Basic Sciences, Miscellaneus : Coloproctology

Celecoxib for the prevention of colorectal adenomatous polyps.
Arber N, Eagle CJ, Spicak J, Racz I, Dite P, Hajer J, Zavoral M, Lechuga MJ, Gerletti P, Tang J, Rosenstein RB, Macdonald K, Bhadra P, Fowler R, Wittes J, Zauber AG, Solomon SD, Levin B
N Engl J Med. 2006 Aug 31;355(9):885-95.

BACKGROUND: Overexpression of cyclooxygenase 2 (COX-2) has been associated with colorectal adenomatous polyps and cancer, prompting researchers to propose its inhibition as a chemopreventive intervention. METHODS: The Prevention of Colorectal Sporadic Adenomatous Polyps trial was a randomized, placebo-controlled, double-blind study of the COX-2 inhibitor celecoxib given daily in a single 400-mg dose. At 107 centers in 32 countries, we randomly assigned 1561 subjects who had had adenomas removed before enrollment to receive celecoxib (933 subjects) or placebo (628 subjects) daily, after stratification according to the use or nonuse of low-dose aspirin. The primary outcome was detection of adenomas at either year 1 or year 3 by colonoscopy and was compared among the groups with the use of the Mantel-Cox test. RESULTS: Colonoscopies were performed at year 1 on 88.7 percent of the subjects who had undergone randomization and at year 3 on 79.2 percent. Of the 557 subjects in the placebo group and the 840 subjects in the celecoxib group who were included in the efficacy analysis, 264 and 270, respectively, were found to have at least one adenoma at year 1, at year 3, or both. The cumulative rate of adenomas detected through year 3 was 33.6 percent in the celecoxib group and 49.3 percent in the placebo group (relative risk, 0.64; 95 percent confidence interval, 0.56 to 0.75; P<0.001). The cumulative rate of advanced adenomas detected through year 3 was 5.3 percent in the celecoxib group and 10.4 percent in the placebo group (relative risk, 0.49; 95 percent confidence interval, 0.33 to 0.73; P<0.001). Adjudicated serious cardiovascular events occurred in 2.5 percent of subjects in the celecoxib group and 1.9 percent of those in the placebo group (relative risk, 1.30; 95 percent confidence interval, 0.65 to 2.62). CONCLUSIONS: The use of 400 mg of celecoxib once daily significantly reduced the occurrence of colorectal adenomas within three years after polypectomy. (ClinicalTrials.gov number, NCT00141193 [ClinicalTrials.gov].).

Systemic treatment of patients who have colorectal cancer and inflammatory bowel disease.
Goessling W, Mayer RJ
Gastroenterol Clin North Am. 2006 Sep;35(3):713-27.

Cancer in Crohn's disease.
Friedman S
Gastroenterol Clin North Am. 2006 Sep;35(3):621-39.

Surveillance for Cancer and Dysplasia in Inflammatory Bowel Disease.
Rubin DT, Kavitt RT
Gastroenterol Clin North Am. 2006 Sep;35(3):581-604.

Natural history and management of flat and polypoid dysplasia in inflammatory bowel disease.
Bernstein CN
Gastroenterol Clin North Am. 2006 Sep;35(3):573-9.

Molecular biology of dysplasia and cancer in inflammatory bowel disease.
Itzkowitz SH
Gastroenterol Clin North Am. 2006 Sep;35(3):553-71.

Pathology of dysplasia and cancer in inflammatory bowel disease.
Odze RD
Gastroenterol Clin North Am. 2006 Sep;35(3):533-52.

Epidemiology and risk factors for colorectal dysplasia and cancer in ulcerative colitis.
Loftus EV Jr
Gastroenterol Clin North Am. 2006 Sep;35(3):517-31.

Long-Term Functional and Quality of Life Outcomes After Coloanal Anastomosis for Distal Rectal Cancer.
Hassan I, Larson DW, Cima RR, Gaw JU, Chua HK, Hahnloser D, Stulak JM, O'byrne MM, Larson DR, Wolff BG, Pemberton JH
Dis Colon Rectum. 2006 Aug 18;.

PURPOSE: This study was designed to evaluate the long-term functional and quality-of-life outcomes of patients after coloanal anastomosis for distal rectal cancer. METHODS: A total of 192 patients underwent coloanal anastomosis between 1982 and 2001 at two tertiary referral institutions. Standardized and validated questionnaires to assess functional and quality-of-life outcomes were mailed to 151 patients, of which 121 patients responded (median follow-up, 65 months). RESULTS: Patients receiving pelvic radiotherapy had more bowel function problems than patients who did not receive pelvic radiotherapy. No significant differences in relevant functional and quality-of-life outcomes were seen among patients who received preoperative or postoperative pelvic radiotherapy. Patients requiring permanent diversion as a result of complications of the surgery had decreased quality of life. CONCLUSIONS: Coloanal anastomosis for distal rectal cancer has favorable long-term outcomes. Pelvic radiotherapy has an adverse effect on subsequent bowel function (whether given preoperatively or postoperatively) in patients who maintain intestinal continuity. Loss of intestinal continuity after a coloanal anastomosis is associated with diminished quality of life.

Colorectal Mucinous Adenocarcinoma: The Clinicopathologic Features and Significance of p16 and p53 Expression.
King-Yin Lam A, Ong K, Ho YH
Dis Colon Rectum. 2006 Aug 17;.

PURPOSE: This study was designed to examine the clinicopathologic features and p53 and p16 expressions in colorectal mucinous adenocarcinoma and colorectal signet-ring cell carcinoma. METHODS: The clinicopathologic features of 36 patients with colorectal mucinous adenocarcinoma and colorectal signet-ring cell carcinoma were analyzed and compared with 228 patients with colorectal adenocarcinomas. The p53 and p16 expressions in the colorectal mucinous adenocarcinoma and colorectal signet-ring cell carcinoma were studied by immunohistochemistry. RESULTS: Colorectal mucinous adenocarcinoma and colorectal signet-ring cell carcinoma accounted for 14 percent of colorectal cancer. The median age at presentation was 67 years. Family history of colorectal cancer in their first-degree relatives was seen in 14 percent of these patients. Fifty-six percent of the carcinomas were located in the proximal colorectum, most commonly in the transverse colon. Two patients had ulcerative colitis. Compared with the usual colorectal adenocarcinoma, colorectal mucinous adenocarcinoma and colorectal signet-ring cell carcinoma was found more often in proximal colorectum (P = 0.002), larger (P = 0.05), and in advanced stages (P = 0.018). Forty-four percent (n = 16) of the colorectal mucinous adenocarcinoma and colorectal signet-ring cell carcinoma showed p53 expression. All the patients with colorectal mucinous adenocarcinoma and colorectal signet-ring cell carcinoma with a positive family history of colorectal adenocarcinoma had tumors that showed p53 expression (P = 0.012). Seventy-eight percent (n = 28) of the tumors showed p16 expression. The median survival of the patients with these tumors was 23 months. The survival of these patients with colorectal mucinous adenocarcinoma and colorectal signet-ring cell carcinoma was poorer if the lesions were of advanced stages (P = 0.023) or with family history of colorectal cancer (P = 0.0015). Also, patients with colorectal mucinous adenocarcinoma and colorectal signet-ring cell carcinoma that did not express p16 and p53 had better survival than other patients (P = 0.04). CONCLUSIONS: Colorectal mucinous adenocarcinoma and colorectal signet-ring cell carcinoma had distinctive clinicopathologic features. Tumor staging, family history of colorectal cancer, and status of p53 and p16 expressions might predict prognosis in these patients.

[Perianal and rectal impalement injuries.]
Joos AK, Herold A, Palma P, Post S
Chirurg. 2006 Aug 4;.

Perianal impalement injuries with or without involvement of the anorectum are rare. Apart from a high variety of injury patterns, there is a multiplicity of diagnostic and therapeutic options. Causes of perianal impalement injury are gunshot, accidents, and medical treatment. The diagnostic work-up includes digital rectal examination followed by rectoscopy and flexible endoscopy under anaesthesia. We propose a new classification for primary extraperitoneal perianal impalement injuries in four stages in which the extension of sphincter and/or rectum injury is of crucial importance. Therapeutic aspects such as wound treatment, enterostomy, drains, and antibiotic treatment are discussed. The proposed classification encompasses recommendations for stage-adapted management and prognosis of these rare injuries.

A 10-year review of surgery for desmoid disease associated with familial adenomatous polyposis.
Latchford AR, Sturt NJ, Neale K, Rogers PA, Phillips RK
Br J Surg. 2006 Sep 4;.

BACKGROUND:: Desmoid tumours affect 10-25 per cent of patients with familial adenomatous polyposis and represent a major cause of morbidity and mortality. Surgery for intra-abdominal desmoids has traditionally been used as a last resort or to manage obstructive complications. The aim was to review 10 years of desmoid surgery in patients with familial adenomatous polyposis from a single centre. METHODS:: Patients who had surgery for desmoid disease between 1994 and 2004 were identified from the Polyposis Registry database and their hospital notes reviewed. RESULTS:: Twenty patients had surgery to remove 32 desmoid tumours (16 intra-abdominal, 12 abdominal wall, four extra-abdominal). Complete clearance was achieved in 19 tumours and, of these, clinically significant recurrence occurred in eight. There was no difference in recurrence rates for site or sex. There was no operative mortality. Intra-abdominal desmoid resection was associated with a mean resection of 45.55 (range 10-200) cm of small bowel. One patient required long-term parenteral feeding. Median follow-up was 5 (range 0.6-10) years. During this period, one patient died (metastatic duodenal cancer); there was no mortality from desmoid disease. CONCLUSION:: Surgery for intra-abdominal desmoids in selected patients is less hazardous than previously reported. Surgery for abdominal wall and extra-abdominal tumours is safe. However, disease recurrence remains a major problem. Copyright (c) 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Mammary Type Tubulolobular Carcinoma of the Anogenital Area: Report of a Case of a Unique Tumor Presumably Originating in Anogenital Mammarylike Glands.
Kazakov DV, Belousova IE, Sima R, Michal M
Am J Surg Pathol. 2006 Sep;30(9):1193-1196.

We present a case of an unusual tumor that occurred in the perianal area of a 64-year-old woman. Clinical investigation revealed no tumor elsewhere. The lesion was removed and the patient is alive without signs of metastasis or recurrence 5.5 years after surgery. Histopathologically, the neoplasm was composed of single-cell cords of uniform round to ovoid cells intermixed with round to elongated tubules showing decapitation secretion at the luminal border. The tubules were mainly composed of a single cell layer, but focally multilayered epithelium (without evidence of myoepithelial cell differentiation) was seen as well as discrete cribriform structures and intraluminal bridges. Overall, the cell cord component slightly dominated over the tubular component, and the two were intermixed. A vague targetoid arrangement of the cell cords was seen focally. Immunohistochemically, the tumor cells in both components reacted positively for E-cadherin, 34betaE12, estrogen receptors and progesterone receptor and were negative for HER2/neu (c-erbB-2). There was no evidence of myoepithelial cell differentiation with calponin. We believe that the present case is best classified as mammary type tubulolobular carcinoma and, given the location, the origin in anogenital mammary-like glands most likely.

Adenosquamous carcinoma of the colon: a rare tumor.
Kiran RP, Tripodi G, Frederick W, Dudrick SJ
Am Surg. 2006 Aug;72(8):754-5.

Adenosquamous carcinoma of the colon is rare. A paraneoplastic syndrome presenting as hypercalcemia may occasionally occur in association with these tumors. Survival for more advanced stages of disease is lower than for patients with adenocarcinoma at a corresponding stage. We report a patient who presented with a primary adenosquamous carcinoma of the rectosigmoid junction and we review the literature regarding the clinical presentation, management, and prognosis of this tumor.

The long-term results of diltiazem treatment for anal fissure.
Nash GF, Kapoor K, Saeb-Parsy K, Kunanadam T, Dawson PM
Int J Clin Pract. 2006 Aug 15;.

The effects of diltiazem treatment on symptoms of chronic anal fissures and their long-term outcome were investigated. One hundred and twelve patients were supplied with 6-week course of 2% diltiazem cream for twice-daily topical application. The medical notes and extended follow-up by telephone for 112 patients were recorded and statistically analysed. The success rate and satisfaction of topical diltiazem were each over two thirds. Nearly 80% of patients reported no adverse effects, and it seems that those complaints attributed to diltiazem rarely led to reduced compliance. After diltiazem therapy for fissure, 59% of patients required further treatment (medical and/or surgical) over the average 2-year period of follow-up. The reported adverse effects of topical diltiazem treatment in patients with anal fissures were more common than previously thought, although compliance was rarely affected. During consultation regarding the advantages and disadvantages of surgical vs. chemical sphincterotomy, patients should be aware that the majority of patients receiving diltiazem as the primary treatment for anal fissure subsequently require further treatment.

Colorectal cancer screening in Health Examination Centers.
Steinmetz J, Spyckerelle Y, Gueguen R, Dupre C
Gastroenterol Clin Biol. 2006 Jun-Jul;30(6-7):832-7.

OBJECTIVES: The aim of this study was to describe the results of colorectal cancer screening performed in the Health Examination Centers of the French general health insurance system. METHODS: The population consisted of 1,262,833 subjects (52.6% men) aged 50 to 74 years old who attended periodic health consultations from 1998 to 2003 in 89 Health Examination Centers in France. Subjects with increased risk for colorectal cancer and subjects with a positive fecal occult blood test (Hemoccult II') were invited to undergo colonoscopy. Subsequent follow-up and diagnostic data were collected. RESULTS: Prior screening practices for colorectal cancer (recent colonoscopy or fecal occult blood test, local screening campaign) were noted in 18% of the subjects attending Health Examination Center consultations. High risk for colorectal cancer (familial or personal factor) without ongoing surveillance or prior screening was observed in 3% of the study population. A fecal occult blood test was proposed to 79% of the population and of them, 89% effectively performed the test: 3.2% of tests were positive. A follow-up protocol was initiated for 63,357 subjects. A colonic exploration was performed in 69% of high-risk subjects and enabled detection of cancer in 85 and adenomas in 1683. A colonic exploration was performed in 88% of subjects with a positive fecal occult blood test and enabled detection of 674 cancers (positive predictive value of fecal occult blood test (PPV)=4.7%) including 174 Dukes A, and 2618 adenomas (PPV=18%) including 776 adenomas measuring more than 10 mm (PPV=5.4%). CONCLUSION: This study confirms the importance of implementing organized screening practices within Health Examination Centers before undertaking a generalized screen campaign targeting the entire French population.

New techniques in the treatment of common perianal diseases: stapled hemorrhoidopexy, botulinum toxin, and fibrin sealant.
Singer M, Cintron J
Surg Clin North Am. 2006 Aug;86(4):937-67.

Labial flap: a versatile tool in the repair of recurrent perineal canal defects.
Chacko J, Sen S, Karl S, Mathai J
Pediatr Surg Int. 2006 Aug 15;.

Perineal canal, a not so uncommon deformity in Asian countries, sometimes breaks down after the usual techniques of repair. The labial pad of fat with its vascular supply provides good tissue for interposition between the rectal and perineal suture lines in these cases, with good results.

Acupuncture and moxibustion in the treatment of ulcerative colitis: A randomized controlled study.
Joos S, Wildau N, Kohnen R, Szecsenyi J, Schuppan D, Willich SN, Hahn EG, Brinkhaus B
Scand J Gastroenterol. 2006 Sep;41(9):1056-63.

Objective. Acupuncture has traditionally been used in the treatment of inflammatory bowel disease in China and is increasingly applied in Western countries. The objective of this study was to investigate the efficacy of acupuncture and moxibustion in the treatment of active ulcerative colitis (UC). Material and methods. In a prospective, randomized, controlled clinical trial 29 patients with mild to moderately active UC (mean age 37.8+/-12.0 years) were randomly assigned to receive either traditional acupuncture and moxa (TCM group, n=15), or sham acupuncture consisting of superficial needling at non-acupuncture points (control group, CG, n = 14). All patients were treated in 10 sessions over a period of 5 weeks and followed-up for 16 weeks. The main outcome measure was the change in the Colitis Activity Index (CAI) after treatment; secondary outcome measures were changes in quality of life, general well-being and serum markers of inflammation. Results. In the TCM group, the CAI decreased from 8.0 (+/-3.7) to 4.2 (+/-2.4) points and in the control group from 6.5 (+/-3.4) to 4.8 (+/-3.9) points (TCM versus CG: p=0.048). In both groups these changes were associated with significant improvements in general well-being (TCM group: from 3.0 (+/-1.8) to 1.8 (+/-1.0); CG: from 3.2 (+/-1.9) to 2.2 (+/-1.7)) and quality of life (TCM group: from 146 (+/-23) to 182 (+/-18); CG: from 157 (+/-20) to 183 (+/-23)). No significant differences between the TCM and CG were found regarding these secondary outcome measures. Conclusions. Differences in efficacy between traditional acupuncture and sham acupuncture were small and significant only for CAI as the main outcome measure. Both traditional and sham acupuncture seem to offer an additional therapeutic benefit in patients with mild to moderately active UC.

Collagenase-3 (MMP-13) expression by inflamed mucosa in inflammatory bowel disease.
Vizoso FJ, Gonzalez LO, Corte MD, Corte MG, Bongera M, Martinez A, Martin A, Andicoechea A, Gava RR
Scand J Gastroenterol. 2006 Sep;41(9):1050-5.

Objective. To determine whether the expression of collagenase-3 (MMP-13) in biopsies from patients with inflammatory bowel disease is correlated with histological inflammation parameters. Material and methods. Fifty-nine patients with inflammatory bowel disease were included in the study. The control group comprised 20 patients free of inflammatory disease and ten patients with acute diverticulitis. MMP-13 expression was determined by immunohistochemical staining and the specimens were assigned a histological inflammation score. Results. It was found that 62.8% of patients with ulcerative colitis (UC) and 54.1% of patients with Crohn's disease (CD) showed MMP-13-positive immunostaining in biopsies from affected areas. MMP-13-positive staining was more intense in ulcerated colonic mucosa. A positive and significant correlation was found between MMP-13 expression and the histological inflammation scores in mucosal samples from patients with CD (r=0.74, p<0.0001) or UC (r=0.62, p<0.0001). However, no MMP-13-positive immunostaining was found in either the biopsy specimens of the control group or those biopsies taken from patients with UC or CD in microscopically confirmed non-affected areas of the colonic mucosa. Similarly, colonic mucosa samples of the 10 patients with acute diverticulitis did not show immunostaining for MMP-13. Conclusions. Our findings demonstrating the absence of MMP-13 expression in non-inflamed colonic mucosa or in acute diverticulitis, as well as a positive correlation between elevated MMP-13 expression and histological criteria of inflammation in patients with inflammatory bowel diseases (CD and UC) suggest a role of the protease in the pathogenesis of these latter processes.

Small-bowel permeability in collagenous colitis.
Wildt S, Madsen JL, Rumessen JJ
Scand J Gastroenterol. 2006 Sep;41(9):1044-9.

Objective. Collagenous colitis (CC) is a chronic inflammatory bowel disease that affects the colon. However, some patients with CC present with accompanying pathologic small-bowel manifestations such as coeliac disease, defects in bile acid absorption and histopathologic changes in small-intestinal biopsies, indicating that CC is a pan-intestinal disease. In small-intestinal disease, the intestinal barrier function may be impaired, and the permeability of the small intestine altered. The purpose of this research was to study small-bowel function in patients with CC as expressed by intestinal permeability. Material andmethods. Ten patients with CC and chronic diarrhoea participated in the study. Coeliac disease was excluded by small-bowel biopsy and/or serology. Intestinal permeability was assessed as urinary excretion (ratios) 2, 4 and 6 h after ingestion of 14C-labelled mannitol (14C-mannitol) and 99mTc-labelled diethylenetriamine-pentaacetic acid (99mTc-DTPA). Data were compared with the results from healthy controls. Results. No difference was found between groups in urinary excretion of 14C-mannitol and 99mTc-DTPA after 2, 4 or 6 h, respectively. Likewise, no significant differences in the 99mTc-DTPA/14C-mannitol ratios between patients and controls were detected after 2 h: 0.030 (0.008-0.130) versus 0.020 (0.007-0.030), p=0.19, after 4 h: 0.040 (0.009-0.180) versus 0.020 (0.008-0.040), p=0.14 or after 6 h: 0.040 (0.012-0.180) versus 0.020 (0.010-0.040), p=0.17. Conclusions. No alterations in intestinal permeability in patients with CC could be demonstrated. Impairment of the integrity of the mucosa of the small bowel and the presence of a general dysfunction of the small intestine in patients with CC seem unlikely.

Change of diagnosis during the first five years after onset of inflammatory bowel disease: Results of a prospective follow-up study (the IBSEN Study).
Henriksen M, Jahnsen J, Lygren I, Sauar J, Schulz T, Stray N, Vatn MH, Moum B, The Ibsen Study Group
Scand J Gastroenterol. 2006 Sep;41(9):1037-43.

Objective. An exact diagnosis of inflammatory bowel disease (IBD) and further subclassification may be difficult even after clinical, radiological and histological examinations. A correct subclassification is important for the success of both medical and surgical therapeutic strategies, but there is a dearth of information available on the frequency of changes in diagnosis in population-based studies. The objective of this work was prospectively to re-evaluate the diagnosis in an unselected cohort of IBD patients during the first five years after the initial diagnosis. Material and methods. Patients classified as IBD or possible IBD in the period 1990-94 (the IBSEN cohort) had their diagnosis re-evaluated after 1 and 5 years. Initially, the patients were classified as ulcerative colitis (UC), Crohn's disease (CD), indeterminate colitis (IC) or possible IBD. At the 5-year visit, patients were classified as UC, CD or non-IBD. Results. A total of 843 patients (518 UC, 221 CD, 40 IC and 64 possible IBD) were identified. Clinical information was available for 94% of the patients who survived after 5 years. A change in diagnosis was found in 9% of the patients initially classified as UC or CD. A change to non-IBD was more frequent than a change between UC and CD. A large proportion of patients initially classified as IC or possible IBD were diagnosed as non-IBD after 5 years (22.5% versus 50%). When IBD was confirmed in these groups, UC was more frequent than CD. Two changes in diagnosis during follow-up were observed in 2.8% of the patients; this was more frequent in patients initially classified as IC or possible IBD. Conclusions. There are obvious diagnostic problems in a minority of patients with IBD; a systematic follow-up is therefore important in these patients.

Robotic-assisted laparoscopic low anterior resection with total mesorectal excision for rectal cancer.
Pigazzi A, Ellenhorn JD, Ballantyne GH, Paz IB
Surg Endosc. 2006 Aug 1;.

BACKGROUND: With advanced stereoscopic vision, lack of tremor, and the ability to rotate the instruments surgeons find that robotic systems are ideal laparoscopic tools. Because of its high operating cost, however, robotic surgery should be reserved to procedures in which the technology can be of maximum benefit, usually when precise dissections in confined spaces are required. Because conventional laparoscopic total mesorectal excision is a challenging procedure, we have sought to assess the utility of the DaVinci robotic system in laparoscopic low anterior resections for cancer of the rectum. METHODS: Between November 2004 and May 2005 robotic-assisted low anterior resection with total mesorectal excision was performed on six consecutive patients with rectal cancer. These cases were compared with six consecutive low anterior resections performed with conventional laparoscopic techniques by the same surgeon. RESULTS: There were no conversions in either group. Operative and pathological data, complications, and hospital stay were similar in the two groups. Robotic operations appeared to cause less strain for the surgeon. CONCLUSIONS: Robotic-assisted laparoscopic low anterior resection for rectal cancer is feasible in experienced hands. This technique may facilitate minimally invasive radical rectal surgery.

The effect of purified micronized flavonoid fraction on the healing of anastomoses in the colon in rats.
Inan A, Sen M, Koca C, Akpinar A, Dener C
Surg Today. 2006;36(9):818-22.

PURPOSE: Anastomotic leakage of colonic and rectal anastomoses is a major complication after large intestine surgery. Many factors influence the healing of colon anastomoses. Flavonoids have been recognized for centuries as physiologically active constituents that are used to treat human diseases. We studied the effects of a clinically used, micronized, purified flavonoid fraction on the healing of colonic anastomosis in rats. METHODS: Male Sprague-Dawley rats were used. The flavonoid group of rats received 100 mg/kg per day of Daflon for 14 days until surgery. Thereafter, a resection and anastomosis were performed. The bursting pressure of the anastomoses and the hydroxyproline levels of the perianastomotic tissue were determined to evaluate the healing on the third and seventh days of surgery for both flavonoid and control groups. RESULTS: The bursting pressure of the flavonoid group was higher on the seventh day. The hydroxyproline levels of the flavonoid group were significantly higher than in the control group on both the third and seventh days after surgery. CONCLUSIONS: Although the micronized purified flavonoid fraction has some inhibitory properties on the healing of the anastomosis, its net effect was to obtain a better anastomotic healing of the colon in rats.

Rectal polyp: Can it be a malignant melanoma?
Saiprasad BR, Prasad MS, Ravishankar TH, Mathur K
Surgery. 2006 Sep;140(3):474-5.

Robotics in colorectal surgery: telemonitoring and telerobotics.
Satava RM
Surg Clin North Am. 2006 Aug;86(4):927-36.

Transanal endoscopic microsurgery.
Cataldo PA
Surg Clin North Am. 2006 Aug;86(4):915-25.

Laparoscopic Rectal Surgery: Rectal Cancer, Pelvic Pouch Surgery, and Rectal Prolapse.
Akbari RP, Read TE
Surg Clin North Am. 2006 Aug;86(4):899-914.

Laparoscopic colon surgery: past, present and future.
Martel G, Boushey RP
Surg Clin North Am. 2006 Aug;86(4):867-97.

July

Diagnosis and management of diverticulitis and appendicitis.
Dominguez EP, Sweeney JF, Choi YU
Gastroenterol Clin North Am. 2006 Jun;35(2):367-91.

Flat and depressed neoplasms of the colon.
Church J
Am J Gastroenterol. 2006 Jul;101(7):1676-7.

Recurrent rectal diverticulitis.
Lundy JB, Edwards KD, Parker DM, Rivera DE
Am Surg. 2006 Jul;72(7):633-6.

Diverticular involvement of the colon is very common in the United States. Patients present with asymptomatic diverticuli and may have complications of these, spanning the spectrum of uncomplicated diverticulitis to an acute surgical abdominal as a result of feculent peritonitis. We discuss a patient requiring low anterior resection for intractable symptoms resulting from recurrent rectal diverticulitis as well as a review of the limited literature on the subject of diverticular disease of the rectum.

Bilateral V-Y advancement flaps for the management of extensive defects of the perianal skin.
Kiran RP, Kalavagunta S, Berube M, Brown W, Richi AA, Dudrick SJ
Am Surg. 2006 Jul;72(7):631-2.

Premalignant and malignant conditions of the skin may sometimes require excision of extensive areas of the skin and subcutaneous tissues. Coverage of the ensuing raw area may be afforded by allowing healing by secondary intention, skin grafts, or flaps. Wide excision of the perianal skin poses special problems. We describe the use of bilateral V-Y advancement flaps for the management of an extensive defect resulting from the wide excision of squamous cell carcinoma arising in scarred perianal skin.

Use of sentinel node mapping for cancer of the colon: 'to map or not to map".
Thomas KA, Lechner J, Shen P, Waters GS, Geisinger KR, Levine EA
Am Surg. 2006 Jul;72(7):606-11; discussion 611-2.

Sentinel lymph node (SLN) mapping has become a cornerstone of oncologic surgery because it is a proven method for identifying nodal disease in melanoma and breast cancer. In addition, it can ameliorate the surgical morbidity secondary to lymphadenectomy. However, experience with SLN mapping for carcinoma of the colon and other visceral malignancies is limited. This study represents an update to our initial pilot experience with SLN mapping for carcinoma of the colon. Consenting patients over the age of 18 diagnosed with adenocarcinoma of the colon were included in this study. At the time of operation, 1 to 2 mL of isosulfan blue was injected with a 25-gauge needle into the subserosa at 4 sites around the edge of the palpable tumor. The SLN was identified visually and excised followed by a standard lymphadenectomy and surgical resection. SLNs were evaluated by standard hematoxylin and eosin (H&E) evaluation as well as immunohistochemical (IHC) techniques for carcinoembryonic antigen and cytokeratin if the H&E was negative. Sixty-nine patients underwent SLN mapping. A SLN was identified in 93 per cent (64 of 69) of patients. Nodal metastases were identified in 38 per cent (26 of 69) of patients overall. In 5 patients, the only positive node identified was the SLN, 2 of which were positive by IHC criteria alone. Therefore, 3 per cent (2 of 69) of patients were upstaged by SLN mapping. This technique was 100 per cent specific while being 46 per cent sensitive. Fourteen patients had false-negative SLNs. Metastasis to regional lymph nodes remains the key prognostic factor for colon cancer. SLN mapping is feasible for colon cancer and can identify a subset of patients who could benefit from adjuvant chemotherapy. Although SLN mapping did not alter the surgical management of colon cancer, it does make possible a more focused and cost-effective pathologic evaluation of nodal disease. We do not suggest routine utilization of SLN mapping for colon cancer, but we believe that the data supports proceeding with a national trial.

Probiotics in the prevention and treatment of gastrointestinal infections.
Huebner ES, Surawicz CM
Gastroenterol Clin North Am. 2006 Jun;35(2):355-65.


New Insights and Directions in Travelers' Diarrhea.
Dupont HL
Gastroenterol Clin North Am. 2006 Jun;35(2):337-353.

An Update on Diagnosis, Treatment, and Prevention of Clostridium difficile-Associated Disease.
Aslam S, Musher DM
Gastroenterol Clin North Am. 2006 Jun;35(2):315-335.

An updated review on cryptosporidium and giardia.
Huang DB, White AC
Gastroenterol Clin North Am. 2006 Jun;35(2):291-314.

A bayesian approach to acute infectious diarrhea in adults.
Goodgame R
Gastroenterol Clin North Am. 2006 Jun;35(2):249-73.

Extraintestinal manifestations of inflammatory bowel diseases.
Kethu SR
J Clin Gastroenterol. 2006 Jul;40(6):467-75.

Inflammatory bowel diseases are associated with extraintestinal manifestations involving almost every organ system in the body. They occur in approximately 20% to 40% of patients with inflammatory bowel diseases. Immune-related and genetic mechanisms play an important role in the pathogenesis of these complications. Peripheral arthritis, erythema nodosum, and episcleritis respond to the treatment of the underlying intestinal inflammation, whereas axial arthropathy, pyoderma gangrenosum, and uveitis do not. Immunomodulator therapy, particularly with biologic agents has been shown to be effective in treating some of the extraintestinal manifestations. Early recognition and treatment are crucial in preventing major morbidity.

Evaluation of the hemodynamics of rectal varices by endoscopic ultrasonography.
Sato T, Yamazaki K, Akaike J
J Gastroenterol. 2006 Jun;41(6):588-92.

BACKGROUND: The usefulness of endoscopic color Doppler ultrasonography (ECDUS) for evaluating hemodynamics is examined in 12 cases of rectal varices. We also evaluate the safety of endoscopic therapies in rectal variceal patients. METHODS: ECDUS was performed for 12 rectal variceal patients with a 7.5-MHz convex-type Pentax FG-32UA system. A Hitachi EUB 525 was used for the display. ECDUS provides a color display of blood flow, and calculates the velocity using a fast-Fourier transform analysis. We monitored the color flow images and measured blood flow velocity in rectal varices. Then, we evaluated the velocity of 350 F2-type esophageal varices via ECDUS, and compared the velocities between rectal varices and esophageal varices. RESULTS: Color flow images of rectal varices and of inflow vessels to rectal varices were obtained in all 12 patients with ECDUS. The mean velocity of F2-type rectal varices was 5.5 +/- 1.3 cm/s (n = 12), while the mean velocity of F2 esophageal varices was 8.4 +/- 3.1 cm/s (range, 4.5-12.5 cm/s) (n = 350) via ECDUS. The velocities in rectal varices were lower than those in esophageal varices. Endoscopic injection sclerotherapy (EIS) was successfully performed in five red-color-sign-positive rectal variceal patients having a mean velocity 5.4 +/- 1.1 cm/s. CONCLUSIONS: The velocities of rectal varices were lower than those of esophageal varices. Evaluation of the hemodynamics of rectal varices is important for determining the appropriate therapeutic option. EIS is an effective therapy in cases of slow variceal flow. ECDUS is a necessary tool for effective and safe EIS for rectal varices.

Effect of concurrent elemental diet on infliximab treatment for Crohn's disease.
Tanaka T, Takahama K, Kimura T, Mizuno T, Nagasaka M, Iwata K, Nakano H, Muramatsu M, Takazoe M
J Gastroenterol Hepatol. 2006 Jul;21(7):1143-9.

Background: Infliximab and elemental diet (ED) have been shown to be effective in the management of Crohn's disease. However, few experiences have been reported regarding their combination therapy. The aim of the present study was to investigate the efficacy and safety of infliximab in Japanese patients, the first such study in Asia, as well as the effect of concomitant ED. Methods: One hundred and ten consecutive patients receiving infliximab were followed up to week 16 after the last infusion, and clinical response and primary outcome were collected. A response was defined as a reduction in Harvey-Bradshaw Index for inflammatory disease and closure of fistula in fistulizing disease. Results: Out of 75 inflammatory and 35 fistulizing disease patients, 68 (90.7%) and 25 (71.4%) responded at week 4, and 38 (50.7%) and 14 (40.0%) continued to respond until week 16, respectively. Interestingly, inflammatory disease patients with concurrent ED had a significantly higher response rate at week 16 (68.4%) than those without ED (32.4%, P = 0.0026). The effects of ED were independent of the usage of azathioprine and smoking habit. Conclusions: Infliximab was clinically useful in the treatment of Crohn's disease in Japanese patients as well as in those in Western countries. The efficacy of concurrent ED was suggestive and should be confirmed in a randomized controlled study.

Hyperplastic polyposis syndrome: phenotypic presentations and the role of MBD4 and MYH.
Chow E, Lipton L, Lynch E, D'Souza R, Aragona C, Hodgkin L, Brown G, Winship I, Barker M, Buchanan D, Cowie S, Nasioulas S, du Sart D, Young J, Leggett B, Jass J, Macrae F
Gastroenterology. 2006 Jul;131(1):30-9.

BACKGROUND & AIMS: Hyperplastic polyposis syndrome (HPS) is defined phenotypically with multiple, large and/or proximal hyperplastic polyps. There is no known germ-line predisposition. We aimed to characterize the clinicopathologic features of 38 patients with HPS and explore the role of germ-line mutations in the base excision repair genes MBD4 and MYH. METHODS: Utilizing clinical databases of The Royal Melbourne Hospital Bowel Cancer Surveillance Service and the Familial Cancer Clinic, 38 patients with HPS were recruited. The patients were analyzed for age at first diagnosis, features of hyperplastic polyposis, family histories of polyposis and colorectal cancer (CRC), coexisting adenomas, serrated adenomas, incidence of CRC, and microsatellite instability in the tumours. Mutation analysis of MBD4 and MYH were performed. RESULTS: Serrated adenomas were common (26%), and 19 (50%) of the 38 patients had a first-degree relative with CRC. Family history of HPS was uncommon, with only 2 cases found. Ten patients developed CRC, and 3 required surgery for polyposis. No pathogenic mutations in MBD4 were detected in the 27 patients tested, but 6 single nucleotide polymorphisms of uncertain functional significance were identified. Pathogenic biallelic MYH mutations were detected in 1 patient. CONCLUSIONS: Mutations in MBD4 are unlikely to be implicated in HPS; MYH mutations should be studied, especially when adenomas occur in the same patient. The clinical, histopathologic, and molecular findings of this study should contribute to our understanding of HPS and its relationship to the serrated neoplasia pathway.

The proximal resection margin for colorectal carcinoma - is 5 centimetres enough?
Teoh AY, Ng SS, Li JC, Yiu RY, Lee JF, Leung KL
Tech Coloproctol. 2006 Jul;10(2):151-2.

Long-term results in patients with T2-3 N0 distal rectal cancer undergoing radiotherapy before transanal endoscopic microsurgery.
Tjandra T
Tech Coloproctol. 2006 Jul;10(2):158; discussion 158-9.

Efficacy and Safety of Botulinum Toxin A Injection Compared with Topical Nitroglycerin Ointment for the Treatment of Chronic Anal Fissure: A Prospective Randomized Study.
Fruehauf H, Fried M, Wegmueller B, Bauerfeind P, Thumshirn M
Am J Gastroenterol. 2006 Jul 18;.e-pub

OBJECTIVES: To evaluate the efficacy and safety of botulinum toxin A injection compared with topical nitroglycerin ointment for the treatment of chronic anal fissure (CAF). METHODS: Fifty outpatients with CAF were randomized to receive either a single botulinum toxin injection (30 IU Botox((R))) or topical nitroglycerin ointment 0.2% b.i.d. for 2 wk. If the initial therapy failed, patients were assigned to the other treatment group for a further 2 wk. If CAF still showed no healing at wk 4, patients received combination therapy of botulinum toxin and nitroglycerin for 4 additional wk. Persisting CAF at wk 8 was treated according to the investigator's decision. Healing rates, symptoms, and side effects of the therapy were recorded at wk 2, 4, 8, 12, and 24 after randomization. RESULTS: The group initially treated with nitroglycerin showed a higher healing rate of CAF (13 of 25, 52%) as compared with the botulinum toxin group (6 of 25, 24%) after the first 2 wk of therapy (p < 0.05). At the end of wk 4, CAF healed in three additional patients, all receiving nitroglycerin after initial botulinum toxin injection. Mild side effects occurred in 13 of 50 (26%) patients, all except one were on nitroglycerin. CONCLUSIONS: Nitroglycerin ointment was superior to the more expensive and invasive botulinum toxin injection for initial healing of CAF, but was associated with more but mild side effects.

Congenital pouch colon: follow-up and functional results after definitive surgery.
Puri A, Chadha R, Choudhury SR, Garg A
J Pediatr Surg. 2006 Aug;41(8):1413-9.

