. MRI with a pelvic coil and an endorectal coil was useful for staging anorectal melanoma. This article describes the initial report of the use of an endorectal coil for malignant melanoma of the anorectum.

Topical 0.5% nifedipine vs. lateral internal sphincterotomy for the treatment of chronic anal fissure: long-term follow-up.
Katsinelos P, Papaziogas B, Koutelidakis I, Paroutoglou G, Dimiropoulos S, Souparis A, Atmatzidis K
Int J Colorectal Dis 2005 Aug 10;.

BACKGROUND: The aim of this study was to compare the efficacy of the local application of 0.5% nifedipine ointment vs. lateral internal sphincterotomy in the healing of chronic anal fissure. PATIENTS AND METHODS: Sixty-four patients with symptomatic chronic anal fissures were randomly assigned to 0.5% nifedipine ointment (n=32) every 8 h for 8 weeks or lateral internal sphincterotomy (n=32). Both groups received stool softeners and fiber supplements and were assessed at 2, 4, 6, and 8 weeks. Long-term outcomes were determined after a median follow-up of 19 months (nifedipine group) and 20.5 months (lateral internal sphincterotomy group). RESULTS: Complete healing at 8 weeks was achieved in 30 out of 31 patients (96.7%) in the nifedipine group and 32 out of 32 patients (100%) in the lateral internal sphincterotomy group (p=0.49). The overall healing rates at the end of follow-up were 28 out of 30 (93%) vs. 32 out of 32 (100%) in the nifedipine and sphincterotomy groups respectively (p=0.48). Two of the 30 patients in the nifedipine group relapsed whereas none in the sphincterotomy group did. Sixteen patients (50%) developed side effects in the nifedipine group, compared with six patients (18.7%) in the sphincterotomy group. CONCLUSIONS: Topical application of 0.5% nifedipine ointment represents a new, promising, easily handled, effective alternative to lateral internal sphincterotomy.

Strictureplasty for active Crohn's disease.
Roy P, Kumar D
Int J Colorectal Dis 2005 Aug 30;:1-6.

BACKGROUND AND AIMS: Several studies over the last 20 years have confirmed the safety and efficacy of strictureplasty in the treatment of obstructive Crohn's disease. However, almost all of these studies use strictureplasty to treat fibrotic strictures: limited resection being preferred to treat active disease strictures. One study dating from 1986 used strictureplasty to treat purely active disease strictures, with disappointing results. No other similar studies have been published. We investigate the complication and recrudescence rates together with the intervention-free intervals in patients undergoing strictureplasty for active disease strictures. METHODS: A retrospective review of 14 patients who underwent strictureplasty either in isolation or in combination with limited resection for active small bowel Crohn's disease between 1996 and 2004 was undertaken. RESULTS: A total of 73 strictureplasties were carried out. There was no operative mortality; however, one patient subsequently died from metastatic small bowel adenocarcinoma arising from existing Crohn's disease. One patient subsequently developed complications directly attributed to strictureplasty and required further surgery. Three patients developed recrudescent disease and required further surgery in the form of either strictureplasty, limited resection or both. All patients undergoing strictureplasty with resection and over 70% of patients undergoing strictureplasty alone were intervention-free at 41 months. With extended follow-up, the same proportion of patients would remain intervention-free at 70 months or longer. CONCLUSIONS: The use of strictureplasty in active disease strictures is well tolerated and has similar, if not better, recurrence and complication rates when compared with limited resection in patients with similar disease profiles.

Anal cancer in renal transplant patients.
Patel HS, Silver AR, Northover JM
Int J Colorectal Dis 2005 Aug 16;:1-5.

PURPOSE: A comprehensive literature review was performed to examine the prevalence of anal cancer, anal intraepithelial neoplasia (AIN) and anal human papillomavirus (HPV) infection in renal transplant recipients who are at risk of anal cancer due to iatrogenic immunosuppression. METHODS: Pertinent articles were identified from searches performed on the National Center for Biotechnology Information database using the following keywords: anal cancer, AIN, screening, renal transplant (or kidney transplant), organ transplant recipients and post-transplant malignancies. RESULTS: The prevalence of AIN is 20% in renal transplant patients. The prevalence of anal HPV infection in established transplant patients is 47%, and the prevalence of anal HPV infection in new transplant patients is 23%. The relative risk for anal cancer in renal transplant patients is 10. CONCLUSIONS: As compared to HIV-positive male patients who practise anal intercourse, renal transplant patients showed a modest rise in relative risk for anal cancer. Screening programmes to detect AIN in HIV-positive patients who practise anal intercourse have been introduced on a preliminary basis in sexual health clinics in the US and may become standard practise in this population. The case for screening in renal transplant patients is unclear and would merit further investigation, especially with reference to the prevalence of anal HPV infection in this population. It may transpire that renal transplant patients would benefit more from HPV prophylaxis rather than screening for AIN.

Giant adenomas of the rectum: complete resection by transanal endoscopic microsurgery (TEM).
Schafer H, Baldus SE, Holscher AH
Int J Colorectal Dis 2005 Aug 20;:1-5.

BACKGROUND: Large sessile adenomas of the rectum, with a diameter greater than 5 cm, have a high risk to undergo malignant transformation. Transanal endoscopic microsurgery (TEM) offers an alternative operation method to low-anterior rectum resection in this potentially benign tumor situation. PATIENTS: We retrospectively investigated patients with giant adenomas of the rectum (>5 cm) who were treated by TEM over the last 10 years. A total of 33 patients met the criteria and were analyzed for postoperative complications, histology, and incidence of occult adenocarcinoma; residual tumor status; and tumor recurrence. RESULTS: Partial suture-line insufficiency (n=5, 15%) was the major postoperative complication, but could be managed conservatively in four cases. The residual adenoma status was 18% (n=6), especially in patients with tumors sizes more than 30 cm(2). In case of adenoma recurrence (n=4, 12%), a conventional transanal excision (Parks) was applicable, as these tumors were mostly located within the suture-line region of the lower rectum. Incidentally, five carcinomas were found in the specimens. In case of advanced tumors (1xpT2, 1xpT3), anterior rectum resection was carried out, whereas for the early tumors (2xpT1 low risk, 1x1 pTis), no further therapy was added. All patients (adenomas and carcinomas, n=33) were without recurrence during follow-up. CONCLUSION: TEM is an alternative method for the resection of large benign rectal tumors located in the mid- and upper third of the rectum. The main postoperative complication is suture-line insufficiency, which generally heals by conservative treatment.

The use of probiotics in functional bowel disease.
Quigley EM
Gastroenterol Clin North Am 2005 Sep;34(3):533-45, x.

The role of enteric microflora in inflammatory bowel disease: human and animal studies with probiotics and prebiotics.
Rioux KP, Madsen KL, Fedorak RN
Gastroenterol Clin North Am 2005 Sep;34(3):465-82, ix.

Technique and Long-Term Results of Intersphincteric Resection for Low Rectal Cancer.
Schiessel R, Novi G, Holzer B, Rosen HR, Renner K, Holbling N, Feil W, Urban M
Dis Colon Rectum 2005 Aug 3;.

PURPOSE: Intersphincteric resection of low rectal tumors is a surgical technique extending rectal resection into the intersphincteric space. This procedure is performed by a synchronous abdominoperineal approach with mesorectal excision and excision of the entire or part of the internal sphincter. This study was designed to evaluate the long-term results of this method focused on continence function and oncologic results. METHODS: From 1984 to 2000, a total of 121 patients were operated on. The patients were evaluated prospectively according to a detailed preoperative and postoperative program. RESULTS: One hundred seventeen patients had rectal cancers, two had dysplastic villous adenomas, and two had carcinoid tumors. Cancers were staged according to the Dukes classification (Stage A in 41 percent, Stage B in 28 percent, and Stage C in 31 percent; median distance from the anal margin, 3 (range, 1-5) cm). Postoperative complications were: one death because of pulmonary embolism, 5.1 percent developed an anastomotic fistula, one patient had a fistula to the bladder requiring reoperation, one patient with ileus needed relaparotomy as well as one for intra-abdominal hemorrhage and a small-bowel fistula. One patient developed a fistula after closing the protective colostomy. Five patients developed late strictures of the coloanal anastomosis. After a median follow-up of 72.86 months, 5.3 percent of patients developed local recurrence. The continence status was satisfactory with 16 patients (13.7 percent) showing continence for solid stool only, and 1 patient (0.8 percent) showing episodes of incontinence. A transient problem was a high stool frequency after closure of the protective stoma. CONCLUSIONS: Intersphincteric resection is a valuable procedure for sphincter-saving rectal surgery. We showed that this technique has satisfactory long-term results in functional and oncologic respects. An important prerequisite is a careful preoperative evaluation of local tumor spread with rectal magnetic resonance imaging excluding infiltration of the external sphincter.

Meat, meat cooking methods and preservation, and risk for colorectal adenoma.
Sinha R, Peters U, Cross AJ, Kulldorff M, Weissfeld JL, Pinsky PF, Rothman N, Hayes RB
Cancer Res 2005 Sep 1;65(17):8034-41.

Cooking meat at high temperatures produces heterocyclic amines (HCAs) and polycyclic aromatic hydrocarbons (PAHs). Processed meats contain N-nitroso compounds. Meat intake may increase cancer risk as HCAs, PAHs, and N-nitroso compounds are carcinogenic in animal models. We investigated meat, processed meat, HCAs, and the PAH benzo(a)pyrene and the risk of colorectal adenoma in 3,696 left-sided (descending and sigmoid colon and rectum) adenoma cases and 34,817 endoscopy-negative controls. Dietary intake was assessed using a 137-item food frequency questionnaire, with additional questions on meats and meat cooking practices. The questionnaire was linked to a previously developed database to determine exposure to HCAs and PAHs. Intake of red meat, with known doneness/cooking methods, was associated with an increased risk of adenoma in the descending and sigmoid colon [odds ratio (OR), 1.26; 95% confidence interval (95% CI), 1.05-1.50 comparing extreme quintiles of intake] but not rectal adenoma. Well-done red meat was associated with increased risk of colorectal adenoma (OR, 1.21; 95% CI, 1.06-1.37). Increased risks for adenoma of the descending colon and sigmoid colon were observed for the two HCAs: 2-amino-3,8-dimethylimidazo[4,5]quinoxaline and 2-amino-1-methyl-6-phenylimidazo[4,5]pyridine (OR, 1.18; 95% CI, 1.01-1.38 and OR, 1.17, 95% CI, 1.01-1.35, respectively) as well as benzo(a)pyrene (OR, 1.18; 95% CI, 1.02-1.35). Greater intake of bacon and sausage was associated with increased colorectal adenoma risk (OR, 1.14; 95% CI, 1.00-1.30); however, total intake of processed meat was not (OR, 1.04; 95% CI, 0.90-1.19). Our study of screening-detected colorectal adenomas shows that red meat and meat cooked at high temperatures are associated with an increased risk of colorectal adenoma.