PURPOSE: In this study, functional results with regard to fecal continence levels and other parameters were studied in 22 patients with congenital pouch colon associated with anorectal agenesis (CPC) more than 3 years old who had undergone definitive pull-through surgery 1 to 13 years earlier. An attempt was made to formulate treatment protocols for management of fecal incontinence and other problems associated with CPC. METHODS: The study sample consisted of 14 males and 8 females. Three of the 8 female patients had had a cloacal malformation. The medical records of the patients were scrutinized and they were classified into 4 subtypes based on the length of normal colon proximal to the colonic pouch. The patients were further categorized into 3 groups based on the terminal bowel that had been pulled-through, namely, the ileum or colon proximal to the colonic pouch or a tubularized segment of the colonic pouch. The somatic growth of the patients was studied. Clinical assessment of fecal continence was performed by the Kelly and the Kiesewetter and Chang scoring systems. A computed tomographic scan of the pelvis with a barium enema was performed to assess the terminal bowel and its placement as well as the bony and muscular anatomy of the pelvis. The urinary system was assessed by a clinical history as well as by abdominal ultrasound and a micturating cystourethrogram. Various treatment modalities including dietary modifications, drugs, and enemas were instituted in patients with poor continence levels, and the response to treatment studied. RESULTS: Thirteen patients (59.2%), all with an ileal pull-through, had height and weight less than 50% of that expected for their ages. Overall fecal continence was "poor" in 17 patients and "fair" in only 5 patients. Patients with pull-through of either ileum or normal colon often had very frequent passage of liquid or semisolid stools, whereas the 4 patients with pull-through of tubularized colon had infrequent passage of semisolid stools with abdominal distension and bloating. One of these 4 patients had massive colonic redilatation necessitating surgical correction. Mucosal prolapse and perineal excoriations were frequent findings. Ultrasonography and micturating cystourethrogram showed hydroureteronephrosis and vesicoureteric reflux in 5 patients. Radiologic assessment revealed that there were no significant sacral abnormalities and the striated sphincteric musculature was well developed, although the levator ani was thinner than normal in 15 patients (68%). The bowel was very well placed in the sphincteric complex in 19 patients (86%). In 7 of the 13 patients who had pull-through of normal ileum or colon, some improvement in continence levels was seen 3 to 6 months after institution of dietary measures, loperamide, and saline-water enemas. Two of 3 patients with pull-through of tubularized colon improved to some extent with colonic washouts alone. Overall, quality of life was poor in the 22 patients. CONCLUSIONS: Despite the fact that the sacrum is usually normal, the sphincteric musculature well developed, and the terminal bowel well placed without any anal strictures, long-term prognosis with regard to fecal continence, growth and development, and quality of life appears to be dismal for all subtypes of CPC, irrespective of the type of definitive surgery performed. Corrective measures also appear to be of limited value. Various newer management modalities for management of fecal incontinence may be considered, but in several patients a permanent abdominal stoma may be a more practical solution.

Penetrating rectal trauma managed by PATH.
Navsaria PH
J Trauma. 2006 Jul;61(1):237; author reply 237.

June

Dai-kenchu-to, a Chinese herbal medicine, improves stasis of patients with total gastrectomy and jejunal pouch interposition.
Endo S, Nishida T, Nishikawa K, Nakajima K, Hasegawa J, Kitagawa T, Ito T, Matsuda H
Am J Surg. 2006 Jul;192(1):9-13.

BACKGROUND: Intestinal motility after gastric surgery frequently is disturbed and results in postoperative intestinal symptoms and poor quality of life (QOL). The purpose of this study was to examine the effects of Dai-kenchu-to on intestinal motility and postoperative QOL of patients. METHODS: Seventeen patients who underwent total gastrectomy with jejunal pouch interposition for gastric cancer in the Department of Surgery of Osaka University Medical Hospital were enrolled. The patients were assigned randomly to the cross-over study with or without 15 g/d of Dai-kenchu-to. Questionnaires and emptying tests using (111)In-labeled liquid and (99m)Tc-labeled solid test meal were performed at the end of each treatment period. A manometric study was performed in 6 patients to measure contractile activity with or without Dai-kenchu-to. RESULTS: Stasis-related symptoms were reduced significantly by Dai-kenchu-to (P = .032). In the emptying test, Dai-kenchu-to accelerated emptying of both liquid (P < .01) and solid (P = .015) meals from the pouch. The pouch showed bursts of contractions, which were increased significantly by oral intake of Dai-kenchu-to (P = .028). CONCLUSIONS: Dai-kenchu-to increased intestinal motility and decreased postoperative symptoms of patients with total gastrectomy with jejunal pouch interposition.

High and intermediate imperforate anus: psychosocial consequences among school-aged children.
Ojmyr-Joelsson M, Nisell M, Frenckner B, Rydelius PA, Christensson K
J Pediatr Surg. 2006 Jul;41(7):1272-8.

BACKGROUND/PURPOSE: Imperforate anus is an unusual malformation, which, even after surgical intervention, usually entails constipation and fecal incontinence. This study aimed to evaluate ongoing psychosocial effects of this birth defect in school-aged children. METHODS: Twenty-five children born with high and intermediate imperforate anus participated in the study, along with their parents and classroom teachers. One group of healthy children and 1 group of children with juvenile chronic arthritis, along with their parents, served as controls. Children and parents individually answered a questionnaire devised for this study. Parents filled out the Child Behavior Checklist and the children's teacher filled out the Teacher's Report Form. RESULTS: According to test results, children with imperforate anus were happy and optimistic. They liked school better and reported better relationships with schoolmates than the other children. The index group reported statistically significantly more frequent constipation. According to parental responses, the imperforate-anus children suffered from fecal incontinence and odor, as well as constipation (P < .001). Index-group parents reported on the Child Behavior Checklist that their children had more emotional and behavioral problems. On the Teacher's Report Form, teachers reported few problems for the same children. CONCLUSIONS: Patients with imperforate anus did not experience psychosocial impairment despite significant functional problems.

Dynamic magnetic resonance imaging of the pelvic floor in children and adolescents with vesical and anorectal malformations.
Boemers TM, Ludwikowski B, Forstner R, Schimke C, Ardelean MA
J Pediatr Surg. 2006 Jul;41(7):1267-71.

BACKGROUND: Magnetic resonance imaging (MRI) of the pelvic floor allows better assessment of pelvic pathology and has a potential as an adjunct for therapy planning. In complex congenital malformations of the pelvic floor and continence organs, it plays a major role in assessing urinary and fecal incontinence or constipation, especially when performed as a dynamic investigation such as MRI defecography. PATIENTS AND METHODS: Twenty-three patients (3-21 years old) with urinary and/or fecal incontinence or constipation attributable to congenital malformations of the pelvic region presented at our institution. The diagnoses were anorectal malformations (18), bladder exstrophy (2), and cloacal exstrophy (3). All patients underwent static and dynamic MRI of the pelvic floor with rest, squeeze, and evacuation in supine position. RESULTS: Morphology and function of the pelvic floor and pelvic organs could be demonstrated in each case. The reason for urinary incontinence, fecal incontinence, or constipation could be defined, and an individual therapeutic management concept was made based upon the data obtained by the investigation. CONCLUSIONS: The advantages of this method, in comparison to others, are direct visualization of the pelvic floor muscles and continence organs and their anatomical relationship during different functional actions. Pelvic floor dysfunction is often the reason for fecal and urinary incontinence and can be detected by MRI. Especially in children, minimizing radiation exposure is of major concern. Disadvantages are the costs and long investigation time.

Colonic triplication associated with anorectal malformation: case presentation of a rare embryological disorder.
Gisquet H, Lemelle JL, Lavrand F, Droulle P, Schmitt M
J Pediatr Surg. 2006 Jul;41(7):e17-9.

Tubular colonic triplication is an extremely rare hindgut malformation, with only 2 reports in the literature to date. The present authors describe the new and unusual case of a boy born with an imperforate anus, rectovesical fistula, and 3 distinct left colons. The bladder was divided by an incomplete septum. Prenatal ultrasound suggested colonic duplication. Surgical management involved resection of the triplicated segment and posterosagittal anorectal pull through.

Nutrition in the prevention of gastrointestinal cancer.
van den Brandt PA, Goldbohm RA
Best Pract Res Clin Gastroenterol. 2006 Jun;20(3):589-603.

Diet has been hypothesized to play a role in the etiology of gastrointestinal cancer for a long time. Initially, strong evidence of such effects was found in retrospective epidemiological studies. Dietary habits, in particular those from the distant past, are difficult to measure, however. Results from recent, prospective and larger studies of better quality did not always confirm these associations. Consumption of fruits and vegetables appear to have a modest role in the prevention of gastrointestinal cancers. In contrast, the roles of alcohol consumption and overweight on risk of gastrointestinal cancer have become much clearer. Overweight and obesity are important risk factors for adenocarcinoma (but not squamous carcinoma) of the esophagus, gastric cardia carcinoma (but not noncardia carcinoma), and colorectal cancer, the latter in particular among men. Alcohol consumption is a risk factor for squamous carcinoma (but not adenocarcinoma) of the esophagus, gastric cancer and colorectal cancer. Selenium may be inversely related to esophageal and gastric cancer.

A comparison of colorectal neoplasia screening tests: a multicentre community-based study of the impact of consumer choice.
Med J Aust. 2006 Jun 5;184(11):546-50.

OBJECTIVE: International guidelines and local practices for colorectal cancer screening suggest an important role for several different screening tests, and for consumer choice. We aimed to determine whether choice of test improved participation in screening. DESIGN: A randomised comparative study offering one of six screening strategies: faecal occult blood testing (FOBT), FOBT and flexible sigmoidoscopy (FS), computed tomography colonography (CTC), colonoscopy, or one of two groups offered a choice of these strategies (one of which was sent an FOBT kit with the letter of invitation, while the other was required to request an FOBT kit by telephone if that was the test chosen). SETTING AND PARTICIPANTS: 1679 people aged 50-54 or 65-69 years, randomly selected from the electoral roll in metropolitan Perth, Adelaide and Melbourne. MAIN OUTCOME MEASURES: Participation, yield of advanced colorectal neoplasia (CRN), acceptability and safety. RESULTS: 346 (20.6%) were excluded from screening, mostly for a recent examination (165), symptoms (72) or personal or family history of colorectal neoplasia or cancer (83). 278 of the 1333 eligible (20.9%; 95% CI, 18.7%-23.1%) participated in screening. Participation was similar by age and sex, but lower in Perth than Adelaide (17.1% v 24.2%; P = 0.01). Participation by screening group was: FOBT, 27.4%; FOBT/FS, 13.7% (P < 0.001 compared with FOBT); CTC, 16.3% (P = 0.005); colonoscopy, 17.8% (P = 0.02); or a choice of test 18.6% ("with FOBT kit"; P = 0.03) or 22.7% ("without FOBT kit"; P = 0.3). Yield of advanced CRN was higher in participants screened by colonoscopy than FOBT (7.9% v 0.8%; P = 0.02). All tests were well accepted and no serious complications arose from screening. CONCLUSION: A choice of screening test did not improve participation. Participation by FOBT was higher than by other tests. Yield of advanced colorectal neoplasia on an intention-to-screen basis, determined by test sensitivity and participation, is likely to be a critical determinant of the effectiveness of screening strategies.

Anorectal malformation with tubular hindgut duplication.
Craigie RJ, Abbaraju JS, Ba'ath ME, Turnock RR, Baillie CT
J Pediatr Surg. 2006 Jun;41(6):e31-4.

The association of hindgut duplication and anorectal malformation is rare. Published classifications of this association are confusing in respect of terminology. We report a case of blind-ending, Y-shaped tubular duplication of the distal hindgut, associated with an anorectal malformation (rectourethral fistula) affecting the colon proper. Surgical options at time of presentation and of reconstructive surgery are discussed. A review and suggested modification of the classifications is presented.

[Bleeding from rectal varices in a patient with severe decompensated cirrhosis: success of endoscopic band ligation. A case report and review of the literature]
Boursier J, Oberti F, Reaud S, Person B, Maurin A, Cales P
Gastroenterol Clin Biol. 2006 May;30(5):783-5.

In patients with cirrhosis, portal hypertension can be complicated by bleeding rectal varices. Treatment of bleeding rectal varices is not well established because clinical therapeutic trials are scarce in the literature and there are only a few case reports. In most cases, first line treatment is endoscopic (band ligation or sclerotherapy) and in case of failure or rebleeding, portosystemic shunts are the second line treatment. The indication of endoscopic treatment is not always easy in patients with cirrhosis and impaired liver function as well as major haemostatic problems. We report the case of a patient with severe decompensated cirrhosis and bleeding rectal varices who was successfully treated by endoscopic band ligation.

[Botulinum toxin and chronic anal fissure]
Daniel F, de Parades V, Siproudhis L, Atienza P
Gastroenterol Clin Biol. 2006 May;30(5):687-95
.
Lateral internal sphincterotomy is widely used in the treatment of chronic anal fissure. However, it is associated with a high rate of irreversible incontinence. For this reason the botulinum toxin has become a medical means of reversible sphincterotomy. Indeed, this neurotoxin induces relaxation of the smooth internal anal sphincter lasting one to three months after one injection. We reviewed the published studies about the use of this technique in the management of chronic anal fissure. Healing occurred in more than 70% of fissures without irreversible incontinence. Although further studies are needed to determine the best modalities of administration, especially due to the remaining significant recurrence rate, this toxin may be a valuable treatment for chronic anal fissure in the future.

Endoluminal endosurgery: rivet application in flexible endoscopy.
Hausmann U, Feussner H, Ahrens P, Heinzl J
Gastrointest Endosc. 2006 Jul;64(1):101-3.

BACKGROUND: Endoluminal endoscopy could be significantly enhanced by adequate approaches to wound closure. Current solutions are basically confined to clip applications. OBJECTIVE: A new approach to sewing in flexible endoscopy is achieved with an endoluminal rivet system. This system allows the application of several ligatures without withdrawing the rivet application device to reload. For this purpose, a pilot experimental study of the device was conducted, which obtained a tissue approximation and avoided the difficult process of knot tying. DESIGN: Pilot experimental study. SETTING: The rivet application was tested through a 1.8-mm working channel of the endoscope in laboratory and postmortem animal tissues. It consists of a flexible anchor at the front and a lockable bracket at the rear. Both edges of a defect of the GI wall can be aligned and compressed, thus leading to wound closure. INTERVENTIONS: Test samples were evaluated in postmortem gastric tissue by using flexible gastroscopes. The feasibility of applying a series of rivets with 1 instrument to close transmural lacerations of the stomach was demonstrated. Further tests were performed to determine the forces to penetrate the gastric wall. MAIN OUTCOME MEASUREMENTS: Tissue closure, rivet degradation. RESULTS: The penetration force can be brought down to less than 0.57 N by using a magnesium tip. The sharp tip of the rivet, which could potentially lacerate healthy tissue after implantation, is degraded in the stomach within the first few hours because of rapid corrosion. LIMITATIONS: Lack of in vivo feasibility data. CONCLUSIONS: Endoluminal wound closure through common gastroscopes and colonoscopes is possible. Further in vivo data are required for the rivet system.

Colonoscopy with polypectomy in anticoagulated patients.
Friedland S, Soetikno R
Gastrointest Endosc. 2006 Jul;64(1):98-100.

BACKGROUND: According to current practice guidelines for performance of colonoscopy in patients requiring long-term anticoagulation, polypectomy is considered a high-risk procedure for which anticoagulation must temporarily be discontinued. However, these guidelines are based on expert opinion, and the bleeding risk after polypectomy in anticoagulated patients is not known. OBJECTIVE: Measure the risk of postpolypectomy bleeding in patients who undergo colonoscopic polypectomy while anticoagulated. DESIGN: Retrospective review of patients who underwent polypectomy without discontinuation of anticoagulation. SETTING: Veterans Administration Palo Alto Health Care System. PATIENTS: Forty-one polypectomies were performed in 21 patients. All patients had been receiving long-term anticoagulation with warfarin; the average international normalized ratio was 2.3 (range 1.4-4.9; normal 0.9-1.2). To prevent supratherapeutic anticoagulation, warfarin was withheld for 36 hours before the procedure while the patients were on a liquid diet. The average polyp size was 5 mm (range 3-10 mm). INTERVENTIONS: All patients underwent polypectomy followed immediately by prophylactic application of one or two clips to prevent bleeding. MAIN OUTCOME MEASUREMENTS: Rate of postpolypectomy bleeding. RESULTS: There were no episodes of postpolypectomy bleeding. The 95% CI for the risk of bleeding was 0% to 8.6% when analyzed per polypectomy and 0% to 15% when analyzed per patient. LIMITATIONS: Small single-center retrospective study. CONCLUSIONS: Our experience suggests that small polyps can be removed with a very low risk of bleeding when clips are applied immediately after polypectomy. If these results can be confirmed in a larger multicenter study, our protocol may become an alternative to withholding anticoagulation in patients at high risk of thrombosis.

Use of Antibiotics in the Treatment of Inflammatory Bowel Disease.
Perencevich M, Burakoff R
Inflamm Bowel Dis. 2006 Jul;12(7):651-664.

ABSTRACT:: An increasing amount of evidence suggests that enteric flora may have a role in the pathogenesis of inflammatory bowel disease (IBD). Patients with IBD appear to have an altered composition of luminal bacteria that may providethe stimulus for the chronic inflammation characterizing IBD. The suspected role of bacteria in the pathogenesis of IBD provides the rationale for using agents, such as antibiotics, that alter the intestinal flora. However, there remains much uncertainty about the optimal use of antibiotics in the treatment of Crohn's disease, ulcerative colitis, and pouchitis. This article reviews the literature and presents a clinical model for the use of antibiotics in IBD.

A Simple Biological Score for Predicting Low Risk of Short-Term Relapse in Crohn's Disease.
Consigny Y, Modigliani R, Colombel JF, Dupas JL, Lemann M, Mary JY (GETAID)
Inflamm Bowel Dis. 2006 Jul;12(7):551-557.

BACKGROUND:: In Crohn's disease, studies have evaluated the ability of biological markers to predict relapse in the next 12 to 18 months, without differentiating early from late relapses. The aim of this study was to look for biological markers of short-term relapse. MATERIALS AND METHODS:: In a previous therapeutic trial, patients with a medically induced clinical remission had biological markers evaluated and updated every 6 weeks. A Cox model with time-dependent covariates was used for analysis. RESULTS:: Among the 71 patients, 38 had a relapse. Multivariate analysis selected 2 markers predictive of relapse: C-reactive protein >20 mg/L and erythrocyte sedimentation rate >15 mm. A binary biological predictive score was derived: "negative" when both were lower than their limits, "positive" when otherwise. The relative risk of short-term relapse for patients with a positive score compared to those with a negative score was 8.0 (95% confidence interval 2.8-22.9). Sensitivity of the score was 89% and specificity was 43%. Assuming a 10% relapse rate every 6 weeks, negative and positive predictive values were 97% and 15%, respectively. CONCLUSIONS:: This simple biological score can predict short-term maintenance of remission in Crohn's disease and may help physicians in the follow-up of patients in clinical remission.

Ulcerative Colitis and Clinical Course: Results of a 5-Year Population-based Follow-up Study (The IBSEN Study).
Henriksen M, Jahnsen J, Lygren I, Sauar J, Kjellevold O, Schulz T, Vatn MH, Moum B
Inflamm Bowel Dis. 2006 Jul;12(7):543-550.

BACKGROUND:: The majority of studies concerning the clinical course and prognosis in ulcerative colitis (UC) are old, retrospective in design, or hospital based. We aimed to identify clinical course and prognosis in a prospective, population-based follow-up study MATERIALS AND METHODS:: Patients diagnosed with inflammatory bowel disease (IBD) or possible IBD in southeastern Norway during the period 1990-1994 were followed prospectively for 5 years. The evaluation at 5 years included an interview, clinical examination, laboratory tests, and colonoscopy. RESULTS:: Of 843 patients diagnosed with IBD, 454 patients who had definite UC and for whom there were sufficient data for analysis were alive 5 years after inclusion in the study. The frequency of colectomy in this population was 7.5%. Forty-one percent of the patients were not taking any kind of medication for IBD at 5 years. Of the patients initially diagnosed with proctitis, 28% had progressed during the observation period, 10% to extensive colitis. The majority of the patients (57%) had no intestinal symptoms at 5 years, and only a minority (7%) had symptoms that interfered with everyday activities. Among the patients who underwent colonoscopy at the 5-year visit, symptoms were frequently reported in patients without macroscopic inflammation (44%). A relapse-free course was observed in 22% of the patients. A decrease in symptoms during the follow-up period was the most frequent course taken by the disease and was observed in 59% of the cases. The extent of disease was unrelated to symptoms at 5 years and also to relapse rate and course of disease during the 5-year period. CONCLUSIONS:: The disease course and prognosis of UC appears better than previously described in the literature. The frequency of surgery was low, and only a minority of the patients had symptoms that interfered with their everyday activities 5 years after diagnosis.

Oral mesalamine and clinical remission are associated with a decrease in the extent of long-standing ulcerative colitis.
Picco MF, Krishna M, Cangemi JR, Shelton D
Inflamm Bowel Dis. 2006 Jul;12(7):537-42.

OBJECTIVE:: To compare colonoscopy alone with surveillance biopsy for the determination of anatomic extent in long-standing ulcerative colitis (UC). To assess the influences of mesalamine use and clinical disease activity on the change of histologic extent with time. MATERIALS AND METHODS:: Disease extent (proctosigmoiditis, left-sided colitis, or pancolitis) measured by colonoscopy and surveillance biopsy was compared among 212 consecutive patients with long-standing UC. Among the 102 patients who had 2 consecutive colonoscopies with surveillance biopsies, the following influences on change in histologic extent were determined: disease activity, mesalamine use, age at disease onset, folic acid, corticosteroid and azathioprine/6-mercaptopurine use, and time between colonoscopies. RESULTS:: Agreement between gross and microscopic findings was poor (kappa = 0.39). Colonoscopy underestimated and overestimated extent in 25.9% and 8.5%, respectively. Microscopic distribution between consecutive colonoscopies remained the same in 60.8%. Where distribution changed, an increase was twice as common as a decrease in extent. There was no difference in age at onset, time between colonoscopies, or disease duration among those with an increase, decrease, or no change in extent. Clinical remission and oral mesalamine were independently associated with 10.7 and 5.8 times the odds of a decrease in disease extent, respectively. Folic acid, topical mesalamine, corticosteroids, and immunomodulators did not influence change in extent. CONCLUSIONS:: UC extent is best determined by surveillance biopsy. Among patients with long-standing UC, histologic extent fluctuates with time. Disease remission and oral mesalamine were independently associated with decreases in disease extent.

Oral probiotics prevent necrotizing enterocolitis.
Lin HC, Su BH, Oh W
J Pediatr. 2006 Jun;148(6):849; author reply 850.

An unusual presacral mass: extramedullary hematopoiesis.
Youngster I, Weiss M, Drobot A, Eitan A
J Gastrointest Surg. 2006 Jun;10(6):927-9.

Presacral masses are a rare finding in the adult patient, confronting the physician with diagnostic and therapeutic challenges. We present an unusual case of a symptomatic presacral mass caused by extramedullary hematopoietic tissue in a thalassemic patient and review the unique aspects of this entity.

Chemical sphincterotomy in the treatment of anal fissure.
MacLean A
J Gastrointest Surg. 2006 May;10(5):629-30.

Diverticulitis: a progressive disease? Do multiple recurrences predict less favorable outcomes?
Chapman JR, Dozois EJ, Wolff BG, Gullerud RE, Larson DR
Ann Surg. 2006 Jun;243(6):876-830; discussion 880-3.

INTRODUCTION: Our understanding of complicated diverticulitis is based on outdated literature. Antecedent episodes of diverticulitis are felt to increase the risk of developing complicated diverticulitis, as well as its subsequent morbidity and mortality. Practice parameters recommend elective resection after 2 episodes of diverticulitis to reduce this morbidity and mortality. METHODS: A total of 150 patients with prior episodes of diverticulitis who were hospitalized with complicated diverticulitis were retrospectively analyzed. Statistical analysis was conducted using chi and Fisher exact test tests. RESULTS: Patients were separated into 2 groups for analysis: group A = those with 1 or 2 prior diverticulitis episodes (n = 118) versus group B = patients with more than 2 prior episodes (n = 32). Characteristics of the groups were similar for age and preexistent comorbid conditions. The majority of patients presented with pericolonic abscess and inflammatory phlegmon. Perforated diverticulitis occurred more often in group A compared with patients with >2 episodes of diverticulitis. Because of the higher rate of perforation, patients in group A underwent surgical diversion more often than group B patients. No significant differences in operative complications, morbidity, or mortality rates were identified between the groups. CONCLUSION: Patients with multiple (>2) episodes of diverticulitis are not at increased risk for poor outcomes if they develop complicated diverticulitis. Morbidity and mortality rates are not significantly different between patients with multiple episodes of diverticulitis compared with those with 1 or 2 prior attacks. Reevaluation of the practice of elective resection as a strategy for reducing the mortality and morbidity from complicated diverticulitis is needed.

A Comparison of Hand-Sewn Versus Stapled Ileal Pouch Anal Anastomosis (IPAA) Following Proctocolectomy: A Meta-Analysis of 4183 Patients.
Lovegrove RE, Constantinides VA, Heriot AG, Athanasiou T, Darzi A, Remzi FH, Nicholls RJ, Fazio VW, Tekkis PP
Ann Surg. 2006 Jul;244(1):18-26.

OBJECTIVE:: Using meta-analytical techniques, the study compared postoperative adverse events and functional outcomes of stapled versus hand-sewn ileal pouch-anal anastomosis (IPAA) following restorative proctocolectomy. BACKGROUND:: The choice of mucosectomy and hand-sewn versus stapled pouch-anal anastomosis has been a subject of debate with no clear consensus as to which method provides better functional results and long-term outcomes. METHODS:: Comparative studies published between 1988 and 2003, of hand-sewn versus stapled IPAA were included. Endpoints were classified into postoperative complications and functional and physiologic outcomes measured at least 3 months following closure of ileostomy or surgery if no proximal diversion was used, quality of life following surgery, and neoplastic transformation within the anal transition zone. RESULTS:: Twenty-one studies, consisting of 4183 patients (2699 hand-sewn and 1484 stapled IPAA) were included. There was no significant difference in the incidence of postoperative complications between the 2 groups. The incidence of nocturnal seepage and pad usage favored the stapled IPAA (odds ratio [OR] = 2.78, P < 0.001 and OR = 4.12, P = 0.007, respectively). The frequency of defecation was not significantly different between the 2 groups (P = 0.562), nor was the use of antidiarrheal medication (OR = 1.27, P = 0.422). Anorectal physiologic measurements demonstrated a significant reduction in the resting and squeeze pressure in the hand-sewn IPAA group by 13.4 and 14.4 mm Hg, respectively (P < 0.018). The stapled IPAA group showed a higher incidence of dysplasia in the anal transition zone that did not reach statistical significance (OR = 0.42, P = 0.080). CONCLUSIONS:: Both techniques had similar early postoperative outcomes; however, stapled IPAA offered improved nocturnal continence, which was reflected in higher anorectal physiologic measurements. A risk of increased incidence of dysplasia in the ATZ may exist in the stapled group that cannot be quantified by this study. We describe a decision algorithm for the choice of IPAA, based on the relative risk of long-term neoplastic transformation.

The healing of colon anastomosis covered with fibrin glue after early postoperative intraperitoneal chemotherapy.
Kanellos I, Christoforidis E, Kanellos D, Pramateftakis MG, Sakkas L, Betsis D
Tech Coloproctol. 2006 Jun;10(2):115-20. Epub 2006 Jun 19.

BACKGROUND: After colon resection for colonic cancer, the administration of antineoplastic agents may prolong survival by killing residual cancer calls and preventing metastasis, but may also slow anastomotic healing. This study was designed to determine the effects of 5-fluorouracil (5-FU) and leucovorin (LEV), injected intraperitoneally, on the healing of colonic anastomoses with or without fibrin glue (FG) covering.METHODS: Sixty rats were randomized to one of four groups. After resection of a transverse colon segment, an end-to-end sutured anastomosis was performed. Rats in the 5-FU+LEV and the 5- FU+LEV+FG groups received 5-FU+LEV intraperitoneally. The colonic anastomoses of the rats in the FG group and in the 5-FU+LEV+FG group were covered with fibrin glue. All rats were killed on postoperative day 8. Bursting pressure measurements were recorded and the anastomoses were examined macroscopically and histologically.RESULTS: The leakage rate of the anastomoses was significantly different among groups. Specifically, the leakage rate was significantly higher in the 5-FU+LEV group (40%) than in the FG and in the 5-FU+LEV+FG groups where there were no leakages (p=0.017). The mean adhesion formation score was significantly higher in rats of the 5-FU+LEV group, compared to the control (p=0.023), the FG (p=0.006) and the 5-FU+LEV+FG (p=0.006) groups. Bursting pressures were significantly lower in the 5-FU+LEV group than in the other groups (p<0.001). Also, bursting pressures were significantly lower in the control group compared to the FG and 5-FU+LEV+FG groups (p<0.001). Rats in the 5-FU+LEV+FG group had significantly greater neoangiogenesis and fibroblast activity than those in the 5-FU+LEV group (p=0.025).CONCLUSION: The early intraperitoneal postoperative administration of 5-fluorouracil plus leucovorin impaired colonic wound healing. However, the application of fibrin glue prevented the deleterious effect

May

Probiotics and inflammatory bowel diseases.
Bai AP, Ouyang Q
Postgrad Med J. 2006 Jun;82(968):376-82.

Enteric microflora profiles vary considerably between active inflammatory bowel diseases (IBD) and healthy conditions. Intestinal microflora may partake in the pathogenesis of IBD by one or some ways: specific pathogenic infection induces abnormal intestinal mucosal inflammation; aberrant microflora components trigger the onset of IBD; abnormal host immune response loses normal immune tolerance to luminal components; luminal antigens permeate through the defective mucosal barrier into mucosal lamina propria and induce abnormal inflammatory response. Preliminary studies suggest that administration of probiotics may be benefit for experimental colitis and clinical trials for IBD. Researches have been studying the function of probiotics. Introduction of probiotics can balance the aberrant enteric microflora in IBD patients, and reinforce the various lines of intestinal defence by inhibiting microbial pathogens growth, increasing intestinal epithelial tight junction and permeability, modulating immune response of intestinal epithelia and mucosal immune cells, secreting antimicrobial products, decomposing luminal pathogenic antigens.

Sphincterolysis: A Novel Approach towards Chronic Anal Fissure.
Gupta PJ
Eur Surg Res. 2006 May 11;38(2):122-126.

Background and Aims:The surgical approach in chronic anal fissure is often found associated with disturbed anal continence as well as recurrence. This report describes the author's approach of 'sphincterolysis' or fragmentation of the fibers of the internal sphincter on the left lateral anal wall. Patients and Methods:132 patients with chronic anal fissures were treated with this technique. Pre- and postoperative anal manometry was recorded. The postoperative course and early and 1-year follow-up results were recorded. Results: Early complications included ecchymosis, hematoma, and pain. Fissure healing and relief of symptoms observed in 97% of patients. A transient, variable degree of incontinence occurred in 23 patients and persistent incontinence to flatus and soiling in 5. Conclusion: Internal anal sphincterolysis is a safe, effective procedure for the treatment of chronic anal fissure. Copyright (c) 2006 S. Karger AG, Basel.

Colonic irrigations: a review of the historical controversy and the potential for adverse effects.
Richards DG, McMillin DL, Mein EA, Nelson CD
J Altern Complement Med. 2006 May;12(4):389-93.

Colonic irrigations enjoy widespread popularity among alternative medicine practitioners, although they are viewed with considerable skepticism by the conventional medical community. Although proponents make claims of substantial health benefits, skeptics cite the lack of evidence for health benefits and emphasize the potential for adverse effects. Yet historically, there are clinical reports of effectiveness and virtually no research refuting these reports. Instead there was a campaign against exaggerated claims by nonmedical practitioners that resulted in a movement away from this form of therapy without any scientific study of efficacy. Given the current popularity of colonic irrigations, it is important that such research be performed, which will require a quantitative estimate of the potential for adverse effects. Although there is little specific literature on colonic irrigations, a review of the literature on related procedures such as enemas and sigmoidoscopies suggests that the risk of serious adverse effects is very low when the irrigations are performed by trained personnel using appropriate equipment.

Rectal cancer: From outcomes of care to process of care.
Ignjatovic D, Bergamaschi R
Scand J Gastroenterol. 2006 Jun;41(6):636-9.

This paper represents a current opinion on the impact surgeons may have on the variability of the quality of care of rectal cancer surgery. No systematic review of the evidence available in the literature is provided. The objective is to present a concise insight on selected outcomes of care studies, to review the limitations of such studies and to discuss the value of process of care studies. Outcomes of care studies measure what happens to patients, and process of care studies measure what is done to patients. Three variables are reviewed: training, volume and individual skill. It is concluded that the quality of the selected outcomes of care studies is not sufficient to draw definitive conclusions on whether surgeons are a variable. Further efforts should prompt process of care studies on rectal cancer surgery. This implies that outcomes should be measured, processes of care modified and outcomes measured again. This cycle should be continuously repeated in order to achieve the best quality of care.

Complementary use of local excision and transanal endoscopic microsurgery for rectal cancer after neoadjuvant chemoradiation.
Caricato M, Borzomati D, Ausania F, Tonini G, Rabitti C, Valeri S, Trodella L, Ripetti V, Coppola R
Surg Endosc. 2006 May 15;.

BACKGROUND: Neoadjuvant therapies have significantly improved local control and survival of patients with rectal cancer. Nevertheless, although a complete pathologic response can be achieved in 30% of cases, a transabdominal surgical resection is always required. This study aimed, for the first time, to test in the literature the feasibility of local excision combined with transanal endoscopic microsurgery (TEM) as a surgical option for patients treated with neoadjuvant chemoradiation. METHODS: Between July 1997 and December 2002, 30 patients with rectal cancer affected by an extraperitoneal tumor entered a protocol consisting of neoadjuvant chemoradiation followed by surgery. The surgical treatment, consisting of open surgery, local excision, or TEM, was planned according to the patient's clinical response after chemoradiation and distance from the anal verge. RESULTS: A significant clinical downstaging was observed in eight patients. Five of these patients underwent TEM, and three had local excision. Consequently, open surgery was performed for 22 patients. Histology showed six cases of complete pathologic response: three in the open surgery group and three in the transanal excision group. After a mean follow-up period of 47 months, the disease-free survival rate was 77% in the open surgery group and 100% in TEM or local excision group. CONCLUSIONS: The findings suggest the complementary feasibility of TEM and local excision after neoadjuvant chemoradiation. However, randomized trials are needed to confirm the oncologic safety of this approach.

Laparoscopic colorectal surgery using low-pressure pneumoperitoneum combined with abdominal wall lift by placement of anchoring sutures around the camera port.
Park IJ, Kim SH, Joh YG, Hahn KY
Surg Endosc. 2006 Jun;20(6):956-9. Epub 2006 May 11.

BACKGROUND: This study aimed to evaluate the feasibility of low-pressure pneumoperitoneum in laparoscopic colorectal surgery. METHODS: The authors designed low-pressure (8 mmHg) laparoscopy combined with abdominal wall lift simply by placement of anchoring sutures around the camera port. RESULTS: The operative indications were 176 colon cancers, 297 rectal cancers, and 45 benign diseases. The average blood loss was 92 ml (range, 20-1200 ml), and the mean operating time was 204 min (range, 23-525 min). Conversion to an open procedure was required in eight cases (1.5%). Two patients experienced intraoperative complications. The mean number of removed lymph nodes was 28.9 in the colon cancer cases and 23.1 in the rectal cancer cases. The mean length of resected specimen was 27.3 cm (range, 8.5-136 cm). Postoperatively, cardiopulmonary complications developed in five patients (0.9%). CONCLUSIONS: Abdominal wall lifting by anchoring sutures around the camera port in addition to low-pressure pneumoperitoneum is a simple, safe, and effective method for laparoscopic colorectal procedure.

Intracorporeal rectal stapling following laparoscopic total mesorectal excision: overcoming a challenge.
Brannigan AE, De Buck S, Suetens P, Penninckx F, D'Hoore A
Surg Endosc. 2006 Jun;20(6):952-5. Epub 2006 May 12.

BACKGROUND: Division of the rectum following total mesorectal excision (TME) using intracorporeal stapling devices is technically difficult due to their width and limited roticulation. More than one cartridge is often required and resultant wedging of the stump may be associated with an appreciable leak rate. METHODS: Three-dimensional reconstruction was performed of CT and MRI images from the lower abdomen of six patients undergoing laparoscopic TME using the Amira software environment. The stapling device was virtually reconstructed by in-house developed software, superimposed over the point of division of the rectum and the site of skin entry identified. RESULTS: The 45 degrees angulation of available roticulating stapling devices precludes perpendicular division of the rectum following laparoscopic TME. The optimal angulation for transverse rectal stapling varied between 62 degrees and 68 degrees . CONCLUSION: A roticulating stapler with minimum angulation of 65 degrees would achieve transverse division of the rectum following laparoscopic TME.

Comparison of laparoscopic and open ileocecal resection for Crohn's disease: a metaanalysis.
Tilney HS, Constantinides VA, Heriot AG, Nicolaou M, Athanasiou T, Ziprin P, Darzi AW, Tekkis PP
Surg Endosc. 2006 May 17;.