Heightened responses to stressors in patients with inflammatory bowel disease.
Farhadi A, Keshavarzian A, Van de Kar LD, Jakate S, Domm A, Zhang L, Shaikh M, Banan A, Fields JZ
Am J Gastroenterol 2005 Aug;100(8):1796-804.

OBJECTIVES: Several studies suggest that stressful situations (stressors) worsen the course of inflammatory bowel disease (IBD), but the mechanism is not known. Based on several lines of evidence, we hypothesized that psychosocial stress activates the brain-gut axis (BGA) and mucosal mast cells (MC), and activated MC produce proinflammatory cytokines. To test this hypothesis, we determined whether stressor-induced activation of BGA is exaggerated in IBD patients. METHODS: Stress was induced in 15 IBD patients who were in remission (inactive IBD) and in seven controls by a widely used stressor, the cold pressor test (CPT), daily for five consecutive days. Induction of stress was confirmed objectively by measurement of stress hormones (serum cortisol and ACTH), and hemodynamic parameters and subjectively by questionnaire. Activation of the BGA by this stressor was assessed by evaluating colonic mucosal MC histology and degranulation, using electron microscopy (EM). The effects of the stressor on the intestinal mucosa were assessed by changes in inflammatory cell histology, epithelial mitochondria (EM), and oxidative tissue injury (assays for protein oxidation). RESULTS: In both study groups, the stressor resulted in (1) increased levels of stress hormones, (2) the expected changes in hemodynamic parameters, (3) activation and degranulation of MC, (4) mitochondrial damage to epithelial cells, and (5) mucosal protein oxidation. These changes were more marked in IBD patients. CONCLUSIONS: The heightened response to the stressors and the greater epithelial damage in IBD patients suggests that stress-induced activation of the BGA and of mucosal MC is important in the initiation and/or flare up of IBD.

Budesonide for maintenance of remission in patients with Crohn's disease in medically induced remission: a predetermined pooled analysis of four randomized, double-blind, placebo-controlled trials.
Sandborn WJ, Lofberg R, Feagan BG, Hanauer SB, Campieri M, Greenberg GR
Am J Gastroenterol 2005 Aug;100(8):1780-7.

OBJECTIVES: To evaluate the efficacy and safety of oral budesonide for maintenance of remission in patients with mild to moderately active Crohn's disease (CD) of the ileum and/or ascending colon. METHODS: Four double-blind, placebo-controlled trials with identical protocols were combined according to a predetermined analysis plan. Three hundred eighty patients with CD in medically induced remission (CD activity index [CDAI]< or =150) were randomized to receive oral budesonide 3 mg, 6 mg, or placebo daily for 12 months. The primary outcome measure was time to relapse (increase in CDAI of 60 points above baseline and >150). RESULTS: The median time to relapse was 268, 170, and 154 days for budesonide 6 mg, budesonide 3 mg, and placebo groups, respectively (p= 0.0072). The frequency of adverse events and glucocorticosteroid side effects were similar in all groups. CONCLUSION: Budesonide 6 mg/day is effective for prolonging time to relapse and for significantly reducing rates of relapse at 3 and 6 months but not 12 months in patients with CD in medically induced remission.

Colonic atresia: spectrum of presentation and pitfalls in management. A review of 14 cases.
Cox SG, Numanoglu A, Millar AJ, Rode H
Pediatr Surg Int 2005 Aug 27;:1-6.

Fourteen cases of colonic atresia seen over a 38-year period are reviewed with particular reference to clinical presentation and pitfalls in management. Seven had Type I atresia, two Type II and five Type IIIa. Ten had associated gastrointestinal anomalies. Management varied considerably. Six had primary colonic anastomosis. Two of these developed complications due to unrecognized distal hypoganglionosis, two had associated jejunal atresias resulting in short bowel syndrome, and two had primary anastomosis protected by proximal ileostomies. Seven had a staged repair with initial defunctioning enterostomy with only one complication, an unfixed mesentery that later resulted in midgut volvulus. The only mortality was a patient in which a jejunal atresia repair leaked as a result of a missed colonic atresia. Operative strategy should depend on the clinical state of the patients, the level of atresia, associated small bowel pathology and exclusion of distal pathology. Primary anastomosis would only rarely be advised with a circumspect approach. Long-term outlook, as in small bowel atresia is generally excellent.

Disseminated mixed intestinal dysmotility(DMID): a new intestinal ganglion cell disorder?
Kobayashi H, Yamataka A, Lane GJ, Miyano T
Pediatr Surg Int 2005 Aug 25;:1-6.

We experienced two cases with disseminated HP and IND occurring with normal bowel in between (disseminated mixed intestinal dysmotility-DMID) and postulate whether it could be classified as a new intestinal motility disorder. Our cases, both boys, died at 3 and 7 months, respectively. Both had irregular stool passage, and abdominal distention with bilious vomiting since birth. On barium enema, both had rigid distal ileum and colon with narrow lumens, with dilated and atonic proximal ileum and jejunum. An ileostomy was created on days 3 and 2 of life, respectively, however, they did not function and jejunostomies were created, which also did not function well. Both boys died after repeated episodes of severe enterocolitis. In each case, three 10 cm specimens were obtained randomly from the jejunum and ileum, and two 5 cm specimens were obtained randomly from each of the ascending colon, transverse colon, descending colon, and rectum and treated with hematoxylin and eosin (H & E) staining, acetylcholine esterase (AchE) histochemistry, and protein gene product 9.5 (PGP9.5) and neural cell adhesion molecule (NCAM) immunohistochemistry for histopathologic assessment. All specimens showed a mixture of disseminated IND and HP, with normal intestine in between. There was abnormal expression of NCAM activity in the intestinal smooth muscle layers in small and large intestine. This is the first report about disseminated IND and HP occurring with normal bowel in between (DMID) and we suggest it should be classified as a new intestinal motility disorder. The present findings demonstrate that patients with DMID have a complicated abnormality of NMJ that may directly influence bowel motility and prognosis according to the severity of the abnormality.

Single-stage operation without temporary colostomy for persistent cloaca with a short common channel.
Masuko T, Higashimoto Y, Iwai J
Pediatr Surg Int 2005 Aug 23;:1-3.

Colorectal decompression with a catheter was performed for evacuation of stool before definitive surgery in two patients with a persistent cloaca. Two newborn female infants with persistent cloaca received placement of a silicone balloon-tipped catheter in the rectum via the cloacal orifice under fluoroscopic guidance at the time of diagnosis. The length of the cloaca was 2 and 1.5 cm, respectively. The diameter of the catheter was matched to the patients' rectal size and the open end was wrapped in a diaper to allow continuous drainage of stool. The infants underwent bowel irrigation with warm saline thrice a day, at home. Total urogenital mobilization was carried out in the infants at the age of 7 and 8 months, respectively. Both infants had no abdominal distension, colorectal dilatation, or urinary tract infection while the catheter was in situ. The postoperative course was uneventful, except for minimal wound dehiscence in one patient. At present, both infants can void spontaneously without any urological problems. In infants with a persistent cloaca less than 3 cm long and normal urinary tract function, adequate evacuation of stool may be achieved by colorectal decompression with a catheter, thus avoiding the need for a colostomy.

Total laparoscopic proctocolectomy with Brooke ileostomy: a novel incisionless surgical treatment for patients with ulcerative colitis.
Larson DW, Dozois E, Sandborn WJ, Cima R
Surg Endosc 2005 Jul 28;.

BACKGROUND: This report describes the clinical benefits and safety of a novel (incisionless) laparoscopic operation for chronic ulcerative colitis. METHODS: The medical records for four patients with the diagnosis of chronic ulcerative colitis who underwent "incisionless" laparoscopic proctocolectomy with Brooke ileostomy were reviewed. A novel technique was used for successfully performance of four total proctocloectomies with end ileostomies that did not require abdominal incisions. The clinical outcomes measured included time to oral intake, time to ostomy output, operative time, postoperative and intraoperative complications, estimated blood loss, and length of stay. RESULTS: All the patients recovered without incident intraoperatively and postoperatively. The operative times ranged from 330 to 550 min. Postoperative findings included median time to oral intake (2 days), median time to ileostomy output (2 days), and median length of stay (4 days). CONCLUSION: This case series demonstrates that an incisionless approach to chronic ulocerative colitis for patients who desire an end ileostomy may be feasible and safe, offering patients short-term recovery and cosmetic benefits.

Distribution of lymph node metastasis in T1 sigmoid colon carcinoma: should we ligate the inferior mesenteric artery?
Kawamura YJ, Sakuragi M, Togashi K, Okada M, Nagai H, Konishi F
Scand J Gastroenterol 2005 Jul;40(7):858-61.

OBJECTIVE: In standard oncological sigmoid colectomy, the inferior mesenteric artery is ligated either at its origin or at the level of the left colic artery. However, in patients with early-stage carcinoma, the distribution of metastatic nodes may be limited. The aim of this study was to clarify the prevalence and distribution of lymph node metastasis in T1 sigmoid colon carcinoma and to determine the adequate range of lymph node dissection. MATERIALS AND METHODS: The study included 121 consecutive patients treated for T1 sigmoid colon carcinoma. Clinicopathologic factors associated with nodal metastasis and the distribution of metastatic nodes were analyzed. RESULTS: Of 121 patients, 12 (10%) had nodal involvement. The depth of invasion and the presence of lymphatic and vascular invasion were significantly associated with nodal metastasis. Of these 12 patients, 11 (92%) had lymph node metastasis confined to pericolic nodes. Nodes along the sigmoidal artery were involved in one patient. There was no involved node along the superior rectal artery or at the root of the inferior mesenteric artery. CONCLUSIONS: Lymph node dissection for T1 sigmoid colon carcinoma should be limited to the root of the sigmoidal artery, and the inferior mesenteric artery should be preserved.

Use of prebiotics for inflammatory bowel disease.
Szilagyi A
Can J Gastroenterol 2005 Aug;19(8):505-10.