BACKGROUND: The role of laparoscopic surgery for patients with ileocecal Crohn's disease is a contentious issue. This metaanalysis aimed to compare open resection with laparoscopically assisted resection for ileocecal Crohn's disease. METHODS: A literature search of the Medline, Ovid, Embase, and Cochrane databases was performed to identify comparative studies reporting outcomes for both laparoscopic and open ileocecal resection. Metaanalytical techniques were applied to identify differences in outcomes between the two groups. Sensitivity analysis was undertaken to evaluate the heterogeneity of the study. RESULTS: Of 20 studies identified by literature review, 15 satisfied the criteria for inclusion in the study. These included outcomes for 783 patients, 338 (43.2%) of whom had undergone laparoscopic resection, with an overall conversion rate to open surgery of 6.8%. The operative time was significantly longer in the laparoscopic group, by 29.6 min (p = 0.002), although the blood loss and complications in the two groups were similar. In terms of postoperative recovery, the laparoscopic patients had a significantly shorter time for recovery of their enteric function and a shorter hospital stay, by 2.7 days (p < 0.001). CONCLUSIONS: For selected patients with noncomplicated ileocecal Crohn's disease, laparoscopic resection offered substantial advantages in terms of more rapid resolution of postoperative ileus and shortened hospital stay. There was no increase in complications, as compared with open surgery. The contraindications to laparoscopic approaches for Crohn's disease remain undefined.

[Results of multivisceral resection of primary colorectal cancer.]
Kruschewski M, Pohlen U, Hotz HG, Ritz JP, Kroesen AJ, Buhr HJ
Zentralbl Chir. 2006 Jun;131(3):217-22.

BACKGROUND: In about 10 % of all patients with colorectal cancer, the primary invention already discloses adhesions or infiltration of adjacent organs. En bloc resection of the tumor-bearing bowel segment with adjacent organs is done to give patients a chance for curation, since intraoperative differentiation is not possible. The aim of this study is characterization of the patient population as well as evaluation of the morbidity and mortality associated with this type of extensive intervention. METHOD: Between 1/95 and 6/04, we analyzed all patients with progressive primary colorectal cancer, who underwent multivisceral surgery with en bloc resection of at least one other organ. The target parameters were tumor characteristics as well as postoperative morbidity and mortality. RESULTS: A total of 1 001 patients with colorectal cancer underwent surgery. 101 patients (10 %) required multivisceral resection. In 17 % the indication was exigent. About 70 % of the interventions involved the colon. Tumor perforation was seen in 17 % of patients with colon cancer and 16 % with rectal cancer. Resection of the inner genitals was most frequent in both colon and rectal cancer (26 and 84 %) followed by small bowel resection (21 %) and partial bladder resection (19 %). Other organs play a secondary role in rectal cancer while partial bladder resection (20 %) and abdominal wall resection (14 %) is observed more frequently in colon cancer. Resection of parenchymatous organs (kidney, suprarenal gland, spleen, pancreas, liver) and others like the stomach is quite rare in colon cancer. Actual tumor infiltration (T4 situation) was observed in 51 % of patients with colon cancer and in 64 % of those with rectal cancer. Local R0 resection (97 vs. 96 %) was successfully performed in nearly all colon and rectal cancer patients. The surgical major complication rate was 9 % in colon cancer and 19 % in rectal cancer. The mortality rate was 4 %. CONCLUSION: Multivisceral en-bloc resection enables local R0 resection in the majority of cases with primary colorectal cancer. Despite sometimes extensive surgery, this type of procedure is associated with an acceptable morbidity and mortality. Since long-term survival is comparable to that in the T category (T3 or T4), multivisceral en-bloc resection is not only justified but also absolutely required in interventions with curative intention.

True or false? The hygiene hypothesis for Crohn's disease.
Lashner BA, Loftus EV Jr
Am J Gastroenterol. 2006 May;101(5):1003-4.

The "hygiene hypothesis" for Crohn's disease postulates that multiple childhood exposures to enteric pathogens protect an individual from developing Crohn's disease later in life, while individuals raised in a more sanitary environment are more likely to develop Crohn's disease. In this issue of the American Journal of Gastroenterology, two Canadian case-control studies come to diametrically opposed conclusions regarding the hygiene hypothesis for Crohn's disease. This difference may be partially related to differences in study population (population based vs hospital based), age of onset, different genetic determinants, urban/rural residence (40% rural vs principally urban), or different exposures from the putative causative agent. As of now, the veracity of the hygiene hypothesis for Crohn's disease is not confirmed.

A population-based case control study of potential risk factors for IBD.
Bernstein CN, Rawsthorne P, Cheang M, Blanchard JF
Am J Gastroenterol. 2006 May;101(5):993-1002.

BACKGROUND: We aimed to pursue potential etiological clues to Crohn's disease (CD) and ulcerative colitis (UC) through a population-based case control survey study. METHODS: Cases with CD (n = 364) and UC (n = 217), ages 18-50 yr were drawn from the population-based University of Manitoba IBD Research Registry. Potential control subjects were drawn from the population-based Manitoba Health Registry by age, gender, and geographic residence matching to the cases (n = 433). Subjects were administered a multiitem questionnaire. RESULTS: By univariate analysis, some of the variables predictive of CD included lower likelihood of living on a farm, of having drunk unpasteurized milk or having eaten pork, and UC patients were less likely to have drunk unpasteurized milk and to have eaten pork. On multivariate analysis, variables significantly associated with CD were being Jewish (OR = 4.32, 95% CI 1.10-16.9), having a first degree relative with IBD (OR = 3.07, 95% CI 1.73-5.46), ever having smoked (OR = 1.54, 95% CI, 1.06-2.25), living longer with a smoker (OR = 1.03, 95% CI, 1.01-1.04). Being a first generation Canadian (OR = 0.33, 95% CI, 0.17-0.62), having pet cats before age 5 (OR = 0.66, 95% CI, 0.46-0.96) and having larger families (OR = 0.87, 95% CI, 0.79-0.96) were protective against CD. For UC being Jewish (OR = 7.46, 95% CI, 2.33-23.89), having a relative with IBD (OR = 2.23, 95% CI, 1.27-3.9), and ever smoking (OR = 1.62, 95% CI, 1.14-2.32) were predictive. CONCLUSION: This study reinforced the increased risk associated with family history, being Jewish, and smoking history, however, a number of significant associations with CD and UC on univariate and multivariate analysis may support the "hygiene hypothesis" and warrant further exploration in prospective studies.

Molecular Diagnosis of Campylobacter jejuni Infection in Cases of Focal Active Colitis.
Lamps LW, Schneider EN, Havens JM, Scott MA, Goldblum JR, Greenson JK, Shaffer RA
Am J Surg Pathol. 2006 Jun;30(6):782-785.

Campylobacter jejuni (CJ) is the most commonly isolated stool pathogen in the United States. Biopsy findings are typically those of focal active colitis (FAC), a nonspecific pattern usually indicating infection or adverse drug effect that is characterized by focal cryptitis and preservation of crypt architecture. We developed a molecular test for CJ that can be performed on routinely processed gastrointestinal biopsy specimens, and assessed what percentage of patients with biopsy findings of FAC have molecular evidence of CJ infection. One hundred and ten colon biopsies diagnosed as FAC were retrieved from three institutions. Polymerase chain reaction (PCR) was performed following DNA extraction; primers were designed to target a 286-bp fragment of the mapA gene that is specific to CJ. Pure genomic DNA derived from cultures served as the positive control; reagent blanks and 50 normal colon specimens served as negative controls. Nineteen percent (21/110) of the FAC biopsies were positive for CJ DNA by PCR analysis. Fourteen CJ-positive patients presented with diarrhea, 3 presented with gastrointestinal bleeding, and 3 had incidental FAC found on screening colonoscopy. Ten patients had abnormal colonoscopic findings, including erythema (4), ulcers (4), colitis (1), and hemorrhage (1). As CJ is an enteric pathogen that is not present in the gut as a commensal organism, the presence of CJ DNA suggests current or recent previous infection in these patients. CJ infection should be considered in patients with diarrhea and colon biopsies showing FAC. Furthermore, PCR analysis performed on fixed, routinely processed colon biopsies is an excellent diagnostic method for detection of this organism.

Acute appendicitis: is there a difference between children and adults?
Lee SL, Ho HS
Am Surg. 2006 May;72(5):409-13.

Historically, the lack of classic symptoms and delay in presentation make diagnosing acute appendicitis more difficult in children, resulting in a higher perforation rate. Despite this, the morbidity of acute appendicitis is usually lower in children. We evaluated the current differences in clinical presentation, diagnostic clues, and the outcomes of acute appendicitis between the two age groups. A retrospective review of 210 consecutive cases of pediatric appendectomy and 744 adult cases for suspected acute appendicitis from January 1995 to December 2000. Pediatric patients were defined as being 13 years and younger. Pediatric patients were similar to adult patients with respect to duration of pain before presentation (2.4 +/- 4.3 days vs 2.5 +/- 7.3 days), number of patients previously evaluated (22.0 vs 17.7%), number of imaging tests (computed tomography or ultrasound; 32.9 vs 40.2%), and number of patients observed (16.7 vs 17.2%). However, pediatric patients required less time for emergency room evaluation (4.0 +/- 2.7 hours vs 5.7 +/- 4.9 hours, P = 0.0001). In children and adults, a history of classic, migrating pain had the highest positive predictive value (94.2 vs 89.6%), followed by a white blood cell count > or =12 x 109/L (91.5 vs 84.3%). The overall negative appendectomy rate was 10.0 per cent for children and 19.0 per cent for adults (P = 0.003); the perforation rate was 19.0 per cent and 13.8 per cent, respectively (P > 0.05). The perforation rate in children was not associated with a delay in presentation (perforated cases, 2.9 +/- 3.3 days compared with nonperforated cases, 2.3 +/- 4.6 days). Mortality and morbidity, including wound infection rate and intra-abdominal abscess rate, were similar. Contrary to traditional teaching, diagnosing acute appendicitis in children is similar to that in adults. A history of migratory pain together with physical findings and leukocytosis remain accurate diagnostic clues for children and adults. Perforation rate and morbidity in children is similar to those in adults. The outcomes of acute appendicitis in children are not associated with a delay in presentation or delay in diagnosis.

Systematic review of postoperative complications in patients with inflammatory bowel disease treated with immunomodulators.
Subramanian V, Pollok RC, Kang JY, Kumar D
Br J Surg. 2006 May 19;.

BACKGROUND:: This systematic review examined the use of immunomodulators and the risk of postoperative complications after abdominal surgery in patients with inflammatory bowel disease. METHODS:: Electronic databases (PubMed, Embase, Ingenta, Zetoc and Ovid) were searched and the reference lists in all articles identified were hand-searched for further relevant papers. Studies were included if they evaluated postoperative complications and defined exposure to individual immunomodulators. RESULTS:: All 11 studies that met the inclusion criteria were observational studies; two were reported only in abstract form. Five studies reported risks associated with azathioprine, five reported risks associated with cyclosporin and three reported risks associated with infliximab. None showed an increased risk of either total or infectious complications associated with immunomodulator use. However, subgroup analysis in one study, published as an abstract, suggested increased rates of anastomotic complications and reoperation associated with azathioprine. CONCLUSION:: Available evidence does not suggest an increased rate of postoperative complications associated with immunomodulator use. Copyright (c) 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Canadian Association of General Surgeons and American College of Surgeons Evidence Based Reviews in Surgery. 17 The timing of elective colectomy in diverticulitis: a decision analysis.
McLeod R, Phang T, Wexner S, Members Of The Evidence Based Reviews In Surgery Group FT
Can J Surg. 2006 Jun;49(3):212-214.

Antisecretory drugs for diarrheal disease.
Farthing MJ
Dig Dis. 2006;24(1-2):47-58.

Acute diarrhea is a major cause of morbidity and mortality worldwide. Infants and pre-school children are the most vulnerable in whom there are 2-3 million deaths each year as a result of the associated dehydration and acidosis. Although oral rehydration therapy has reduced mortality during the past 30 years ago, the search for agents that will directly inhibit intestinal secretory mechanisms and thereby reduce faecal losses in patients with high-volume watery diarrhea has continued for more than 20 years. A variety of potential targets for antisecretory agents have been explored which include loci within the enterocyte (the chloride channel, calcium-calmodulin) and other sites such as enteric nerves and endogenous mediators (such as 5-HT, prostaglandins). Although the potential of calcium-calmodulin inhibition has as yet not been realised, preliminary studies suggest that there are chloride channel blockers under development that will find a place in the management of secretory diarrheas. Recent work has highlighted the importance of neurohumoral mechanisms in the pathogenesis of acute diarrhea. Potentiation of the effects of endogenous enkephalin activity by enkephalinase inhibition has already produced a safe, effective anti-secretory drug, racecadotril. Speculative early work indicates that there may be a role for antagonists of 5-HT, substance P, and VIP receptors. There now seems to be a real possibility that antisecretory therapy will become more widely available in the future.

Sacral osteomyelitis after ileal pouch-anal anastomosis: report of four cases.
Taylor WE, Wolff BG, Pemberton JH, Yaszemski MJ
Dis Colon Rectum. 2006 Jun;49(6):913-8.

PURPOSE: This study describes an institutional experience with sacral osteomyelitis after proctocolectomy and ileal pouch-anal anastomosis. METHODS: A total of 2,375 patients underwent ileal pouch-anal anastomosis at the Mayo Clinic between January 1981 and January 2002. In addition, we have served as a tertiary referral base for patients with complications after ileal pouch-anal anastomosis performed at other institutions. Review of our ileal pouch-anal anastomosis prospective database and directed search of the central pathology, microbiology, radiology, and surgical records at the Mayo Clinic was performed using these keywords: osteomyelitis, ileal pouch-anal anastomosis, inflammatory bowel disease, chronic ulcerative colitis, and Crohn's disease. RESULTS: Two of 2,375 patients (0.08 percent) with ileal pouch-anal anastomosis performed at our institution have had sacral osteomyelitis. In addition, two patients have been referred for continuing care after construction of an ileal pouch-anal anastomosis and diagnosis of sacral osteomyelitis at another institution. Two of the four patients maintained normal pouch function after sacral debridement and a period of fecal stream diversion. One patient remains diverted with resolved sacral osteomyelitis after debridement. The last patient died from squamous-cell cancer involving the sacrum. CONCLUSIONS: Sacral osteomyelitis is a rare and heretofore unreported complication of ileal pouch-anal anastomosis. Conservative measures using antibiotics alone proved unsuccessful, and delaying definitive management may have contributed to the degeneration of a chronic sacral abscess into squamous-cell cancer. With more aggressive treatment comprising sacral debridement, long-term antibiotics, and fecal diversion, pouch function can potentially be preserved.

Effective screening for bowel cancer: a United kingdom perspective.
Thompson MR, Steele RJ, Atkin WS
Dis Colon Rectum. 2006 Jun;49(6):895-908.

Bowel cancer is a major cause of morbidity and death and is a high cost to health care systems. Screening currently offers the best chance of improving outcomes from bowel cancer. When introducing screening, the problems encountered in other cancers need to be avoided to maximize benefits and minimize harms.

Long-term results of "chemical sphincterotomy" for chronic anal fissure: a prospective study.
Lysy J, Israeli E, Levy S, Rozentzweig G, Strauss-Liviatan N, Goldin E
Dis Colon Rectum. 2006 Jun;49(6):858-64.

INTRODUCTION: Pharmacologic anal sphincter relaxants promote fissure healing; however, their effect is transient and the risk of late recurrence remains uncertain. METHODS: From August 1997 to August 2002, patients with chronic anal fissure attending our outpatient clinic were treated with a protocol that included: topical isosorbide dinitrate, 2.5 mg, or nifedipine, 0.2 percent t.i.d., or the combination of both. Botulinum toxin 20 units was injected to the internal anal sphincter to those who failed. All the patients were contacted and interviewed during November to December 2002. RESULTS: Follow-up was a median of 47.43 +/- 13 (range, 4.7-60) months. A total of 455 patients completed the study; 323 patients (71 percent) healed at follow-up ending: 170 of the healed patients had one or more recurrences that responded to further treatment (37.4 percent), whereas 153 patients (33.6 percent) healed and had no recurrences. One hundred thirty-two patients (29 percent) did not heal and were referred to lateral sphincterotomy. Long intervals between symptoms appearance and treatment initiation decreased healing and increased recurrence rates (P = 0.03 and 0.01 respectively). CONCLUSIONS: Topical treatment is effective for patients with chronic anal fissure, at short-term and long-term periods. Because for many patients it is not a definitive treatment, it can be offered to those who are ready to receive repeated treatments. Longer intervals between symptom appearance and treatment initiation negatively affects fissure healing and recurrence rate.

Prediction of postoperative mortality in elderly patients with colorectal cancer.
Heriot AG, Tekkis PP, Smith JJ, Cohen CR, Montgomery A, Audisio RA, Thompson MR, Stamatakis JD
Dis Colon Rectum. 2006 Jun;49(6):816-24.

PURPOSE: This study was designed to develop a model for predicting postoperative mortality in elderly patients undergoing surgery for colorectal cancer. METHODS: This multicenter study was conducted by using routinely collected clinical data, assessing patients older than aged 80 years, with 30-day operative mortality as the primary end point. Data were collected from The Association of Coloproctology of Great Britain and Ireland database, encompassing 8,077 newly diagnosed colorectal cancer patients undergoing resectional surgery in 79 hospitals between April 2000 to March 2002, The Association of Coloproctology Malignant Bowel Obstruction Study, encompassing 1,046 patients with malignant bowel obstruction in 148 hospitals, between April 1998 to March 1999, and The Wales-Trent audit, encompassing 3,522 newly diagnosed colorectal cancer patients, between July 1992 to June 1993. A multilevel logistic regression model was developed to adjust for case-mix and to accommodate the variability of outcomes between the three study populations. The model was internally validated using a Bayesian resampling technique and tested using measures of discrimination, calibration, and subgroup analysis. RESULTS: A total of 2,533 patients satisfied the inclusion criteria, with a 30-day mortality of 15.6 percent. Multivariate analysis identified the following independent risk factors: age (odds ratio for 85-90, 90-95, >95 vs. 80-85 = 1.1, 1.8, 2.9), American Society of Anesthesiology grade (odds ratio for Grade III, IV vs. I-II = 2.7, 6.1), operative urgency (odds ratio for emergency vs. elective = 1.9), no cancer excision vs. resection (odds ratio = 1.2), and metastatic disease (odds ratio for metastases vs. no metastases = 1.9). The model offered adequate discrimination (area under receiver operator curve = 0.732) and excellent agreement between observed and predicted outcomes during eight colorectal procedures (P = 0.885). CONCLUSIONS: The elderly colorectal cancer model can accurately estimate 30-day mortality in patients older than aged 80 years undergoing surgery for colorectal cancer. Because the mortality can be considerable, this may have important implications when determining management for this group of patients.

Rectal Cancer in the Young Patient.
Endreseth BH, Romundstad P, Myrvold HE, Hestvik UE, Bjerkeset T, Wibe A
Dis Colon Rectum. 2006 Jun 2;.

PURPOSE: The purpose of this national study was to evaluate the results of treatment for young rectal cancer patients. METHODS: This prospective study from the Norwegian Rectal Cancer Project includes all 2,283 patients younger than aged 70 years with adenocarcinoma of the rectum from November 1993 to December 1999. Patients younger than aged 40 years (n = 45), 40 to 44 years (n = 87), 45 to 49 years (n = 153), and 50 to 69 years (n = 1998) were compared for patient and tumor characteristics and five-year overall survival. Patients treated for cure (n = 1,354) were evaluated for local recurrence, distant metastasis, and disease-free survival. RESULTS: Patients younger than aged 40 years had significantly higher frequencies of poorly differentiated tumors (27 vs. 12-16 percent; P = 0.014), N2-stage (37 vs. 13-18 percent; P = 0.001), and distant metastases (38 vs. 19-24 percent; P = 0.019) compared with older patients. Among those treated for cure, 56 percent of the patients younger than aged 40 years developed distant metastases compared with 20 to 26 percent of the older patients (P = 0.003). Overall five-year survival was 54 percent for patients younger than aged 40years compared with 71 to 88 percent for the older patients (P = 0.029). Age younger than 40 years was a significant independent prognostic factor and increased the risk for metastasis and death. CONCLUSIONS: Patients younger than aged 40 years had a more advanced stage at the time of diagnosis and poor prognosis compared with older patients. Young patients treated for cure more often developed distant metastases and had inferior survival.

Risk Factors and Indications for Colectomy in Ulcerative Colitis Patients are Different According to Patient's Clinical Background.
Kuriyama M, Kato J, Fujimoto T, Nasu J, Miyaike J, Morita T, Okada H, Suzuki S, Shiode J, Yamamoto H, Shiratori Y
Dis Colon Rectum. 2006 Jun 2;.

PURPOSE: Despite progress in medical treatment for ulcerative colitis, a considerable fraction of ulcerative colitis patients undergo colectomy. We analyzed the clinical variables of ulcerative colitis patients and determined the risk factors and indications for colectomy. METHODS: The clinical records of 981 consecutive Japanese patients with ulcerative colitis were reviewed both retrospectively and prospectively. RESULTS: Of 981 patients with ulcerative colitis, 85 patients underwent colectomy. Multivariate analysis indicated that male gender (risk ratio, 2.16; 95 percent confidence interval, 1.37-3.42), onset year during and after 2000 (risk ratio, 2.85; 95 percent confidence interval, 1.31-6.22), severe disease activity (risk ratio, 2; 95 percent confidence interval, 1.15-3.48), corticosteroid resistance (risk ratio, 7.05; 95 percent confidence interval, 4.29-11.59), and complications because of corticosteroid administration (risk ratio, 3.55; 95 percent confidence interval, 2.08-6.06) were significant risk factors for colectomy. In patients with disease duration of more than five years, only corticosteroid resistance and complications because of corticosteroid were significant risk factors for colectomy. When we stratified indications for colectomy for the 85 cases via patient disease duration, massive hemorrhage was a relatively frequent cause of colectomy in patients with a disease duration of less than five years (P = 0.091). On the other hand, colon dysplasia or cancer was a major cause for colectomy in patients with a disease duration of more than ten years (P = 0.0001). CONCLUSIONS: In ulcerative colitis patients, the risk factors and indications for colectomy were different according to the patient's clinical background. Our findings may help to predict patients with ulcerative colitis who have a high risk for colectomy.

Practice Parameters for Sigmoid Diverticulitis. Surgeons.
Rafferty J, Shellito P, Hyman NH, Buie WD
Dis Colon Rectum. 2006 Jun 2;.

Operating Behind Denonvilliers' Fascia for Reliable Preservation of Urogenital Autonomic Nerves in Total Mesorectal Excision: A Histologic Study Using Cadaveric Specimens, Including a Surgical Experiment Using Fresh Cadaveric Models.
Kinugasa Y, Murakami G, Uchimoto K, Takenaka A, Yajima T, Sugihara K
Dis Colon Rectum. 2006 May 31;.

PURPOSE: Little is known about which urogenital nerves are liable to be injured along surgical planes in front of or behind Denonvilliers' fascia. METHODS AND RESULTS: Using semiserial histology for five fixed male pelves, we demonstrated that: 1) left/right communicating branches of bilateral pelvic plexuses run immediately in front of Denonvilliers' fascia; and 2) a lateral continuation of Denonvilliers' fascia separates the urogenital neurovascular bundle from the mesorectum. Notably, the mesorectum contains no or few extramural ganglion cells. At the level of the seminal vesicles, incision in front of Denonvilliers' fascia seems likely to injure superior parts of the pelvic plexus and the left/right communication. Moreover, at the prostate level, this incision misleads the surgical plane into the neurovascular bundle. Fresh cadaveric dissections of five unfixed male pelves confirmed that the surgical plane in front of Denonvilliers' fascia continues to a fascial space for the pelvic plexus containing ganglion cell clusters lateral and/or inferior to the seminal vesicles. CONCLUSIONS: To preserve all autonomic nerves for urogenital function, optimal total mesorectal excision for rectal cancer requires dissection behind Denonvilliers' fascia.

Increased Experience and Surgical Technique Lead to Improved Outcome After Ileal Pouch-Anal Anastomosis: A Population-Based Study.
Kennedy ED, Rothwell DM, Cohen Z, McLeod RS
Dis Colon Rectum. 2006 May 19;.

PURPOSE: This study was designed to determine whether changes in length of stay and 30-day readmission, reoperation, and excision rates for the ileal pouch-anal anastomosis occurred over time and with changes in surgical technique and hospital volume. METHODS: Using three population-based administrative databases, data on all ileal pouch-anal anastomoses performed in the province of Ontario between January 1992 and June 1998 were obtained. The effect of age, gender, stage of the procedure, year of surgery, and hospital volume were examined for their effect on length of stay and readmission, reoperation, and excision rates. RESULTS: There were 1,285 ileal pouch-anal anastomoses performed in 58 hospitals. There was a significant decrease in length of stay and reoperation and excision rates but a concommitant increase in readmission rate during the study period. Patients younger than aged 40 years had a significantly lower length of stay and excision rate. Patients who had a two-stage procedure had a shorter length of stay, readmission, and reoperative rate compared with those having a three-stage procedure. Hospital volume was a significant predictor of need for reoperation and excision with both low-volume and medium-volume hospitals having significantly higher rates than high-volume hospitals. CONCLUSIONS: Outcome after ileal pouch-anal anastomosis has improved. It is significantly better in patients younger than aged 40 years, having a two-stage procedure, and where surgery is performed at high-volume hospitals. It is likely that both modifications in surgical technique and surgical experience have led to improvements in clinical outcome after ileal pouch-anal anastomosis.

Antinociceptive Effect of Botulinum Toxin: An Added Value to Chemical Sphincterotomy in Anal Fissure? Btx-A Analgesic Effect in Anal Fissure?
Runfola M, Di Mugno M, Balletta A, Magalini SC, Gui D
Dis Colon Rectum. 2006 May 17;.

Pyogenic granuloma of the colon.
Field M, Inston N, Zanetto U, Cruikshank N
Int J Colorectal Dis. 2006 May 30;.

Changes in surgical therapy for Crohn's disease over 33 years: a prospective longitudinal study.
Siassi M, Weiger A, Hohenberger W, Kessler H
Int J Colorectal Dis. 2006 May 30;.

INTRODUCTION: Changes in surgery for Crohn's disease were analyzed in a single institution over a period of 33 years. MATERIALS AND METHODS: The data of all patients undergoing abdominal surgery for Crohn's disease between 1970 and 2002 were collected prospectively in an electronic database. The study period was divided into three periods of 11 years, each (group 1, 1970-1980; group 2, 1981-1991; group 3, 1992-2002). RESULTS: There was an increase in patients' age at time of hospital admission from 32.0+/-0.9 to 32.4+/-0.5 and 37.7+/-0.7 years, in the duration of disease from 4.9+/-0.3 to 7.3+/-0.3 and 8.8+/-0.5 years, and in the number of drug-induced remissions before surgery from 3.1+/-0.5 to 6.1+/-0.2 and 4.9+/-0.3 in groups 1, 2, and 3, respectively (p<0.01). The rates of elective surgery compared to urgent or emergency surgery increased from 69.5 to 81.4 and 80.9% in the corresponding groups (p<0.01). A significant decrease in hospital mortality was observed. The analysis of Crohn's complications demanding surgery revealed a significant increase of rates of stenosis and subileus. Furthermore, there was a significant increase in serious acute complications like free bowel perforations and peritonitis. CONCLUSION: Improved medical treatment may lead to higher rates of elective operations. However, prolonged conservative treatment may also increase the number of serious complications before surgery. Therefore, a multidisciplinary approach with early involvement of the

Incident rates of colonic neoplasia in older patients: When should we stop screening?
Harewood GC, Lawlor GO, Larson MV
J Gastroenterol Hepatol. 2006 Jun;21(6):1021-5.

Introduction: Current guidelines endorse colon cancer screening every 5-10 years in patients over 50 years of age. However, there is no consensus regarding what age is appropriate to stop screening. The aim of this study was to characterize neoplasia occurrence/recurrence in a large cohort of patients >/=70 years of age undergoing colonoscopy. Methods: The Mayo Rochester endoscopic database was reviewed to determine the incidence of colonic neoplasia in patients >/=70 years undergoing two colonoscopies at least 12 months apart between January 1996 and December 2000. Patients were classified based on (i) age: 70-74, 75-79, >/=80 years; and (ii) polyp detection on initial examination, that is, subsequent examination for screening or surveillance. Results: Overall, 1353 patients underwent two colonoscopies at least 12 months apart (median interval 140 weeks) with removal of polyp on initial examination in 726 (53.7%) patients (surveillance cohort). On subsequent endoscopy, polyps >/=10 mm were detected in 54 (4.0%) and cancer in 13 (1.0%) patients. All age groups were well matched with respect to detection of neoplasia on index examination (P = 0.9) and polyp size on initial colonoscopy among the surveillance group (P = 0.9). Using a Cox proportional hazards model, adjusted hazard ratios (95% confidence interval [CI]) for neoplasia (polyps >/=10 mm) were: 2.0 (1.50-2.73, P < 0.0001) (surveillance vs screening), 1.33 (0.96-1.79, P = 0.08) (>/=80 vs 70-74), and 1.05 (0.78-1.38, P = 0.75) (75-79 vs 70-74). Adjusted hazard ratios for development of cancer were: 1.87 (1.03-3.97, P = 0.04) (surveillance vs screening), 1.73 (0.84-3.56, P = 0.13) (>/=80 vs 70-74), and 1.38 (0.71-2.77, P = 0.34) (75-79 vs 70-74). Conclusions: Prior history of neoplasia remains a strong risk factor for colorectal neoplasia development in elderly patients and should be considered when deciding the need for continuing screening/surveillance. Incident neoplasia rates in a previously screened elderly population rise slowly with advancing age although cancer rates rise more sharply. Therefore, screening still retains a role in elderly patients; however, clinical judgment is still required to individualize screening practice. As the risk of competing comorbid illnesses continues to increase over time, the threshold to perform colon screening should increase accordingly.

Autoantibody profiles in microscopic colitis.
Holstein A, Burmeister J, Plaschke A, Rosemeier D, Widjaja A, Egberts EH
J Gastroenterol Hepatol. 2006 Jun;21(6):1016-20.

Objective: The etiology of microscopic colitis is unclear; an autoimmune response and pharmacological induction have been proposed as possible mechanisms. We conducted a multicentre cross-sectional study to compare the antibody profiles of patients with collagenous and lymphocytic colitis with those of a control group. Methods: The medical histories and antibody profiles of 26 patients with collagenous and 16 patients with lymphocytic colitis were compared with the corresponding data of 43 controls without gastroenterological disease. Antibodies to the following structures were determined: intestinal goblet cells, antinuclear antibodies (ANA), antineutrophil cytoplasmic antibodies, anti-Saccharomyces cerevisiae antibody (ASCA), tissue transglutaminase, gliadin, pancreatic acini, glutamate decarboxylase, tyrosine phosphatase IA-2 and thyroid (microsomal anitbodies, MAB). Results: Patients with collagenous and lymphocytic colitis had been treated significantly more often with H(2)-receptor antagonists and non-steroidal anti-inflammatory drugs (P = 0.026 and 0.014, respectively). Additional diseases of presumed autoimmune etiology were present in 43% (18/42) of patients. Comparison with the controls showed significantly more positive findings for ANA immunoglobulin G (IgG), gliadin immunoglobulin A (IgA) and ASCA (IgA and IgG) in patients with collagenous colitis but not in those with lymphocytic colitis. Collagenous colitis was associated with positive ASCA in 15% of patients and lymphocytic colitis in 13%. Conclusions: The autoantibodies investigated are of no diagnostic relevance to microscopic colitis. Positive ANA and strong associations with other autoimmune diseases point to an autoimmune etiology. H(2)-receptor antagonists and non-steroidal anti-inflammatory drugs might also be of pathogenetic significance.

Guidelines for colonoscopy surveillance after polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society.
Winawer SJ, Zauber AG, Fletcher RH, Stillman JS, O'Brien MJ, Levin B, Smith RA, Lieberman DA, Burt RW, Levin TR, Bond JH, Brooks D, Byers T, Hyman N, Kirk L, Thorson A, Simmang C, Johnson D, Rex DK
Gastroenterology. 2006 May;130(6):1872-85.

Adenomatous polyps are the most common neoplastic findings discovered in people who undergo colorectal screening or who have a diagnostic work-up for symptoms. It was common practice in the 1970s for these patients to have annual follow-up surveillance examinations to detect additional new adenomas and missed synchronous adenomas. As a result of the National Polyp Study report in 1993, which showed clearly in a randomized design that the first postpolypectomy examination could be deferred for 3 years, guidelines published by a gastrointestinal consortium in 1997 recommended that the first follow-up surveillance take place 3 years after polypectomy for most patients. In 2003 these guidelines were updated and colonoscopy was recommended as the only follow-up examination, stratification at baseline into low risk and higher risk for subsequent adenomas was suggested. The 1997 and 2003 guidelines dealt with both screening and surveillance. However, it has become increasingly clear that postpolypectomy surveillance is now a large part of endoscopic practice, draining resources from screening and diagnosis. In addition, surveys have shown that a large proportion of endoscopists are conducting surveillance examinations at shorter intervals than recommended in the guidelines. In the present report, a careful analytic approach was designed to address all evidence available in the literature to delineate predictors of advanced pathology, both cancer and advanced adenomas, so that patients can be stratified more definitely at their baseline colonoscopy into those at lower risk or increased risk for a subsequent advanced neoplasia. People at increased risk have either 3 or more adenomas, high-grade dysplasia, villous features, or an adenoma 1 cm or larger in size. It is recommended that they have a 3-year follow-up colonoscopy. People at lower risk who have 1 or 2 small (<1 cm) tubular adenomas with no high-grade dysplasia can have a follow-up evaluation in 5-10 years, whereas people with hyperplastic polyps only should have a 10-year follow-up evaluation, as for average-risk people. There have been recent studies that have reported a significant number of missed cancers by colonoscopy. However, high-quality baseline colonoscopy with excellent patient preparation and adequate withdrawal time should minimize this and reduce clinicians concerns. These guidelines were developed jointly by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society to provide a broader consensus and thereby increase the use of the recommendations by endoscopists. The adoption of these guidelines nationally can have a dramatic impact on shifting available resources from intensive surveillance to screening. It has been shown that the first screening colonoscopy and polypectomy produces the greatest effects on reducing the incidence of colorectal cancer in patients with adenomatous polyps.

Guidelines for colonoscopy surveillance after cancer resection: a consensus update by the American Cancer Society and the US Multi-Society Task Force on Colorectal Cancer.
Rex DK, Kahi CJ, Levin B, Smith RA, Bond JH, Brooks D, Burt RW, Byers T, Fletcher RH, Hyman N, Johnson D, Kirk L, Lieberman DA, Levin TR, O'Brien MJ, Simmang C, Thorson AG, Winawer SJ
Gastroenterology. 2006 May;130(6):1865-71.

Patients with resected colorectal cancer are at risk for recurrent cancer and metachronous neoplasms in the colon. This joint update of guidelines by the American Cancer Society and the US Multi-Society Task Force on Colorectal Cancer addresses only the use of endoscopy in the surveillance of these patients. Patients with endoscopically resected Stage I colorectal cancer, surgically resected Stages II and III cancers, and Stage IV cancer resected for cure (isolated hepatic or pulmonary metastasis) are candidates for endoscopic surveillance. The colorectum should be carefully cleared of synchronous neoplasia in the perioperative period. In nonobstructed colons, colonoscopy should be performed preoperatively. In obstructed colons, double-contrast barium enema or computed tomography colonography should be performed preoperatively, and colonoscopy should be performed 3 to 6 months after surgery. These steps complete the process of clearing synchronous disease. After clearing for synchronous disease, another colonoscopy should be performed in 1 year to look for metachronous lesions. This recommendation is based on reports of a high incidence of apparently metachronous second cancers in the first 2 years after resection. If the examination at 1 year is normal, then the interval before the next subsequent examination should be 3 years. If that examination is normal, then the interval before the next subsequent examination should be 5 years. Shorter intervals may be indicated by associated adenoma findings (see "Guidelines for Colonoscopy Surveillance After Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society"). Shorter intervals also are indicated if the patient's age, family history, or tumor testing indicate definite or probable hereditary nonpolyposis colorectal cancer. Patients undergoing low anterior resection of rectal cancer generally have higher rates of local cancer recurrence compared with those with colon cancer. Although effectiveness is not proven, performance of endoscopic ultrasound or flexible sigmoidoscopy at 3- to 6-month intervals for the first 2 years after resection can be considered for the purpose of detecting a surgically curable recurrence of the original rectal cancer.

Therapeutic action of ghrelin in a mouse model of colitis.
Gonzalez-Rey E, Chorny A, Delgado M
Gastroenterology. 2006 May;130(6):1707-20.

BACKGROUND & AIMS: Ghrelin is a novel growth hormone-releasing peptide with potential endogenous anti-inflammatory activities ameliorating some pathologic inflammatory conditions. Crohn's disease is a chronic debilitating disease characterized by severe T helper cell (Th)1-driven inflammation of the colon. The aim of this study was to investigate the therapeutic effect of ghrelin in a murine model of colitis. METHODS: We examined the anti-inflammatory action of ghrelin in the colitis induced by intracolonic administration of trinitrobenzene sulfonic acid. Diverse clinical signs of the disease were evaluated, including weight loss, diarrhea, colitis, and histopathology. We also investigated the mechanisms involved in the potential therapeutic effect of ghrelin, such as inflammatory cytokines and chemokines, Th1-type response, and regulatory factors. RESULTS: Ghrelin ameliorated significantly the clinical and histopathologic severity of the trinitrobenzene sulfonic acid-induced colitis; abrogating body weight loss, diarrhea, and inflammation; and increasing survival. The therapeutic effect was associated with down-regulation of both inflammatory and Th1-driven autoimmune response through the regulation of a wide spectrum of inflammatory mediators. In addition, a partial involvement of interluekin-10/transforming growth factor-beta1-secreting regulatory T cells in this therapeutic effect was demonstrated. Importantly, the ghrelin treatment was therapeutically effective in established colitis and avoided the recurrence of the disease. CONCLUSIONS: Our data demonstrate novel anti-inflammatory actions for ghrelin in the gastrointestinal tract, ie, the capacity to deactivate the intestinal inflammatory response and to restore mucosal immune tolerance at multiple levels. Consequently, ghrelin administration represents a novel possible therapeutic approach for the treatment of Crohn's disease and other Th1-mediated inflammatory diseases, such as rheumatoid arthritis and multiple sclerosis.

A peri-anal extramammary Paget's disease associated with two well-differentiated invasive intramucosal sigmoid carcinomas, a very rare case: an immunohistochemical and clinical review of extramammary Paget's disease.
Le Fur R, Mears L, Dannawi Z
Ann R Coll Surg Engl. 2004 Nov;86(6):26-31.

Pregnancy and delivery in patients with enterostomy due to anorectal complications from Crohn's disease.
Takahashi K, Funayama Y, Fukushima K, Shibata C, Ogawa H, Kumagai E, Sasaki I
Int J Colorectal Dis. 2006 May 20;.

BACKGROUND AND AIMS: Enterostomy is often undergone by patients with Crohn's disease (CD) due to severe anorectal lesions such as rectovaginal fistula (RVF). Reports of successful pregnancy and delivery, which are important determinants of quality of life for female CD patients with stoma, are limited. Thus, we investigated problems associated with pregnancy and delivery in female CD patients at our hospital. MATERIALS AND METHODS: Between 1985 and 2003, five female CD patients with enterostoma carried seven pregnancies and delivered eight babies in our hospital. For this study, we investigated CD activity, fetal growth, stoma complications, and the outcome of delivery in these seven pregnancies. RESULTS: Among the five patients, four underwent loop ileostomy and one loop sigmoidostomy for treatment of RVF or severe stricture of the rectum or sigmoid colon. Except for one case, no fertility treatment was done. During pregnancy, a flare-up was observed in one patient and was successfully treated with corticosteroids. Although home enteral or parenteral nutrition was required in two cases, fetal growth was within the normal range in all pregnancies. Preterm delivery occurred in one case with a twin pregnancy. The mean diameter of stoma increased during pregnancy (p<0.01), and a mucosal laceration of stoma by the edge of an ostomy appliance occurred in one case. All deliveries were safe, with six cesarean sections and one transvaginal delivery. After each delivery, the stoma returned to pre-pregnancy size. CONCLUSIONS: Pregnancy and delivery in CD patients with stoma is safe and should be encouraged. However, special attention to disease activity, nutritional support, and stoma-related complications is recommended.

Attitudes and knowledge of colorectal cancer and screening in Hong Kong: a population-based study.
Wong BC, Chan AO, Wong WM, Hui WM, Kung HF, Lam SK
J Gastroenterol Hepatol. 2006 Jan;21(1 Pt 1):41-6.

BACKGROUND: Colorectal cancer (CRC) ranks third of all cancer mortalities in Hong Kong. CRC screening can reduce mortality. However, participation in the CRC screening program depends on the knowledge and attitude of the population. The aim of this study is to investigate the knowledge and attitude towards CRC screening in the Hong Kong population. METHODS: One thousand and thirty-three patients were interviewed by telephone survey. Knowledge and attitudes were assessed by using questionnaires. RESULTS: Only 8.9% of the respondents were able to mention that CRC was the second commonest cancer cause of death; 4.5% believed they would have a higher chance of developing CRC as compared to other cancers, and 7.4% could mention one of the screening methods. Approximately half (50.3%) were unable to identify any available screening venue. Approximately one-third (29.5%) indicated that they would definitely join a free CRC screening program, but the percentage dropped to 7.9% when a paid screening program was offered. Some (30.4%) of the respondents had the wrong impression that they did not require CRC screening because they were asymptomatic. Multivariate analysis showed that the independent predictor for participating in free screening was the concern level of getting CRC, while that for a paid screening program was a positive family history of CRC and the concern level. The concern level was dependent on a positive family history and knowledge of CRC. CONCLUSION: The general population in Hong Kong had deficient knowledge of CRC and screening. Education on the impact of CRC and beneficial effects of CRC screening should be offered before launching a CRC screening program.

April

[Fiction and facts about multi-modal therapy in rectal cancer]
Ulrich A, Weitz J, Friess H, Buchler M
Zentralbl Chir. 2006 Apr;131(2):134-9.

The prognosis of patients with rectal cancer has been improved significantly after introduction of the total mesorectal excision (TME). Just by performing TME, the local recurrence rates could be decreased to less than 10 %, independent of multi-modal therapeutic concepts. In contrast, the local recurrence rate reached 4 to 55 % (median 20 %) in a German multicenter study in 1995 prior to the nationwide introduction of TME. The goal of this overview is to compare the different concepts in the multi-modal therapy of rectal cancer with their advantages and disadvantages based on the current literature. Mentioned will be local recurrence rates and survival, but also toxicity, costs and acceptance of patients. Furthermore, a preview is given about future developments.

Chronic Pouchitis After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: Effect on Quality of Life.
Turina M, Pennington CJ, Kimberling J, Stromberg AJ, Petras RE, Galandiuk S
J Gastrointest Surg. 2006 Apr;10(4):600-606.

Chronic pouchitis can be observed in up to 30% of patients after proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). It remains a poorly understood complication and often requires chronic antibiotic and antidiarrheal treatment. We hypothesized that its occurrence can be predicted by distinct clinical parameters and that it adversely affects quality of life. Sixty-eight of 129 consecutive UC patients who underwent IPAA over a 10-year period were evaluated by Cleveland Clinic Global Quality of Life questionnaires, telephone interviews, and by chart review. Using bivariate comparison, clinical predictors for the occurrence of chronic pouchitis were sought, and postoperative data analyzed with regard to functional results and quality of life. Nineteen of 68 patients (28%) experienced chronic pouchitis, but its occurrence could not be predicted by any variable assessed. Patients with chronic pouchitis complained of more frequent fecal incontinence (32% vs. 4% in controls; P < 0.01), of more frequent bowel movements (7.7/day vs. 6.2/day; P < 0.05), and experienced severe abdominal pain more often (P < 0.05). Overall quality of life and satisfaction with surgery, as well as subjective health and energy levels were lower in patients with chronic pouchitis (P < 0.01); however, greater than 80% of these patients would consider undergoing the same procedure again.

Probiotic Treatment of Collagenous Colitis: A Randomized, Double-blind, Placebo-controlled Trial With Lactobacillus acidophilus and Bifidobacterium animalis subsp. Lactis.
Wildt S, Munck LK, Vinter-Jensen L, Hanse BF, Nordgaard-Lassen I, Christensen S, Avnstroem S, Rasmussen SN, Rumessen JJ
Inflamm Bowel Dis. 2006 May;12(5):395-401.

BACKGROUND:: Probiotic treatment may be effective in diseases involving gut microflora and intestinal inflammation. In collagenous colitis (CC), a potential pathogenic role of the gut microflora has been proposed. The effect of probiotic treatment in CC is unknown. Our aim was to investigate the clinical effect of treatment with Lactobacillus acidophilus LA-5 and Bifidobacterium animalis subsp. lactis BB-12 (AB-Cap-10) in patients with CC. MATERIALS AND METHODS:: Patients with CC and diarrhea were in a double-blind placebo-controlled study randomized (2:1) to AB-Cap-10 or placebo for 12 weeks. The primary end point was reduction in bowel frequency per week of >/=50%. Secondary end points were changes in bowel frequencies, stool consistency, stool weight, histopathology, and abdominal bloating and pain. RESULTS:: Twenty-nine patients were randomized: 21 to probiotics and 8 to placebo. Reduction in bowel frequency per week of >/=50% occurred in 6 of 21 (29%) and in 1 of 8 (13%) patients receiving probiotic and placebo, respectively (P = 0.635). No differences between treatments were observed regarding the secondary end points. Post hoc analysis showed a median reduction in bowel frequency per week from 32 (range 18-84) to 23 (range 11-56; P < 0.005), a reduction in number of days with liquid stools per week from 6 days (range 0-7 days) to 1 day (range 0-7 days; P < 0.005), and an increase in number of days with solid stools per week (P < 0.05) in the AB-Cap-10 group. CONCLUSIONS:: AB-Cap-10 had no significant effect on the chosen end points. Post hoc analysis demonstrated amelioration of clinical symptoms in the AB-Cap-10 group, indicating that probiotic treatment may potentially influence the disease course of CC.

Successful infliximab therapy for oral Crohn's disease.
Cardoso H, Nunes AC, Carneiro F, Tavarela Veloso F
Inflamm Bowel Dis. 2006 Apr;12(4):337-8.

Rifaximin for active ulcerative colitis.
Guslandi M, Petrone MC, Testoni PA
Inflamm Bowel Dis. 2006 Apr;12(4):335.

Role of infliximab in ulcerative colitis: further questions.
Lees CW, Shand AG, Penman ID, Satsangi J, Arnott ID
Inflamm Bowel Dis. 2006 Apr;12(4):335-7.

Outcomes of placebo therapy in inflammatory bowel disease.
Su C
Inflamm Bowel Dis. 2006 Apr;12(4):328-33.

Placebo is important in assessing drug response, particularly in diseases characterized by spontaneous periods of acute exacerbation and quiescence. Randomized, placebo-controlled trials are the most objective means of evaluating drug efficacy, although the conduct of such clinical trials may not always be practical or ethical in all disease states. In inflammatory bowel disease (IBD), most patients experience intermittent episodes of active disease alternating with variable periods of remission. Thus, development of new medical therapies for IBD requires proof of superiority to placebo or alternative therapies. In this regard, knowledge of the outcomes of patients receiving placebo therapy and their influencing factors is important for proper study design and meaningful results. Such knowledge also is essential for interpreting results of open-label studies often necessary before randomized controlled trials can be conducted. In addition, the disease course of placebo-treated patients in clinical trials of IBD serves as an approximation of the natural history of these patients. The knowledge of placebo response in these patients provides clinicians with an important piece of information in prognosticating and making management decisions. This review presents our current knowledge of placebo therapy in IBD. Specifically, the existing literature on the outcomes and predictors of outcomes in patients receiving placebo therapy in clinical trials of IBD is reviewed.

Revisiting the immunomodulators tacrolimus, methotrexate, and mycophenolate mofetil: their mechanisms of action and role in the treatment of IBD.
van Dieren JM, Kuipers EJ, Samsom JN, Nieuwenhuis EE, van der Woude CJ
Inflamm Bowel Dis. 2006 Apr;12(4):311-27.

Inflammatory bowel diseases (IBDs) are thought to result from unopposed immune responses to normal gut flora in a genetically susceptible host. A variety of immunomodulating therapies are applied for the treatment of patients with IBDs. The first-line treatment for IBDs consists of 5-aminosalicylate and/or budesonide. However, these first-line therapies are often not suitable for continuous treatment or do not suffice for the treatment of severe IBD. Recently, efforts have been made to generate novel selective drugs that are more effective and have fewer side effects. Despite promising results, most of these novel drugs are still in a developmental stage and unavailable for clinical application. Yet, another class of established immunomodulators exists that is successful in the treatment of inflammatory bowel diseases. While waiting for emerging novel therapies, the use of these more established drugs should be considered. Furthermore, one of the advantages of using established immunomodulators is the well-documented knowledge on the long-term side effects and on the mechanisms of action. In this review, the authors discuss 3 well-known immunomodulators that are being applied with increased frequency for the treatment of IBD: tacrolimus, methotrexate, and mycophenolate mofetil. These agents have been used for many years as treatment modalities for immunosuppression after organ transplantation, for the treatment of cancer, and for immunomodulation in several other immune-mediated diseases. First, this review discusses the potential targets for immunomodulating therapies in IBDs. Second, the immunomodulating mechanisms and effects of the 3 immunomodulators are discussed in relationship to these treatment targets.

Predicting the Crohn's disease activity index from the Harvey-Bradshaw Index.
Best WR
Inflamm Bowel Dis. 2006 Apr;12(4):304-10.

BACKGROUND: The Crohn's Disease Activity Index (CDAI) was developed in the 1970s to assess the degree of illness in individuals with Crohn's disease and has since been used widely in clinical trials of the condition. The Harvey-Bradshaw Index (HBI) is a simplification of the CDAI, designed to make data collection and computation easier. It is purported, on the basis of a 0.93 correlation coefficient, to give "essentially the same information." However, correlation is an incomplete way to assess sameness, and this study aimed to develop a method for predicting CDAI from HBI values, including relevant prediction limits. MATERIALS AND METHODS: Data used in developing both indexes were combined. Single visits of 224 patients with Crohn's disease were plotted on a scattergram. HBI values seen were integers from 0 through 19. Mean and standard deviation of CDAI were determined for each HBI value that included a sufficient number of patients. Standard deviation of CDAI showed a linear increase with increasing HBI. Therefore, regression of CDAI on HBI was weighted on the inverse of the estimated CDAI standard deviation. RESULTS: Regression predicted a 27-CDAI-unit increase for each HBI unit. Calculated 95% prediction limits were almost straight, diverging lines, bracketing 95% of observations. A table gives central tendency and 95% prediction limits of CDAI for any HBI, as well as key clinical benchmarks. CONCLUSIONS: There is a good but far from perfect relationship between CDAI and HBI. CDAI is preferred for clinical trials; HBI is easier to use.

Pain and mechanical properties of the rectum in patients with active ulcerative colitis.
Drewes AM, Frokjaer JB, Larsen E, Reddy H, Arendt-Nielsen L, Gregersen H
Inflamm Bowel Dis. 2006 Apr;12(4):294-303.

BACKGROUND: The pain, urgency, and incontinence in ulcerative colitis may be related to changes in viscoelastic properties of the gut wall or to alterations of the sensory pathways. In the present study, we used an advanced rectal probe to study the mechanosensory and smooth muscle properties in patients with active disease. METHODS: Nine patients with ulcerative colitis (mean age 39.5 years) with exacerbation limited to the rectum and sigmoid colon and 17 age-matched healthy subjects were included. The rectum was distended before and after pharmacological relaxation of the smooth muscle until moderate pain was reported, and the cross-sectional area, volume, pressure, tension, and strain were computed. To investigate central integration of a tonic stimulus, the bag was finally distended to the pain threshold; then, the cross-sectional area was held constant for 2 min. RESULTS: The patients were hypersensitive to mechanical stimuli as assessed by the cross-sectional area (F = 21.7; P < 0.001). There were no differences in compliance or stiffness between the 2 groups, but the hypersensitivity was abolished after muscle relaxation. Together with the muscle analysis, this finding demonstrated that the smooth muscles were tonically contracted in the inflamed rectum, resulting in a decreased rectal circumference. The tonic distensions did not evoke central integration of the pain response, indicating that hyperalgesia is more likely related to peripheral factors. CONCLUSIONS: Patients with active ulcerative colitis have hypersensitivity and increased tone of the smooth muscles, which may explain the symptoms. Drugs that affect smooth muscle contraction may be helpful in difficult cases.

Associations of allelic variants of the multidrug resistance gene (ABCB1 or MDR1) and inflammatory bowel disease and their effects on disease behavior: a case-control and meta-analysis study.
Onnie CM, Fisher SA, Pattni R, Sanderson J, Forbes A, Lewis CM, Mathew CG
Inflamm Bowel Dis. 2006 Apr;12(4):263-71.

BACKGROUND: Allelic variants of the ATP-binding cassette, subfamily B member 1 (ABCB1), also known as the multidrug resistance gene (MDR1) that encodes the membrane-bound efflux transporter P-glycoprotein 170 (PGP-170), have been associated with inflammatory bowel disease but with conflicting results. METHODS: The present study examined the association of ABCB1 C3435T and G2677T/A in a large British case-control cohort of 828 Crohn's disease, 580 ulcerative colitis (UC) cases, and 285 healthy controls. The effect of these variants was further examined with respect to phenotypic and epidemiological characteristics. A meta-analysis was carried out of our results and those from 8 previously published association studies of the C3435T variant in inflammatory bowel disease. RESULTS: The 2677T allele was significantly increased in British UC cases compared with controls (45.2% vs. 39.6%; P = 0.034). In particular, the TT genotype was significantly associated with severe UC (odds ratio [OR] 1.90; 95% CI 1.01-3.55) and the use of steroids in UC (OR 1.77; 95% CI 1.08-2.88). No significant association was seen with C3435T and UC, Crohn's disease, or any clinical subgroup. A meta-analysis of 9 association studies of C3435T showed a significant association of the 3435T allele with UC (OR 1.12; 95% CI 1.02-1.23; P = 0.013) but not with CD. CONCLUSIONS: These results indicate that ABCB1 sequence variants are associated with a small increase in the risk of developing UC and may influence disease behavior.

Indeterminate colitis: a significant subgroup of pediatric IBD.
Carvalho RS, Abadom V, Dilworth HP, Thompson R, Oliva-Hemker M, Cuffari C
Inflamm Bowel Dis. 2006 Apr;12(4):258-62.

BACKGROUND: Indeterminate colitis (IC) is a subgroup of inflammatory bowel disease (IBD) that cannot be characterized as either ulcerative colitis (UC) or Crohn's disease (CD). Our aims are to determine the prevalence of IC in our pediatric patient population and to describe its clinical presentation, natural history,and disease distribution. METHODS: We performed a retrospective database analysis of all children diagnosed with IBD at the Johns Hopkins Children's IBD Center between 1996 and 2001. Patient demographics, including age, sex, and age at disease onset, were tallied. Disease distribution was identified on the basis of a review of all endoscopic, colonoscopic, histopathological, and radiological records. All of the patients were followed up clinically to determine the extent of disease progression on the basis of the initial diagnosis of IC. RESULTS: Among 250 children registered in the database, 127 (50.8%) had a diagnosis of CD, 49 (19.6%) had UC, and 74(29.6%) had IC. Patients with IC had a significantly younger mean +/- SEM age (9.53 +/- 4.8 years) at diagnosis compared with patients with CD (12.4 +/- 3.8 years; P < 0.001) but not compared with patients with UC (7.41 +/- 3.5 years). Among the patients with IC, 59 (79.7%) had a pancolitis at diagnosis, and the remaining 15 had left-sided disease that progressed to a pancolitis within a mean of 6 years. Twenty-five patients (33.7%) with an initial diagnosis of IC were reclassified to either CD or UC after a median follow-up of 1.9 years (range 0.6-4.5 years). Forty-nine patients (66.2%) maintained their diagnosis of IC after a mean follow-up of 7 years (SEM 2.5 years). CONCLUSIONS: IC is a distinct pediatric subgroup of IBD with a prevalence that is higher than that observed in adults. Children with IC have an early age of disease onset and a disease that rapidly progresses to pancolitis. Longitudinal studies are needed to determine the clinical implications of this pediatric IBD subgroup.

Evaluation and analysis of colonoscopy in the diagnosis of 186 cases of ulcerative colitis patients.
Ding YJ, Yu JP, Luo HS, Zhou ZY, Liu J
Int J Clin Pract. 2006 Mar 27;.

Summary The objective of this study was to evaluate the diagnostic value of colonoscopy plus biopsy in patients with ulcerative colitis (UC). Retrospective analysis was performed on clinical data in 186 cases. Erosions, or ulcers, together with mucosal hyperemia and oedema were the most common manifestations of colonoscopy in 87% of patients. In about 56.4% of 186 cases, such manifestations occurred in the rectum and the sigmoid colon. Nearly 65.6% of the patients had a chronic intermittent clinical course. One case developed colon cancer, and another case had toxic megacolon; each case represents 0.05% of the total 186 patients. Therefore, prevalence of both malignancy and complication is low. Colonoscopy plus biopsy is considered to be the major means of the diagnosis of UC, demonstrating its value in differential diagnosis.

Diagnostic challenge of hyper-IgD syndrome in four children with inflammatory gastrointestinal complaints.
Oretti C, Barbi E, Marchetti F, Lepore L, Ventura A, D'Osualdo A, Gattorno M, Martelossi S, Tommasini A
Scand J Gastroenterol. 2006 Apr;41(4):430-6.

OBJECTIVE: Hyper-IgD syndrome (HIDS) is a rare autosomal recessive disease characterized by recurrent fever, lymphadenopathy, diarrhoea, abdominal pain, headache, arthralgia and skin rash. Abdominal symptomatology may mimic inflammatory bowel disease. We report on four patients with HIDS who had been previously investigated for Crohn's disease (CD). The levels of IgD were measured in a series of patients with CD to evaluate the specificity of this assay in the differential diagnosis between the two conditions. MATERIAL AND METHODS: Diagnosis of HIDS was based on clinical criteria as well as immunological or genetic data. IgD levels were measured in the four subjects affected by HIDS, in 59 patients with CD and in a group of 160 healthy controls. RESULT: All patients underwent a variety of gastroenterological investigations because inflammatory bowel disease was suspected. Ultrasonography was pathologic in all the patients, showing enlargement of mesenteric lymph nodes. Abdominal leucocyte scintigraphy displayed diffuse signals of mild to moderate degree. IgD and IgA levels were elevated in three out of four patients. No difference in IgD values was found in CD patients as compared to the control group. CONCLUSIONS: Gastrointestinal complaints associated with recurrent fever and mesenteric adenopathy warrant genetic investigation for HIDS, in order to avoid unnecessary invasive investigations and treatment.

Screening of tumor necrosis factor receptor-associated factor 6 as a candidate gene for inflammatory bowel disease.
Lappalainen M, Paavola-Sakki P, Halme L, Turunen U, Helio T, Farkkila M, Kontula K
Scand J Gastroenterol. 2006 Apr;41(4):424-9.

OBJECTIVE: The two forms of inflammatory bowel disease (IBD), Crohn's disease (CD) and ulcerative colitis (UC), are thought to arise because of an interplay of unfavorable genetic and exogenous factors. During a genome-wide linkage study of IBD, we observed a nominal linkage to chromosome 11p12-q13 that was further confirmed upon fine density mapping. This chromosomal region contains a functional IBD candidate gene coding for tumor necrosis factor receptor-associated factor 6 (TRAF6), a signal transducer regulating innate and adaptive immunity as well as bone homeostasis. MATERIAL AND METHODS: Using denaturing high-performance liquid chromatography (dHPLC) and DNA sequencing, all exons and exon-intron boundaries of the TRAF6 gene in probands of 95 IBD families were initially screened; this material comprised 20 CD, 39 UC and 36 mixed families. RESULTS: No nucleotide changes in the coding sequence of TRAF6 were detected, but a single-base insertion/deletion polymorphism in a polythymine stretch (containing 8 or 7 thymines, respectively) in intron 3 was identified. However, examination of an extended material of 290 unrelated CD patients, 416 UC patients and 320 healthy blood donors failed to show any association with this 7T/8T variation and IBD, nor was this polymorphism related to specific clinical features in IBD. CONCLUSIONS: Our study tends to exclude a good positional and functional candidate gene, TRAF6, as an IBD predisposing gene and lends support to the idea that the function of TRAF6 is important enough not to permit structural alterations of this mediator.

[Multimodal treatment of colon cancer?]
Fahlke J, Schmidt C, Tautenhahn J, Hribaschek A, Stubs P, Lippert H
Zentralbl Chir. 2006 Apr;131(2):126-33.

Surgical therapy is still the basis of therapy of patients with colon carcinoma. Multimodal therapeutical concepts are presently applied as a therapeutical standard in the adjuvant therapy and increasingly in the systemic therapy of patients with primarily inoperable metastases of the liver to reach a secondary operability. Interdisciplinary multimodal therapeutical concepts are even accepted within the therapy of metastasized colon carcinomas. There are still unanswered questions regarding sequences of palliative systemic therapies and their combinations with local ablative methods.

Optimizing management of distal ulcerative colitis.
Nilsson A
Scand J Gastroenterol. 2006 May;41(5):511-23.

Botulinum toxin and chronic anal fissure.
Cadeddu F, Brisinda G, Marniga G, Maria G
Am J Gastroenterol. 2006 Apr;101(4):909-10.

Botulinum toxin and chronic anal fissure.
Cadeddu F, Brisinda G, Marniga G, Maria G
Am J Gastroenterol. 2006 Apr;101(4):909-10.

Meta-analysis of probiotics for the prevention of antibiotic associated diarrhea and the treatment of Clostridium difficile disease.
McFarland LV
Am J Gastroenterol. 2006 Apr;101(4):812-22.

CONTEXT: Antibiotic-associated diarrhea (AAD) is a common complication of most antibiotics and Clostridium difficile disease (CDD), which also is incited by antibiotics, is a leading cause of nosocomial outbreaks of diarrhea and colitis. The use of probiotics for these two related diseases remains controversial. OBJECTIVE: To compare the efficacy of probiotics for the prevention of AAD and the treatment of CDD based on the published randomized, controlled clinical trials. DATA SOURCES: PubMed, Medline, Google Scholar, NIH registry of clinical trials, metaRegister, and Cochrane Central Register of Controlled Trials were searched from 1977 to 2005, unrestricted by language. Secondary searches of reference lists, authors, reviews, commentaries, associated diseases, books, and meeting abstracts. STUDY SELECTION: Trials were included in which specific probiotics given to either prevent or treat the diseases of interest. Trials were required to be randomized, controlled, blinded efficacy trials in humans published in peer-reviewed journals. Trials that were excluded were pre-clinical, safety, Phase 1 studies in volunteers, reviews, duplicate reports, trials of unspecified probiotics, trials of prebiotics, not the disease being studied, or inconsistent outcome measures. Thirty-one of 180 screened studies (totally 3,164 subjects) met the inclusion and exclusion criteria. DATA EXTRACTION: One reviewer identified studies and abstracted data on sample size, population characteristics, treatments, and outcomes. DATA SYNTHESIS: From 25 randomized controlled trials (RCTs), probiotics significantly reduced the relative risk of AAD (RR = 0.43, 95% CI 0.31, 0.58, p < 0.001). From six randomized trials, probiotics had significant efficacy for CDD (RR = 0.59, 95% CI 0.41, 0.85, p = 0.005). CONCLUSION: A variety of different types of probiotics show promise as effective therapies for these two diseases. Using meta-analyses, three types of probiotics (Saccharomyces boulardii, Lactobacillus rhamnosus GG, and probiotic mixtures) significantly reduced the development of antibiotic-associated diarrhea. Only S. boulardii was effective for CDD.

Intraperitoneal fluid therapy: an alternative to intravenous treatment in a patient with limited vascular access.
Asheim P, Uggen PE, Aasarod K, Aadahl P
Anaesthesia. 2006 May;61(5):502-4.

Summary We describe a 58-year-old female with Crohn's disease and short bowel syndrome after repeated intestinal resections, with only 90 cm of small intestine left. She had been dependent on vascular access for total parenteral nutrition for 16 years. Due to intravascular complications after numerous long-term central venous catheters, her vascular accessibility became limited. During the course of a year she was fed enterally through a gastrostomy, but required supplementary fluid therapy through peripheral venous route. Because of extremely limited venous access, we decided to implant an intraperitoneal catheter for administration of crystalloid fluid. The first intraperitoneal catheter had to be removed because of a postoperative infection, but after antibiotic treatment, a second intraperitoneal catheter was implanted without complications, through which the patient is now fully provided with crystalloid fluid (Ringer's acetate). Abdominal ultrasound examination shows good absorption of the fluid, and for the first time in 16 years the patient does not need intravascular access. We suggest that intraperitoneal administration of fluid may be an alternative for patients with limited vascular access.

Hyperbaric oxygen enhances the efficiency of 5-aminosalicylic acid in acetic acid-induced colitis in rats.
Gorgulu S, Yagci G, Kaymakcioglu N, Ozkara M, Kurt B, Ozcan A, Kaya O, Sadir S, Tufan T
Dig Dis Sci. 2006 Mar;51(3):480-7.

The aim of this study was to assess the efficiency of hyperbaric oxygen alone and in combination with 5-aminosalicylic acid in the acetic acid-induced colitis model, a well-known experimental model of inflammatory bowel disease in rats. Rats were randomly divided into five groups. In the noncolitis control group, rats were given isotonic saline, while in the other groups rats were treated by intracolonic administration of 4% acetic acid. In group 2, the untreated control group, no additional therapy was applied. In groups 3, 4, and 5 hyperbaric oxygen, 5-aminosalicylic acid. and 5-aminosalicylic acid + hyperbaric oxygen therapies were applied, respectively. Administration of acetic acid caused an inflammatory response in all animals. Histopathologic score was significantly higher in group 2 than in any other group. 5-Aminosalicylic acid and hyperbaric oxygen significantly decreased the histopathologic score (P < 0.05). Myeloperoxidase activity was also reduced significantly by 5-aminosalicylic acid (P < 0.05) but not by hyperbaric oxygen. The most prominent ameliorative effect, however, was seen in group 5 and the histopathologic score and myeloperoxidase activity were significantly lower than in groups 3 (P < 0.05) and 4 (P < 0.001). Hydroxyproline level also increased significantly in group 5, but not in groups 3 and 4 (P < 0.001). These findings indicate that hyperbaric oxygen therapy is effective in reducing the extent of colitis induced by acetic acid, although it is not as potent as 5-aminosalicylic acid. The combination of hyperbaric oxygen and 5-aminosalicylic acid, however, led to a much more prominent reduction in the severity of colitis. Hyperbaric oxygen may have a promising place in the treatment of inflammatory bowel disease.

Prediction of Postoperative Mortality in Elderly Patients With Colorectal Cancer.
Heriot AG, Tekkis PP, Smith JJ, Cohen CR, Montgomery A, Audisio RA, Thompson MR, Stamatakis JD
Dis Colon Rectum. 2006 May 11;.

PURPOSE: This study was designed to develop a model for predicting postoperative mortality in elderly patients undergoing surgery for colorectal cancer. METHODS: This multicenter study was conducted by using routinely collected clinical data, assessing patients older than aged 80 years, with 30-day operative mortality as the primary end point. Data were collected from The Association of Coloproctology of Great Britain and Ireland database, encompassing 8,077 newly diagnosed colorectal cancer patients undergoing resectional surgery in 79 hospitals between April 2000 to March 2002, The Association of Coloproctology Malignant Bowel Obstruction Study, encompassing 1,046 patients with malignant bowel obstruction in 148 hospitals, between April 1998 to March 1999, and The Wales-Trent audit, encompassing 3,522 newly diagnosed colorectal cancer patients, between July 1992 to June 1993. A multilevel logistic regression model was developed to adjust for case-mix and to accommodate the variability of outcomes between the three study populations. The model was internally validated using a Bayesian resampling technique and tested using measures of discrimination, calibration, and subgroup analysis. RESULTS: A total of 2,533 patients satisfied the inclusion criteria, with a 30-day mortality of 15.6 percent. Multivariate analysis identified the following independent risk factors: age (odds ratio for 85-90, 90-95, >95 vs. 80-85 = 1.1, 1.8, 2.9), American Society of Anesthesiology grade (odds ratio for Grade III, IV vs. I-II = 2.7, 6.1), operative urgency (odds ratio for emergency vs. elective = 1.9), no cancer excision vs. resection (odds ratio = 1.2), and metastatic disease (odds ratio for metastases vs. no metastases = 1.9). The model offered adequate discrimination (area under receiver operator curve = 0.732) and excellent agreement between observed and predicted outcomes during eight colorectal procedures (P = 0.885). CONCLUSIONS: The elderly colorectal cancer model can accurately estimate 30-day mortality in patients older than aged 80 years undergoing surgery for colorectal cancer. Because the mortality can be considerable, this may have important implications when determining management for this group of patients.

Measuring the Quality of Colorectal Cancer Screening: The Importance of Follow-Up.
Etzioni DA, Yano EM, Rubenstein LV, Lee ML, Ko CY, Brook RH, Parkerton PH, Asch SM
Dis Colon Rectum. 2006 May 3;.

PURPOSE: As evidence mounts for effectiveness, an increasing proportion of the United States population undergoes colorectal cancer screening. However, relatively little is known about rates of follow-up after abnormal results from initial screening tests. This study examines patterns of colorectal cancer screening and follow-up within the nation's largest integrated health care system: the Veterans Health Administration. METHODS: We obtained information about patients who received colorectal cancer screening in the Veterans Health Administration from an existing quality improvement program and from the Veterans Health Administration's electronic medical record. Linking these data, we analyzed receipt of screening and follow-up testing after a positive fecal occult blood test. RESULTS: A total of 39,870 patients met criteria for colorectal cancer screening; of these 61 percent were screened. Screening was more likely in patients aged 70 to 80 years than in those younger or older. Female gender (relative risk, 0.92; 95 percent confidence interval, 0.9-0.95), Black race (relative risk, 0.92; 95 percent confidence interval, 0.89-0.96), lower income, and infrequent primary care visits were associated with lower likelihood of screening. Of those patients with a positive fecal occult blood test (n = 313), 59 percent received a follow-up barium enema or colonoscopy. Patient-level factors did not predict receipt of a follow-up test. CONCLUSIONS: The Veterans Health Administration rates for colorectal cancer screening are significantly higher than the national average. However, 41 percent of patients with positive fecal occult blood tests failed to receive follow-up testing. Efforts to measure the quality of colorectal cancer screening programs should focus on the entire diagnostic process.

A Consensus Document on Bowel Preparation Before Colonoscopy: Prepared by a Task Force From The American Society of Colon and Rectal Surgeons (ASCRS), The American Society for Gastrointestinal Endoscopy (ASGE), and The Society of American Gastrointestinal
Wexner SD, Beck DE, Baron TH, Fanelli RD, Hyman N, Shen B, Wasco KE
Dis Colon Rectum. 2006 May 2;.

Focus Group on Laparoscopic Colectomy Education as Endorsed by The American Society of Colon and Rectal Surgeons (ASCRS) and The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).
Fleshman J, Marcello P, Stamos MJ, Wexner SD
Dis Colon Rectum. 2006 May 2;.

Need for Guidelines for Screening in Anal Cancer: A Lesson From Cervical Cancer.
Hayanga A
Dis Colon Rectum. 2006 May 2;.

Effective Screening for Bowel Cancer: A United Kingdom Perspective.
Thompson MR, Steele RJ, Atkin WS
Dis Colon Rectum. 2006 Apr 28;.

Bowel cancer is a major cause of morbidity and death and is a high cost to health care systems. Screening currently offers the best chance of improving outcomes from bowel cancer. When introducing screening, the problems encountered in other cancers need to be avoided to maximize benefits and minimize harms.

Long-Term Results of "Chemical Sphincterotomy" for Chronic Anal Fissure: A Prospective Study.
Lysy J, Israeli E, Levy S, Rozentzweig G, Strauss-Liviatan N, Goldin E
Dis Colon Rectum. 2006 Apr 28;.

INTRODUCTION: Pharmacologic anal sphincter relaxants promote fissure healing; however, their effect is transient and the risk of late recurrence remains uncertain. METHODS: From August 1997 to August 2002, patients with chronic anal fissure attending our outpatient clinic were treated with a protocol that included: topical isosorbide dinitrate, 2.5 mg, or nifedipine, 0.2 percent t.i.d., or the combination of both. Botulinum toxin 20 units was injected to the internal anal sphincter to those who failed. All the patients were contacted and interviewed during November to December 2002. RESULTS: Follow-up was a median of 47.43 +/- 13 (range, 4.7-60) months. A total of 455 patients completed the study; 323 patients (71 percent) healed at follow-up ending: 170 of the healed patients had one or more recurrences that responded to further treatment (37.4 percent), whereas 153 patients (33.6 percent) healed and had no recurrences. One hundred thirty-two patients (29 percent) did not heal and were referred to lateral sphincterotomy. Long intervals between symptoms appearance and treatment initiation decreased healing and increased recurrence rates (P = 0.03 and 0.01 respectively). CONCLUSIONS: Topical treatment is effective for patients with chronic anal fissure, at short-term and long-term periods. Because for many patients it is not a definitive treatment, it can be offered to those who are ready to receive repeated treatments. Longer intervals between symptom appearance and treatment initiation negatively affects fissure healing and recurrence rate.

Abdominoperineal Excision With Partial Anterior En Bloc Resection in Multimodal Management of Low Rectal Cancer: A Strategy to Reduce Local Recurrence.
Smedh K, Khani MH, Kraaz W, Raab Y, Strand E
Dis Colon Rectum. 2006 Apr 19;.

PURPOSE: Total mesorectal excision is the gold standard inthe performance of an abdominoperineal resection but little has changed in the way the perineal operation is performed. A frequent problem is anterior dissection. The aim of this study was to present the results of abdominoperineal resection using selected partial anterior en bloc resection to reduce recurrence. METHODS: The data were population-based and prospectively registered. Two experienced surgeons performed the operations. In selected cases, depending on clinical and magnetic resonance imaging findings, parts of the vagina or prostate close to the tumor were resected. All specimens were examined according to Quirke. RESULTS: Sixty-three patients underwent abdominoperineal resection with total mesorectal excision; 56 received preoperative radiotherapy. The tumors involved the anterior bowel wall in 40 cases and in 23 (58 percent) of them, en bloc resections were performed. The distance from the tumor to the conventional resection margin (without en bloc resection) was 0 mm in ten cases. The median follow-up period was 37 months. So far, one (1.7 percent) local recurrence has been detected in 58 (92 percent) curative and indeterminate cases. The cancer-specific five-year survival in these cases was 87 percent (Kaplan-Meier). CONCLUSION: A multimodal management regimen in patients with low rectal cancer, including preoperative radiotherapy and abdominoperineal resection with a high frequency of partial en bloc resection of the vagina or prostate, resulted in excellent local control and survival. In some male patients, excenteration with urinary stoma can be avoided.

Controlled Dose Delivery in Topical Treatment of Anal Fissure: Pilot Study of a New Paradigm.
Torrabadella L, Salgado G
Dis Colon Rectum. 2006 Apr 13;.

PURPOSE: Topical nitroglycerin has been widely used as a means for avoiding surgery in patients with anal fissure. However, nitroglycerin has not been universally accepted for this application because of inconsistency of efficacy and side effects. This study compares conventional digital application with precise intra-anal dosing of nitroglycerin using a specialized dose-delivery device and anal cannula. METHODS: Twenty-six consecutive patients (13 males) with chronic anal fissure and no previous treatment were randomly allocated to receive 0.75 ml of 0.3 percent nitroglycerin ointment (2.25 mg nitroglycerin) t.i.d. intra-anal using the cannula (Group A) or perianally with the gloved finger (Group B). Nitroglycerin dosage was controlled in Group A by the dose-delivery device connected to the cannula and by single-dose preloaded syringes in Group B. RESULTS: Anal manometry: pressure reduction after application of nitroglycerin was 47 +/- 18.6 in Group A and 20.7 +/- 13.4 percent in Group B (P < 0.01). Headaches were reported by 1 of 10 patients in Group A and 10 of 12 patients in Group B (P = 0.0027). Seven patients of Group B had to be crossed to intra-anal treatment as a result of intensity of headaches. Pain relief was noted by 8 of 10 and 9 of 12 patients in Groups A and B, respectively (P = 0.6). Sphincterotomy was required in only 13.6 percent of all patients. CONCLUSIONS: Controlled intra-anal dosing of topical nitroglycerin produces a significantly greater reduction in sphincteric pressure and lower incidence of headaches than with perianal administration of the same dose ofointment. These results suggest a new paradigm for increasing safety and efficacy of dose-dependent prescription anal topical medications.