The relevance of diet in both the pathogenesis and the therapy of inflammatory bowel disease is an evolving science. Disturbance of intestinal microflora (dysbiosis) is putatively a key element in the environmental component causing inflammatory bowel disease. Prebiotics are among the dietary components used in an attempt to counteract dysbiosis. Such predominantly carbohydrate dietary components exert effects on the luminal environment by physicochemical changes through pH alteration, by production of short chain fatty acids and by selectively promoting putatively 'health-beneficial' bacteria. The present review elaborates on some of the background rationale and mechanisms on the use of prebiotics. Additionally, published animal and human trials are discussed.

Perianal problems in patients with ulcerative colitis.
Hamzaoglu I, Hodin RA
Inflamm Bowel Dis 2005 Sep;11(9):856-9.

Magnetic resonance imaging of the small bowel in Crohn's disease.
Frokjaer JB, Larsen E, Steffensen E, Nielsen AH, Drewes AM
Scand J Gastroenterol 2005 Jul;40(7):832-42.

OBJECTIVE: There may be advantages in using magnetic resonance imaging (MRI) in small-bowel disease. The aims of this study were to optimize the MRI examination technique and to evaluate the capabilities of MRI compared with those of conventional enteroclysis (CE). MATERIALS AND METHODS: MRI and CE were performed in 36 patients suspected of Crohn's disease. Based on 26 pilot studies optimal oral administration of plum juice and bulk fibre laxative was found. T2-weighted and gadolinium enhanced T1-weighted images were obtained using a breath-holding technique and butylscopolamine. Virtual endoscopy was performed. Conventional enteroclysis entailed duodenal intubation and administration of barium and air. Two radiologists evaluated the examinations independently. Finally, each patient scored the degree of discomfort, and preference for either MRI or CE was found. RESULTS: The MRI technique ensured sufficient distension of the small bowel and small-bowel changes were found in 12 patients. In 3 patients this was not seen on conventional enteroclysis, which did not reveal any pathology that was not already seen on MRI. Pathological abdominal changes were found in 70% more patients during MRI than during conventional enteroclysis (p < 0.001). Endoscopic examination corresponded with the MRI findings. The examination quality decreased with increasing age (p = 0.002) and the interobserver agreement of the pathological changes was high (p < 0.001). Virtual endoscopy resulted in excellent demonstration of the mucosal surface. The examination discomfort scores obtained during the MRI were lower than those during conventional enteroclysis (p < 0.001). CONCLUSIONS: MRI using the current technique is preferable to conventional enteroclysis because of superior demonstration of the entire small-bowel pathology, low level of patient discomfort and absence of radiation exposure.

Women patients' preference for women physicians is a barrier to colon cancer screening.
Menees SB, Inadomi JM, Korsnes S, Elta GH
Gastrointest Endosc 2005 Aug;62(2):219-23.

Background The preference of women patients for women physicians has been shown in many specialties. Women patients awaiting a lower endoscopy have been shown to have a preference for women endoscopists. The reasons for this preference and the strength of this preference have not been studied in the primary care setting. Methods A questionnaire was given to female patients who were waiting for primary care appointments at 4 offices. Patients reported sociodemographic characteristics, experiences with colorectal cancer (CRC), barriers to CRC screening, gender preference of their physician, the significance, and reasons for this preference. Results A total of 202 women patients aged 40 to 70 years (mean 53 years) completed the questionnaire. Of these patients, 43% preferred a woman endoscopist, and of these, 87% would be willing to wait >30 days for a woman endoscopist, and 14% would be willing to pay more for one. The most common reason (in 75%) for this gender preference was embarrassment. Univariate analysis revealed that gender of the primary care physician (PCP), younger patient age, current employment, and no previous history of colonoscopy were predictors of preference for a woman endoscopist. Of these variables, only female gender of the PCP (OR 2.84: 95% CI[1.49, 5.40]) and employment (OR 2.4: 95% CI[1.23, 4.67]) were positive predictors for a woman endoscopist preference by multivariable analysis; 5% stated that they would not undergo a colonoscopy unless guaranteed a woman endoscopist. The sole independent factor associated with adherence to screening was PCP recommendation (OR 2.93: 95% CI[1.63, 5.39]). Conclusions Women patients frequently prefer a woman endoscopist, and this preference is reported as being strong enough to delay the procedure and to incur personal expense. It is an absolute barrier to endoscopy according to 5% in this subset of women surveyed. Interventions must be made in the primary care setting to address this issue and to increase the participation of women patients in CRC screening.

Anorectal Malformations: Does Healthcare Meet the Needs?
Hartman EE, Sprangers MA, Visser MR, Oort FJ, Hanneman MJ, van Heurn LW, de Langen ZJ, Madern GC, Rieu PN, van der Zee DC, Looyaard N, Aronson DC
J Pediatr Gastroenterol Nutr 2005 Aug;41(2):210-215.

OBJECTIVES: The first aim was to identify the types of healthcare services used by children, adolescents, and adults with anorectal malformation (ARM) in relation to the severity of their disease and to examine whether additional care was needed. The second aim was to evaluate specific areas in the healthcare system, including provided information, transfer from pediatric to adult care, and satisfaction with the provided care. METHODS: Three hundred eighty-six (61%) patients with ARM, ages 6 to 52, completed a questionnaire that assessed their use of healthcare services and the need for additional services. Also, questions were asked about specific areas in the healthcare system. Clinical and sociodemographic characteristics were extracted from medical records. RESULTS: In the preceding 6 months 50% of the children, 24% of the adolescents, and 24% of the adults consulted a medical specialist. Compared with patients with a mild form of ARM in the age range of 6 to 16 years, the more severely afflicted patients visited medical professionals more often (18% vs. 32%). Particularly, adolescents in the age range of 12 to 16 years with a severe form of the disease more often visited the pediatric surgeon than their peers with a mild form (2% vs. 16%). Twenty-three percent of the children, 7% of the adolescents, and 8% of the adults consulted a nonmedical professional. Twenty percent of the children, 13% of the adolescents, and 17% of the adults would have liked additional or more treatment of a nonmedical professional. In 6 months, 40% of the children, 24% of the adolescents, and 20% of the adults received treatment information. One third of the adult patients who were transferred to "adult" surgeons encountered transfer problems. Almost all patients were satisfied with the care provided. CONCLUSIONS: There is good access to medical healthcare services, especially for children. However, more psychosocial and paramedical care is considered necessary. As could be expected, children and adolescents with a severe form of the disease reported to have visited a medical specialist more often. Although healthcare for patients with ARM may be improved at certain points, most parents and patients were very satisfied with the care provided.

Aerophagia in children: characterization of a functional gastrointestinal disorder.
Chitkara DK, Bredenood AJ, Wang M, Rucker MJ, Talley NJ
Neurogastroenterol Motil 2005 Aug;17(4):518-22.

Abstract The purpose of this study was to describe presenting symptoms, diagnostic testing, treatments and outcomes in a group of children with a diagnosis of aerophagia. A computerized diagnostic index was used to identify all children between the age of 1 and 17 years diagnosed with aerophagia at a tertiary care medical centre between 1975 and 2003. Individual medical charts were abstracted for information on the demographics, clinical features, co-morbid diagnoses, diagnostic work up and treatment of children with aerophagia. Information on presenting symptoms was also collected for a group of children who were retrospectively classified as having functional dyspepsia for comparison (n = 40). Forty-five children had a diagnosis of aerophagia. The mean duration of symptoms in children with aerophagia was 16 +/- 5 months. The most common gastrointestinal symptoms were abdominal pain, distention and frequent belching. Children with functional dyspepsia had a higher prevalence of nausea, vomiting, abdominal pain and unintentional weight loss compared to children with aerophagia (all P < 0.05). In conclusion, aerophagia is a disorder that is diagnosed in neurologically normal males and females, who can experience prolonged symptoms. Although many children with aerophagia present with upper gastrointestinal symptoms, the disorder appears to be distinct from functional dyspepsia.

Towards a better understanding of abdominal bloating and distension in functional gastrointestinal disorders.
Houghton LA, Whorwell PJ
Neurogastroenterol Motil 2005 Aug;17(4):500-11.

Abstract Abdominal bloating is an extremely common symptom affecting up to 96% of patients with functional gastrointestinal disorders and even 30% of the general population. To date bloating has often been viewed as being synonymous with an actual increase in abdominal girth, but recent evidence suggests that this is not necessarily the case. This review examines the relationship between the symptom of bloating and the physical sign of abdominal distension, as well as examining the epidemiology, pathophysiology and treatment options available for this debilitating aspect of the functional gastrointestinal disorders. Pathophysiological mechanisms explored include psychological factors, intestinal gas accumulation, fluid retention, food intolerance and malabsorption of sugars, weakness of abdominal musculature, and altered sensorimotor function. Treatment options are currently rather limited but include dietary changes, pharmacological approaches, probiotics and hypnotherapy.

Other strategies for evaluating rectal bleeding in younger patients.
Alonso-Coello P, Wong RF, Kuwada SK
J Fam Pract 2005 Aug;54(8):688-9.

Quality of Life in Colorectal Cancer Patients with Colectomy and the Validation of the Functional Assessment of Cancer Therapy-Colorectal (FACT-C), Version 4.
Yoo HJ, Kim JC, Eremenco S, Han OS
J Pain Symptom Manage 2005 Jul;30(1):24-32.

The purpose of this study was to determine whether the Functional Assessment of Cancer Therapy-Colorectal (the FACT-C), a disease-specific tool for the assessment of colorectal cancer patients' QOL, is a valid assessment tool for measuring QOL changes. Ninety-eight colorectal cancer patients performed the assessment at baseline and 52 of these patients completed the instrument at one month and six months after colectomy. In addition to the FACT-C, the shortened forms of the Profile of Mood States, the Eastern Cooperative Oncology Group Performance Status Rating, Neuroticism Scale in the Eysenck Personality Questionnaire, and Functional Living Index-Cancer were completed. We found convergent and divergent validity and good reliability of the FACT-C. Patients' overall QOL was lower at one month after colectomy and recovered to the pre-surgery level at six months after colectomy.

A solitary rectal ulcer mimicking rectal cancer.
Delgado J, Delgado B, Sztarkier I, Sperber AD, Walfisch S
Gastrointest Endosc 2005 Aug;62(2):309.

Inverted appendiceal orifice masquerading as a cecal polyp on virtual colonoscopy.
Koff JM, Choi JR, Hwang I
Gastrointest Endosc 2005 Aug;62(2):308.

Mesenteric abscess in Crohn's disease.
Hokama A, Kinjo F, Tomiyama R, Kishimoto K, Maeda K, Miyagi S, Nakama M, Saito A
Gastrointest Endosc 2005 Aug;62(2):306.