Endoscopic Posterior Mesorectal Resection After Transanal Local Excision of T1 Carcinomas of the Lower Third of the Rectum.
Zerz A, Muller-Stich BP, Beck J, Linke GR, Tarantino I, Lange J
Dis Colon Rectum. 2006 Apr 13;.

PURPOSE: The rectum-sparing transanal local excision is a well-established treatment of T1 carcinomas of the lower third of the rectum. A potentially increased locoregional recurrence rate by this procedure is tolerated because of the high morbidity and mortality risk of transabdominal rectal resection. Dorsoposterior extraperitoneal pelviscopy makes it possible to remove the relevant lymphatic drainage of the lower third of the rectum minimally invasively, in the sense of a rectum-sparing endoscopic posterior mesorectal resection. It has to be considered whether endoscopic posterior mesorectal resection in combination with transanal local excision allows for local radicality and an adequate tumor staging in T1 carcinomas of the lower third of the rectum, in terms of better-directed therapy planning compared with transanal local excision alone. METHODS: We operated on 11 consecutive patients with T1 carcinomas of the lower third of the rectum by transanal local excision in combination with endoscopic posterior mesorectal resection as a two-stage procedure in the period from 1998 to 2005. RESULTS: It was possible to perform a complete excision of the primary and to resect the posterior part of the mesorectum in all cases. Postoperative morbidity consisted of two transient neurologic complications and a pulmonary embolism. There was no mortality. Histologic analysis revealed a median of eight (range, 4-20) lymph nodes. Two patients diagnosed with lymph-node metastases received adjuvant radiochemotherapy. After a median follow-up of 48 (range, 4-60) months, there was noevidence for locoregional recurrence. In one patient liver metastasis was detected eight months postoperatively. CONCLUSIONS: Radical excision of the primary tumor and an adequate tumor staging in T1 carcinomas of the lower third of the rectum seems to be achievable by means of transanal local excision and endoscopic posterior mesorectal resection.

Prospective randomised trial comparing ileocaecal interposition and colon-J-pouch as rectal replacement after total mesorectal excision.
Rink AD, Haaf F, Knupper N, Vestweber KH
Int J Colorectal Dis. 2006 Apr 20;.

BACKGROUND: Ileocaecal interposition (ICI) is a technique of rectal replacement after total mesorectal excision (TME), but the method has never been evaluated in a randomised fashion. We performed a randomised, controlled trial to compare ICI and colon-J-pouch (CJP) for rectal replacements after TME for rectal cancer. MATERIALS AND METHODS: Fifteen patients were enrolled into each treatment group of the trial according to the protocol. Follow-up evaluations were performed 3 months and 1 year after ileostomy closure and at a mean of 5 years after initial surgery. RESULTS: Similar results between the groups were found for incontinence, urgency, constipation and quality of life at all follow-ups. The frequency of defecation was slightly lower in the CJP group at 3 months [3 (2-6) vs 5 (2-11) (p=0.043)] and at 1 year [3 (2-5) vs 5 (2-8) (p=0.034)]. However, this difference lost significance if patients who had postoperative radiotherapy were excluded from the analysis. Four out of the 15 patients treated with ICI experienced bowel obstruction, which required open surgery in two, endoscopic dilatation in one or maintenance of the ileostomy in one patient. None of the patients treated with CJP had similar complications. CONCLUSIONS: ICI and CJP reconstruction result in a similar functional outcome and quality of life. As ICI did not show any benefit over CJP and tended to result in a higher frequency of defecation, it should not be used as a first choice treatment. In addition, ICI was associated with significant complications after radiotherapy. Therefore, it must not be used if postoperative radiochemotheray is intended.

Serum ghrelin levels in children with celiac disease.
Selimoglu MA, Altinkaynak S, Ertekin V, Akcay F
J Clin Gastroenterol. 2006 Mar;40(3):191-4.

OBJECTIVES: Ghrelin, a gastrointestinal hormone, has effects on nutrient intake and growth. Because celiac disease (CD) has intestinal histopathologic alterations and subsequent malnutrition and/or growth failure, we hypothesized that there would be alterations in serum ghrelin levels of those patients. In this study, we aimed to determine serum ghrelin levels in childhood CD, to observe probable alterations under gluten-free diet (GFD), and to see whether there is a relationship between ghrelin levels and the presentation of the disease and/or diet compliance. METHODS: Thirty-six children with CD and 10 healthy children were included. Serum fasting ghrelin level was measured using radioimmunoassay method. After 6 months under GFD, sera of 19 patients were retested for ghrelin level. RESULTS: Mean serum ghrelin levels in children with CD and in controls were 478.2+/-154.6 and 108.3+/-49.1 pg/mL, respectively (P<0.001). Serum ghrelin level was not different in different clinical presentations. Ghrelin was negatively correlated with body mass index, both in healthy children and in children with CD on admission (P<0.01). Ghrelin level was lower after 6 months under GFDcompared with the level detected on admission (P<0.001), but was still higher compared with that of healthy children (P<0.001). Strict diet compliance lowered ghrelin level, although not statistically. CONCLUSIONS: Ghrelin is increased in childhood CD and is responsive to GFD. Further studies are needed to clarify the mechanism underlying its action in CD.

Single-dose quinolone treatment in acute gastroenteritis.
Zamir D, Weiler Z, Kogan E, Ben-Valid E, Hay E, Reitblat T, Polishchuk I
J Clin Gastroenterol. 2006 Mar;40(3):186-90.

BACKGROUND: Acute diarrhea is a common disease worldwide and in Israel, a Mediterranean country. Acute bacterial gastroenteritis (ABGE) is the leading cause of severe diarrhea in Israel in summer and early autumn. Although there are some reports showing some benefit from empiric antibiotic therapy in acute gastroenteritis, most are old reports using nondefinitive diagnostic criteria and using 5-day antibiotic regimens. AIMS: 1. To examine the efficiency of antibiotic therapy in relatively severe ABGE in general. 2. To check the efficiency of the different types of quinolones in the treatment of ABGE. 3. To compare various therapy regimens. METHODS: All patients admitted to the Barzilai Medical Center emergency room during the period June to October in 2002-2004 who were defined by protocol as having relatively severe gastroenteritis and required hospitalization in the Department of Internal Medicine were included in the study. All were randomized either to a supportive treatment only group (STG) or to the antibiotic treatment group (ATG) of ofloxacin or levofloxacin with a single dose or BID for 5 days in addition to STGs. All patients were interviewed a week later about their medical history and duration of symptomatology. RESULTS: One hundred thirty-nine patients were found eligible for the study in the above-mentioned period. Abdominal pain resolved 1.3 days earlier in the ATG in comparison to the STG whereas vomiting and diarrhea disappeared 1.0 and 0.8 days earlier, respectively, in the ATG versus the STG. In terms of fever abatement there was no difference between the regimens and no significant difference in symptomatology disappearance between various types of quinolones used or between the single antibiotic dose regimen and the 5-day antibiotic regimen groups. CONCLUSIONS: 1. Antibiotic therapy was found to shorten duration of symptoms in patients with relatively severe gastroenteritis. 2. Single-dose therapy is as effective and certainly significantly more cost effective in comparison to the 5-day antibiotic treatment regimen.

The nature of inflammatory bowel disease in patients with coexistent colonic diverticulosis.
Sultan K, Fields S, Panagopoulos G, Korelitz BI
J Clin Gastroenterol. 2006 Apr;40(4):317-21.

GOALS/BACKGROUND: Reports of segmental colitis with diverticula regard this entity as a local disease. Our goal was to reexamine the association of diverticula to colitis and question the relationship of colonic diverticulosis with generalized inflammatory bowel disease (IBD). STUDY: A retrospective database review of more than 1,600 patients matched 100 cases with IBD and colonic diverticulosis with a control group of 100 patients with IBD without diverticulosis. Patients were matched by gender, IBD diagnosis, and date of birth. Variables examined included disease distribution, strictures, fistulae, extraintestinal manifestations (EIMs), family history, and age at IBD diagnosis. RESULTS: For all IBD diagnoses, more sigmoid inflammation occurred in cases with diverticular disease: 82% versus 65% for controls (P = 0.005), and in the rectum: 85% versus 69% for controls (P = 0.005). In the Crohn's disease with diverticulosis subset, sigmoid inflammation was more common: 70% versus 42% for controls (P = 0.007), and in the rectum: 70% versus 46% for controls (P = 0.02). Disease distribution was otherwise similar throughout the colon, ileum, and jejunum. The incidence of strictures (P = 0.99) and fistulae (P = 0.69) was similar. EIMs were more frequent in cases with diverticulosis: 28% versus 16% (P = 0.05). Family history of IBD was similar: 26% for cases and 16% for controls (P = 0.12). Age at IBD diagnosis was significantly greater in diverticulosis cases compared with controls: 51.5 years (+/-17.6) versus 42.8 years (+/- 17.5) (P < 0.001), respectively. CONCLUSIONS: We observed an increased frequency of sigmoid and rectal inflammation, EIMs, and an older age of IBD onset in cases with diverticulosis. This suggests a role for diverticula in IBD beyond that of a mere coincidental finding.

Mesalazine and/or Lactobacillus casei in preventing recurrence of symptomatic uncomplicated diverticular disease of the colon: a prospective, randomized, open-label study.
Tursi A, Brandimarte G, Giorgetti GM, Elisei W
J Clin Gastroenterol. 2006 Apr;40(4):312-6.

GOALS: To investigate the effectiveness and safety of mesalazine, with or without Lactobacillus casei, in preventing recurrence of symptomatic diverticular disease of the colon. BACKGROUND: Both mesalazine and probiotics showed recently their effectiveness in obtaining remission of symptomatic uncomplicated diverticular disease of the colon. Consistent data are not available on the optimal therapy to prevent recurrence of symptomatic diverticular disease of the colon. STUDY: Multicenter, prospective, randomized, open-label study. Ninety consecutive patients (36 men, 54 women, mean age 67.5 y, range 39 to 84 y), previously affected by symptomatic uncomplicated diverticular disease of the colon (remission obtained with rifaximin 800 mg/d plus mesalazine 2.4 g/d for 10 d, followed by mesalazine 1.6 g/d for 8 wk), were enrolled in a 12-month follow-up. The following symptoms were assessed at entry and through follow-up by using a quantitative scale: (1) constipation, (2) diarrhea, (3) abdominal pain, (4) rectal bleeding, and (5) mucus with the stools. After recruitment, the patients were randomly assigned to one of the following 3 groups: mesalazine 1.6 g/d (group M), L. casei DG 16 billion/d for 15 d/mo (group L); mesalazine 1.6 g/d+L. casei DG 16 billion/d for 15 d/mo (group LM). RESULTS: Eighty-five patients completed the study (94.5%): 2 patients (2.22%, 1 of group M and 1 of group LM) were withdrawn from the study for protocol violation and 1 (1.11%) for hospital admission due to acute pulmonary disease (group L); 2 patients (2.22%) were lost to follow-up. Seventy-five patients (88.2%) were symptom free after the 12th month of treatment (overall symptomatic score: (0): 23/27 patients of group M [on intention to treat: 76.7% confidence interval (CI 95%: 61.5 to 91.8)], 23/29 of group L [on intention to treat: 76.7% (CI 95%: 61.5 to 91.8)], 29/29 of group LM [on intention to treat: 96% (CI 95%: 94.2 to 100)] (P < 0.05). Only 10 patients (11.1%) showed recurrence of symptoms (overall symptomatic score: 68). CONCLUSIONS: Both mesalazine and L. casei DG seem to be effective in preventing recurrence of symptomatic uncomplicated diverticular disease of the colon, but their association seems to be more promising in this field.

Epithelial cell proliferation of the colonic mucosa in different degrees of colonic diverticular disease.
Tursi A, Brandimarte G, Elisei W, Inchingolo CD, Aiello F
J Clin Gastroenterol. 2006 Apr;40(4):306-11.

GOAL: This study assesses the epithelial cell proliferation in different degrees of diverticular disease and compares this with two different control groups. BACKGROUND: Hyperproliferation of the colonic mucosa has been recently described in diverticular disease (DD), but it is unknown whether this finding is present in every degree of DD. PATIENTS AND METHODS: Thirty consecutive patients with a new endoscopic diagnosis of DD (10 with asymptomatic diverticulosis, 10 with symptomatic uncomplicated DD, and 10 with acute uncomplicated diverticulitis) were enrolled. Ten matched healthy people and 10 patients with ulcerative colitis (UC) (5 with UC in remission and 5 with active UC) were enrolled as control groups. The Ki-67 antigen index of the whole crypt and the upper third was separately evaluated. RESULTS: Ki-67 index of the whole crypt and the upper third of the crypt was significantly higher in all degrees of DD compared with the healthy control group. In particular, asymptomatic diverticulosis showed a threefold higher Ki-67 index compared with that of the healthy control group (5.4% and 5.6% vs. 1.6% and 1.8%, respectively, P = 0.005), and similar to that of UC in remission (5.4% and 5.6% vs. 5.9% and 5.8%, respectively, P = not significant). CONCLUSIONS: We found an upward shifting of cellular proliferation of the colonic mucosa in patients with different degrees of DD. In particular, asymptomatic diverticulosis seems to show the same risk for colonic carcinoma as that of UC.

Initial experience with a general population colorectal cancer screening clinic.
Brosseuk D, Oosthuizen J, Pinchbeck M
Am J Surg. 2006 May;191(5):669-72.

BACKGROUND: Recognition of adenoma to carcinoma progression has established colorectal cancer as a preventable malignancy. Colorectal cancer is, therefore, an ideal malignancy for preventative screening given the presence of a benign precursor. We set out to establish a pilot low-risk endoscopic screening clinic and we discuss our initial results. METHODS: A retrospective chart review of all patients referred to a new low-risk colorectal cancer endoscopic screening clinic from October 1, 2004 to September 30, 2005 was performed. Those patients found to have adenomas or carcinomas were analyzed further regarding location of neoplasm and pathologic findings. RESULTS: A total of 379 low-risk patients attended the colorectal cancer screening clinics. The age range of the patients was 50 to 86 years. The male to female ratio was 254 to 128. A total of 257 patients had flexible sigmoidoscopy as the initial screen, 24 patients had partial colonoscopy, and 98 patients had complete initial colonoscopy. A total of 152 patients had polyps removed, of which 63 patients had adenomas, 3 had adenocarcinomas, 1 had a carcinoid, and the remaining had an assortment of nonneoplastic polyps. Of the 67 patients with neoplasms, 50 were left of the splenic flexure, 11 were right of the splenic flexure, and 5 patients had lesions both proximal and distal to the flexure. Thirty-two of the 67 patients had complete colonoscopy at the initial procedure and, thus far, 21 patients have had completion colonoscopies, of which 9 patients had further neoplasms identified beyond the splenic flexure. All 3 patients with carcinoma had early tumors resected with curative intent, with negative margins and negative nodes. CONCLUSIONS: Our initial experience with a low-risk general population colorectal cancer endoscopic screening clinic yielded 18% of patients with neoplasms, and 1% had curable cancers resected.

Familial expression of anti-Escherichia coli outer membrane porin C in relatives of patients with Crohn's disease.
Mei L, Targan SR, Landers CJ, Dutridge D, Ippoliti A, Vasiliauskas EA, Papadakis KA, Fleshner PR, Rotter JI, Yang H
Gastroenterology. 2006 Apr;130(4):1078-85.

BACKGROUND & AIMS: Crohn's disease (CD) is a genetically complex disorder with strong familial aggregation. Pathogenesis appears to involve dysregulation of the immune response to endogenous bacteria. Anti-Escherichia coli outer membrane porin C (anti-OmpC) expression reflects an exaggerated response to commensal bacteria and occurs with higher frequency in CD. The aim of this study was to determine whether there is familial aggregation and genetic determination of anti-OmpC expression in CD families. METHODS: Study groups consisted of 787 CD patients, 389 ulcerative colitis (UC) patients, 619 unaffected relatives, and 216 healthy controls. Serum anti-OmpC was detected by enzyme-linked immunosorbent assay. RESULTS: CD patients had a greater percentage of anti-OmpC than UC patients and healthy controls. Anti-OmpC expression was more frequent in unaffected relatives from CD-only or mixed families, compared with healthy controls (P = .002 and .0001, respectively), and it was more frequent in UC patients from mixed families than those from UC-only families (P = .02). There was a significant familiality in anti-OmpC expression: P = .02 for qualitative concordance and P < .0001 for quantitative intraclass correlation. The heritability estimate for anti-OmpC level was .39 (P < .0001). CONCLUSIONS: Anti-OmpC is a heritable immunophenotype. Increased anti-OmpC expression in the unaffected family members of CD patients suggests that anti-OmpC may be an immunologic risk marker for CD. That UC patients in mixed families had a higher response to OmpC than those in UC-only families indicates pathophysiologic heterogeneity within UC.

March

Can the clinical history distinguish between organic and functional dyspepsia?
Moayyedi P, Talley NJ, Fennerty MB, Vakil N
JAMA. 2006 Apr 5;295(13):1566-76.

CONTEXT: Upper gastrointestinal symptoms occur in 40% of the population. An accurate diagnosis would help rationalize investigation and treatment. OBJECTIVE: To systematically review the literature of the accuracy of primary care physicians, gastroenterologists, or computer models in diagnosing organic dyspepsia. DATA SOURCES: A search of Cochrane Controlled Trials Register (December 2003), MEDLINE (1966-December 2003), EMBASE (1988-December 2003), and CINAHL (1982-December 2003) for studies that reported on cohorts of patients attending for endoscopy that had symptoms, clinical opinion, or both recorded before investigation. STUDY SELECTION: Studies that prospectively compared the diagnosis reached by a clinician, computer model, or both with results of upper gastrointestinal endoscopy in adult patients with upper gastrointestinal symptoms. DATA EXTRACTION: Two authors independently assessed studies (n = 79) for eligibility and abstracted data for estimating likelihood ratios (LRs) of clinical opinion, computer models, or both in diagnosing an organic cause for dyspepsia. DATA SYNTHESIS: Fifteen studies were identified that evaluated 11 366 patients, with 4817 patients (42%) classified as having organic dyspepsia. The computer models performed similarly to the clinician; therefore, the 2 approaches were combined. The diagnosis reached by the clinician or computer model suggesting organic dyspepsia had an LR of 1.6 (95% confidence interval [CI], 1.4-1.8), and a negative result decreased the likelihood of organic dyspepsia (LR, 0.46; 95% CI, 0.38-0.55). A diagnosis of peptic ulcer disease performed similarly with an LR of 2.2 (95% CI, 1.9-2.6), but an evaluation that suggested the absence of peptic ulcer disease had an LR of 0.45 (95% CI, 0.38-0.53). A clinical history suggesting esophagitis had an LR of 2.4 (95% CI, 1.9-3.0) vs a negative history that had an LR of 0.50 (95% CI, 0.42-0.60). CONCLUSION: Neither clinical impression nor computer models that incorporated patient demographics, risk factors, history items, and symptoms adequately distinguished between organic and functional disease in patients referred for endoscopic evaluation of dyspepsia.

Bowel management for patients with myelodysplasia.
Doolin E
Surg Clin North Am. 2006 Apr;86(2):505-14.

Penetrating rectal trauma: management by anatomic distinction improves outcome.
Weinberg JA, Fabian TC, Magnotti LJ, Minard G, Bee TK, Edwards N, Claridge JA, Croce MA
J Trauma. 2006 Mar;60(3):508-13; discussion 513-14.

BACKGROUND: Controversy persists regarding the optimal management of penetrating rectal injuries, specifically with respect to the routine application of diversion and presacral drainage. Our previous experience suggested that management decisions based on precise anatomic characterization of injury relative to retroperitoneal involvement might improve outcome. A clinical pathway was developed and implemented. Patients managed by the pathway (PATH) were compared with the previous study (PREV, n=58) to determine the impact of the clinical pathway on outcome. METHODS: Consecutive patients with full-thickness penetrating rectal injury subsequent to the development of the pathway were evaluated. Intraperitoneal rectal injuries (IP) were treated with primary repair. Injuries to the proximal two-thirds and accessible distal one-third of the extraperitoneal rectum (EP) were treated with repair and selective fecal diversion. Inaccessible distal EP injuries were treated with diversion and presacral drainage. Infectious complications (wound infection, bacteremia, intraabdominal abscess, retroperitoneal abscess) were compared between the PATH and PREV groups. RESULTS: In all, 54 patients were identified. Demographics, injury severity, and preventive antibiotics (24-hour) were similar between groups. Overall infectious complication rate was 13% in the PATH group versus 31% in the PREV group (p<0.05). There was a zero incidence of retrorectal abscess in the PATH group versus 11% of the total complications in the PREV group. CONCLUSIONS: Implementation of the pathway resulted in a significant decrease in infectious morbidity. Management by anatomic distinction allows for omission of colostomy in most IP injuries and select EP injuries, while diminishing the risk of retrorectal abscess in EP injuries with the judicious application of presacral drainage.

Follow-up of anorectal anomalies: the Italian parents' and patients' perspective.
Aminoff D, La Sala E, Zaccara A
J Pediatr Surg. 2006 Apr;41(4):837-41.

BACKGROUND: Several studies addressed the long-term follow-up of anorectal anomalies (ARM) in relation to clinical issues (eg, continence) and quality of life. However, most of these studies are based upon questionnaires designed by physicians and/or health-care professionals, which may be sources of bias. METHODS: To investigate whether parents of children (patients themselves or older children or adults) who were born with ARM had the perception that they received appropriate care and follow-up, a survey was carried out in Italy, in 2003, among families with children with ARM. A 20-item questionnaire was mailed to 425 patients and parents listed in the AIMAR (Italian association for anorectal malformation) database and was returned by 209 families. The questionnaire covered different aspects of ARM: type of malformations and surgery, associated anomalies, fecal and urinary continence, as well as aspects about information given to the parents and satisfaction of care and follow-up received. RESULT: The patients and parents demonstrated a good understanding of distribution of malformations and their anatomical classification; nevertheless, 67% of responders had to travel outside their living area for surgery. Bowel management (BM) was commonly used among subjects; however, a significant percentage of patients using regular enemas were still soiling (58 patients were clean and 116 soiled). Urinary continence problems were mostly found in females with cloaca; nevertheless, 21 male patients reported occasional dribbling of difficult interpretation. Most subjects were provided with a good explanation about their or their child's malformation at time of reconstructive surgery, but the same level of information was missing about functional prognosis later in life when the need of an appropriate psychologic support was also felt. CONCLUSIONS: Patients and parents born with ARM are generally satisfied with the information received and with the short-term postreconstructive follow-up care. At longer follow-up, although more than a quarter of patients are completely clean, there is a significant percentage of subjects who still soil while following a BM program. This is explained by the small number of nurses and BM specialists who are involved in the rehabilitation process and by the lack of appropriate information about functional prognosis that are conveyed to the parents. In this respect, psychologic support in bridging the gap between cure and care may be critical.

Colostomy in anorectal malformations: a procedure with serious but preventable complications.
Pena A, Migotto-Krieger M, Levitt MA
J Pediatr Surg. 2006 Apr;41(4):748-56; discussion 748-56.

PURPOSE: Colostomy for patients with anorectal malformations decompresses an obstructed colon, avoids fecal contamination of the urinary tract, and protects a future perineal operation. The procedure is associated with several significant complications. MATERIALS AND METHODS: The medical records of 1700 cases of anorectal malformations were retrospectively reviewed. A total of 230 patients underwent reconstruction without a colostomy. Of the remaining 1470 patients, 1420 had their colostomy performed at another institution (group A) and 50 did at our institution (group B) using a specific technique with separated stomas in the descending colon. RESULTS: There were 616 complications identified in 464 patients of group A and in 4 patients in group B, an incidence of 33% vs 8% (P < .01). Complications in group A were classified into several groups. The first group was mislocation (282 cases), including 116 with stomas too close to each other, 97 with stomas located too distally in the rectosigmoid (which interfered with the pull-through), 30 with inverted stomas, 21 with stomas too far apart from each other, and 18 with right upper sigmoidostomies. The second largest group was prolapse (119 cases), which occurred mainly in mobile portions of the colon. The third group was composed of general surgical complications after colostomy closure (82 cases), such as intestinal obstruction (47 cases), wound infection (13 cases), incisional hernia (11 cases), anastomotic dehiscence (7 cases), sepsis (3 cases), and bleeding (1 case). Two of the septic patients died. Another group included 62 patients who received a Hartmann's procedure, which we considered to be contraindicated in anorectal malformations. A total of 42 patients suffered from stenosis of the stoma; 29, from retraction. CONCLUSIONS: Most colostomy complications are preventable using separated stomas in the descending colon. Mislocated stomas lead to problems with appliance application, interference with the pull-through, megasigmoid, distal fecal impaction, and urinary tract infections. Loop colostomies lead to urinary tract infections, distal fecal impaction, and prolapse. Prolapse is a potentially dangerous complication that mostly occurs when the stoma is placed in a mobile portion of the colon. Recognizing this makes the complication preventable by trying to create colostomies in fixed portions of the colon or by fixing the bowel to the abdominal wall when necessary. The trend to avoid colostomies is justified; however, colostomy is the best way to prevent complications in anorectal surgery and, when indicated, should be done with a meticulous technique following strict rules to avoid complications.

Anal canal duplication in children: a new technique.
Tiryaki T, Senel E, Atayurt H
Pediatr Surg Int. 2006 Mar 15;.

Anal canal duplication (ACD) is a very rare abnormality. Because of the high rate of malignant changes in anal canal duplications complete removal of the ACD is recommended. In the current study, simple mucosectomy for management of cases of ACD has been discussed. There was no complication and patients had good cosmetic results with a normal sphincter control. This technique is simple, safe, takes less time and achieves good anatomic appearance and functional results.

The anatomical significance and techniques of laparoscopic rectal surgery.
Chengyu L, Xiaoxin J, Jian Z, Chen G, Qi Y
Surg Endosc. 2006 Mar 16;.

BACKGROUND: Because there are difficulties associated with the technique of laparoscopic colorectal surgery, thorough knowledge of the anatomy is particularly important. We pay close attention to anatomical features during laparoscopic rectal surgery. In this study, we analyze the association of the anatomy with the operative procedure. METHODS: Laparoscopic rectal surgery was performed on 117 patients (66 men) with benign and malignant diseases in the rectum by the complete laparoscopy or hand-assisted technique. All operations were mainly performed by the first author. The association between anatomy and the operation was analyzed. RESULTS: The mean operative time was 144 min (range, 87-235). The hand-assisted technique was performed in two patients. Four patients required conversion to laparotomy due to the amount of fat in three patients and disruption of the Endo-stapler in one patient, for a conversion rate of 1.7%. Operative blood loss was small, averaging 126 ml (range, 50-350). No injury of the ureters, major bleeding in front of the sacrum, or other operation-related severe complications occurred during or after operation. In one case, dissecting disrupted the anterior left wall of the rectum. CONCLUSION: By mastering the anatomical features of laparoscopic rectum surgery, operative mistakes and complications can be reduced. Particular attention must be paid to the anatomy of the obese patient undergoing laparoscopy. It is very convenient that the corresponding skills can be applied in the course of dissection and exposure.

Staging of colon and rectal cancer: from endoscopy to molecular markers.
Greene FL
Surg Endosc. 2006 Apr;20 Suppl 2:S475-8. Epub 2006 Mar 16.

The primary management of colorectal cancer begins with preoperative diagnosis and the ability to stage the extent of the tumor burden clinically. Endoscopic approaches have been pivotal in this management strategy, and have given rise to endoscopic techniques allowing for primary resection and treatment of metastases. This advance has allowed for the continued development of pathologic staging as used in the tumor node metastasis (TNM) system. The next major milestone in the staging of large bowel cancer will be to blend current anatomic staging strategies with specific molecular markers that will refine subsets appropriate for targeted therapy.

A Common Polymorphism in the Interleukin 8 Gene Promoter Is Associated with Clostridium difficile Diarrhea.
Jiang ZD, Dupont HL, Garey K, Price M, Graham G, Okhuysen P, Dao-Tran T, Larocco M
Am J Gastroenterol. 2006 Mar 30;.

OBJECTIVE: Mucosal interleukin 8 (IL-8) and neutrophil recruitment are central to the pathogenesis of Clostridium difficile (CD) toxin-induced diarrhea (CDD). We hypothesized that like other inflammatory mucosal infections, susceptibility to CDD would relate to genetically determined variations in the production of IL-8. METHODS: Fecal IL-8 production and single nucleotide polymorphism (SNP) frequency in the -251 region of the IL-8 gene were determined in hospitalized patients: 42 with CDD, 42 with CD-negative diarrhea, and 41 without diarrhea. Cases and controls were matched by age, length of hospital stay, comorbidity, and receipt of antibiotics. RESULTS: An association was found between the IL-8 -251 A/A allele and occurrence of CDD, 39%versus 16% (OR = 3.26, 95% CI 1.09-9.17) and 17% (OR = 5.50, 95% CI 1.22-24.8) for the two control groups. Comparing results by IL-8 genotype for the CDD cases, median and mean fecal IL-8 levels were significantly higher for the -251 A/A genotype (p= 0.03 for median and 0.001 for mean). CONCLUSIONS: These studies indicate a common SNP in the IL-8 gene is associated with increased susceptibility to CDD and with increased fecal IL-8 in diarrheal stools.

Colonic wall thickening on computed tomography scan and clinical correlation. Does it suggest the presence of an underlying neoplasia?
Moraitis D, Singh P, Jayadevan R, Cayten CG
Am Surg. 2006 Mar;72(3):269-71.

The widespread use of computed tomography (CT) scanning technology frequently leads to the incidental discovery of thickened bowel wall. The clinical significance of such a CT scan finding is largely under-investigated. The purpose of our study was to determine the incidence of significant clinical pathology and, particularly, neoplasia in patients with abnormally thickened bowel on CT scan examination. This is a single institution retrospective analysis of patients that underwent CT scanning of their abdomen. The radiological picture was correlated with colonoscopic findings. A total of 40 consecutive patients with thickened bowel on CT scan that also underwent colonoscopy were identified and their records were reviewed. Thirty-five patients had no history of previous gastrointestinal disorder and form our study group. The median age of the patients was 69 years (range, 24-97 years). There were 26 female and 9 male patients. The incidental CT finding of bowel wall thickening was the only reason for the colonoscopy in 14 (35%) out of the 40 patients. Eight (23%) patients with thick bowel had colonic neoplasia based on pathology. Five (14%) patients had invasive adenocarcinoma of the colon. Four (11%) of the 5 patients with colon adenocarcinoma did not have any associated gastrointestinal symptoms or signs. One (3%) patient had lymphoma of the colon and two (6%) had benign polyps. Colonoscopy was unremarkable in 10 (28%) patients. The incidental finding of colonic thickening on CT imaging could be associated with underlying colonic malignancy and, more importantly, represent the initial disease presentation. Therefore, we propose that these patients should undergo colonoscopy.

Molecular biology of squamous cell carcinoma of the anus.
Gervaz P, Hirschel B, Morel P
Br J Surg. 2006 Apr 11;93(5):531-538.

BACKGROUND:: Squamous cell carcinoma of the anal canal provides a model for studying the contribution of human papillomavirus (HPV) and human immunodeficiency virus (HIV) infection to the development of neoplasia. This paper reviews the existing literature relating to the molecular biology of anal squamous cell carcinoma and proposes a theory of pathogenesis. METHODS:: A Medline literature search was performed to identify English articles on the pathogenesis of squamous cell carcinoma of the anus; further articles were obtained from the references quoted in the literature initially reviewed. RESULTS:: HPV infection and subsequent HPV DNA integration are necessary, but not sufficient, to cause cancer progression. Loss of heterozygosity at 11q23 is the most consistent genomic change observed. Loss of heterozygosity at 17p, 18q and 5q is frequently observed in tumours of HIV-negative patients, but not in those of HIV-positive patients. Current data suggest that mutations in p53, DCC and APC tumour suppressor genes contribute to the stepwise progression of anal squamous cell carcinoma in immunocompetent individuals. CONCLUSION:: In comparison with immunocompetent individuals, HIV-positive patients have persistent HPV infection in the anal canal. In this population, microsatellite instability, rather than chromosomal instability, appears to be a preferred pathway for rapid progression towards invasive carcinoma.

Evaluation of the Risk of a Nonrestorative Resection for the Treatment of Diverticular Disease: The Cleveland Clinic Diverticular Disease Propensity Score.
Aydin HN, Tekkis PP, Remzi FH, Constantinides V, Fazio VW
Dis Colon Rectum. 2006 Apr 10;.

PURPOSE: The choice of operation for diverticular disease is a contentious issue, particularly in patients with acute symptoms. This study compares early outcomes between primary resection and anastomosis and Hartmann's resection and describes a propensity score for the selection of patients for nonrestorative procedures. METHODS: Data were collected from 731 patients undergoing primary resection and anastomosis (Group 1) and 123 patients undergoing primary Hartmann's resection (Group 2) for diverticular disease in a single tertiary referral center from January 1981 to May 2003. Multifactorial logistic regression was used to develop a propensity score for estimating the likelihood of performing a nonrestorative procedure. RESULTS: Operative 30-day mortality and surgical or medical complications were 0.7 percent, 26.0 percent, and 4.8 percent for primary resection and anastomosis and 12 percent, 43.9 percent, and 14.6 percent for Hartmann's resection, respectively (P < 0.001). There was no difference in the readmission rates between primary resection and anastomosis and Hartmann's resection (7.6 percent vs. 9.9 percent, P = 0.428). Laparoscopy was used for 32.7 percent of primary resection and anastomosis vs. 1.6 percent for Hartmann's resection (P < 0.001). Independentpredictors in favor for Hartmann's resection were body mass index >/=30 kg/m(2) (odd's ratio = 2.32), Mannheim peritonitis index >10 (odd's ratio = 6.75), operative urgency (emergency, urgent vs. elective surgery, odd's ratio = 16.08vs. 13.32), and Hinchey stage >II (odd's ratio = 27.82). The area under the receiver operating characteristic curve for the choice of operative procedure was 93.9 percent. CONCLUSIONS: Although Hartmann's resection was associated with a higher incidence of postoperative adverse events, the choice of operation was dependent on the patient presentation and intra-abdominal contamination, which can be quantified in the preoperative setting by the Cleveland Clinic diverticulitis propensity score.

Results of Lateral Internal Sphincterotomy for Chronic Anal Fissure With Particular Reference to Quality of Life.
Mentes BB, Tezcaner T, Yilmaz U, Leventoglu S, Oguz M
Dis Colon Rectum. 2006 Apr 7;.

PURPOSE: The aim of this study was to investigate the effects of lateral internal sphincterotomy on quality of life in patients with chronic anal fissure using the Gastrointestinal Quality of Life Index and the Fecal Incontinence Quality of Life Scale. METHODS: Adult patients with chronic anal fissure underwent lateral internal sphincterotomy with the open technique. Two hundred forty-four patients completed the Gastrointestinal Quality of Life Index questionnaire at admission and at 12 months postoperatively. The Fecal Incontinence Severity Index score was calculated preoperatively and at 2 and 12 months postoperatively. The Fecal Incontinence Quality of Life Scale was administered to any patient who had a Fecal Incontinence Severity Index score greater than 0 at 12 months postoperatively. RESULTS: The mean preoperative Gastrointestinal Quality of Life Index score was 118.34 +/- 6.33, which developed to 140.74 +/- 2.38 postoperatively (P< 0.001). At the two-month follow-up, 18 patients (7.38 percent) had a Fecal Incontinence Severity Index score greater than 0. By 12 months, the number of patients with Fecal Incontinence Severity Index score greater than 0 was reduced to seven (2.87 percent). These seven patients had a Gastrointestinal Quality of Life Index score similar to that of the group with postoperative Fecal Incontinence Severity Index score of 0, and only three patients (1.22 percent) had evident deterioration in the Fecal Incontinence Quality of Life Scale. The 12-month total Gastrointestinal Quality of Life Index score of the three patients who developed anal abscess/fistula after sphincterotomy (139.33 +/- 3.21) was similar to the Gastrointestinal Quality of Life Index score of those without complications. However, the Gastrointestinal Quality of Life Index score of the recurrent cases (111.53 +/- 3.53) was apparently low. CONCLUSION: The gastrointestinal quality of life improved significantly following lateral internal sphincterotomy, regardless of the surgical complications or postoperative disturbances of continence. Only 1.2 percent of the patients experienced deterioration in Fecal Incontinence Quality of Life Scale.

Laparoscopic Colon Resection for Polyps: A Good Novice Case?
Ross HM, Li C, Rosenthal J, Kessler J, Fogt F
Dis Colon Rectum. 2006 Apr 7;.

PURPOSE: Laparoscopic colon resection of the endoscopically unresectable polyp has been considered an ideal case for the surgeon with moderate laparoscopic colectomy experience because tissues are not inflamed and the lymphadenectomy may not need to be as extensive compared with that required for cancer. To assess the appropriateness of this approach, we evaluated the incidence of invasive cancer in a series of laparoscopic colon resections for polyps. METHODS: A retrospective review was performed of 55 consecutive patients undergoing laparoscopic colon resection for endoscopically unresectable polyps during a 35-month period. Colonoscopy data, polyp characteristics, and final colon pathology were reviewed. RESULTS: On final pathologic examination, 18.2 percent of patients had invasive adenocarcinoma. Patient age, gender, indication for colonoscopy, polyp size, polyp location, polyp characteristics, and colonoscopic biopsy pathology were not predictive of adenocarcinoma on final pathology. CONCLUSIONS: A significant number of endoscopically unresectable polyps harbor adenocarcinoma, thereby requiring a formal lymphadenectomy at resection. Caution should be exercised when considering the laparoscopic resection of an endoscopically unresectable polyp as a "learning" case.

Morbidity of Temporary Loop Ileostomy in Patients With Colorectal Cancer.
Thalheimer A, Bueter M, Kortuem M, Thiede A, Meyer D
Dis Colon Rectum. 2006 Apr 7;.

PURPOSE: This study was designed to quantify the temporary loop ileostomy-related morbidity in patients with colorectal cancer and contrast the morbidity rates after ileostomy closure before, during, and after the start of adjuvant therapy. METHODS: Between 1997 and 2004, 120 patients with colorectal carcinoma underwent colorectal resection and creation of a temporary loop ileostomy to protect the low anastomosis. Stoma-related complications and perioperative morbidity after ileostomy closure were assessed retrospectively by reviewing the medical records. RESULTS: Sixteen of the 120 patients (13.3 percent) suffered stoma-related complications, requiring early ileostomy closure in three. After ileostomy closure, anastomotic leakage of the ileoileostomy occurred in 3 of the 120 patients (2.5 percent), 2 of them died postoperatively (1.7 percent). The rate of minor complications (16.7 percent in all patients) was much higher in patients undergoing adjuvant chemotherapy or radiochemotherapy (25.5 percent) than in patients receiving no additional therapy (9.2 percent). In the former patients, there was a trend toward fewer complications when ileostomy closure was performed before (12.5 percent), rather than during (42.9 percent) or after (21.2 percent), the start of adjuvant therapy. CONCLUSIONS: The morbidity following closure of a temporary loop ileostomy in colorectal cancer patients is much higher in patients receiving adjuvant chemotherapy or radiochemotherapy. The morbidity, however, might possibly be lowered to the level of patients receiving no additional therapy if ileostomy closure is performed before the start of adjuvant therapy.

Impact of Functional Results on Quality of Life After Rectal Cancer Surgery.
Vironen JH, Kairaluoma M, Aalto AM, Kellokumpu IH
Dis Colon Rectum. 2006 Apr 5;.

PURPOSE: Quality of life is an important outcome measure that has to be considered when deciding treatment strategy for rectal cancer. The aim of this study was to find out the impact of surgery-related adverse effects on quality of life. METHODS: The RAND-36 questionnaire and questionnaires assessing urinary, sexual, and bowel dysfunction were administered to 94 patients with no sign of recurrence a minimum of one year after curative surgery. Results were compared with age-matched and gender-matched general population. RESULTS: Eighty-two (87 percent) patients answered the questionnaires. Major bowel dysfunction was as common after high anterior resection as after low anterior resection. Urinary complaints occurred as often after anterior resection as after abdominoperineal resection, but sexual dysfunction was more common after abdominoperineal resection. Overall, the patients reported better general health perception but poorer social functioning than population controls. In particular, elderly patients reported a significantly better quality of life in many dimensions than their population controls. There was no significant difference in quality of life between treatment groups. Major bowel dysfunction after anterior resection impaired social functioning compared with that of patients without such symptoms. Urinary dysfunction impaired social functioning and impotence impaired physical and social functioning. CONCLUSIONS: Quality of life after rectal cancer surgery is not worse than that of the general population. The major adverse impact of bowel and urogenital dysfunction is on social functioning. These adverse effects need to be discussed with the patient and preoperative function needs to be taken into account when choosing between treatment options. Permanent colostomy is not always the factor that disrupts a person's quality of life most.

The Effect on Morbidity of Mesentery Lengthening Techniques and the Use of a Covering Stoma After Ileoanal Pouch Surgery.
Araki T, Parc Y, Lefevre J, Dehni N, Tiret E, Parc R
Dis Colon Rectum. 2006 Apr 4;.

PURPOSE: A tension-free anastomosis in a restorative proctocolectomy requires sufficient length of small-bowel mesentery. To ensure adequate length, it has been proposed that the superior mesenteric artery be divided and the right colon marginal vascular arcade be preserved. This study was designed to evaluate the influence of mesenteric lengthening techniques on the need for a stoma and on early outcomes after restorative proctocolectomy. METHODS: Records of patients who had a restorative proctocolectomy between January 1998 and October 2003 were reviewed. Patient and disease characteristics, operative techniques and findings, the need for a stoma, and postoperative complications were recorded. RESULTS: In one patient a restorative proctocolectomy was not possible. The remaining 220 patients were divided into two groups: Group A (inflammatory bowel disease; n = 123) and Group B (noninflammatory bowel disease; n = 97). Sixty-nine patients (31.4 percent) had major comorbidities. A lengthening technique was performed in 120 patients (54.5 percent) by dividing the ileocecal artery (n = 37) or the superior mesenteric artery (n = 88); 5 patients had only the marginal vascular arcade preserved. An ileostomy was not required in 116 patients (52.7 percent). In multivariate analysis, in Group B the only surgical variable influencing the need for an ileostomy was preservation of the marginal vascular arcade (50 vs. 14.7 percent; P < 0.0005). Complications occurred in 41 patients (18.6 percent), more frequently for those in GroupA and for patients receiving steroids (23.6 vs. 12.4 percent, P = 0.012; 10.4 vs. 6.8 percent, P = 0.0172). CONCLUSIONS: The use of mesentery lengthening techniques allows a restorative proctocolectomy to be performed in almost all patients without increasing morbidity and may reduce the number of covering stomas. Because division of the ileocecal and/or superior mesenteric arteries may be required, preservation of the marginal vascular arcade is essential whenever possible.

Anal involvement in pemphigus vulgaris.
Malik M, El Tal AE, Ahmed AR
Dis Colon Rectum. 2006 Apr;49(4):500-6.

INTRODUCTION: Anal involvement in patients with pemphigus vulgaris has rarely been reported. We report 16 pemphigus vulgaris patients with anal involvement. METHODS: We retrospectively reviewed the clinical data on 16 patients treated at a tertiary dermatology referral center. RESULTS: Of 16 patients with anal involvement of pemphigus vulgaris, ten were female and six were male. The mean age of onset was 56 (range, 37-82) years. All patients had involvement of pemphigus vulgaris at multiple sites, including oral involvement. Recurrent episodes of anal pemphigus vulgaris were noted in nine (56 percent) patients, with a mean of 2.4 recurrences (range, 1-11). In all patients, pemphigus vulgaris was controlled with systemic and local therapy. Long-term follow-up for a mean of 53 (range, 4-188) months indicated that no long-term sequela occurred because of anal involvement. CONCLUSIONS: Anal involvement in pemphigus vulgaris is not very common and generally occurs in patients with severe disease. With appropriate topical and systemic therapy, patients have full recovery with no sequelae.

Long-term effect of preoperative radiation therapy on anorectal function.
Pollack J, Holm T, Cedermark B, Holmstrom B, Mellgren A
Dis Colon Rectum. 2006 Mar;49(3):345-52.

PURPOSE: Preoperative radiotherapy improves local control in rectal cancer treatment, but there are few reports on the influence of radiotherapy on anorectal function. The aim of the present study was to assess late effects of short-course, high-dose radiotherapy on anorectal function after low anterior resection for rectal cancer. METHODS: Sixty-four patients, randomized within the Stockholm Radiotherapy Trials and operated on with low anterior resection with or without preoperative radiotherapy (mean, 14 years), previously were followed up with quality-of-life questionnaires, clinical examination, anorectal manometry, and endoanal ultrasound. Twenty-one patients had received preoperative radiotherapy of the rectum and 43 patients had been treated with surgery alone. RESULTS: Impaired anorectal function was common after low anterior resection for rectal cancer and the risk was increased after radiotherapy. Irradiated patients had significantly more symptoms of fecal incontinence (57 vs. 26 percent, P = 0.01), soiling (38 vs. 16 percent, P = 0.04), and significantly more bowel movements per week (20 vs. 10, P = 0.02). At anorectal manometry, irradiated patients had significantly lower resting (35 mmHg vs. 62 mmHg, P < 0,001) and squeeze pressures (104 mmHg vs. 143 mmHg, P = 0.05). At endoanal ultrasound, irradiated patients had significantly more scarring of the anal sphincters (33 vs. 13 percent, P = 0.03). There were no significant differences in quality-of-life scores between irradiated and nonirradiated patients; however, patients with anal incontinence had significantly lower quality-of-life scores compared to continent patients. CONCLUSIONS: Short-course radiotherapy, including the anal sphincters, impairs anorectal function and increases gastrointestinal symptoms permanently when the anal sphincters are irradiated.

Survival from rectal and anal cancers in England and Wales, 1986-2001.
Jeffreys M, Rachet B, McDowell S, Habib AG, Lepage C, Coleman MP
Eur J Cancer. 2006 Apr 3;.

The aim of this study was to investigate the effects of tumour and patient characteristics on trends in the survival of patients with cancer of the anus or rectum in England and Wales. A total of 132,542 adults (15-99 years) who were diagnosed during the 14 years 1986-1999 were followed up to 2001 through the National Health Service Central Register. Relative survival up to 5 years after diagnosis was estimated, using deprivation-specific life tables. Generalised linear models were used to estimate relative excess risks of death, adjusted for patient and tumour characteristics. The results showed that 5-year relative survival was higher in women, younger patients and more affluent patients, and higher for anal cancer than rectal cancer. Survival improved by more than 10% from the late 1980s (around 38%) to the late 1990s (49%). This trend was not explained by changes in the distribution of age, anatomical site, morphology or deprivation. The trend was more marked in younger and more affluent patients, and for adenocarcinoma and epidermoid carcinoma than for tumours with other morphology. The inequality in survival between affluent and deprived patients widened. It is concluded that improvements in survival may reflect improvements in disease stage, diagnostic technique or treatment. Which of these factors contribute to the widening socioeconomic inequalities in survival remains to be elucidated.

Neurological symptoms suggestive of demyelination in Crohn's disease after infliximab therapy.
Dubcenco E, Ottaway CA, Chen DL, Baker JP
Eur J Gastroenterol Hepatol. 2006 May;18(5):565-566.

Anti-TNFalpha drugs are currently used in the treatment of patients with Crohn's disease. Studies have reported neurological side effects occurring after anti-TNFalpha treatment, including infliximab-induced complications.

McKittrick-Wheelock syndrome: a rare cause of diarrhoea.
Lepur D, Klinar I, Mise B, Himbele J, Vranjican Z, Barsic B
Eur J Gastroenterol Hepatol. 2006 May;18(5):557-559.

McKittrick-Wheelock syndrome is a rare disorder caused by fluid and electrolyte hypersecretion from a rectal tumour. The most frequently reported tumours are villous adenomas. Dehydration with severe hyponatremia, hypokalemia, metabolic acidosis, acute renal failure and watery diarrhoea is typical. The authors present a case of McKittrick-Wheelock syndrome caused by rectal adenocarcinoma.

Nodular regenerative hyperplasia: a reversible entity associated with azathioprine therapy.
Seiderer J, Zech CJ, Diebold J, Schoenberg SO, Brand S, Tillack C, Goke B, Ochsenkuhn T
Eur J Gastroenterol Hepatol. 2006 May;18(5):553-5.

Azathioprine represents an effective and widely used immunosuppressant; however, there are increasing concerns about the hepatotoxicity of thiopurines because of an entity called 'nodular regenerative hyperplasia' (NRH) observed in patients treated with 6-thioguanine. In line with this hypothesis, we report and comment on a patient with inflammatory bowel disease (IBD) diagnosed with NRH as a reversible but potentially serious hepatotoxic side-effect of azathioprine. Our report strengthens the importance of further safety studies to evaluate the aetiology and prevalence of NRH in IBD patients before general conclusions on the use of thiopurines can be drawn. Physicians caring for IBD patients need to be alert to this rare but serious complication.

Prevention of postoperative recurrence of Crohn's disease by infliximab.
Sorrentino D, Terrosu G, Avellini C, Beltrami CA, Bresadola V, Toso F
Eur J Gastroenterol Hepatol. 2006 Apr;18(4):457-9.

The prevention of the recurrence of Crohn's disease after surgery remains difficult. The monoclonal antibody anti-TNF-alpha, infliximab, is very effective in inducing and maintaining the remission of uncomplicated, active Crohn's disease. We present here the case of a 23-year-old white woman who underwent resection for a sigmoid stricture caused by Crohn's disease. Surgery removed the involved colon, and pathology confirmed the stricture to be fibrotic. Two weeks after the operation she was given infliximab at the dose of 5 mg/kg body weight and followed in time. Since then, she has been disease free for approximately 4 years after surgery on clinical, radiological and endoscopic/histological grounds (Crohn's Disease Activity Index </=110 on all occasions). Up to now, she has had no increase in inflammatory indices, no anaemia and no abnormal blood tests. In contrast, all of five control patients operated in the same period with colonic or ileocolonic resection for symptomatic strictures and treated with mesalamine or no medication developed endoscopic or clinical recurrence (abdominal pain or diarrhoea) by year 3. This is the first case, to our knowledge, in which infliximab has been successfully used to prevent the postsurgical recurrence of Crohn's disease, an event so far considered to be inescapable. We believe that, with this aim in mind, clinical trials with this drug are warranted.

The fate of the rectal stump after subtotal colectomy for ulcerative colitis.
Bohm G, O'dwyer ST
Int J Colorectal Dis. 2006 Apr 4;.

OBJECTIVE: To review the outcome of patients who had undergone subtotal colectomy for ulcerative colitis with formation of a rectal stump. To specifically look at the fate of the rectal stump, whether patients underwent emergency colectomy as opposed to urgent or elective resection. PATIENTS AND METHODS: Between January 1990 and August 2000, a total of 31 patients underwent subtotal colectomy for ulcerative colitis. Patients were identified using the computerized coding system for the years 1995 to 2000, supplemented by pathology records, discharge letters, and operation notes. Postal and telephone surveys were undertaken using a standard questionnaire assessing social, physical, sexual, and bowel activities of patients. RESULTS: In 28 out of 31 patients, the follow-up was complete. Twenty-four of 28 patients (86%) underwent excision of rectal stump. Four patients (14%) preferred to undergo excision of rectum only, resulting in a permanent ileostomy; 20/28 (71%) had attempted ileal pouch-anal anastomosis, with success in 85%. In four patients (14%), the rectal stump remained in situ and was associated with a decrease in the quality of life. There were no perioperative deaths and morbidity was low for all procedures. CONCLUSION: These data show that after subtotal colectomy, the majority of our ulcerative colitis patients undergo ileal pouch-anal anastomosis. Patients' satisfaction is high with reasonable social and excellent sexual function on quality of life assessment. During its retention, the rectal stump causes considerable symptoms. When left in situ, it is associated with a decrease in the quality of life.

Immunosuppressive drugs in ulcerative colitis: twisting facts to suit theories?
Sands BE
Gut. 2006 Apr;55(4):437-41.

Immunosuppressive drugs have become a mainstay of therapy for the inflammatory bowel diseases. Although robust evidence exists in support of the use of these drugs in Crohn's disease, a close evaluation of the available data in ulcerative colitis reveals a much weaker evidence base. In particular, randomised controlled trials of azathioprine, the most commonly used immunosuppressive agent, do not provide rich evidence of efficacy whereas observational cohorts suggest this agent is effective, particularly in patients with relapsing disease who require corticosteroids. Ciclosporin is also effective in the most refractory cases but its efficacy needs to be carefully weighed against the possibility of rare but life threatening complications. Although the evidence base in support of immunosuppressive drugs in ulcerative colitis is not as strong as in Crohn's disease, these agents clearly have a role in the treatment of this disease.

Predictors of Crohn's disease.
Beaugerie L, Seksik P, Nion-Larmurier I, Gendre JP, Cosnes J
Gastroenterology. 2006 Mar;130 (3):650-6.

BACKGROUND & AIMS: Early intensive therapy in Crohn's disease should be considered only in patients with disabling disease. The aim of our study was to identify at diagnosis factors predictive of a subsequent 5-year disabling course. METHODS: Among the 1526 patients seen at our unit with Crohn's disease diagnosed between 1985 and 1998, we excluded patients operated on within the first month of the disease, patients with inadequate data, and patients with severe chronic nondigestive disease. In the 1188 remaining patients, Crohn's disease course within the first 5 years of the disease was categorized as disabling when at least 1 of the criteria of clinical severity, conventionally predefined, was present. RESULTS: Among the 1123 patients with follow-up data allowing full 5-year course classification, the rate of disabling disease was 85.2%. Independent factors present at diagnosis and significantly associated with subsequent 5-year disabling were the initial requirement for steroid use (OR 3.1 [95% CI: 2.2-4.4]), an age below 40 years (OR 2.1 [95% CI: 1.3-3.6]), and the presence of perianal disease (OR 1.8 [95% CI: 1.2-2.8]). The positive predictive value of disabling disease in patients with 2 and 3 predictive factors of disabling disease was 0.91 and 0.93, respectively. These values were 0.84 and 0.91, respectively, when tested prospectively in an independent group of 302 consecutive patients seen at our institution from 1998. CONCLUSIONS: At diagnosis of Crohn's disease in a referral center, factors predictive of subsequent 5-year disabling course are an age below 40 years, the presence of perianal disease, and the initial requirement for steroids.

Symptomatic presentation of early colorectal cancer.
Smith D, Ballal M, Hodder R, Soin G, Selvachandran SN, Cade D
Ann R Coll Surg Engl. 2006 Mar;88(2):185-90.

INTRODUCTION: It is believed that increased detection of earlier stage colorectal cancer can only be achieved by screening asymptomatic individuals. We describe a referral pathway for a symptomatic population which achieves a 30% Dukes' A detection rate.PATIENTS AND METHODS: From October 1999, 4253 patients with distal colonic symptoms, referred by general practitioners, completed a patient consultation questionnaire (PCQ) linked to a computerised record. A weighted numerical score (WNS) was derived for each patient. Patients underwent flexible sigmoidoscopy, a diagnostic outcome was recorded and later Dukes' stage appended. Early and advanced colorectal cancers were separated and PCQ derived symptom profiles compared. Chi-square, Fisher exact, Student's t-test and logistic regression were used for statistical analysis.RESULTS: A total of 183 patients had cancer, 55 (30%) were Dukes' A early colorectal cancers, 112 were advanced colorectal cancers (Dukes' B-D) and 16 could not be staged. Early colorectal cancers had significant symptoms and comparable profile to advanced colorectal cancers. The tendency in advanced colorectal cancers was towards greater symptom prevalence for only a few primary and systemic symptoms, as reflected by a higher WNS of 75 (P = 0.001)CONCLUSIONS: Early colorectal cancers do have significant symptoms which can easily be captured by a PCQ and objective scoring tool in the secondary care setting. Detection of these cancers has the potential to improve survival.

Subspecialisation and its effect on the management of rectal cancer.
Ng VV, Tytherleigh MG, Fowler L, Farouk R
Ann R Coll Surg Engl. 2006 Mar;88(2):181-4.

INTRODUCTION: To assess the impact of subspecialisation on surgical and oncological outcomes after rectal cancer surgery in a single surgical unit within a district general hospital.PATIENTS AND METHODS: A total of 207 patients with rectal cancer treated surgically by two colorectal surgeons and four experienced general surgeons at the Royal Berkshire Hospital, Reading, England between January 1995 and December 1999 were studied. A retrospective case-note review of each patient's personal details, operative and histological findings, their subsequent clinical progress and oncological outcomes, including 5-year survival were recorded.RESULTS: In the study group, 127 patients were treated by a colorectal surgeon and 80 by general surgeons. Pre-operative radiotherapy was more likely to be given to patients treated by a colorectal surgeon. Fewer permanent stomas were performed by colorectal surgeons. Postoperative morbidity, transfusion requirements, anastomotic leak rates and 30-day mortality were not significantly different. Tumour-involved circumferential resection margins, local recurrence rates and risk of distant metastases were similar between the two groups of surgeons.CONCLUSIONS: Colorectal subspecialisation has resulted in an increased use of pre-operative radiotherapy and fewer permanent stomas. No significant improvement in surgical or oncological outcomes after rectal cancer surgery have been observed.

Associations between the age at diagnosis and location of colorectal cancer and the use of alcohol and tobacco: implications for screening.
Zisman AL, Nickolov A, Brand RE, Gorchow A, Roy HK
Arch Intern Med. 2006 Mar 27;166(6):629-34.

BACKGROUND: Individualizing recommendations for colorectal cancer (CRC) screening intervals and modalities requires accurate risk assessment. Although hereditary predisposition is commonly used, the effect of exogenous risk factors has remained largely unexplored. To address this, we analyzed the age at presentation and location of CRC in relation to alcohol and tobacco use. METHODS: We queried the IMPAC Medical Registry Services Cancer Information Resource File for CRCs diagnosed between June 1, 1993, and December 31, 2003. Subjects were classified as current, past, or never users of alcohol and tobacco. A logistic regression model for location of CRC and a linear regression model for age at diagnosis were constructed using these explanatory variables along with gender, race, and insurance status. RESULTS: Our data set consisted of 161 172 patients with CRC. Current drinking, smoking, and smoking plus drinking were associated with younger ages at onset of CRC (adjusted age difference, 5.2, 5.2, and 7.8 years, respectively; P<.001 for all). A distal location of CRC was more likely to occur in current drinkers (odds ratio, 1.192; 95% confidence interval, 1.15-1.23) and smokers (odds ratio, 1.164; 95% confidence interval, 1.12-1.21). Colorectal cancer in men tended to occur earlier (adjusted age difference, 1.9 years; P<.001) and have a distal predominance (odds ratio, 1.42; P<.001) compared with women. The smoking but not the drinking effect size was greater in women than in men (adjusted age difference, 2.6 years; P<.001). CONCLUSIONS: Alcohol use, tobacco use, and male gender were associated with earlier onset and a distal location of CRC. If confirmed, these factors should guide recommendations regarding initiation of CRC screening and, possibly, choice of techniques.

Daclizumab, a humanized monoclonal antibody to the interleukin-2 receptor (CD25), for the treatment of moderately to severely active ulcerative colitis: a randomised, double-blind, placebo-controlled, dose- ranging trial.
Van Assche G, Sandborn WJ, Feagan BG, Salzberg B, Silvers D, Monroe P, Pandak WM, Anderson FH, Valentine JF, Wild GE, Geenen DJ, Sprague R, Targan SR, Rutgeerts PJ, Vexler V, Young D, Shames RS
Gut. 2006 Apr 7;.

BACKGROUND: An uncontrolled pilot study demonstrated that daclizumab, a humanized monoclonal antibody to the interleukin-2 receptor (CD25), might be effective for the treatment of active ulcerative colitis. METHODS: A randomized, double-blind, placebo- controlled trial was conducted to evaluate the efficacy of daclizumab induction therapy in patients with active ulcerative colitis. One hundred fifty-nine patients with moderate ulcerative colitis were randomized to receive induction therapy with daclizumab 1 mg/kg IV at weeks 0 and 4, or 2 mg/kg IV at weeks 0, 2, 4, and 6, or placebo. The primary endpoint was induction of remission at week 8. Remission was defined as a Mayo score of 0 on both the endoscopy and rectal bleeding components and a score of 0 or 1 on the stool frequency and physician's global assessment components. Response was defined as a decrease from baseline in the Mayo score of at least 3 points. RESULTS: Two percent of patients receiving daclizumab 1 mg/kg (p=0.11 vs. placebo) and 7 percent of patients receiving 2 mg/kg (p=0.73) were in remission at week 8, compared with 10 percent of those who received placebo. Response occurred at week 8 in 25 percent of patients receiving daclizumab 1 mg/kg (p=0.04) and 33 percent of patients receiving 2 mg/kg (p=0.30) versus 44 percent of those receiving placebo. Daclizumab was well tolerated. The most frequently reported adverse events in daclizumab-treated patients greater than placebo-treated patients were nasopharyngits (14.6%) and pyrexia (10.7%). CONCLUSION: Patients with moderate ulcerative colitis who are treated with daclizumab are not more likely to be in remission or response at 8 weeks than patients treated with placebo.

February

Can the clinical history distinguish between organic and functional dyspepsia?
Moayyedi P, Talley NJ, Fennerty MB, Vakil N
JAMA. 2006 Apr 5;295(13):1566-76.

CONTEXT: Upper gastrointestinal symptoms occur in 40% of the population. An accurate diagnosis would help rationalize investigation and treatment. OBJECTIVE: To systematically review the literature of the accuracy of primary care physicians, gastroenterologists, or computer models in diagnosing organic dyspepsia. DATA SOURCES: A search of Cochrane Controlled Trials Register (December 2003), MEDLINE (1966-December 2003), EMBASE (1988-December 2003), and CINAHL (1982-December 2003) for studies that reported on cohorts of patients attending for endoscopy that had symptoms, clinical opinion, or both recorded before investigation. STUDY SELECTION: Studies that prospectively compared the diagnosis reached by a clinician, computer model, or both with results of upper gastrointestinal endoscopy in adult patients with upper gastrointestinal symptoms. DATA EXTRACTION: Two authors independently assessed studies (n = 79) for eligibility and abstracted data for estimating likelihood ratios (LRs) of clinical opinion, computer models, or both in diagnosing an organic cause for dyspepsia. DATA SYNTHESIS: Fifteen studies were identified that evaluated 11 366 patients, with 4817 patients (42%) classified as having organic dyspepsia. The computer models performed similarly to the clinician; therefore, the 2 approaches were combined. The diagnosis reached by the clinician or computer model suggesting organic dyspepsia had an LR of 1.6 (95% confidence interval [CI], 1.4-1.8), and a negative result decreased the likelihood of organic dyspepsia (LR, 0.46; 95% CI, 0.38-0.55). A diagnosis of peptic ulcer disease performed similarly with an LR of 2.2 (95% CI, 1.9-2.6), but an evaluation that suggested the absence of peptic ulcer disease had an LR of 0.45 (95% CI, 0.38-0.53). A clinical history suggesting esophagitis had an LR of 2.4 (95% CI, 1.9-3.0) vs a negative history that had an LR of 0.50 (95% CI, 0.42-0.60). CONCLUSION: Neither clinical impression nor computer models that incorporated patient demographics, risk factors, history items, and symptoms adequately distinguished between organic and functional disease in patients referred for endoscopic evaluation of dyspepsia.

Bowel management for patients with myelodysplasia.
Doolin E
Surg Clin North Am. 2006 Apr;86(2):505-14.

Penetrating rectal trauma: management by anatomic distinction improves outcome.
Weinberg JA, Fabian TC, Magnotti LJ, Minard G, Bee TK, Edwards N, Claridge JA, Croce MA
J Trauma. 2006 Mar;60(3):508-13; discussion 513-14.

BACKGROUND: Controversy persists regarding the optimal management of penetrating rectal injuries, specifically with respect to the routine application of diversion and presacral drainage. Our previous experience suggested that management decisions based on precise anatomic characterization of injury relative to retroperitoneal involvement might improve outcome. A clinical pathway was developed and implemented. Patients managed by the pathway (PATH) were compared with the previous study (PREV, n=58) to determine the impact of the clinical pathway on outcome. METHODS: Consecutive patients with full-thickness penetrating rectal injury subsequent to the development of the pathway were evaluated. Intraperitoneal rectal injuries (IP) were treated with primary repair. Injuries to the proximal two-thirds and accessible distal one-third of the extraperitoneal rectum (EP) were treated with repair and selective fecal diversion. Inaccessible distal EP injuries were treated with diversion and presacral drainage. Infectious complications (wound infection, bacteremia, intraabdominal abscess, retroperitoneal abscess) were compared between the PATH and PREV groups. RESULTS: In all, 54 patients were identified. Demographics, injury severity, and preventive antibiotics (24-hour) were similar between groups. Overall infectious complication rate was 13% in the PATH group versus 31% in the PREV group (p<0.05). There was a zero incidence of retrorectal abscess in the PATH group versus 11% of the total complications in the PREV group. CONCLUSIONS: Implementation of the pathway resulted in a significant decrease in infectious morbidity. Management by anatomic distinction allows for omission of colostomy in most IP injuries and select EP injuries, while diminishing the risk of retrorectal abscess in EP injuries with the judicious application of presacral drainage.

Follow-up of anorectal anomalies: the Italian parents' and patients' perspective.
Aminoff D, La Sala E, Zaccara A
J Pediatr Surg. 2006 Apr;41(4):837-41.

BACKGROUND: Several studies addressed the long-term follow-up of anorectal anomalies (ARM) in relation to clinical issues (eg, continence) and quality of life. However, most of these studies are based upon questionnaires designed by physicians and/or health-care professionals, which may be sources of bias. METHODS: To investigate whether parents of children (patients themselves or older children or adults) who were born with ARM had the perception that they received appropriate care and follow-up, a survey was carried out in Italy, in 2003, among families with children with ARM. A 20-item questionnaire was mailed to 425 patients and parents listed in the AIMAR (Italian association for anorectal malformation) database and was returned by 209 families. The questionnaire covered different aspects of ARM: type of malformations and surgery, associated anomalies, fecal and urinary continence, as well as aspects about information given to the parents and satisfaction of care and follow-up received. RESULT: The patients and parents demonstrated a good understanding of distribution of malformations and their anatomical classification; nevertheless, 67% of responders had to travel outside their living area for surgery. Bowel management (BM) was commonly used among subjects; however, a significant percentage of patients using regular enemas were still soiling (58 patients were clean and 116 soiled). Urinary continence problems were mostly found in females with cloaca; nevertheless, 21 male patients reported occasional dribbling of difficult interpretation. Most subjects were provided with a good explanation about their or their child's malformation at time of reconstructive surgery, but the same level of information was missing about functional prognosis later in life when the need of an appropriate psychologic support was also felt. CONCLUSIONS: Patients and parents born with ARM are generally satisfied with the information received and with the short-term postreconstructive follow-up care. At longer follow-up, although more than a quarter of patients are completely clean, there is a significant percentage of subjects who still soil while following a BM program. This is explained by the small number of nurses and BM specialists who are involved in the rehabilitation process and by the lack of appropriate information about functional prognosis that are conveyed to the parents. In this respect, psychologic support in bridging the gap between cure and care may be critical.

Colostomy in anorectal malformations: a procedure with serious but preventable complications.
Pena A, Migotto-Krieger M, Levitt MA
J Pediatr Surg. 2006 Apr;41(4):748-56; discussion 748-56.

PURPOSE: Colostomy for patients with anorectal malformations decompresses an obstructed colon, avoids fecal contamination of the urinary tract, and protects a future perineal operation. The procedure is associated with several significant complications. MATERIALS AND METHODS: The medical records of 1700 cases of anorectal malformations were retrospectively reviewed. A total of 230 patients underwent reconstruction without a colostomy. Of the remaining 1470 patients, 1420 had their colostomy performed at another institution (group A) and 50 did at our institution (group B) using a specific technique with separated stomas in the descending colon. RESULTS: There were 616 complications identified in 464 patients of group A and in 4 patients in group B, an incidence of 33% vs 8% (P < .01). Complications in group A were classified into several groups. The first group was mislocation (282 cases), including 116 with stomas too close to each other, 97 with stomas located too distally in the rectosigmoid (which interfered with the pull-through), 30 with inverted stomas, 21 with stomas too far apart from each other, and 18 with right upper sigmoidostomies. The second largest group was prolapse (119 cases), which occurred mainly in mobile portions of the colon. The third group was composed of general surgical complications after colostomy closure (82 cases), such as intestinal obstruction (47 cases), wound infection (13 cases), incisional hernia (11 cases), anastomotic dehiscence (7 cases), sepsis (3 cases), and bleeding (1 case). Two of the septic patients died. Another group included 62 patients who received a Hartmann's procedure, which we considered to be contraindicated in anorectal malformations. A total of 42 patients suffered from stenosis of the stoma; 29, from retraction. CONCLUSIONS: Most colostomy complications are preventable using separated stomas in the descending colon. Mislocated stomas lead to problems with appliance application, interference with the pull-through, megasigmoid, distal fecal impaction, and urinary tract infections. Loop colostomies lead to urinary tract infections, distal fecal impaction, and prolapse. Prolapse is a potentially dangerous complication that mostly occurs when the stoma is placed in a mobile portion of the colon. Recognizing this makes the complication preventable by trying to create colostomies in fixed portions of the colon or by fixing the bowel to the abdominal wall when necessary. The trend to avoid colostomies is justified; however, colostomy is the best way to prevent complications in anorectal surgery and, when indicated, should be done with a meticulous technique following strict rules to avoid complications.

Anal canal duplication in children: a new technique.
Tiryaki T, Senel E, Atayurt H
Pediatr Surg Int. 2006 Mar 15;.

Anal canal duplication (ACD) is a very rare abnormality. Because of the high rate of malignant changes in anal canal duplications complete removal of the ACD is recommended. In the current study, simple mucosectomy for management of cases of ACD has been discussed. There was no complication and patients had good cosmetic results with a normal sphincter control. This technique is simple, safe, takes less time and achieves good anatomic appearance and functional results.

The anatomical significance and techniques of laparoscopic rectal surgery.
Chengyu L, Xiaoxin J, Jian Z, Chen G, Qi Y
Surg Endosc. 2006 Mar 16;.

BACKGROUND: Because there are difficulties associated with the technique of laparoscopic colorectal surgery, thorough knowledge of the anatomy is particularly important. We pay close attention to anatomical features during laparoscopic rectal surgery. In this study, we analyze the association of the anatomy with the operative procedure. METHODS: Laparoscopic rectal surgery was performed on 117 patients (66 men) with benign and malignant diseases in the rectum by the complete laparoscopy or hand-assisted technique. All operations were mainly performed by the first author. The association between anatomy and the operation was analyzed. RESULTS: The mean operative time was 144 min (range, 87-235). The hand-assisted technique was performed in two patients. Four patients required conversion to laparotomy due to the amount of fat in three patients and disruption of the Endo-stapler in one patient, for a conversion rate of 1.7%. Operative blood loss was small, averaging 126 ml (range, 50-350). No injury of the ureters, major bleeding in front of the sacrum, or other operation-related severe complications occurred during or after operation. In one case, dissecting disrupted the anterior left wall of the rectum. CONCLUSION: By mastering the anatomical features of laparoscopic rectum surgery, operative mistakes and complications can be reduced. Particular attention must be paid to the anatomy of the obese patient undergoing laparoscopy. It is very convenient that the corresponding skills can be applied in the course of dissection and exposure.

Staging of colon and rectal cancer: from endoscopy to molecular markers.
Greene FL
Surg Endosc. 2006 Apr;20 Suppl 2:S475-8. Epub 2006 Mar 16.

The primary management of colorectal cancer begins with preoperative diagnosis and the ability to stage the extent of the tumor burden clinically. Endoscopic approaches have been pivotal in this management strategy, and have given rise to endoscopic techniques allowing for primary resection and treatment of metastases. This advance has allowed for the continued development of pathologic staging as used in the tumor node metastasis (TNM) system. The next major milestone in the staging of large bowel cancer will be to blend current anatomic staging strategies with specific molecular markers that will refine subsets appropriate for targeted therapy.

A Common Polymorphism in the Interleukin 8 Gene Promoter Is Associated with Clostridium difficile Diarrhea.
Jiang ZD, Dupont HL, Garey K, Price M, Graham G, Okhuysen P, Dao-Tran T, Larocco M
Am J Gastroenterol. 2006 Mar 30;.

OBJECTIVE: Mucosal interleukin 8 (IL-8) and neutrophil recruitment are central to the pathogenesis of Clostridium difficile (CD) toxin-induced diarrhea (CDD). We hypothesized that like other inflammatory mucosal infections, susceptibility to CDD would relate to genetically determined variations in the production of IL-8. METHODS: Fecal IL-8 production and single nucleotide polymorphism (SNP) frequency in the -251 region of the IL-8 gene were determined in hospitalized patients: 42 with CDD, 42 with CD-negative diarrhea, and 41 without diarrhea. Cases and controls were matched by age, length of hospital stay, comorbidity, and receipt of antibiotics. RESULTS: An association was found between the IL-8 -251 A/A allele and occurrence of CDD, 39%versus 16% (OR = 3.26, 95% CI 1.09-9.17) and 17% (OR = 5.50, 95% CI 1.22-24.8) for the two control groups. Comparing results by IL-8 genotype for the CDD cases, median and mean fecal IL-8 levels were significantly higher for the -251 A/A genotype (p= 0.03 for median and 0.001 for mean). CONCLUSIONS: These studies indicate a common SNP in the IL-8 gene is associated with increased susceptibility to CDD and with increased fecal IL-8 in diarrheal stools.

Colonic wall thickening on computed tomography scan and clinical correlation. Does it suggest the presence of an underlying neoplasia?
Moraitis D, Singh P, Jayadevan R, Cayten CG
Am Surg. 2006 Mar;72(3):269-71.

The widespread use of computed tomography (CT) scanning technology frequently leads to the incidental discovery of thickened bowel wall. The clinical significance of such a CT scan finding is largely under-investigated. The purpose of our study was to determine the incidence of significant clinical pathology and, particularly, neoplasia in patients with abnormally thickened bowel on CT scan examination. This is a single institution retrospective analysis of patients that underwent CT scanning of their abdomen. The radiological picture was correlated with colonoscopic findings. A total of 40 consecutive patients with thickened bowel on CT scan that also underwent colonoscopy were identified and their records were reviewed. Thirty-five patients had no history of previous gastrointestinal disorder and form our study group. The median age of the patients was 69 years (range, 24-97 years). There were 26 female and 9 male patients. The incidental CT finding of bowel wall thickening was the only reason for the colonoscopy in 14 (35%) out of the 40 patients. Eight (23%) patients with thick bowel had colonic neoplasia based on pathology. Five (14%) patients had invasive adenocarcinoma of the colon. Four (11%) of the 5 patients with colon adenocarcinoma did not have any associated gastrointestinal symptoms or signs. One (3%) patient had lymphoma of the colon and two (6%) had benign polyps. Colonoscopy was unremarkable in 10 (28%) patients. The incidental finding of colonic thickening on CT imaging could be associated with underlying colonic malignancy and, more importantly, represent the initial disease presentation. Therefore, we propose that these patients should undergo colonoscopy.

Molecular biology of squamous cell carcinoma of the anus.
Gervaz P, Hirschel B, Morel P
Br J Surg. 2006 Apr 11;93(5):531-538.