A new sinker-assisted endoscopic submucosal dissection for colorectal cancer.
Saito Y, Emura F, Matsuda T, Uraoka T, Nakajima T, Ikematsu H, Gotoda T, Saito D, Fujii T
Gastrointest Endosc 2005 Aug;62(2):297-301.

Background Endoscopic submucosal dissection (ESD) is accepted as a minimally invasive treatment for early gastric cancer, but it is not widely used to treat the colorectum because of its degree of technical difficulty. Thus, a noninvasive tool that facilitates the direct visualization of the submucosal layer is needed. Methods Traction-assisted dissection was performed on 4 superficial lesions. The system consisted of a metallic clip attached by a nylon line to a sinker 6 x 4 x 4 mm in size and weighing 1 g. After partially dissecting the submucosa, the clip was attached to the edge of the exfoliated mucosa and the weight of the sinker pulled down the partly resected lesion. Observations In all 4 cases, the sinker allowed direct visualization of the cutting line, and en bloc resection was successfully accomplished. Conclusions These preliminary results suggest that sinker-assisted ESD is effective for the complete removal of selected superficial early colorectal cancer.

Complete duplication of the bladder, urethra and external genitalia in a male neonate with an imperforate anus.
Voigt HR, Wentzel SW
Int J Urol 2005 Jul;12(7):702-4.

A rare case of a male neonate with complete duplication of the bladder, urethra and external genitalia with associated anomalies is reported. In addition to the above, the patient had a hypoplastic left kidney, bilateral bifid scrotums (four hemi-scrotums), an imperforate anus and a mass on the perineum.

Postoperative Crohn's disease.
Penner RM, Madsen KL, Fedorak RN
Inflamm Bowel Dis 2005 Aug;11(8):765-77.

More than three quarters of patients with Crohn's disease (CD) will require surgery. After resection, disease recurs postoperatively with a median time to second resection of about 10 years. Despite its importance, the postoperative period remains one of the most poorly understood clinical settings in the field. Postoperatively, CD may exhibit unique pathophysiologic features, but the current state of knowledge does not allow for identification of patients at risk for relapse, and leaves clinicians without guidance on optimal maintenance treatment. Therapies used as maintenance for CD in other settings may have different efficacies when used after surgery, and clinical research in patients requiring surgery is limited by the subset of patients available for study. Despite the many limitations in current knowledge of postoperative CD, it is an exciting field because new developments have improved patient care, and ongoing research has the potential for further gains.

RDP58 Is a Novel and Potentially Effective Oral Therapy for Ulcerative Colitis.
Travis S, Yap LM, Hawkey C, Warren B, Lazarov M, Fong T, Tesi RJ
Inflamm Bowel Dis 2005 Aug;11(8):713-719.

BACKGROUND: RDP58 is a novel anti-inflammatory d-amino acid decapeptide that inhibits synthesis of proinflammatory cytokines by disrupting cell signaling at the pre-MAPK MyD88-IRAK-TRAF6 protein complex. We therefore evaluated its efficacy and safety in parallel multicenter, double-blind, randomized concept studies in ulcerative colitis (UC). METHODS: In the first trial, 34 patients with mild to moderate active UC were randomized (1:2) to placebo (n = 13) or RDP58 100 mg (n = 21). In the second trial, 93 similar patients were randomized (1:1:1) to placebo (n = 30) RDP58 200 mg (n = 31), or RDP 300 mg (n = 32). In both studies, treatment success was defined as a simple clinical colitis activity index score of no more than 3 at 28 days. Sigmoidoscopy and rectal biopsy (at baseline and 28 days) and safety measures (baseline and 28 and 56 days) were other endpoints. RESULTS: Treatment success on RDP 100 mg was 29% versus 46% on placebo (P = 0.46). There were no significant differences in sigmoidoscopy or histology score. In the second study, treatment success on the higher doses of RDP58 (200 and 300 mg) was 71% and 72%, respectively, versus 43% on placebo (P = 0.016). Improvements in sigmoidoscopy scores (41% on 200 mg and 46% on 300 mg versus 32% on placebo) did not reach significance, but histology scores improved significantly (P = 0.002) versus placebo. Overall, adverse events were no different between placebo (3.3 +/- 2.4) and RDP58 (2.7 +/- 1.4, 300-mg group). CONCLUSIONS: RDP58 at a dose of 200 or 300 mg, but not 100 mg, was effective in mild-to-moderate UC. RDP58 was safe and well tolerated, and its novel action makes it an attractive potential therapy.

Anterior resection of rectal cancer without bowel preparation and diverting stoma.
Vlot EA, Zeebregts CJ, Gerritsen JJ, Mulder HJ, Mastboom WJ, Klaase JM
Surg Today 2005;35(8):629-33.

PURPOSE: Since the introduction of total mesorectal excision (TME) as the standard operation technique for rectal cancer, anastomotic leakage percentages of up to 18% have been reported. To prevent such leakage, the use of mechanical bowel preparation and also the construction of a diverting ileostoma or colostomy have been standard procedures for years. In our institute, however, all patients undergoing colorectal surgery are operated upon without these measures. The present study was undertaken to investigate the results of this strategy in terms of the occurrence of postoperative anastomotic leakage. METHODS: All patients who underwent an elective (low) anterior resection between January 1996 and December 2001 (n = 144) entered the study. The clinical and pathological records of these patients were reviewed retrospectively. The exclusion criteria were patients with fixed rectal carcinoma who received preoperative radiotherapy and/or a stoma only at operation, emergency operations, abdominoperoneal resections, and Hartmann's procedures. RESULTS: Anastomotic leakage occurred in 7 out of 144 patients (4.9%). There was a trend toward a higher leakage frequency in men, in patients with a distal anastomosis, in patients with a stapled anastomosis, and in patients with a T3-T4 tumor or with positive lymph nodes. None of these factors, however, had a significant prognostic value based on a univariate or multivariate analysis. Those who died after leakage tended to be older than those who did not (P < 0.05). CONCLUSION: A (low) anterior resection can be performed safely without mechanical bowel preparation or a diverting stoma, and results in an anastomotic leakage percentage of less than 5%. Appropriate selection of patients may be important, but none of the investigated patient- or tumor-related factors could be identified as decisive.

Anal mucosal electric sensation in postoperative patients with anorectal malformations.
Ikeda T, Tomita R, Koshinaga T
J Pediatr Surg 2005 Jul;40(7):1146-50.

BACKGROUND: No previous report has, to our knowledge, been made on anal mucosal electric sensation in postoperative patients with anorectal malformations (ARMs). We studied the anal mucosal electric sensory threshold (AMEST) in comparison with clinical manifestation. METHODS: The study included 25 patients with ARMs who underwent anorectoplasty (ARMs group) and 10 subjects (control group). Based on the type of ARMs, patients were divided into 3 subgroups: high type, n = 14; intermediate type, n = 6; low type, n = 5. The AMEST was measured at 3 positions, at the anal skin margin and 1 and 2 cm from the anal skin margin. The AMEST was analyzed compared with the type of ARMs and clinical manifestation. RESULTS: The AMEST clearly increased at the 3 sites in patients with ARMs, especially those with high and intermediate types, compared with control subjects. The sensitivity threshold in the lower anal canal in the low-type subgroup was about the same as that in the control group. An analysis of clinical manifestations showed significantly increased thresholds in the upper and middle anal canal in the group of patients with difficulty in discriminating between gas and defecation and with fecal incontinence (P < .01 and P < .05). CONCLUSIONS: The AMEST for the high-type and intermediate-type subgroups in the ARMs group was worse than that in the low-type subgroup and control group. The AMEST in the upper and middle anal canal was important for gas and defecation distinction and fecal maintenance.

Predictors of colorectal cancer screening: A comparison of men and women.
McGregor SE, Bryant HE
Can J Gastroenterol 2005 Jun;19(6):343-9.

BACKGROUND: New Canadian guidelines recommend screening average-risk adults to reduce mortality from colorectal cancer, the second most common cause of cancer death among Canadians. The present study examined the self-reported prevalence of colorectal cancer testing and sex-specific predictors of having had a fecal occult blood (FOB) test for screening, among a cohort of Alberta residents aged 50 to 69 years. METHODS: Subjects (n=5009) enrolled in a geographically based cohort study completed a Health and Lifestyle Questionnaire between October 2000 and June 2002 that ascertained their colorectal cancer detection practices, as well as demographic and other health and lifestyle characteristics. RESULTS: Patterns of FOB testing, and sigmoidoscopy or colonoscopy, were similar for men and women. The majority of subjects (83.3%) reported no first-degree family history of colorectal cancer or bowel conditions, and they were considered to be at average risk. Few average-risk subjects reported having a screening FOB test within the past two years (7.7% [95% CI 6.7% to 8.7%] of subjects aged 50 to 59 years and 12.5% [95% CI 10.9% to 14.3%] of subjects aged 60 to 69 years). In men, the strongest predictors of having a screening FOB test in the past two years were a recent history of prostate-specific antigen testing and educational attainment. Among women, the strongest predictors were a recent history of having had a Pap test, a recent mammogram, employment status and educational attainment. CONCLUSIONS: Screening for colorectal cancer in average-risk adults was infrequent in this sample and lagged behind screening for other cancers. Screening of average-risk adults occurred primarily in people already accessing the health care system, suggesting that public education programs will be required to increase screening rates.

Laparoscopy-assisted low anterior resection with a prolapsing technique for low rectal cancer.
Fukunaga M, Kidokoro A, Iba T, Sugiyama K, Fukunaga T, Nagakari K, Suda M, Yoshikawa S
Surg Today 2005;35(7):598-602.

Laparoscopy-assisted low anterior resection (LAR) for low rectal cancer is a difficult procedure, presenting problems with rectal washout, selecting the appropriate distal transection line, and achieving safe anastomosis. To resolve these problems, we used a prolapsing technique to perform laparoscopy-assisted LAR. Total mesorectal excision (TME) is performed laparoscopically. The proximal colon is transected laparoscopically with the aid of an endoscopic stapler, and the distal rectum, including the lesion, are everted and pulled transanally to outside the body. Only washout of and wiping off the distal rectum and intestinal resection are performed extracorporeally. The distal rectum is pushed back through the anus into the pelvis, and intracorporeal anastomosis is completed laparoscopically with a double-stapling technique. Our limited experience suggests that the prolapsing technique helps to prevent problems with laparoscopy-assisted LAR in selected patients with low rectal cancer.

Reproduction and ulcerative colitis: a review.
Sela HY, Rojansky N, Hershko AY
J Reprod Med 2005 May;50(5):361-6.