BACKGROUND: Squamous cell carcinoma of the anal canal provides a model for studying the contribution of human papillomavirus (HPV) and human immunodeficiency virus (HIV) infection to the development of neoplasia. This paper reviews the existing literature relating to the molecular biology of anal squamous cell carcinoma and proposes a theory of pathogenesis. METHODS: A Medline literature search was performed to identify English articles on the pathogenesis of squamous cell carcinoma of the anus; further articles were obtained from the references quoted in the literature initially reviewed. RESULTS: HPV infection and subsequent HPV DNA integration are necessary, but not sufficient, to cause cancer progression. Loss of heterozygosity at 11q23 is the most consistent genomic change observed. Loss of heterozygosity at 17p, 18q and 5q is frequently observed in tumours of HIV-negative patients, but not in those of HIV-positive patients. Current data suggest that mutations in p53, DCC and APC tumour suppressor genes contribute to the stepwise progression of anal squamous cell carcinoma in immunocompetent individuals. CONCLUSION: In comparison with immunocompetent individuals, HIV-positive patients have persistent HPV infection in the anal canal. In this population, microsatellite instability, rather than chromosomal instability, appears to be a preferred pathway for rapid progression towards invasive carcinoma.

Evaluation of the Risk of a Nonrestorative Resection for the Treatment of Diverticular Disease: The Cleveland Clinic Diverticular Disease Propensity Score.
Aydin HN, Tekkis PP, Remzi FH, Constantinides V, Fazio VW
Dis Colon Rectum. 2006 Apr 10;.

PURPOSE: The choice of operation for diverticular disease is a contentious issue, particularly in patients with acute symptoms. This study compares early outcomes between primary resection and anastomosis and Hartmann's resection and describes a propensity score for the selection of patients for nonrestorative procedures. METHODS: Data were collected from 731 patients undergoing primary resection and anastomosis (Group 1) and 123 patients undergoing primary Hartmann's resection (Group 2) for diverticular disease in a single tertiary referral center from January 1981 to May 2003. Multifactorial logistic regression was used to develop a propensity score for estimating the likelihood of performing a nonrestorative procedure. RESULTS: Operative 30-day mortality and surgical or medical complications were 0.7 percent, 26.0 percent, and 4.8 percent for primary resection and anastomosis and 12 percent, 43.9 percent, and 14.6 percent for Hartmann's resection, respectively (P < 0.001). There was no difference in the readmission rates between primary resection and anastomosis and Hartmann's resection (7.6 percent vs. 9.9 percent, P = 0.428). Laparoscopy was used for 32.7 percent of primary resection and anastomosis vs. 1.6 percent for Hartmann's resection (P < 0.001). Independentpredictors in favor for Hartmann's resection were body mass index >/=30 kg/m(2) (odd's ratio = 2.32), Mannheim peritonitis index >10 (odd's ratio = 6.75), operative urgency (emergency, urgent vs. elective surgery, odd's ratio = 16.08vs. 13.32), and Hinchey stage >II (odd's ratio = 27.82). The area under the receiver operating characteristic curve for the choice of operative procedure was 93.9 percent. CONCLUSIONS: Although Hartmann's resection was associated with a higher incidence of postoperative adverse events, the choice of operation was dependent on the patient presentation and intra-abdominal contamination, which can be quantified in the preoperative setting by the Cleveland Clinic diverticulitis propensity score.

Results of Lateral Internal Sphincterotomy for Chronic Anal Fissure With Particular Reference to Quality of Life.
Mentes BB, Tezcaner T, Yilmaz U, Leventoglu S, Oguz M
Dis Colon Rectum. 2006 Apr 7;.

PURPOSE: The aim of this study was to investigate the effects of lateral internal sphincterotomy on quality of life in patients with chronic anal fissure using the Gastrointestinal Quality of Life Index and the Fecal Incontinence Quality of Life Scale. METHODS: Adult patients with chronic anal fissure underwent lateral internal sphincterotomy with the open technique. Two hundred forty-four patients completed the Gastrointestinal Quality of Life Index questionnaire at admission and at 12 months postoperatively. The Fecal Incontinence Severity Index score was calculated preoperatively and at 2 and 12 months postoperatively. The Fecal Incontinence Quality of Life Scale was administered to any patient who had a Fecal Incontinence Severity Index score greater than 0 at 12 months postoperatively. RESULTS: The mean preoperative Gastrointestinal Quality of Life Index score was 118.34 +/- 6.33, which developed to 140.74 +/- 2.38 postoperatively (P< 0.001). At the two-month follow-up, 18 patients (7.38 percent) had a Fecal Incontinence Severity Index score greater than 0. By 12 months, the number of patients with Fecal Incontinence Severity Index score greater than 0 was reduced to seven (2.87 percent). These seven patients had a Gastrointestinal Quality of Life Index score similar to that of the group with postoperative Fecal Incontinence Severity Index score of 0, and only three patients (1.22 percent) had evident deterioration in the Fecal Incontinence Quality of Life Scale. The 12-month total Gastrointestinal Quality of Life Index score of the three patients who developed anal abscess/fistula after sphincterotomy (139.33 +/- 3.21) was similar to the Gastrointestinal Quality of Life Index score of those without complications. However, the Gastrointestinal Quality of Life Index score of the recurrent cases (111.53 +/- 3.53) was apparently low. CONCLUSION: The gastrointestinal quality of life improved significantly following lateral internal sphincterotomy, regardless of the surgical complications or postoperative disturbances of continence. Only 1.2 percent of the patients experienced deterioration in Fecal Incontinence Quality of Life Scale.

Laparoscopic Colon Resection for Polyps: A Good Novice Case?
Ross HM, Li C, Rosenthal J, Kessler J, Fogt F
Dis Colon Rectum. 2006 Apr 7;.

PURPOSE: Laparoscopic colon resection of the endoscopically unresectable polyp has been considered an ideal case for the surgeon with moderate laparoscopic colectomy experience because tissues are not inflamed and the lymphadenectomy may not need to be as extensive compared with that required for cancer. To assess the appropriateness of this approach, we evaluated the incidence of invasive cancer in a series of laparoscopic colon resections for polyps. METHODS: A retrospective review was performed of 55 consecutive patients undergoing laparoscopic colon resection for endoscopically unresectable polyps during a 35-month period. Colonoscopy data, polyp characteristics, and final colon pathology were reviewed. RESULTS: On final pathologic examination, 18.2 percent of patients had invasive adenocarcinoma. Patient age, gender, indication for colonoscopy, polyp size, polyp location, polyp characteristics, and colonoscopic biopsy pathology were not predictive of adenocarcinoma on final pathology. CONCLUSIONS: A significant number of endoscopically unresectable polyps harbor adenocarcinoma, thereby requiring a formal lymphadenectomy at resection. Caution should be exercised when considering the laparoscopic resection of an endoscopically unresectable polyp as a "learning" case.

Morbidity of Temporary Loop Ileostomy in Patients With Colorectal Cancer.
Thalheimer A, Bueter M, Kortuem M, Thiede A, Meyer D
Dis Colon Rectum. 2006 Apr 7;.

PURPOSE: This study was designed to quantify the temporary loop ileostomy-related morbidity in patients with colorectal cancer and contrast the morbidity rates after ileostomy closure before, during, and after the start of adjuvant therapy. METHODS: Between 1997 and 2004, 120 patients with colorectal carcinoma underwent colorectal resection and creation of a temporary loop ileostomy to protect the low anastomosis. Stoma-related complications and perioperative morbidity after ileostomy closure were assessed retrospectively by reviewing the medical records. RESULTS: Sixteen of the 120 patients (13.3 percent) suffered stoma-related complications, requiring early ileostomy closure in three. After ileostomy closure, anastomotic leakage of the ileoileostomy occurred in 3 of the 120 patients (2.5 percent), 2 of them died postoperatively (1.7 percent). The rate of minor complications (16.7 percent in all patients) was much higher in patients undergoing adjuvant chemotherapy or radiochemotherapy (25.5 percent) than in patients receiving no additional therapy (9.2 percent). In the former patients, there was a trend toward fewer complications when ileostomy closure was performed before (12.5 percent), rather than during (42.9 percent) or after (21.2 percent), the start of adjuvant therapy. CONCLUSIONS: The morbidity following closure of a temporary loop ileostomy in colorectal cancer patients is much higher in patients receiving adjuvant chemotherapy or radiochemotherapy. The morbidity, however, might possibly be lowered to the level of patients receiving no additional therapy if ileostomy closure is performed before the start of adjuvant therapy.

Impact of Functional Results on Quality of Life After Rectal Cancer Surgery.
Vironen JH, Kairaluoma M, Aalto AM, Kellokumpu IH
Dis Colon Rectum. 2006 Apr 5;.

PURPOSE: Quality of life is an important outcome measure that has to be considered when deciding treatment strategy for rectal cancer. The aim of this study was to find out the impact of surgery-related adverse effects on quality of life. METHODS: The RAND-36 questionnaire and questionnaires assessing urinary, sexual, and bowel dysfunction were administered to 94 patients with no sign of recurrence a minimum of one year after curative surgery. Results were compared with age-matched and gender-matched general population. RESULTS: Eighty-two (87 percent) patients answered the questionnaires. Major bowel dysfunction was as common after high anterior resection as after low anterior resection. Urinary complaints occurred as often after anterior resection as after abdominoperineal resection, but sexual dysfunction was more common after abdominoperineal resection. Overall, the patients reported better general health perception but poorer social functioning than population controls. In particular, elderly patients reported a significantly better quality of life in many dimensions than their population controls. There was no significant difference in quality of life between treatment groups. Major bowel dysfunction after anterior resection impaired social functioning compared with that of patients without such symptoms. Urinary dysfunction impaired social functioning and impotence impaired physical and social functioning. CONCLUSIONS: Quality of life after rectal cancer surgery is not worse than that of the general population. The major adverse impact of bowel and urogenital dysfunction is on social functioning. These adverse effects need to be discussed with the patient and preoperative function needs to be taken into account when choosing between treatment options. Permanent colostomy is not always the factor that disrupts a person's quality of life most.

The Effect on Morbidity of Mesentery Lengthening Techniques and the Use of a Covering Stoma After Ileoanal Pouch Surgery.
Araki T, Parc Y, Lefevre J, Dehni N, Tiret E, Parc R
Dis Colon Rectum. 2006 Apr 4;.

PURPOSE: A tension-free anastomosis in a restorative proctocolectomy requires sufficient length of small-bowel mesentery. To ensure adequate length, it has been proposed that the superior mesenteric artery be divided and the right colon marginal vascular arcade be preserved. This study was designed to evaluate the influence of mesenteric lengthening techniques on the need for a stoma and on early outcomes after restorative proctocolectomy. METHODS: Records of patients who had a restorative proctocolectomy between January 1998 and October 2003 were reviewed. Patient and disease characteristics, operative techniques and findings, the need for a stoma, and postoperative complications were recorded. RESULTS: In one patient a restorative proctocolectomy was not possible. The remaining 220 patients were divided into two groups: Group A (inflammatory bowel disease; n = 123) and Group B (noninflammatory bowel disease; n = 97). Sixty-nine patients (31.4 percent) had major comorbidities. A lengthening technique was performed in 120 patients (54.5 percent) by dividing the ileocecal artery (n = 37) or the superior mesenteric artery (n = 88); 5 patients had only the marginal vascular arcade preserved. An ileostomy was not required in 116 patients (52.7 percent). In multivariate analysis, in Group B the only surgical variable influencing the need for an ileostomy was preservation of the marginal vascular arcade (50 vs. 14.7 percent; P < 0.0005). Complications occurred in 41 patients (18.6 percent), more frequently for those in GroupA and for patients receiving steroids (23.6 vs. 12.4 percent, P = 0.012; 10.4 vs. 6.8 percent, P = 0.0172). CONCLUSIONS: The use of mesentery lengthening techniques allows a restorative proctocolectomy to be performed in almost all patients without increasing morbidity and may reduce the number of covering stomas. Because division of the ileocecal and/or superior mesenteric arteries may be required, preservation of the marginal vascular arcade is essential whenever possible.

Anal involvement in pemphigus vulgaris.
Malik M, El Tal AE, Ahmed AR
Dis Colon Rectum. 2006 Apr;49(4):500-6.

INTRODUCTION: Anal involvement in patients with pemphigus vulgaris has rarely been reported. We report 16 pemphigus vulgaris patients with anal involvement. METHODS: We retrospectively reviewed the clinical data on 16 patients treated at a tertiary dermatology referral center. RESULTS: Of 16 patients with anal involvement of pemphigus vulgaris, ten were female and six were male. The mean age of onset was 56 (range, 37-82) years. All patients had involvement of pemphigus vulgaris at multiple sites, including oral involvement. Recurrent episodes of anal pemphigus vulgaris were noted in nine (56 percent) patients, with a mean of 2.4 recurrences (range, 1-11). In all patients, pemphigus vulgaris was controlled with systemic and local therapy. Long-term follow-up for a mean of 53 (range, 4-188) months indicated that no long-term sequela occurred because of anal involvement. CONCLUSIONS: Anal involvement in pemphigus vulgaris is not very common and generally occurs in patients with severe disease. With appropriate topical and systemic therapy, patients have full recovery with no sequelae.

Long-term effect of preoperative radiation therapy on anorectal function.
Pollack J, Holm T, Cedermark B, Holmstrom B, Mellgren A
Dis Colon Rectum. 2006 Mar;49(3):345-52.

PURPOSE: Preoperative radiotherapy improves local control in rectal cancer treatment, but there are few reports on the influence of radiotherapy on anorectal function. The aim of the present study was to assess late effects of short-course, high-dose radiotherapy on anorectal function after low anterior resection for rectal cancer. METHODS: Sixty-four patients, randomized within the Stockholm Radiotherapy Trials and operated on with low anterior resection with or without preoperative radiotherapy (mean, 14 years), previously were followed up with quality-of-life questionnaires, clinical examination, anorectal manometry, and endoanal ultrasound. Twenty-one patients had received preoperative radiotherapy of the rectum and 43 patients had been treated with surgery alone. RESULTS: Impaired anorectal function was common after low anterior resection for rectal cancer and the risk was increased after radiotherapy. Irradiated patients had significantly more symptoms of fecal incontinence (57 vs. 26 percent, P = 0.01), soiling (38 vs. 16 percent, P = 0.04), and significantly more bowel movements per week (20 vs. 10, P = 0.02). At anorectal manometry, irradiated patients had significantly lower resting (35 mmHg vs. 62 mmHg, P < 0,001) and squeeze pressures (104 mmHg vs. 143 mmHg, P = 0.05). At endoanal ultrasound, irradiated patients had significantly more scarring of the anal sphincters (33 vs. 13 percent, P = 0.03). There were no significant differences in quality-of-life scores between irradiated and nonirradiated patients; however, patients with anal incontinence had significantly lower quality-of-life scores compared to continent patients. CONCLUSIONS: Short-course radiotherapy, including the anal sphincters, impairs anorectal function and increases gastrointestinal symptoms permanently when the anal sphincters are irradiated.

Survival from rectal and anal cancers in England and Wales, 1986-2001.
Jeffreys M, Rachet B, McDowell S, Habib AG, Lepage C, Coleman MP
Eur J Cancer. 2006 Apr 3;.

The aim of this study was to investigate the effects of tumour and patient characteristics on trends in the survival of patients with cancer of the anus or rectum in England and Wales. A total of 132,542 adults (15-99 years) who were diagnosed during the 14 years 1986-1999 were followed up to 2001 through the National Health Service Central Register. Relative survival up to 5 years after diagnosis was estimated, using deprivation-specific life tables. Generalised linear models were used to estimate relative excess risks of death, adjusted for patient and tumour characteristics. The results showed that 5-year relative survival was higher in women, younger patients and more affluent patients, and higher for anal cancer than rectal cancer. Survival improved by more than 10% from the late 1980s (around 38%) to the late 1990s (49%). This trend was not explained by changes in the distribution of age, anatomical site, morphology or deprivation. The trend was more marked in younger and more affluent patients, and for adenocarcinoma and epidermoid carcinoma than for tumours with other morphology. The inequality in survival between affluent and deprived patients widened. It is concluded that improvements in survival may reflect improvements in disease stage, diagnostic technique or treatment. Which of these factors contribute to the widening socioeconomic inequalities in survival remains to be elucidated.

Neurological symptoms suggestive of demyelination in Crohn's disease after infliximab therapy.
Dubcenco E, Ottaway CA, Chen DL, Baker JP
Eur J Gastroenterol Hepatol. 2006 May;18(5):565-566.

Anti-TNFalpha drugs are currently used in the treatment of patients with Crohn's disease. Studies have reported neurological side effects occurring after anti-TNFalpha treatment, including infliximab-induced complications.

McKittrick-Wheelock syndrome: a rare cause of diarrhoea.
Lepur D, Klinar I, Mise B, Himbele J, Vranjican Z, Barsic B
Eur J Gastroenterol Hepatol. 2006 May;18(5):557-559.

McKittrick-Wheelock syndrome is a rare disorder caused by fluid and electrolyte hypersecretion from a rectal tumour. The most frequently reported tumours are villous adenomas. Dehydration with severe hyponatremia, hypokalemia, metabolic acidosis, acute renal failure and watery diarrhoea is typical. The authors present a case of McKittrick-Wheelock syndrome caused by rectal adenocarcinoma.

Nodular regenerative hyperplasia: a reversible entity associated with azathioprine therapy.
Seiderer J, Zech CJ, Diebold J, Schoenberg SO, Brand S, Tillack C, Goke B, Ochsenkuhn T
Eur J Gastroenterol Hepatol. 2006 May;18(5):553-5.

Azathioprine represents an effective and widely used immunosuppressant; however, there are increasing concerns about the hepatotoxicity of thiopurines because of an entity called 'nodular regenerative hyperplasia' (NRH) observed in patients treated with 6-thioguanine. In line with this hypothesis, we report and comment on a patient with inflammatory bowel disease (IBD) diagnosed with NRH as a reversible but potentially serious hepatotoxic side-effect of azathioprine. Our report strengthens the importance of further safety studies to evaluate the aetiology and prevalence of NRH in IBD patients before general conclusions on the use of thiopurines can be drawn. Physicians caring for IBD patients need to be alert to this rare but serious complication.

Prevention of postoperative recurrence of Crohn's disease by infliximab.
Sorrentino D, Terrosu G, Avellini C, Beltrami CA, Bresadola V, Toso F
Eur J Gastroenterol Hepatol. 2006 Apr;18(4):457-9.

The prevention of the recurrence of Crohn's disease after surgery remains difficult. The monoclonal antibody anti-TNF-alpha, infliximab, is very effective in inducing and maintaining the remission of uncomplicated, active Crohn's disease. We present here the case of a 23-year-old white woman who underwent resection for a sigmoid stricture caused by Crohn's disease. Surgery removed the involved colon, and pathology confirmed the stricture to be fibrotic. Two weeks after the operation she was given infliximab at the dose of 5 mg/kg body weight and followed in time. Since then, she has been disease free for approximately 4 years after surgery on clinical, radiological and endoscopic/histological grounds (Crohn's Disease Activity Index </=110 on all occasions). Up to now, she has had no increase in inflammatory indices, no anaemia and no abnormal blood tests. In contrast, all of five control patients operated in the same period with colonic or ileocolonic resection for symptomatic strictures and treated with mesalamine or no medication developed endoscopic or clinical recurrence (abdominal pain or diarrhoea) by year 3. This is the first case, to our knowledge, in which infliximab has been successfully used to prevent the postsurgical recurrence of Crohn's disease, an event so far considered to be inescapable. We believe that, with this aim in mind, clinical trials with this drug are warranted.

The fate of the rectal stump after subtotal colectomy for ulcerative colitis.
Bohm G, O'dwyer ST
Int J Colorectal Dis. 2006 Apr 4;.

OBJECTIVE: To review the outcome of patients who had undergone subtotal colectomy for ulcerative colitis with formation of a rectal stump. To specifically look at the fate of the rectal stump, whether patients underwent emergency colectomy as opposed to urgent or elective resection. PATIENTS AND METHODS: Between January 1990 and August 2000, a total of 31 patients underwent subtotal colectomy for ulcerative colitis. Patients were identified using the computerized coding system for the years 1995 to 2000, supplemented by pathology records, discharge letters, and operation notes. Postal and telephone surveys were undertaken using a standard questionnaire assessing social, physical, sexual, and bowel activities of patients. RESULTS: In 28 out of 31 patients, the follow-up was complete. Twenty-four of 28 patients (86%) underwent excision of rectal stump. Four patients (14%) preferred to undergo excision of rectum only, resulting in a permanent ileostomy; 20/28 (71%) had attempted ileal pouch-anal anastomosis, with success in 85%. In four patients (14%), the rectal stump remained in situ and was associated with a decrease in the quality of life. There were no perioperative deaths and morbidity was low for all procedures. CONCLUSION: These data show that after subtotal colectomy, the majority of our ulcerative colitis patients undergo ileal pouch-anal anastomosis. Patients' satisfaction is high with reasonable social and excellent sexual function on quality of life assessment. During its retention, the rectal stump causes considerable symptoms. When left in situ, it is associated with a decrease in the quality of life.

Immunosuppressive drugs in ulcerative colitis: twisting facts to suit theories?
Sands BE
Gut. 2006 Apr;55(4):437-41.

Immunosuppressive drugs have become a mainstay of therapy for the inflammatory bowel diseases. Although robust evidence exists in support of the use of these drugs in Crohn's disease, a close evaluation of the available data in ulcerative colitis reveals a much weaker evidence base. In particular, randomised controlled trials of azathioprine, the most commonly used immunosuppressive agent, do not provide rich evidence of efficacy whereas observational cohorts suggest this agent is effective, particularly in patients with relapsing disease who require corticosteroids. Ciclosporin is also effective in the most refractory cases but its efficacy needs to be carefully weighed against the possibility of rare but life threatening complications. Although the evidence base in support of immunosuppressive drugs in ulcerative colitis is not as strong as in Crohn's disease, these agents clearly have a role in the treatment of this disease.

Predictors of Crohn's disease.
Beaugerie L, Seksik P, Nion-Larmurier I, Gendre JP, Cosnes J
Gastroenterology. 2006 Mar;130(3):650-6.

BACKGROUND & AIMS: Early intensive therapy in Crohn's disease should be considered only in patients with disabling disease. The aim of our study was to identify at diagnosis factors predictive of a subsequent 5-year disabling course. METHODS: Among the 1526 patients seen at our unit with Crohn's disease diagnosed between 1985 and 1998, we excluded patients operated on within the first month of the disease, patients with inadequate data, and patients with severe chronic nondigestive disease. In the 1188 remaining patients, Crohn's disease course within the first 5 years of the disease was categorized as disabling when at least 1 of the criteria of clinical severity, conventionally predefined, was present. RESULTS: Among the 1123 patients with follow-up data allowing full 5-year course classification, the rate of disabling disease was 85.2%. Independent factors present at diagnosis and significantly associated with subsequent 5-year disabling were the initial requirement for steroid use (OR 3.1 [95% CI: 2.2-4.4]), an age below 40 years (OR 2.1 [95% CI: 1.3-3.6]), and the presence of perianal disease (OR 1.8 [95% CI: 1.2-2.8]). The positive predictive value of disabling disease in patients with 2 and 3 predictive factors of disabling disease was 0.91 and 0.93, respectively. These values were 0.84 and 0.91, respectively, when tested prospectively in an independent group of 302 consecutive patients seen at our institution from 1998. CONCLUSIONS: At diagnosis of Crohn's disease in a referral center, factors predictive of subsequent 5-year disabling course are an age below 40 years, the presence of perianal disease, and the initial requirement for steroids.

Symptomatic presentation of early colorectal cancer.
Smith D, Ballal M, Hodder R, Soin G, Selvachandran SN, Cade D
Ann R Coll Surg Engl. 2006 Mar;88(2):185-90.

INTRODUCTION: It is believed that increased detection of earlier stage colorectal cancer can only be achieved by screening asymptomatic individuals. We describe a referral pathway for a symptomatic population which achieves a 30% Dukes' A detection rate.PATIENTS AND METHODS: From October 1999, 4253 patients with distal colonic symptoms, referred by general practitioners, completed a patient consultation questionnaire (PCQ) linked to a computerised record. A weighted numerical score (WNS) was derived for each patient. Patients underwent flexible sigmoidoscopy, a diagnostic outcome was recorded and later Dukes' stage appended. Early and advanced colorectal cancers were separated and PCQ derived symptom profiles compared. Chi-square, Fisher exact, Student's t-test and logistic regression were used for statistical analysis.RESULTS: A total of 183 patients had cancer, 55 (30%) were Dukes' A early colorectal cancers, 112 were advanced colorectal cancers (Dukes' B-D) and 16 could not be staged. Early colorectal cancers had significant symptoms and comparable profile to advanced colorectal cancers. The tendency in advanced colorectal cancers was towards greater symptom prevalence for only a few primary and systemic symptoms, as reflected by a higher WNS of 75 (P = 0.001)CONCLUSIONS: Early colorectal cancers do have significant symptoms which can easily be captured by a PCQ and objective scoring tool in the secondary care setting. Detection of these cancers has the potential to improve survival.

Subspecialisation and its effect on the management of rectal cancer.
Ng VV, Tytherleigh MG, Fowler L, Farouk R
Ann R Coll Surg Engl. 2006 Mar;88(2):181-4.

INTRODUCTION: To assess the impact of subspecialisation on surgical and oncological outcomes after rectal cancer surgery in a single surgical unit within a district general hospital.PATIENTS AND METHODS: A total of 207 patients with rectal cancer treated surgically by two colorectal surgeons and four experienced general surgeons at the Royal Berkshire Hospital, Reading, England between January 1995 and December 1999 were studied. A retrospective case-note review of each patient's personal details, operative and histological findings, their subsequent clinical progress and oncological outcomes, including 5-year survival were recorded.RESULTS: In the study group, 127 patients were treated by a colorectal surgeon and 80 by general surgeons. Pre-operative radiotherapy was more likely to be given to patients treated by a colorectal surgeon. Fewer permanent stomas were performed by colorectal surgeons. Postoperative morbidity, transfusion requirements, anastomotic leak rates and 30-day mortality were not significantly different. Tumour-involved circumferential resection margins, local recurrence rates and risk of distant metastases were similar between the two groups of surgeons.CONCLUSIONS: Colorectal subspecialisation has resulted in an increased use of pre-operative radiotherapy and fewer permanent stomas. No significant improvement in surgical or oncological outcomes after rectal cancer surgery have been observed.

Associations between the age at diagnosis and location of colorectal cancer and the use of alcohol and tobacco: implications for screening.
Zisman AL, Nickolov A, Brand RE, Gorchow A, Roy HK
Arch Intern Med. 2006 Mar 27;166(6):629-34.

BACKGROUND: Individualizing recommendations for colorectal cancer (CRC) screening intervals and modalities requires accurate risk assessment. Although hereditary predisposition is commonly used, the effect of exogenous risk factors has remained largely unexplored. To address this, we analyzed the age at presentation and location of CRC in relation to alcohol and tobacco use. METHODS: We queried the IMPAC Medical Registry Services Cancer Information Resource File for CRCs diagnosed between June 1, 1993, and December 31, 2003. Subjects were classified as current, past, or never users of alcohol and tobacco. A logistic regression model for location of CRC and a linear regression model for age at diagnosis were constructed using these explanatory variables along with gender, race, and insurance status. RESULTS: Our data set consisted of 161 172 patients with CRC. Current drinking, smoking, and smoking plus drinking were associated with younger ages at onset of CRC (adjusted age difference, 5.2, 5.2, and 7.8 years, respectively; P<.001 for all). A distal location of CRC was more likely to occur in current drinkers (odds ratio, 1.192; 95% confidence interval, 1.15-1.23) and smokers (odds ratio, 1.164; 95% confidence interval, 1.12-1.21). Colorectal cancer in men tended to occur earlier (adjusted age difference, 1.9 years; P<.001) and have a distal predominance (odds ratio, 1.42; P<.001) compared with women. The smoking but not the drinking effect size was greater in women than in men (adjusted age difference, 2.6 years; P<.001). CONCLUSIONS: Alcohol use, tobacco use, and male gender were associated with earlier onset and a distal location of CRC. If confirmed, these factors should guide recommendations regarding initiation of CRC screening and, possibly, choice of techniques.

Daclizumab, a humanized monoclonal antibody to the interleukin-2 receptor (CD25), for the treatment of moderately to severely active ulcerative colitis: a randomised, double-blind, placebo-controlled, dose- ranging trial.
Van Assche G, Sandborn WJ, Feagan BG, Salzberg B, Silvers D, Monroe P, Pandak WM, Anderson FH, Valentine JF, Wild GE, Geenen DJ, Sprague R, Targan SR, Rutgeerts PJ, Vexler V, Young D, Shames RS
Gut. 2006 Apr 7;.

BACKGROUND: An uncontrolled pilot study demonstrated that daclizumab, a humanized monoclonal antibody to the interleukin-2 receptor (CD25), might be effective for the treatment of active ulcerative colitis. METHODS: A randomized, double-blind, placebo- controlled trial was conducted to evaluate the efficacy of daclizumab induction therapy in patients with active ulcerative colitis. One hundred fifty-nine patients with moderate ulcerative colitis were randomized to receive induction therapy with daclizumab 1 mg/kg IV at weeks 0 and 4, or 2 mg/kg IV at weeks 0, 2, 4, and 6, or placebo. The primary endpoint was induction of remission at week 8. Remission was defined as a Mayo score of 0 on both the endoscopy and rectal bleeding components and a score of 0 or 1 on the stool frequency and physician's global assessment components. Response was defined as a decrease from baseline in the Mayo score of at least 3 points. RESULTS: Two percent of patients receiving daclizumab 1 mg/kg (p=0.11 vs. placebo) and 7 percent of patients receiving 2 mg/kg (p=0.73) were in remission at week 8, compared with 10 percent of those who received placebo. Response occurred at week 8 in 25 percent of patients receiving daclizumab 1 mg/kg (p=0.04) and 33 percent of patients receiving 2 mg/kg (p=0.30) versus 44 percent of those receiving placebo. Daclizumab was well tolerated. The most frequently reported adverse events in daclizumab-treated patients greater than placebo-treated patients were nasopharyngits (14.6%) and pyrexia (10.7%). CONCLUSION: Patients with moderate ulcerative colitis who are treated with daclizumab are not more likely to be in remission or response at 8 weeks than patients treated with placebo.

Surveillance colonoscopy in patients with colorectal cancer: how often should we be doing it?
Mathew J, Saklani AK, Borghol M
Surgeon. 2006 Feb;4(1):3-5, 62.

BACKGROUND: The optimum protocol for colonoscopic surveillance following curative resection for colorectal cancer has not been established. The aim was to assess the incidence of recurrence and metachronous tumours in our less intensive colonoscopic surveillance programme and compare our results with those reported from intensive surveillance programmes. METHODS: Colonoscopic records of patients who had surveillance colonoscopy following curative resection from April 1998 to March 2003 for cancer were available from the endoscopy department computer database. The variables studied included the tumour site, Duke's stage, number of recurrences, number of metachronous tumours, size and number of polyps and their biopsy results. RESULTS: There were a total of 105 patients. Two patients were diagnosed with metachronous tumours and three with recurrence. Adenomatous polyps were identified in 24 patients of which nine had multiple/advanced adenomas (equal to or more than 1cm adenomatous polyps, or with severe dysplasia). CONCLUSION: The risk of development of colonic pathology following curative resection for colorectal cancer is low. More intensive follow-up should be reserved for patients with additional risk of developing further cancers.

Rectal cancer surgery in the elderly: A multivariate analysis of outcome risk factors.
Bufalari A, Giustozzi G, Burattini MF, Servili S, Bussotti C, Lucaroni E, Ricci E, Sciannameo F
J Surg Oncol. 2006 Mar 1;93(3):173-80.

BACKGROUND AND OBJECTIVES: Geriatric population life expectancy is rapidly increasing and the impact of major surgical procedures is not well defined. The purpose of this study was to compare short term surgical results assessing mortality and morbidity and long-term survival and disease-free interval in elective rectal surgery patients older than 65 years of age. The main independent risk factors of mortality, morbidity, and overall and disease-free survival were also identified. METHODS: Out of 177 rectal cancer accepted consecutively from 1991 to 2002, we studied the main clinical and pathological parameters comparing patients older and younger than 65 years. Data have been collected in a database and variables considered were studied by univariate analysis; independent predictive factors of 30-day mortality and morbidity were identified by multiple logistic regression analysis. Overall, cancer specific and disease-free survival curves were obtained with the Kaplan-Meier method and results compared with the log-rank test. Independent risk factors of overall and disease-free survival have been identified by multivariate logistic regression analysis. RESULTS: In patients younger and older than 65 years postoperative mortality (3.2% vs. 9.6%) and morbidity (30% vs. 29%) were not significantly different. Variables independently associated with 30-day mortality were the duration of surgical procedures and postoperative complications. The Kaplan-Meier survival curves showed a significantly worst overall survival (P = 0.003), cancer specific survival (P = 0.02), and disease-free survival (P = 0.03) in patients aged 65 years or more. Multivariate analysis showed that pT, grading, preoperative CEA level, gender, and site of the tumor along the rectum, the number of blood transfusion and the age group of more than 65 years are independent risk factors for both overall survival and disease-free interval. The presence of residual disease was an adjunctive factor of overall survival, whereas the Astler and Coller staging was a risk factor for the disease-free survival. CONCLUSION: The short-term prognosis for elective rectal cancer procedure in patients over 65 years of age was comparable to that of younger patients, whereas long term cancer-related survival was statistically worst in older patients. J. Surg. Oncol. 2006;93: 173-180. (c) 2006 Wiley-Liss, Inc.

Totally laparoscopic low anterior resection with transperineal handsewn colonic J-pouch anal anastomosis for low rectal cancer.
Person B, Vivas DA, Wexner SD
Surg Endosc. 2006 Feb 27;.

Laparoscopic abdominoperineal resection for lower rectal cancers How do we do it?
Liang JT, Lai HS, Lee PH
Surg Endosc. 2006 Feb 21;.

BACKGROUND: The appropriateness of the laparoscopic approach for the resection of rectal cancer has been controversial, although it is well established in colon cancer. This is a phase II study of laparoscopic abdominoperineal resection (APR) in the treatment of lower rectal cancers. METHODS: Patients with lower rectal adenocarcinoma located within 6 cm above the anal verge were recruited and subjected to laparoscopic APR. The surgical principle included en bloc resection with high ligation of inferior mesenteric vessels by no-touch isolation and total mesorectal excision. Details of the surgical procedures are presented in the video. The technical efficiency and outcome of this surgical approach were evaluated prospectively. This study was approved by the institutional review board of National Taiwan University Hospital (NTUH). RESULTS: A total of 22 patients were enrolled in the study from January 2003 to December 2004 under the ethical guidelines of clinical trials in NTUH. There were 12 females and 10 males, with an age distribution of 62.5 +/- 10.4 years. The body mass index was 24.8 +/- 4.0 kg/m(2). Physical status (American Society of Anesthesiology classification) was class I in 12, class II in eight, and class III in two patients. Tumor size was 44.0 +/- 12.0 mm in diameter. Two patients were in pathologic TNM stage I, 14 in stage II, and six in stage III. The operation time was 214.0 +/- 28.4 min. Blood loss was 54.0 +/- 14.0 ml. Because the tumor specimen was retrieved from a perineal wound, the five 5 to 12 mm working ports constituted the abdominal wound. There were no major complications. However, wound infection of port sites was detected in one patient. The patients had a quick convalescence, as evaluated by the length of postoperative ileus (48.0 +/- 12.0 h), length of hospitalization (8.0 +/- 2.0 days), and degree of postoperative pain (3.5 +/- 0.5 visual analogue scale). Return to partial activity, full activity, and work was 2.0 +/- 0.5, 4.0 +/- 0.8, and 6.0 +/- 0.5 weeks, respectively. The number of cleared lymph nodes was 14.0 +/- 2.0. During follow-up (median, 18 months; range, 6-30), lung metastasis and local pelvic recurrence developed in one and two patients, respectively. Besides the expenses covered by the National Bureau of Health Insurance of Taiwan, the additional payment by patients undergoing laparoscopic procedures was NT $24,000 +/- 3000 (1 U.S. dollar = 32 NT$). CONCLUSIONS: In our clinical setting, laparoscopic APR can be performed with good technical efficiency, quick functional recovery, and mild disability. The short-term oncologic results of laparoscopic APR seem to be acceptable, but further long-term follow-up for these patients is mandatory to define the oncologic outcomes of this approach.

An exceptional type of anorectal malformation: anorectal atresia with posterior fistula in a newborn male.
Mboyo A, Aubert D, Vrsansky P
J Pediatr Surg. 2006 Feb;41(2):e7-9.

The authors report the case of a newborn male with an exceptional type of anorectal atresia with a fistula that passes posterior to the muscle complex and exits at a site just to the tip of the coccyx. This anorectal malformation was associated with other abnormalities including agenesis of the right kidney, pyelic dilatation of the left kidney, duplicity, and left megaureter. There was no defect in the spine. The anorectal malformation was managed successfully by a posterior sagittal approach according to the Pena procedure.

Functional outcome and quality of life in anorectal malformations.
Goyal A, Williams JM, Kenny SE, Lwin R, Baillie CT, Lamont GL, Turnock RR
J Pediatr Surg. 2006 Feb;41(2):318-22.
BACKGROUND/PURPOSE: The aim of this study was to assess the early functional outcome and quality of life (QOL) in children with anorectal malformations. METHODS: Children treated for anorectal malformations (ARMs) from 1994 to 2000 were evaluated if 4 years or older. Primary outcome measures were bowel function score, assessed by functional outcome questionnaire, and QOL using the Pediatric Quality of Life Inventory (PedsQL 4). The secondary outcome measure was age at potty training. Twenty healthy children were used as controls for functional outcome and age at potty training. Data are reported as mean (SD) unless otherwise stated. RESULTS: Eighty children were evaluated during the study period. The mean age at follow-up was 82 months (18.7). The response rate was 76.3% (58/76) for bowel function and 77.5% (62/80) for QOL questionnaires. Functional outcome score (maximum 20) decreased significantly with increasing severity of the ARM (male perineal fistula, 16 [3]; female perineal fistula, 15 [3]; rectourethral fistula, 12 [4]; vestibular fistula, 13 [3.5]; bladder neck fistula, 6 [2]; analysis of variance, P = .001). However, there was no difference in QOL between patients with ARM and controls. There was no correlation between age and either bowel function score (Pearson r2 = 0.06) or QOL (Pearson r(2) = 0.12). Affected children took significantly longer to achieve potty training for bladder (35 [13.8] months vs 26 [8.7] months for controls [t test, P = .005]) and bowels (38 [16] months vs 25 [7] months [t test, P = .001]). CONCLUSION: Children with ARMs have significantly worse bowel function than their peers, depending on the type of lesion. Despite these findings, QOL was not significantly impaired. No correlation was demonstrated between age and either functional outcome or QOL.