Ulcerative colitis is a chronic inflammatory bowel disease. The onset peaks at age 15-30 years and coincides with the reproductive period. We screened and summarized the relevant English-language publications (Entrez-PubMed) on ulcerative colitis, fertility and pregnancy. The presence of ulcerative colitis per se does not seem to significantly alterfertility in young women. However, associated conditions, such as active disease, surgical interventions and medication, may interfere with reproduction. It is difficult to draw conclusions regarding the effect of ulcerative colitis on pregnancy outcome in terms of pregnancy loss, intrauterine growth restriction, low birth weight, preterm labor, stillbirth and perinatal mortality. Nevertheless, it appears that major complications do not occur in ulcerative colitis patients more frequently than in healthy women. The rate of exacerbation is probably the same for pregnant and nonpregnant women. Disease control during pregnancy is of the utmost importance. Fortunately, most drugs can by used safely during pregnancy.

Incidence, Clinical Presentation and Location at Diagnosis of Pediatric Inflammatory Bowel Disease: A Prospective Population-Based Study in Northern France (1988-1999).
Auvin S, Molinie F, Gower-Rousseau C, Brazier F, Merle V, Grandbastien B, Marti R, Lerebours E, Dupas JL, Colombel JF, Salomez JL, Cortot A, Turck D
J Pediatr Gastroenterol Nutr 2005 Jul;41(1):49-55.

OBJECTIVE: To assess the incidence and location at diagnosis of inflammatory bowel disease in children and adolescents in northern France between 1988 and 1999. METHODS: A 12-year prospective population-based study was conducted by gastroenterologists and pediatric gastroenterologists of northern France (1,312,141 children <17 years of age). RESULTS: From 1988 to 1999, 509 cases of childhood inflammatory bowel disease were recorded (7.2% of all inflammatory bowel disease cases in Northern France): 367 Crohn disease, 122 ulcerative colitis and 20 indeterminate colitis. The mean standardized incidence was 3.1/10 for inflammatory bowel disease as a whole (2.3 for Crohn disease, 0.8 for ulcerative colitis and 0.12 for indeterminate colitis). Crohn disease location at diagnosis was: small bowel and colon (71%), colon only (10%) and small bowel only (19%). Location of initial ulcerative colitis was: proctitis (11%), left colitis (57%) and pancolitis (32%). Although ulcerative colitis incidence remained stable (0.8), Crohn disease incidence increased from 2.1 in 1988 to 1990 to 2.6 in 1997 to 1999 (P = 0.2). CONCLUSIONS: The incidence of Crohn disease in the children of northern France showed an increasing trend (20%; not significant) during the 12-year period while the incidence of ulcerative colitis remained stable. In the entire population(children and adults)the incidence of Crohn disease increased significantly (+23%; P < 0.001), while the incidence of ulcerative colitis decreased (-17%; P < 0.0001).

Infantile proctocolitis: are we empirically too casual?
Lake A
J Pediatr Gastroenterol Nutr 2005 Jul;41(1):14-5.

Inflammatory Bowel Disease in Children and Adolescents: Recommendations for Diagnosis-The Porto Criteria.
J Pediatr Gastroenterol Nutr 2005 Jul;41(1):1-7.
Ulcerative colitis and Crohn disease may present before the age of 20 years in 25% to 30% of all patients with inflammatory bowel
disease. Reported incidence figures vary considerably depending on the collection of data. Multicenter, multinational collaboration is needed when studying pediatric inflammatory bowel disease. The essential first step is uniformity in the work-up and criteria used for diagnosis. The Porto diagnostic criteria presented here provide the tool that is needed. These criteria are the result of consensus reached by the ESPGHAN inflammatory bowel disease working group. Diagnosis of Crohn disease, ulcerative colitis and indeterminate colitis is based on clinical signs and symptoms, endoscopy and histology and radiology. Every child suspected of inflammatory bowel disease should undergo a complete diagnostic program consisting of colonoscopy with ileal intubation, upper gastrointestinal endoscopy and (in all cases except in definite ulcerative colitis) radiologic contrast imaging of the small bowel. Multiple biopsies from all segments of the gastrointestinal tract are needed for a complete histologic evaluation. A diagnosis of indeterminate colitis cannot be made unless a full diagnostic program has been performed. Hepatology and Nutrition (ESPGHAN).

Re: "Perianal presentation of Langerhans cell histiocytosis in children"
Sabri M, Ranganathan S
J Pediatr Gastroenterol Nutr 2005 Jul;41(1):136.

Perianal Presentation of Langerhans Cell Histiocytosis in Children.
Kader HA, Maller ES
J Pediatr Gastroenterol Nutr 2005 Jul;41(1):135.

Frequency of hereditary non-polyposis colorectal cancer among Uruguayan patients with colorectal cancer.
Sarroca C, Valle AD, Fresco R, Renkonen E, Peltomaki P, Lynch H
Clin Genet 2005 Jul;68(1):80-7.

Few studies have investigated the frequency of hereditary non-polyposis colorectal cancer (HNPCC) in patients with colorectal cancer (CRC), and these have shown marked geographic variations. The aim of this study was to estimate the frequency of HNPCC in a cohort of Uruguayan CRC patients. We included all patients operated consecutively for CRC in the Hospital Central de las Fuerzas Armadas (Uruguay) between 1987 and 2003. Cases were classified into three groups: (i) those fulfilling Amsterdam criteria; (ii) those not fulfilling Amsterdam criteria but considered as a population at increased risk of cancer; and (iii) sporadic CRC. Genetic analysis to detect point mutations in hMLH/hMSH2/hMSH6 genes was performed in group 1 patients. Cases not showing mutations were tested by multiplex ligation-dependent probe amplification. Among 461 patients, group 1 represented 2.6%, group 2 represented 5.6%, and sporadic cases 91.8%. hMLH1/hMSH2/hMSH6 mutations were found in 25% of cases classified as HNPCC (two in hMLH1 and one in hMSH2). No mutations were detected in hMSH6 gene. The proportion of CRC patients that fulfilled Amsterdam criteria agrees with other reports. However, the percentage of HNPCC cases with identified mutations (25%) may be lower than that reported from other populations. This may reflect, among other possible causes, a different genetic profile in the Uruguayan population.

Hand-sewn coloanal anastomosis for distal rectal cancer: long-term clinical outcomes.
Baik SH, Kim NK, Lee KY, Sohn SK, Cho CH
J Gastrointest Surg 2005 Jul-Aug;9(6):775-80.

As the oncologic safety of coloanal anastomosis (CAA) has been proved by many other authors, the incidence of CAA following ultralow anterior resection has increased. The purpose of this study is to evaluate the functional outcome and complications of patients who underwent ultralow anterior resection and CAA for distal rectal cancer. Fifty-seven patients underwent CAA following ultralow anterior resection between July 1997 and November 2003. Forty-four patients, who were followed up more than 6 months after diverting ileostomy closure, were evaluated for recurrence, complications, and functional outcomes. The mean follow-up period was 36.3 +/- 22.8 months (range, 8-83 months). The complications were multiple fistula (n=3), fistula with anal stenosis (n=1), local recurrence with anal stenosis (n=1), and anal stenosis (n=7). Anal incontinence (Kirwan grade III) was noted in 14 patients, and bowel movements were observed more than six times per day in 16 patients. Overall recurrence occurred in six patients (13.6%). The 5-year survival rate was 85.3%, and the disease-free 5-year survival rate was 73.3%. Although CAA in patients with rectal cancer provides excellent long-term survival, a low risk of recurrence, and tolerable function, complications and poor functional outcomes of CAA do occur. Therefore, the choice of this method should be considered carefully.

Screening methods for high-grade dysplasia in patients with anal condyloma(1).
Papaconstantinou HT, Lee AJ, Simmang CL, Ashfaq R, Gokaslan ST, Sokol S, Huber PJ Jr, Gregorcyk SG
J Surg Res 2005 Jul 1;127(1):8-13.

Human papilloma virus (HPV) is one of the most common sexually transmitted diseases in the United States. HPV infection can cause anal condylomas and is a risk factor for dysplasia. High-grade dysplasia may progress to squamous cell carcinoma. Currently, biopsy and histological examination are required to grade dysplasia. The purpose of this study is to determine whether anal cytology, morphological characteristics, and/or the presence of high-risk oncogenic HPV-types are effective noninvasive methods to detect high-risk anal condylomas. PATIENTS AND METHODS: From November 2003 to June 2004, all patients with anal condyloma were prospectively evaluated for anal cytology, high-risk oncogenic HPV-types, and tissue biopsies. The Bethesda classification system was used to classify cytologic findings and histological examination, which were grouped as high-risk (HRL) and low-risk (LRL) lesions. Histology results served as true disease for all comparisons. RESULTS: Forty-seven patients with anal condyloma were studied; 43 (91.5%) were men, and the mean age was 39 +/- 11 years. Histology showed 19 (40.5%) patients with HRL, and 28 (59.5%) patients with LRL. Cytology correctly identified 8 patients with HRL and 27 patients with LRL (sensitivity 42% and specificity 96%). High-risk oncogenic HPV-types were found in 84.2% of HRL and 39.3% of LRL (P = 0.0029). Combining cytology with oncogenic HPV-testing, the sensitivity of detecting HRL increased to 89%, and specificity decreased to 42%. CONCLUSION: Anal cytology alone is not accurate for detecting HRL in patients with anal condylomas. Combining oncogenic HPV-testing with cytology is more sensitive in detecting HRL in patients with anal condyloma, and therefore, a more effective screening tool.

Anterior Resection of Rectal Cancer Through a One Hand-Size Incision with or without Laparoscopy: Proposal of One Hand-Size Incision Surgery (OHaSIS).
Yamaguchi Y, Minami K, Kawabuchi Y, Emi M, Toge T
J Surg Res 2005 Jun 14;.

BACKGROUND: One hand-size incision surgery (OHaSIS) is a surgery that is carried out through one hand-size incision with or without laparoscopy. Safety, feasibility and recovery advantage of the anterior resection of rectal cancer by the OHaSIS were studied. STUDY DESIGN: Nineteen consecutive patients with rectal cancer, consisting of seven rectosigmoid, six upper rectal, and six lower rectal cancers, were treated with anterior resection, including seven high, six low, three super-low, and three partial intersphincteric resections, through a suprapubic longitudinal one hand-size incision. The initial 11 patients were treated in combination with laparoscopy and the following eight patients were treated without laparoscopy. RESULTS: All anterior resections with mesorectal excision were completed in a safe manner with acceptable operative time (average 245 min), blood loss (average 280 g), and postoperative complications without any elongation of the initial incision. When compared with 12 previous high and low anterior resections by conventional open surgery (OS), the 13 high and low anterior resections by the OHaSIS showed equivalent operative time, blood loss, anastomotic procedures of single stapling, lymph node numbers dissected, surgical margin of the anal side of the tumor, and complications. Moreover, analysis of perioperative parameters for surgical invasiveness, including a body temperature >37 degrees C, days of bed rest, and days of use of parenteral narcotics, revealed a recovery advantage in the OHaSIS group compared with that in the OS group. CONCLUSIONS: These results suggest that anterior resection for patients with rectal cancer by the OHaSIS is safe, feasible, and less invasive than conventional OS, and has sufficient operative performance. Although the survival benefit and recurrence rate by this approach must be ensured in a future trial, we would like to propose the new concept of OHaSIS for treating rectal cancer.

Perianal abscesses due to ingested foreign bodies.
Delikoukos S, Zacharoulis D, Hatzitheofilou C
Int J Clin Pract 2005 Jul;59(7):856-7.

Summary Four cases of perianal abscesses due to foreign bodies (FBs) impacted in the anal canal are reported. The clinical presentation mimics common causes of acute anal pain. Digital rectal examination under local or general anaesthesia and/or proctoscopy can establish the diagnosis, but may miss the presence of an FB. Incision and drainage of the abscess along with removal of the FB results in immediate pain relief and long-term cure. Impacted FBs must not be overlooked as an unusual cause of perianal abscess.

Early results of a rotational flap to treat chronic anal fissures.
Singh M, Sharma A, Gardiner A, Duthie GS
Int J Colorectal Dis 2005 Jul;20(4):339-42. Epub 2004 Nov 20.

BACKGROUND: Treatment of anal fissures has changed dramatically in the past decade. Only a few fail to respond to medical therapy. Sphincterotomy and anal dilatation have fallen out of favour due to the risk of incontinence. Island flaps have been proposed to address this, but 60-70% of flap donor sites break down with complications. We proposed that using a rotational flap would overcome this problem.METHODS: Twenty-one patients (14 women,7 men) with chronic anal fissures were treated with rotation flap from perianal skin. The median age was 43 (range 21-76) years. All patients had failed chemical sphincterotomy and showed no signs of improvement following at least a 3-month course of topical GTN 0.2% ointment.RESULTS: The median hospital stay was 2 days. Seventeen patients had complete resolution of symptoms. Only one patient continued to have severe pain. Two developed a recurrent fissure. One patient had a combined fistula-fissure complex at diagnosis and suffered from a breakdown of the flap and donor site. Another patient had had haemorrhoidectomy and an advancement flap in the past. He developed problems with the donor site, which was successfully managed conservatively. One patient had persistent mild pain after surgery, but the cause could not be found. None of the patients suffered continence defects after surgery.CONCLUSION: Use of a rotational flap is a simple, safe and successful treatment for anal fissures. Donor site problems are minimised using this approach. It should be a treatment of choice when surgery is required for chronic anal fissures, particularly in patients in whom there is a risk of incontinence.

Genetic basis for increased intestinal permeability in families with Crohn's disease: role of CARD15 3020insC mutation?
Buhner S, Buning C, Genschel J, Kling K, Hermann D, Dignass A, Kuechler I, Krueger S, Schmidt HH, Lochs H
Gut 2005 Jul 6;.

A genetically impaired intestinal barrier function has long been suspected to be a predisposing factor for Crohn's disease (CD). Recently mutations of the CARD15 gene have been identified and associated with CD. We hypothesize that a CARD15 mutation may be associated with an impaired intestinal barrier. METHODS: We studied 128 patients with quiescent CD, 129 first degree relatives (CD-R), 66 non related household members (CD-NR), and 96 healthy controls. The three most common CARD15 polymorphisms (R702W, G908R, 3020insC) were analysed and the intestinal permeability was determined by the lactulose / mannitol ratio (PI). RESULTS: Intestinal permeability was significantly increased in CD and CD-R groups compared to CD-NR and controls. Values above the normal range were seen in 44% of CD and 26% of CD-R, but only in 6% of CD-NR, and in none of the controls. A household community with CD patients, representing a common environment, was not associated with increased intestinal permeability in family members. However, 40% of CD first degree relatives carrying a CARD15 3020insC mutation and 75% (3/4) of those CD-R with combined 3020insC and R702W mutations had increased intestinal permeability compared to only 15% of the wild-types, indicating a genetic influence on the barrier function. R702W and G908R mutations were not associated with a high permeability. CONCLUSIONS: In healthy first degree relatives a high mucosal permeability is associated with the presence of a CARD15 3020insC mutation. This indicates that genetic factors may be involved in the impairment of the intestinal barrier function in families with IBD.

5-aminosalicylate use and colorectal cancer risk in inflammatory bowel disease: a large epidemiological study.
van Staa TP, Card TR, Leufkens HG, Logan RF
Gut 2005 Jun 30;.

The objective of this study was to evaluate the risk of colorectal cancer (CRC) in patients taking aminosalicylates (5-ASA) for IBD. The General Practice Research Database (GPRD) which contains the primary care records of 5 million people in the UK was used to identify users of either mesalazine, balsalazide, olsalazine, or sulfasalazine with a history of IBD. In a nested case-control analysis, each incident CRC case with any use of a 5-ASA in the 6 months before the CRC diagnosis was matched by age, sex, and calendar time to six control patients who were also currently using a 5- ASA. Patients were then classified according to regularity of use. The analysis was controlled for body mass index, IBD duration, history of colorectal polyps, use of NSAIDs, paracetamol, aspirin, immunosuppressants, oral and rectal glucocorticoids, and prior GI hospitalization, recorded colonoscopy, or number of GP visits for IBD symptoms in the 6 to 24 months before diagnosis. The study population included 18,969 patients, of whom 100 patients had developed CRC during 5-ASA exposure. Most of these cases had a history of ulcerative colitis (76 patients). In the case-control analysis, regular users defined as having 6 or more 5-ASA prescriptions in the previous 12 months were found to have a decreased risk of CRC compared to irregular users (crude OR 0.67 [0.44-1.03]; adjusted OR 0.60 [0.38-0.96]). Regular users of sulfasalazine with 6 to 12 prescriptions before had an adjusted OR of 0.95 [0.22-4.11]; with 13 to 30 prior prescriptions this was 0.41 [0.14-1.20] and with > 30 prior prescriptions this was 0.77 [0.37-1.60]. For mesalazine users, these figures were 1.13 [0.49-2.59], 0.30 [0.11-0.83], and 0.31 [0.11-0.84], respectively. In conclusion, these results show that regular 5-ASA use is associated with some reduction in risk of CRC developing in ulcerative colitis.

The effect of physical activity and body size on survival after diagnosis with colorectal cancer.
Haydon AM, Macinnis R, English D, Giles G
Gut 2005 Jun 21;.

BACKGROUND: Physical inactivity and obesity increase the risk of colorectal cancer, but little is known about whether they influence prognosis after diagnosis. METHODS: Incident cases of colorectal cancer were identified among participants of the Melbourne Collaborative Cohort Study, a prospective cohort study of 41,528 Australians recruited from 1990 to 1994. Participants diagnosed with their first colorectal cancer between recruitment and August 1, 2002 were eligible. At the time of study entry, body measurements were taken and participants were interviewed about their physical activity. Information on tumor site and stage, treatments given, recurrences and deaths were obtained from systematic review of the medical records. RESULTS: 526 cases of colorectal cancer were identified. Median follow up among survivors was 5.5 years, and 208 deaths had occurred, including 181 from colorectal cancer. Exercise was shown to improve outcomes, whereas increasing percent body fat and waist circumference were associated with poorer survival. After adjusting for age, sex and tumor stage, exercisers had improved disease-specific survival (hazard ratio 0.73, 95 percent confidence interval 0.54 to 1.00). The benefit of exercise was largely confined to stage II-III tumors (hazard ratio 0.49, 95 percent confidence interval 0.30 to 0.79). Increasing percent body fat resulted in an increase in disease-specific deaths (hazard ratio 1.33 per 10 kg, 95 percent confidence interval 1.04 to 1.71). Similarly, increasing waist circumference reduced disease- specific survival (hazard ratio 1.20 per 10 cm, 95 percent confidence interval 1.05 to 1.37. CONCLUSIONS: Increased central adiposity and a lack of regular physical activity prior to the diagnosis of colorectal cancer is associated with poorer overall and disease-specific survival.

Randomised, controlled trial, of azathioprine and 5- aminosalicylic acid for treatment of steroid-dependent ulcerative colitis.
Ardizzone S, Maconi G, Russo A, Imbesi V, Colombo E, Bianchi Porro G
Gut 2005 Jun 21;.

BACKGROUND AND AIMS: There are limited evidence- based data concerning the use of azathioprine in ulcerative colitis. We aimed to compare the efficacy of azathioprine and oral 5-aminosalicylic acid in inducing remission of steroid-dependent ulcerative colitis. METHODS: 72 patients with steroid-dependent ulcerative colitis were admitted to this investigator- blind study. Steroid-dependence was defined as a requirement for steroid therapy at >/=10 mg/day during the preceding 6 months, with at least two attempts to discontinue the medication. The disease had to be clinically and endoscopically active at study entry, and all patients were taking systemic prednisolone (40 mg/day). Patients were randomized to receive azathioprine 2 mg/kg/day or oral 5-aminosalicylic acid, 3.2 g/day, for a 6-month follow-up period. The outcome of the treatment was defined as (1) success, indicating induction of clinical and endoscopic remission and steroid discontinuation, (2) failure, indicating the need for at least one further cycle of systemic steroids to control symptoms, apart from the initial one, or colectomy. RESULTS: Significantly more patients in the azathioprine than in the 5-aminosalicylic acid group had clinical and endoscopic remission, and discontinued steroid therapy, both at the intention-to-treat [azathioprine vs 5-aminosalicylic acid: 19/36 patients (53%) vs 7/36 (21%), OR = 4.78, 95%CI 1.57-14.5], and per protocol analysis [azathioprine vs 5-aminosalicylic acid: 19/33 patients (58%) vs 7/34 (21%), OR = 5.26; 95% CI 1.59-18.1]. CONCLUSIONS: Azathioprine is significantly more effective than 5-aminosalicylic acid in inducing clinical and endoscopic remission and avoiding steroid requirement in the treatment of steroid-dependent ulcerative colitis.

Small-bowel diverticulosis.
Cunningham SC, Gannon CJ, Napolitano LM
Am J Surg 2005 Jul;190(1):37-8.