Transanal endoscopic-assisted proctoplasty--a novel surgical approach for individual management of patients with imperforate anus without fistula.
Pakarinen MP, Baillie C, Koivusalo A, Rintala RJ
J Pediatr Surg. 2006 Feb;41(2):314-7.

BACKGROUND/AIM: Imperforate anus without fistula consists of a spectrum of defects with variable distance between the rectal pouch and the perineum. We have developed a novel surgical approach for individual management of these patients based on precise knowledge of the level of the anomaly. METHODS: All consecutive patients with imperforate anus without fistula between 2002 and 2004 had sigmoidostomy performed after having failed to pass meconium in the first 24 hours. The upper pouch was intraluminally visualized using retrograde endoscopy through the sigmoid mucous fistula. The distal termination of the rectum was clearly identified as by convergence of the anal columns. Bright translumination of the endoscope light from the rectum to the anal dimple within the external sphincter indicated a low malformation amenable to transanal proctoplasty. The rectum was incised from below under endoscopic visual control. Poor translumination indicated a higher defect, in which case, the operation was converted to standard posterior sagittal anorectoplasty. RESULTS: Seven patients (6 boys) were identified. Four patients (3 boys) completed transanal endoscopic-assisted proctoplasty. In all cases, the convergence of anal columns indicating rectal termination was right above the anal pit at the site of the maximal external sphincter squeeze. In 3 patients, the operation was converted to posterior sagittal anorectoplasty after verification of a higher anomaly by endoscopy. There were no operative complications. The median follow-up was 3 months (range, 1-26 months). All patients have an appropriate size anus and regular bowel actions. CONCLUSIONS: Transanal endoscopic-assisted proctoplasty allows safe and anatomical reconstruction of the anorectum, as well as contemporaneous closure of the sigmoidostomy in a significant proportion of patients with imperforate anus without fistula, avoiding the potential complications associated with the open posterior sagittal approach.

[Cutaneous metastasis of Crohn's disease.]
Masmoudi A, Abdelmaksoud W, Bouassida S, Khabir A, Charfeddine A, Fourati H, Boudawara T, Baklouti S, Krichen M, Turki H, Zahaf A
Presse Med. 2006 Feb;35(2 Pt 1):230-2.

Introduction>Involvement of the skin in Crohn's disease is rare. We report the case of a young woman presenting cutaneous nodules revealing a Crohn's disease. Case report>R. K. a 19 year old woman was admitted the impatient clinic for a 2 week history of nodular lesions of the extremities. Simultaneously, she had watery diarrhoea and abdominal pain associated with a bad general condition and fever. Skin examination showed ulcerated lesions with a non infiltrated inflammatory bader of the left food and the right calf associated with an abscess of the left forearm. Skin biopsy showed an inflammatory infiltrate of the deep dermis with tuberculoid noncaseating granulomas. Colonoscopy demonstrated multiple ulcers, a "globlestone appearance" of the glow and segmental glitis. Colonoscopy was followed by a peritonitis which made steroid therapy questionable. Meanwhile, the patient underwent a colonostomy and was fed intravenously, the skin lesions resolved. A follow up colonoscopy demonstrated colon polyps, and the biopsy of the colon showed features of colitis and "follicular" duodenitis which was in concordance with the diagnosis of Crohn's disease. Commentaries>Usually, cutaneous lesions in Crohn's disease are consistent with nodules and granulomatous fissures of the grain. Involvement of the mucosa is rare. We report the case of "metastatic" localisation of nodular abscesses in Corhn disease. Improvement of cutaneous lesions might be explained by the nonuse of the digestive track allowed by the parenteral supplementation.

Gastrointestinal malignancies evaluated with (18)F-fluoro-2-deoxyglucose positron emission tomography.
Chin BB, Chang PP
Best Pract Res Clin Gastroenterol. 2006 Feb;20(1):3-21.

(18)F-fluoro-2-deoxyglucose positron emission tomography has demonstrated high accuracy in the staging and evaluation of colorectal and esophageal carcinomas. FDG PET is demonstrating increasing utility in a number of other gastrointestinal tumours and clinical scenarios. The established clinical indications for its use, the diagnostic accuracy, and limitations will be reviewed. Data on the emerging indications and limitations for pancreatic, hepatocellular, and gastric carcinomas, as well as gastrointestinal stromal tumours, cholangiocarcinoma, and carcinoma of unknown primary will also be briefly discussed. The use of combined PET-CT is demonstrating further improvements in diagnostic accuracy.

Complementary and alternative medicine use by patients with inflammatory bowel disease: results from a postal survey.
Bensoussan M, Jovenin N, Garcia B, Vandromme L, Jolly D, Bouche O, Thiefin G, Cadiot G
Gastroenterol Clin Biol. 2006 Jan;30(1):14-23.

AIMS: Thirty to 50% of north American patients with inflammatory bowel disease (IBD) have been reported to use complementary and alternative medicine (CAM). There is no data in France. The aim of this study was to evaluate the frequency of CAM use and the reasons in a French population of patients with IBD. PATIENTS AND METHODS: An anonymous postal survey was done with a questionnaire mailed to all the patients with IBD, 16 to 79 year-old, followed-up in a public and a private medical centre of Reims, between January 2001 and December 2003. RESULTS: The final sample included 447 patients; 325 (72.7%) filled up the questionnaire: 219 (67.4%) had Crohn's disease, 94 (28.8%) ulcerative colitis and 12 (3.7%) indeterminate colitis. Sixty-nine patients (21.2%) reported CAM use for IBD. The mean number of CAM used simultaneously was 2.9. The most frequently used CAM treatment was homeopathy (40.6%), followed by magnetism (34.8%) and acupuncture (33.3%). The majority of patients (74.8%) never talked about CAM use with their IBD physician. Multivariate analysis showed that the factors significantly associated with CAM use were female gender (odds ratio (OR)=3.5, CI95%: 1.8-6.9), the low level of confidence in their doctor (OR=4.8, CI95%: 1.1-19.8) and the research of informations about their disease (OR=4.6, CI 95%: 2.0-10.7). CONCLUSION: Twenty-one percent of patients with IBD are using CAM, most of the time without talking about it with their physician. The quality of the relationship between the patient and his physician and female sex, more than the perceived severity of the disease, were the main determinants of that use.

Colonic pseudolipomatosis: clinical, endoscopical and pathological features in nine cases.
Brevet M, Chatelain D, Bartoli E, Geslin G, Delcenserie R, Braillon A, Sevestre H, Dupas JL
Gastroenterol Clin Biol. 2006 Jan;30(1):9-13.

Colonic pseudolipomatosis is a rare and benign condition. It is not well known by gastroenterologists and its pathogenesis is still unclear. METHODS: All cases of colonic pseudolipomatosis seen between February 2002 and June 2004 at the Amiens Universisty Hospital were identified and analyzed. RESULTS: During this period, 2099 colonoscopies were performed and 9 cases of colonic pseudolipomatosis were diagnosed (0.4%). Patients were all males aged from 41 to 67 (median age 52 years). They consulted for rectal bleeding (two patients), diarrhea (two patients) or abdominal pain (two patients). In three patients, colonic pseudolipomatosis was a fortuitous discovery during colonoscopy for polyp surveillance. The lesions presented as whitish and yellowish slightly elevated plaques ranging in size from a few millimeters to 4 cm. They extended over a two to 20 cm-long area, located in the right (two patients), transverse (four patients) or left colon (three patients). Microscopic examination showed empty spaces in the lamina propria measuring from 50 to 600 microm. They were negative for anti-CD31, CD34 and PS100 antibodies at immunohistochemistry and negative for Sudan black in three cases. The ultrastructural study showed in two cases round spaces containing small fibrillary protein-like deposits that might be lymph. CONCLUSION: Colonic pseudolipomatosis is rare. Its pathogenesis is not well-known but could be due to gas invasion or extravasation of lymph into lamina propria, maybe induced by mucosal lesions related to barotrauma or certain colonoscope cleaning solutions.

The right test for colon cancer screening?
Wei JT, Sandler RS
Gastrointest Endosc. 2006 Mar;63(3):459-60.

Relieving Symptoms in Cancer: Innovative Use of Art Therapy.
Nainis N, Paice JA, Ratner J, Wirth JH, Lai J, Shott S
J Pain Symptom Manage. 2006 Feb;31(2):162-169.

Art therapy has been used in a variety of clinical settings and populations, although few studies have explored its use in cancer symptom control. The specific aim of this study was to determine the effect of a 1-hour art therapy session on pain and other symptoms common to adult cancer inpatients. A quasi-experimental design was used (n=50). The Edmonton Symptom Assessment Scale (ESAS) and the Spielberger State-Trait Anxiety Index (STAI-S) were used prior to and after the art therapy to quantify symptoms, while open-ended questions evaluated the subjects' perceptions of the experience. There were statistically significant reductions in eight of nine symptoms measured by the ESAS, including the global distress score, as well as significant differences in most of the domains measured by the STAI-S. Subjects overwhelmingly expressed comfort with the process and desire to continue with therapy. This study provides beginning evidence for the efficacy of art therapy in reducing a broad spectrum of symptoms in cancer inpatients.

Mesna Protects Intestinal Mucosa from Ischemia/Reperfusion Injury.
Ypsilantis P, Lambropoulou M, Tentes I, Kortsaris A, Papadopoulos N, Simopoulos C
J Surg Res. 2006 Feb 23;.

BACKGROUND: Mesna is a thiol used for the prevention of oxazaphosphorine-induced hemorrhagic cystitis. However, its antioxidant properties on renal and hepatorenal oxidative damage, as well as its mucoprotective effect on the intestinal epithelium have also been shown. The aim of this study was to investigate the potential beneficial effect of mesna on ischemia/reperfusion (I/R)-induced oxidant damage of the intestinal mucosa. MATERIALS AND METHODS: Wistar rats were subjected to intestinal I/R for 30 min, induced by occlusion of the superior mesenteric artery, followed by 60 min reperfusion. Mesna was administered at 3 time points relative to ischemia; 60 min before ischemia, at the onset of ischemia or at the onset of reperfusion. At the end of the study period, jejunal segments were excised and assessed for histopathologic score, apoptotic index using the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick-end labeling (TUNEL) assay and glutathione/glutathione disulfide (GSH/GSSG) ratio, as a marker of oxidative stress. RESULTS: I/R caused deterioration of histological characteristics and induction of apoptosis and oxidative stress in the intestinal mucosa. Changes regarding histology and apoptosis were prevented when mesna was administered 60 min before ischemia, but were attenuated when mesna was administered at the onset of ischemia or reperfusion. In all mesna groups, oxidative stress was reduced. CONCLUSIONS: Mesna can ameliorate or even prevent intestinal I/R injury by reducing oxidative stress.

Magnetic resonance imaging of gastrointestinal stromal tumor in the abdomen and pelvis.
Amano M, Okuda T, Amano Y, Tajiri T, Kumazaki T
Clin Imaging. 2006 Mar-Apr;30(2):127-31.

This study aimed to evaluate magnetic resonance (MR) imaging appearances of 11 gastrointestinal stromal tumors in the abdomen and pelvis and compared them with some histological findings. Gastrointestinal stromal tumor showed nonhomogeneous signal intensity and included hemorrhage in large tumors. Gastrointestinal stromal tumors showed a wide variety of enhancement, and contrast enhancement of the tumor was consistent with mitosis index as well as the largest diameter of the tumor. Contrast-enhanced MR imaging may be useful in the assessment of tumor activity.

Surgery for recurrent rectal carcinoma: The role of preoperative magnetic resonance imaging.
Messiou C, Chalmers A, Boyle K, Sagar P
Clin Radiol. 2006 Mar;61(3):250-8.

Despite apparent curative resection of rectal carcinoma, local recurrence rates of between 3 and 32% have been reported. For those patients, radical surgical resection offers the only hope of cure. We present a review of the magnetic resonance imaging (MRI) findings and contraindications to curative surgery demonstrated using imaging.

Life Events and Inflammatory Bowel Disease Relapse: A Prospective Study of Patients Enrolled in Remission.
Vidal A, Gomez-Gil E, Sans M, Portella MJ, Salamero M, Pique JM, Panes J
Am J Gastroenterol. 2006 Feb 22;.

OBJECTIVES: The impact of life events in recurrence of inflammatory bowel disease (IBD) is unclear. We sought to determine whether stressful life events or the emotional impact of these events are associated with IBD relapses, hypothesizing that the exposure of life events among patients with inactive disease will increase the risk of subsequent relapses. METHODS: In this prospective study, 163 patients with inactive IBD, who had had at least one relapse in a 2-yr period before entry into the study, were enrolled. The Spanish version of the Social Readjustment Rating Scale (SRRS) (measuring life events), a measure of the emotional impact of these life events, and an IBD activity index were completed monthly up to the end of the study (maximum 11 months) or up to a relapse. Biological factors associated with an increased risk of relapse were identified in patients who relapsed. RESULTS: Fifty-one patients relapsed (32.9%), 104 remained in remission, and 8 dropped out. Multivariate Cox regression analysis with time dependent variables showed that the number of life events was not associated with the rate of relapse after adjustment for significant covariates on the subsequent month (hazard ratio = 0.88, 95% CI = 0.68-1.13, p= 0.33) or in the time-lagged analysis. The emotional impact of stressful events was also not associated with the risk of relapse. When patients who suffered a biological risk factor for relapsing were excluded in subsequent statistical analyses, similar results were obtained. CONCLUSIONS: Our results suggest that stressful life events do not trigger exacerbations in patients suffering from IBD.

Chronic anal fissure: 1994 and a decade later-are we doing better?
Floyd ND, Kondylis L, Kondylis PD, Reilly JC
Am J Surg. 2006 Mar;191(3):344-8.

BACKGROUND: Debate exists regarding whether the use of topical agents and Botox injections are as efficacious as sphincterotomy for the treatment of chronic anal fissure. METHODS: A retrospective review was performed to assess changes in management and outcomes of chronic anal fissure care in a community based colorectal practice between the individual years 1994 and 2003. RESULTS: Forty-seven patients in 1994 underwent lateral partial internal sphincterotomy and had a 100% healing rate. Thirty-nine patients were treated in 2003, with 32 undergoing Botox injection and 7 undergoing sphincterotomy initially. Of the Botox patients, 35% had recurrence, and 7 subsequently required sphincterotomy. Ultimate healing rates in 2003 were 97%. Time to heal was markedly prolonged in 2003 compared with 1994. Complication rates were similar, and there was no lifestyle-altering incontinence. CONCLUSIONS: Our review documents a significant change in the community approach to chronic fissure management. The addition of multiple treatment modalities prolongs time to healing from initial evaluation, but they allowed 72% of patients to avoid the need for permanent sphincter division while maintaining ultimate rates of healing.

Endoscopic ultrasound staging of rectal cancer: Diagnostic value before and following chemoradiation.
Maor Y, Nadler M, Barshack I, Zmora O, Koller M, Kundel Y, Fidder H, Bar-Meir S, Avidan B
J Gastroenterol Hepatol. 2006 Feb;21(2):454-8.

Background: Endoscopic ultrasound (EUS) has been shown to be a reliable tool for staging rectal cancer. Nevertheless, the accuracy of EUS after chemoradiation remains unclear; therefore the purpose of the present paper was to compare the accuracy of EUS staging for rectal cancer before and following chemoradiation. Methods: Patients with rectal cancer undergoing EUS staging were stratified into two groups. Group I consisted of 66 patients who underwent surgery following EUS staging without preoperative chemoradiation. Group II consisted of 25 patients who had EUS evaluation following chemoradiation. The EUS staging was compared to surgical/pathological staging. Results: The accuracy of the T staging for group I was 86% (57/66). Inaccurate staging was mainly associated with overstaging EUS T2 tumors. The accuracy of the N staging for group I was 71% (47/66). The accuracy of EUS for a composite T and N staging relevant to treatment decisions in group I was 91%. In group II, the accuracy of T and N staging was 72% (18/25) and 80% (20/25), respectively. Overstaging EUS T3 tumors accounted for most inaccurate staging. The EUS staging predicted post-chemoradiation T0N0 stage correctly in only 50% of cases. Conclusions: Preoperative staging of rectal cancer by EUS is a useful modality in determining the need for preoperative chemoradiation. The EUS T staging following chemoradiation appears to be less accurate. Detection of complete response may be insufficient for selecting patients for limited surgical intervention.

Meta-analysis of short-term outcomes after laparoscopic resection for rectal cancer.
Gao F, Cao YF, Chen LS
Int J Colorectal Dis. 2006 Feb 7;:1-5.

BACKGROUND: Laparoscopic resection (LR) has become increasingly popular for the management of rectal cancer. Despite a decade of experience, the safety and efficacy of LR for rectal cancer remains to be established. This report performs a meta-analysis to compare LR with conventional open resection (CR) in patients with rectal cancer. METHODS: Using a defined search strategy, studies directly comparing CR with LR for rectal cancer were identified. The data for patients with rectal cancer treated with both approaches were extracted and used in our meta-analysis. Open surgery and laparoscopic surgery were compared in terms of postoperative mortality, morbidity, complications, oncological clearance, operating time, and time before recovery to a normal diet. RESULTS: Compared with CR, LR is associated with lower morbidity rates [OR 0.63 (0.41, 1.96) P=0.03], longer operating times [weighted mean difference 1.59 (1.20, 1.98) P<0.00001], similar mortality rates, wound healing disorder rates, urinary disorder rates, cardiopulmony disease rates, all leakage rates, all abscess rates and a positive rate of margin. CONCLUSION: LR is associated with less postoperative morbidity, but longer operation time. A prospective randomized controlled trial is warranted to fully investigate these and other outcome measures.

Massive hematochezia from acute hemorrhagic rectal ulcer in patients with severe comorbid illness: rapid control of bleeding by per anal suturing of bleeder using anoretractor.
Hung HY, Changchien CR, You JF, Chen JS, Chiang JM, Yeh CY, Fan CW, Tang R, Hsieh PS, Tasi WS
Dis Colon Rectum. 2006 Feb;49(2):238-43.

PURPOSE: Massive hematochezia from acute hemorrhagic rectal ulcer can arise in patients with severe comorbid illness who are bedridden for long periods. If the bleeder is not found and treated immediately, the bleeding will cause deterioration of health and even threaten life. The results of the current study show how quickly and safely per anal suturing can treat acute hemorrhagic rectal ulcer. METHODS: From January 2003 to December 2003, the records of 26 patients who underwent per anal suturing of acute hemorrhagic rectal ulcer were retrospectively reviewed. The identification of acute hemorrhagic rectal ulcer was confirmed by clinical and anoscopic examination. RESULTS: Most of these patients were elderly and bedridden (14 men; median age 69 years). Main comorbid illnesses existed in all patients and included liver cirrhosis (8 patients, 31 percent), sepsis (13 patients, 50 percent), cerebral vascular accident (15 patients, 58 percent), respiratory failure (13 patients, 50 percent), and malignancy (7 patients, 27 percent). Effective hemostasis was achieved in all patients by direct suture of bleeding ulcer. No complications developed relative to the per anal suturing procedure among any patients. Although 11 patients developed recurrent hematochezia, 9 patients responded to repeated therapy. The risk factors associated with recurrent bleeding were severity of disease and abnormal coagulation. CONCLUSIONS: When massive hematochezia occurs in bedridden patients with severe comorbid illness, it is essential to investigate the lower rectum, which often is affected by acute hemorrhagic rectal ulcer. Recognition of this clinical presentation will result in early identification and therapy. Per anal suturing of a bleeder at the bedside provides a quick, safe, and successful management of acute hemorrhagic rectal ulcer.

The Outcome After Restorative Proctocolectomy With or Without Defunctioning Ileostomy.
Remzi FH, Fazio VW, Gorgun E, Ooi BS, Hammel J, Preen M, Church JM, Madbouly K, Lavery IC
Dis Colon Rectum. 2006 Mar 8;.

PURPOSE: Controversy exists regarding the safety for omission of diverting ileostomy in restorative proctocolectomy because of fears of increased septic complications. This study was designed to evaluate the outcomes of restorative proctocolectomy in a consecutive series of patients by comparing postoperative complications, functional results, and quality of life in patients with and without diverting ileostomy. METHODS: Data regarding demographics, length of stay, surgical characteristics, and complications were reviewed and recorded according to the presence (n= 1,725) or absence (n = 277) of a diverting ileostomy at the time of pelvic pouch surgery. Criteria for omission of ileostomy included: stapled anastomosis, tension-free anastomosis, intact tissue rings, good hemostasis, absence of airleaks, malnutrition, toxicity, anemia, and prolonged consumption of steroids. Functional outcome and quality of lifeindicators were prospectively recorded and compared. RESULTS: Patients in the ileostomy group had greater body surface area and older mean age at time of surgery, were taking greater doses of steroids preoperatively, and required more blood transfusions at the time of surgery compared with the one-stage (P < 0.05). There were no differences between the two groups in septic complications (P > 0.05). Early postoperative ileus was more common in the one-stage group (P < 0.001). There were no differences between the groups in quality of life and functional outcomes. CONCLUSIONS: For carefully selected patients undergoing restorative proctocolectomy with ileal pouch-anal anastomosis, omission of diverting ileostomy is a safe procedure that does not lead to an increase inseptic complications or mortality. Quality of life and functional results are similar to those who undergo ileal pouch-anal anastomosis with diversion, provided that certain selection factors are considered.

Laparoscopic Total Mesorectal Excision for Rectal Cancers.
Liang JT, Lai HS, Lee PH
Dis Colon Rectum. 2006 Mar 8;.

INTRODUCTION: More and more colorectal surgeons believe that total mesorectal excision can achieve favorable oncologic results for the treatment of rectal cancers. The present study is a feasibility study aiming to evaluate if total mesorectal excision can be safely performed by laparoscopic approach with beneficial functional recovery. METHODS: A total of 44 patients (from January 2004 to February 2005) with middle rectal cancer (the average distance from anal verge was 7.8 cm, ranging from 5.0 to 10.0 cm) without preoperative chemoradiation therapy were selected to undergo laparoscopic total mesorectal excision. Before the study entry, all patients underwent pelvic magnetic resonance imaging or multislice spiral computed tomography to evaluate the circumferential resection margin of rectal cancer. Only patients whose circumferential resection margin was not involved by rectal cancer were considered as potentially curable by total mesorectal excision procedures and were enrolled for this study. The operation procedures were conducted according to the guidelines advocated by Heald et al.1 and were shown in the video. Posteriorly, the dissection was along the 'holy plane' downward to the level of levator ani muscle. Anteriorly, the dissection plane was at the anterior part of Denonvilliers fascia. Laterally, the lateral ligaments were sharply cauterized at the medial part. The resected bowel was reconstructed with stapled end-to-end anastomosis. The surgical outcomes of this procedure were prospectively evaluated. RESULTS: The laparoscopic total mesorectal excision was performed with acceptable operation time (234.4+/-44.4 minutes, mean+/-standard deviation) and little blood loss (80.0+/-24.0 ml) through a small wound (5.0+/-0.5 cm). Histopathology showed that all patients were able to get adequate distal section margins (mean: 2.8 cm; range: 1.6-5.4 cm) and negative circumferential resection margins (mean: 8.4mm; range: 2-14 mm). The number of dissected lymph nodes was 16.0+/-4.0. The pathologic tumor-node-metastasis stages were as follows: Stage I: n= 4; Stage II: n = 22; Stage III: n = 18. Two patients (4.5 percent) were diverted by protective ileostomy. There was no mortality within 30 days after operation. However, anastomotic leakage occurred in 3 patients. The patients have quick functional recovery, as evaluated by the length of postoperative ileus (48.0+/-12.0 hours), hospitalization (9.0+/-1.0 days) and degree of postoperative pain (3.5+/-0.5, visual analog scale). Besides the expenses covered by the National Bureau of Health Insurance in Taiwan, the patient had to pay an extra expense of NT$ 65000.08000.0 (1.0US dollars = 32.0 NT$). During the follow-up periods (median: 14 months, range. 2 to 27 months), three patients of Stage III and 1 patient of Stage II developed a recurrent disease (lung metastasis: n = 2; liver metastasis: n = 1, and pelvic recurrence, n = 1). CONCLUSION: By laparoscopic approach, the total mesorectal excision for rectal cancers can be safely performed with good functional recovery. However, with only a median follow-up of 14 months in this case series, the long-term oncologic outcomes for these patients remain a question. Further randomized prospective study is thus mandatory to provide solid evidence of this approach.

Antimicrobials in the management of inflammatory bowel disease.
Gionchetti P, Rizzello F, Lammers KM, Morselli C, Tambasco R, Campieri M
Digestion. 2006;73 Suppl 1:77-85. Epub 2006 Feb 8.

Many experimental and clinical observations suggest a potential role for intestinal microflora in the pathogenesis of inflammatory bowel disease (IBD). Manipulation of the luminal content using antibiotics may therefore represent a potentially effective therapeutic option. However, the available studies do not support the use of antimicrobials in ulcerative colitis and larger studies are required. These drugs are however effective in treating septic complications of Crohn's disease (CD). The use of antibacterial agents as primary therapy for CD is more controversial, although this approach is frequently and successfully adopted in clinical practice. Despite the fact that properly controlled trials have been not carried out, antimicrobials are the mainstay of the treatment of pouchitis. Rifaximin is a poorly absorbed, broad-spectrum antibiotic that, thanks to its efficacy and long-term safety, could represent the preferred tool of manipulating enteric flora in patients with IBD. Preliminary data suggest that rifaximin may be beneficial in the treatment of active ulcerative colitis (and pouchitis), mild to moderate CD as well as prevention of post-operative recurrence of CD.

Inflammatory bowel disease: current therapeutic options.
Domenech E
Digestion. 2006;73 Suppl 1:67-76. Epub 2006 Feb 8.

Medical management of inflammatory bowel diseases (IBD) includes two treatment strategies: induction and maintenance of remission. 5-Aminosalicylates are mostly used for mild active IBD and for maintenance treatment in ulcerative colitis (UC). Glucocorticoids remain, despite their frequent (and occasionally severe) side effects, as the mainstay for induction of remission in moderate to severe active IBD, both UC and Crohn's disease (CD). Cyclosporine and infliximab have emerged as the main, rapid-acting, alternatives in steroid-refractory UC and CD, respectively. Thiopurines (azathioprine and 6-mercaptopurine) are the most efficient and used immunomodulators in IBD; steroid refractoriness, steroid dependency, and long-term maintenance of remission for both UC and CD are their main indications. Methotrexate and infliximab may be used in the same clinical settings as thiopurines in CD, but not in UC; however, these drugs are a second-line treatment because of safety profile and economic costs.

Population-based study of risk factors for postoperative death after anterior resection of the rectum.
Matthiessen P, Hallbook O, Rutegard J, Sjodahl R
Br J Surg. 2006 Feb 20;.

BACKGROUND: The aim of this population-based study was to analyse risk factors for death within 30 days after anterior resection of the rectum. METHODS: Between 1987 and 1995 a total of 6833 patients underwent elective anterior resection of the rectum in Sweden. One hundred and forty of these patients died within 30 days or during the initial hospital stay. These patients were compared with a randomly chosen cohort of 423 patients who underwent the same operation during the same interval, and were alive after 30 days and discharged from hospital. The association between death and 12 putative risk factors was studied. RESULTS: The mortality rate after elective anterior resection was 2.1 per cent (140 of 6833). The incidence of clinical anastomotic leakage was 42.1 per cent (59 of 140) among those who died and 10.9 per cent (46 of 423) in the cohort group. Multivariate regression analysis identified clinical leakage, increased age, male sex, Dukes' 'D' stage and intraoperative adverse events as independent risk factors for death within 30 days. CONCLUSION: Clinical anastomotic leakage was a major cause of postoperative death after anterior resection. Copyright (c) 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Screening practices of patients presenting for resection of a colorectal neoplasm.
Hedrick TL, Galloway RP, McElearney ST, Smith RL, Ledesma EJ, Wilson WH, Sawyer RG, Friel CM, Foley EF
Am Surg. 2006 Jan;72(1):89-95.

Multiple studies demonstrate the efficacy of colorectal cancer (CRC) screening in patients over 50 years of age. However, there is a lack of consensus regarding which screening method to use, and compliance has been poor. The objective of this study was to identify the CRC screening practices at two institutions and determine the relationship between screening and pathologic stage for patients presenting with a colorectal neoplasm. This study, conducted at the University of Virginia (UVA) Health System and the Salem Veterans Affairs Medical Center (VAMC) between October 30, 2000, and September 1, 2004, included 198 patients > or = 50 years who presented for resection of a primary colorectal neoplasm. Pathologic stage and prior screening were identified retrospectively through chart review and patient response to an anonymous survey. Prior screening was demonstrated in 71 per cent of patients. Colonoscopy was the most commonly used modality. There was a higher percentage of CRC screening at VAMC compared with UVA (80% vs 62%, P < 0.0008). Patients at UVA were more likely screened with colonoscopy, whereas fecal occult blood testing (FOBT) was most common at VAMC (P < 0.0001). Prior CRC screening and cancer stage were inversely related. Ninety-one per cent of patients with benign polyps had been screened prior to diagnosis, compared with 72 per cent of patients with stage I and II cancer and 54 per cent of patients with stage III and IV cancer (P < 0.05). Of patients presenting for surgery, 71 per cent underwent CRC screening. Variability exists in the methods employed for CRC screening. CRC screening facilitates diagnosis at an early stage.

Nonsurgical treatment of chronic anal fissure: nitroglycerin and dilatation versus nifedipine and botulinum toxin.
Tranqui P, Trottier DC, Victor C, Freeman JB
Can J Surg. 2006 Feb;49(1):41-5.

BACKGROUND: Surgical sphincterotomy for chronic anal fissure can cause fecal incontinence. This has led to the investigation of nonsurgical treatment options that avoid permanent damage to the internal anal sphincter. METHODS: We conducted a retrospective, ongoing chart review with telephone follow-up of 88 patients treated for chronic anal fissure between November 1996 and December 2002. During the first half of the study period, patients were treated with topical nitroglycerin and pneumatic dilatation. With the availability of new therapies in June 1999, subsequent patients received topical nifedipine and botulinum toxin injections (30-100 units). Lateral anal sphincterotomy was reserved for patients who failed medical treatment. RESULTS: In 98% of patients the fissure healed with conservative nonsurgical treatment. The combination of nifedipine and botulinum toxin was superior to nitroglycerin and pneumatic dilatation with respect to both healing (94% v. 71%, p < 0.05) and recurrence rate (2% v. 27%, p < 0.01). There was no statistical difference between the number of dilatations and botulinum toxin injections needed to achieve healing. Three patients who received botulinum toxin reported mild transient flatus incontinence. At an average telephone follow-up of 27 months, 92% of patients reported having no pain or only mild occasional pain with bowel movements. CONCLUSIONS: Chronic anal fissures can be simply and effectively treated medically without the risk of incontinence associated with sphincterotomy. Topical nifedipine and botulinum toxin injections are an excellent combination, associated with a low recurrence rate and minimal side effects.

Long-Term Effect of Preoperative Radiation Therapy on Anorectal Function.
Pollack J, Holm T, Cedermark B, Holmstrom B, Mellgren A
Dis Colon Rectum. 2006 Jan 31;.

PURPOSE: Preoperative radiotherapy improves local control in rectal cancer treatment, but there are few reports on the influence of radiotherapy on anorectal function. The aim of the present study was to assess late effects of short-course, high-dose radiotherapy on anorectal function after low anterior resection for rectal cancer. METHODS: Sixty-four patients, randomized within the Stockholm Radiotherapy Trials and operated on with low anterior resection with or without preoperative radiotherapy (mean, 14 years), previously were followed up with quality-of-life questionnaires, clinical examination, anorectal manometry, and endoanal ultrasound. Twenty-one patients had received preoperative radiotherapy of the rectum and 43 patients had been treated with surgery alone. RESULTS: Impaired anorectal function was common after low anterior resection for rectal cancer and the risk was increased after radiotherapy. Irradiated patients had significantly more symptoms of fecal incontinence (57 vs. 26 percent, P = 0.01), soiling (38 vs. 16 percent, P = 0.04), and significantly more bowel movements per week (20 vs. 10, P = 0.02). At anorectal manometry, irradiated patients had significantly lower resting (35 mmHg vs. 62 mmHg, P < 0,001) and squeeze pressures (104 mmHg vs. 143 mmHg, P = 0.05). At endoanal ultrasound, irradiated patients had significantly more scarring of the anal sphincters (33 vs. 13 percent, P = 0.03). There were no significant differences in quality-of-life scores between irradiated and nonirradiated patients; however, patients with anal incontinence had significantly lower quality-of-life scores compared to continent patients. CONCLUSIONS: Short-course radiotherapy, including the anal sphincters, impairs anorectal function and increases gastrointestinal symptoms permanently when the anal sphincters are irradiated.

Treatment of anastomotic leakage after rectal resection with transrectal vacuum-assisted drainage (VAC) A method for rapid control of pelvic sepsis and healing.
Nagell CF, Holte K
Int J Colorectal Dis. 2006 Jan 31;:1-4.

OBJECTIVE: Anastomotic leakage after rectal resection is associated with high morbidity and mortality. Patients without peritonitis can be treated conservatively by transrectal rinsing and drainage. However, healing is often very slow, and formation of abundant scar tissue resulting in a poor functional result is not uncommon. Vacuum-assisted closure (VAC) has been shown to accelerate wound healing by increasing local blood flow, reducing bacterial load and stimulating growth of granulation tissue. In this paper, we describe VAC as a method for treating anastomotic leakage after rectal resection. METHODS: Four patients with anastomotic leakage after rectal resections were treated with VAC. RESULTS: Healing time for these patients was median 51 days (43-195). The control group consisted of patients treated conservatively in the previous 5-year period. Ten patients were identified with median healing time 336 days (52-1434). CONCLUSION: VAC treatment may possibly shorten healing time of anastomotic leakages after rectal resection. However, the presented results are preliminary, with only few patients included, and obviously, larger, randomized, clinical trials are needed to confirm these results and establish the indication for VAC treatment in clinical practice. We believe VAC therapy is a promising treatment of anastomotic leakage after rectal resection.

Resection and primary anastomosis in acute complicated diverticulitis, a systematic review of the literature.
Abbas S
Int J Colorectal Dis. 2006 Jan 7;:1-7.

OBJECTIVE: To determine the safety and feasibility of primary resection and anastomosis with or without a diverting stoma, as compared to Hartmann's procedure, for patients with acute complicated sigmoid diverticulitis. SEARCH STRATEGY: MEDLINE was searched for studies and trials conducted between 1966 and December 2003. This search revealed trials comparing primary resection and anastomosis to Hartmann's procedure. The term "diverticulitis, colonic" with the sub-heading "surgery" was used and the search was limited to human studies and clinical trials. Additional studies were found using the MeSH terms: "surgical procedures, operative", "surgical anastomosis", and "Hartmann procedure", combined with the term "diverticulitis, colonic". The author also searched EMBASE and the Cochrane database for clinical trials using similar terminology. No language restrictions were applied. RESULTS: Eighteen studies met the inclusion criteria and reported 884 patients with acute complicated diverticulitis. None of these studies were randomised; it is likely that there was a significant degree of selection bias. No significant differences were found between primary resection with anastomosis and Hartmann's procedure with respect to mortality, morbidity, sepsis, wound complications and duration of procedure and anti-biotic treatment. Some studies found that primary anastomosis and a protecting stoma, with or without intra-operative colonic lavage, have more favourable results than Hartmann's procedure. CONCLUSIONS: This review suggests that surgical resection and primary anastomosis in acute diverticulitis with peritonitis compares favourably with Hartmann's procedure in terms of peri-operative complications. The need for revision of Hartmann's procedure could be subsequently avoided. Some articles showed that patients with severe peritonitis, who had a diverting stoma, in the setting of resection and primary anastomosis, had the lowest complication rate. However, the quality of these studies was poor with the presence of selection bias.

Revolution and Evolution: 30 Years of Ileoanal Pouch Surgery.
Bach SP, Mortensen NJ
Inflamm Bowel Dis. 2006 Feb;12(2):131-145.

Specificities of the Fecal Microbiota in Inflammatory Bowel Disease.
Sokol H, Seksik P, Rigottier-Gois L, Lay C, Lepage P, Podglajen I, Marteau P, Dore J
Inflamm Bowel Dis. 2006 Feb;12(2):106-111.

Effect of DSS-induced colitis on visceral sensitivity to colorectal distension in mice.
Larsson MH, Rapp L, Lindstrom E
Neurogastroenterol Motil. 2006 Feb;18(2):144-52.

Crohn Disease: mural attenuation and thickness at contrast-enhanced CT Enterography--correlation with endoscopic and histologic findings of inflammation.
Bodily KD, Fletcher JG, Solem CA, Johnson CD, Fidler JL, Barlow JM, Bruesewitz MR, McCollough CH, Sandborn WJ, Loftus EV Jr, Harmsen WS, Crownhart BS
Radiology. 2006 Feb;238(2):505-16.

Is Rectal Washout Necessary in Anterior Resection for Rectal Cancer? A Prospective Clinical Study.
Terzi C, Unek T, Sagol O, Yilmaz T, Fuzun M, Sokmen S, Ergor G, Kupelioglu A
World J Surg. 2006 Feb;30(2):233-241.

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