Diffuse jejunoileal diverticulosis with pneumoperitoneum but without peritonitis is an uncommon but well-documented entity. Cases of jejunoileal diverticular perforation in which the perforation is evident are managed with resection of the diseased bowel and primary anastomosis. In the absence of an intraoperative finding of a perforation or an area of discrete inflammation, copious irrigation and closure of the abdomen is appropriate in cases of diffuse small-bowel diverticulosis.

Incidence and outcome of complications following restorative proctocolectomy.
Arai K, Koganei K, Kimura H, Akatani M, Kitoh F, Sugita A, Fukushima T
Am J Surg 2005 Jul;190(1):39-42.

BACKGROUND: Complications were analyzed in 296 patients with ulcerative colitis who underwent restorative proctocolectomy. METHODS: In 96.3% of patients, the pouch was anastomosed using the double stapling method. A total of 44.6% of patients underwent restorative proctocolectomy in 1 stage without ileostomy and 53% in 2 stages. Complications were divided into 2 stages: early (within 1 month) and late (after 1 month); moreover, the annual incidences were calculated, mean onset time, and pouch survival rate. RESULTS: The overall incidence of complications was 52.7%. Early complications (13.2%) occurred significantly less often than late complications (46.3%) (P < .05). Thirty-five (17.7%) of 198 complications required surgery. The cumulative 5- and 10-year pouch survival rate was 99%, respectively. CONCLUSIONS: The rate of complications after restorative proctocolectomy was almost equivalent to that in other reports, but the pouch survival rate was very high.

Evaluation of the Learning Curve in Laparoscopic Colorectal Surgery: Comparison of Right-Sided and Left-Sided Resections.
Tekkis PP, Senagore AJ, Delaney CP, Fazio VW
Ann Surg 2005 Jul;242(1):83-91.

OBJECTIVE: To provide a multidimensional analysis of the learning curve in major laparoscopic colonic and rectal surgery and compare outcomes between right-sided versus left-sided resections. SUMMARY BACKGROUND DATA: The laparoscopic learning curve is known to vary between surgeons, may be influenced by the patient selection and operative complexity, and requires appropriate case-mix adjustment. METHODS: This is a descriptive single-center study using routinely collected clinical data from 900 patients undergoing laparoscopic surgery between November 1991 and April 2003. Outcome measures included operation time, conversion rate (CR), and readmission and postoperative complication rates. Multifactorial logistic regression analysis was used to identify patient-, surgeon-, and procedure-related factors associated with conversion of laparoscopic to open surgery. A risk-adjusted Cumulative Sum (CUSUM) model was used for evaluating the learning curve for right and left-sided resections. RESULTS: The conversion rate for right-sided colonic resections was 8.1% (n = 457) compared with 15.3% for left-sided colorectal resections (n = 443). Independent predictors of conversion of laparoscopic to open surgery were the body mass index (BMI) (odds ratio [OR] = 1.07 per unit increase), ASA grade (OR = 1.63 per unit increase), type of resection (left colorectal versus right colonic procedures, OR = 1.5), presence of intra-abdominal abscess (OR = 5.0) or enteric fistula (OR = 4.6), and surgeon's experience (OR 0.9 per 10 additional cases performed). Having adjusted for case-mix, the CUSUM analysis demonstrated a learning curve of 55 cases for right-sided colonic resections versus 62 cases for left-sided resections. Median operative time declined with operative experience (P<0.001). Readmission rates and postoperative complications remained unchanged throughout the series and were not dependent on operative experience. CONCLUSIONS: Conversion rates for laparoscopic colectomy are dependent on a multitude of factors that require appropriate adjustment including the learning curve (operative experience) for individual surgeons. The laparoscopic model described can be used as the basis for performance monitoring between or within institutions.

The Modern Abdominoperineal Excision: The Next Challenge After Total Mesorectal Excision.
Marr R, Birbeck K, Garvican J, Macklin CP, Tiffin NJ, Parsons WJ, Dixon MF, Mapstone NP, Sebag-Montefiore D, Scott N, Johnston D, Sagar P, Finan P, Quirke P

Ann Surg 2005 Jul;242(1):74-82.
OBJECTIVES: Examine the cause of local recurrence (LR) and patient survival (S) following abdominoperineal resection (APR) and anterior resection (AR) for rectal carcinoma and the effect of introduction of total mesorectal excision (TME) on APR. METHODS: A total of 608 patients underwent surgery for rectal cancer in Leeds from 1986 to 1997. CRM status and follow-up data of local recurrence and patient survival were available for 561 patients, of whom 190 underwent APR (32.4%) and 371 AR (63.3%). Also, a retrospective study of pathologic images of 93 specimens of rectal carcinoma. RESULTS: Patients undergoing APR had a higher LR and lower survival (LR, 22.3% versus 13.5%, P = 0.002; S, 52.3% versus 65.8%, P = 0.003) than AR. LR free rates were lower in the APR group and cancer specific survival was lowered (LR, 66% versus 77%, log rank P = 0.03; S, 48% versus 59%, log rank P = 0.02). Morphometry: total area of surgically removed tissue outside the muscularis propria was smaller in APR specimens (n = 27) than AR specimens (n = 66) (P < 0.0001). Linear dimensions of transverse slices of tissue containing tumor, median posterior, and lateral measurements were smaller (P < 0.05) in the APR than the AR group. APR specimens with histologically positive CRM (n = 11) had a smaller area of tissue outside the muscularis propria (P = 0.04) compared with the CRM-negative APR specimens (n = 16). Incidence of CRM involvement in the APR group (41%) was higher than in the AR group (12%) (P = 0.006) in the 1997 to 2000 cohort. Similar results (36% and 22%) were found in the 1986 to 1997 cohort (P = 0.002). CONCLUSIONS: Patients treated by APR have a higher rate of CRM involvement, a higher LR, and poorer prognosis than AR. The frequency of CRM involvement for APR has not diminished with TME. CRM involvement in the APR specimens is related to the removal of less tissue at the level of the tumor in an APR. Where possible, a more radical operation should be considered for all low rectal cancer tumors.

Perspectives on Vacuum-Assisted Closure Therapy in Pilonidal Sinus Surgery.
Winter D
Dis Colon Rectum 2005 Jun 24;.

Stem cell factor (SCF) and interleukin 3 (IL-3) in the sera of patients with colorectal cancer.
Mroczko B, Szmitkowski M, Wereszczynska-Siemiatkowska U, Okulczyk B
Dig Dis Sci 2005 Jun;50(6):1019-24.
For a long time markers that can detect a malignant cell transformation as early as possible have been sought. Substances which have been discovered are known as tumor markers. Stem cell factor (SCF) and interleukin 3 (IL-3) are members of a group of glycoprotein growth factors called hematopoietic cytokines (HCs). These factors take part in the regulation of developmental processes of hematopoietic progenitor cells and it was proved that HCs can be produced by different cancer cells, including colorectal cancer. The aim of this study was to investigate a potential role for SCF and IL-3 as tumor markers for colorectal cancer. We compared the serum levels of SCF and IL-3 in colorectal cancer patients with those in healthy subjects (control group) and commonly accepted tumor markers, such as carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9). We defined the diagnostic sensitivity, specificity, positive predictive value, negative predictive value, and receiver-operating characteristics (ROC) curve of tested substances. SCF and IL-3 were determined using enzyme-linked immunosorbent assay (ELISA). CEA and CA 19-9 were measured by microparticle enzyme immunoassay. The serum levels of HCs and tumor markers were investigated in 75 patients with colorectal cancer and in 40 healthy subjects. There were significant differences in the level of circulating SCF and IL-3 in the colorectal cancer patients compared to the control group. Moreover, the diagnostic sensitivity of SCF was higher than the sensitivity of CEA and CA 19-9. The SCF area under the ROC curve was larger than the IL-3 area but smaller than the CEA and CA 19-9 areas. The diagnostic specificities of cytokines were lower than those of tumor markers, but the combined use of cytokines and tumor markers increased the diagnostic values. The highest values of diagnostic parameters were observed for the combined use of SCF and CA 19-9. These results suggest a potential role for SCF and IL-3 as tumor markers for colorectal cancer, especially in combination with CEA or CA 19-9.

Guided Imagery and Relaxation in Conventional Colorectal Resections: A Randomized, Controlled, Partially Blinded Trial.
Haase O, Schwenk W, Hermann C, Muller JM
Dis Colon Rectum 2005 Jun 27;.

PURPOSE: The aim of this study was to investigate whether brief psychologic interventions to reduce perioperative stress may improve the postoperative course of patients undergoing abdominal surgery. METHODS: We used a randomized, controlled, partially blinded trial to evaluate the differential effectiveness of two brief psychologic interventions (guided imagery and progressive muscle relaxation) on analgesic requirement, pain perception, pulmonary function, duration of postoperative ileus, and fatigue after conventional resection of colorectal carcinoma in elderly cancer patients. RESULTS: Sixty patients (20 guided imagery, 22 relaxation, 18 control) were evaluated. Acceptance of the brief psychologic interventions was high and 90 percent of the patients indicated that they would recommend it to other patients. Analgesic consumption (P = 0.6) and subjective pain intensity at rest (P = 0.3) and while coughing (P = 0.3) were not different between groups. Recovery of pulmonary function, duration of postoperative ileus, and subjective postoperative fatigue were also not influenced. When the data from intervention groups were pooled, again no benefits were detected compared with the control group. CONCLUSIONS: Brief psychologic interventions such as guided imagery and relaxation yielded a very positive patient response but did not show a clinically relevant influence on the postoperative physiologic course of elderly patients undergoing conventional resections of colorectal cancer.

Tumor Site Predicts Outcome After Radiochemotherapy in Squamous-Cell Carcinoma of the Anal Region: Long-Term Results of 101 Patients.
Grabenbauer GG, Kessler H, Matzel KE, Sauer R, Hohenberger W, Schneider IH
Dis Colon Rectum 2005 Jun 29;.

PURPOSE: This study was designed to assess the long-term results following radiochemotherapy in patients with anal squamous-cell carcinoma and to evaluate the impact of tumor location on response, survival, and colostomy-free survival. PATIENTS AND METHODS: Between 1985 and 2001, a total of 101 patients with anal carcinoma were registered for curative treatment, of whom 77 had involvement of the anal canal alone, 10 cases had extension into the perianal skin, and 14 patients had pure anal margin tumors. Small tumors of the anal margin were not included since they were treated by surgical excision only. Among the 101 patients were 74 women and 27 men with a median age of 62 (range, 26-84) years. T categories (International Union against Cancer) were T1 (15), T2 (36), T3 (34), and T4 (16). Seventy-one patients had no evidence of nodal disease, whereas 30 presented with involved regional nodes. Radiation treatment was directed to the primary tumor region and to the inguinal, perirectal, and internal iliac nodes using a three-field to four-field box technique with 10MV photons up to a total dose of 5040 cGy. Lesions greater than 5 cm received an additional boost by interstitial or external radiation depending on circumferential extension of the residual tumor. All patients were scheduled for simultaneous chemotherapy with two cycles of 5-fluorouracil at a dose of 1000 mg/m (2)/day as 120 hours of continuous intravenous infusion on Days 1 to 5 and 29 to 33 and mitomycin C at 10 mg/m (2)/day on Days 1 and 29. Median follow-up time was was 7.5 (range, 1-16) years. RESULTS: Overall survival and colostomy-free survival rates for patients with anal canal cancer were 75 percent and 87 percent at five years, respectively. Patients with anal margin cancer had a less favorable outcome with five-year-overall and colostomy-free survival rates of 54 percent and 69 percent, respectively. After correction for imbalance between anal canal and anal margin tumors, i.e., exclusion of T1 tumors of the anal canal, difference in overall survival remained significant (73 percent vs. 54 percent, P = 0.01). Following multivariate analysis, tumor location (anal canal vs. anal margin, P = 0.02), age (P = 0.003), and dose intensity of chemotherapy (</=75 percent vs. >75 percent, P = 0.03) remained independent significant factors for overall survival. Initial tumor response at six weeks (P = 0.03) was predictive for colostomy-free survival. CONCLUSIONS: With colostomy-free survival rates around 85 percent, long-term treatment results for anal canal carcinoma have reached a satisfactory level. However, patients with larger lesions of the perianal skin are at high risk for locoregional recurrence and possible treatment intensification in this subgroup seems desirable.

Integrity of the Anal Sphincters After Pouch-Anal Anastomosis: Evaluation With Three-Dimensional Endoanal Ultrasonography.
Gosselink MP, West RL, Kuipers EJ, Hansen BE, Schouten WR
Dis Colon Rectum 2005 Jun 6;.

PURPOSE: The aim of the present study was to assess the integrity of the anal sphincters after handsewn pouch-anal anastomosis performed with the help of a Scott retractor. For this purpose the anal sphincters were visualized with three-dimensional endoanal ultrasonography. METHODS: Patients undergoing a colonic pouch-anal anastomosis or an ileal pouch-anal anastomosis were included. Before and six months after the procedure, the length and volume of both sphincters were assessed with three-dimensional endoanal ultrasonography, and anal manometry was performed. Continence scores were determined using the Fecal Incontinence Severity Index (FISI). RESULTS: Fifteen patients with a colonic pouch and 13 patients with an ileal pouch were examined. Six months after the procedure, three-dimensional endoanal ultrasonography showed significant alterations of the internal anal sphincter in eight patients with a colonic pouch-anal anastomosis (53 percent) and in eight patients with an ileal pouch-anal anastomosis (62 percent). These alterations were characterized by asymmetry or thinning. No defects were seen in the colonic pouch group, but, in two patients with an ileal pouch, a small defect in the internal anal sphincter was found. A decrease in internal anal sphincter volume was seen only in patients with a colonic pouch-anal anastomosis (P = 0.009). In both groups the length of the internal anal sphincter and the length, thickness, and volume of the external anal sphincter remained the same. After the procedure a reduction of maximum anal resting pressure was found in both groups (colonic pouch: P < 0.001, ileal pouch: P = 0.001). Maximum anal squeeze pressure was reduced in only patients with an ileal pouch-anal anastomosis (P = 0.006). The observed alterations of the internal anal sphincter and the manometric findings showed no correlation with the postoperative Fecal Incontinence Severity Index scores. CONCLUSION: Handsewn pouch-anal anastomosis, performed with the help of a Scott retractor, only rarely leads to internal anal sphincter defects, but three-dimensional endoanal ultrasonography shows alterations of the internal anal sphincter in 57 percent of the patients. No correlation was observed between these alterations and the functional outcome.

Tumors of the Retrorectal Space.
Hobson KG, Ghaemmaghami V, Roe JP, Goodnight JE, Khatri VP
Dis Colon Rectum 2005 Jun 24;.

PURPOSE: Retrorectal tumors are a diverse group of masses derived from a variety of embryologic origins. Because of this, some confusion is associated with their diagnosis and management. Although rare, a basic understanding of the etiology, presentation, work-up, and treatment of retrorectal masses is essential. METHODS: The incidence, classification, diagnosis, treatment, and prognosis of these masses are presented. A comprehensive review of the literature is included in our analysis. RESULTS: Retrorectal lesions can be classified as congenital, inflammatory, neurogenic, osseous, or miscellaneous. Benign and malignant lesions behave similarly. The most common presentation is an asymptomatic mass discovered on routine rectal examination, but certain nonspecific symptoms can be elicited by careful history. Biopsy of these lesions should be avoided to prevent tumor seeding, fecal fistula, meningitis, and abscess formation. Complete surgical resection, usually after appropriate specialized imaging, remains the cornerstone of their treatment. Three approaches commonly used for resection are abdominal, transsacral, or a combined abdominosacral approach. Prognosis is directly related primarily to local control, which often is difficult to achieve for malignant lesions. CONCLUSIONS: Retrorectal masses present a challenging surgical problem from diagnosis to treatment. A high index of suspicion and resultant early diagnosis, followed by thorough preoperative planning, is required for optimal management and outcome.

Mechanical Bowel Preparation or Not? Outcome of a Multicenter, Randomized Trial in Elective Open Colon Surgery.
Fa-Si-Oen P, Roumen R, Buitenweg J, van de Velde C, van Geldere D, Putter H, Verwaest C, Verhoef L, de Waard JW, Swank D, D'Hoore A, Croiset van Uchelen F
Dis Colon Rectum 2005 Jun 7;.

PURPOSE: Mechanical bowel preparation is common practice in elective colon surgery. In recent literature the value of this procedure is under discussion. To verify the value of mechanical bowel preparation in elective open colon surgery, a randomized clinical trial was conducted. METHODS: During a prospective, multicenter, randomized study, 250 patients undergoing elective open colon surgery were randomized between receiving mechanical bowel preparation with polyethylene glycol (PEG group, 125 patients) and having a normal meal preoperatively (normal meal preoperatively group, 125 patients). Outcome parameters were wound infection with bacterial results of intraoperative swabs and anastomotic leak. RESULTS: In the polyethylene glycol group there were a total of nine wound infections (7.2 percent) and seven anastomotic leaks (5.6 percent) compared with seven wound infections (5.6 percent) (P = 0.61) and six anastomotic leaks (4.8 percent) (P = 0.78) in the normal meal preoperatively group. Bacterial results showed 52 percent sterile subcutis swabs in the PEG group and 63 percent sterile subcutis swabs in the normal meal preoperatively group (P = 0.11). CONCLUSION: In the pres-ent study we could not detect a difference in outcome parameters between patients receiving mechanical bowel preparation in elective open colon surgery and patients without preoperative treatment of the bowel. The present study, although underpowered, did not show a difference in the primary outcome of bacterial wound cultures between patients receiving preoperative mechanical bowel preparation and patients receiving no preoperative bowel treatment. We conclude that there may be no need to continue the use of mechanical bowel preparation in elective open colon surgery.

Delayed Treatment for Rectal Cancer.
Ristvedt SL, Birnbaum EH, Dietz DW, Fleshman JW, Kodner IJ, Read TE
Dis Colon Rectum 2005 Jun 16;.

PURPOSE: Reports of the relationship between length of delay before diagnosis of rectal cancer and stage of the disease have been mixed. The present study documented the magnitude and medical ramifications of delay in diagnosing rectal cancer. METHODS: One hundred twenty patients who had been recently diagnosed with rectal cancer provided information regarding history of symptoms and initial perceptions of those symptoms. Patients also estimated the time elapsed from onset of symptoms until their first consultation with a physician, as well as time elapsed from consultation until the diagnosis of rectal cancer was made. Stage information was gathered from patient charts. RESULTS: For 106 of the patients, the first sign of rectal cancer was in the form of symptoms, and the most common first symptom was rectal bleeding. For the remaining 14 patients, their cancer was first discovered through routine examination. Over 75 percent of patients with symptoms did not initially believe that they were caused by cancer or any other serious problem, and over 50 percent attributed their symptoms to hemorrhoids. There was a clear trend, albeit statistically nonsignificant, toward worsening disease with longer delays. Median delay times in weeks were Stage I (10.0 weeks), Stage II (14.0 weeks), Stage III (18.5 weeks), and Stage IV (26.0 weeks). CONCLUSIONS: Delayed diagnosis for rectal cancer remains a significant problem, with instances of delay attributable to both patient and physician. Delayed diagnosis can result in more serious disease and, when attributable to the physician, can result in damaged trust and sometimes legal action.

Bowel Preparation Is Associated With Spillage of Bowel Contents in Colorectal Surgery.
Mahajna A, Krausz M, Rosin D, Shabtai M, Hershko D, Ayalon A, Zmora O
Dis Colon Rectum 2005 Jun 16;.

PURPOSE: Infectious complications pose a significant cause of morbidity in colon and rectal surgery. This study was designed to
assess the effect of bowel preparation on spillage of bowel contents into the peritoneal cavity during colorectal surgery, and its potential effect on the rate of postoperative infectious complications. METHODS: The quality of bowel preparation and the incidence of spillage of bowel contents were prospectively assessed in patients undergoing elective colon and rectal resection. The patients were followed for 30 days for postoperative infectious and noninfectious complications. RESULTS: A total of 333 patients were included in this study, of which 181 did not receive mechanical bowel preparation. Intraoperative spillage of bowel contents occurred in 48 patients (14 percent), whereas in 285 patients (86 percent), spillage did not occur. There was a trend toward a higher rate of overall surgical infectious and noninfectious complications in patients who had spillage of bowel contents compared with patients without spillage; however, this difference was not statistically significant (18.7 vs. 11 percent, and 29 vs. 19 percent, respectively). Preoperative mechanical bowel preparation and colocolonic or colorectal anastomosis was associated with a higher rate of bowel contents spillage, although this difference did not reach statistical significance. Liquid colonic contents caused significantly higher rates of spillage. CONCLUSIONS: Spillage of bowel contents into the peritoneal cavity during colon and rectal surgery may increase the rate of postoperative infectious complications. In addition, inadequate mechanical bowel preparation, leading to liquid bowel contents, increases the rate of intraoperative spillage.

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