Colonic transit before and after resection rectopexy for full-thickness rectal prolapse.

BACKGROUND: The objective of this study was to measure the change in colonic transit time after resection rectopexy for complete rectal prolapse. METHODS: We prospectively carried out isotope colonic transit studies before resection rectopexy in 38 patients with full-thickness complete rectal prolapse and invited them to attend for a postoperative transit study at least 1 year after resection rectopexy. RESULTS: Preoperatively, 27 (70 %) patients had abnormally prolonged colonic transit times, while 11 had normal colonic transit. Twenty-two (61 %) patients agreed to attend for a three-day colonic transit study. Resection rectopexy failed to correct delayed colonic transit in all patients with abnormal preoperative tests, while 4 patients developed new delayed transit and 2 with normal transit were unchanged. CONCLUSIONS: The study suggests that most prolapse patients have a pan-colonic motility disorder that is not corrected by rectopexy and resection of most of the left colon. If resection rectopexy fails to correct abnormal transit, this study questions the rationale for continuing to offer resection and supports less invasive surgical procedures such as ventral rectopexy.

Subspecialist emergency management of diverticulitis is associated with reduced mortality and fewer stomas.

AIM: The aim of the study was to compare outcomes for emergency management of diverticulitis before and after the creation of a regional subspecialist colorectal unit. METHOD: We retrieved data on all emergency admissions for diverticulitis from the regional surgical audit database and compared results before (January 1998 to August 2002) and after (August 2002 to December 2008) establishment of the subspecialist colorectal surgery unit in August 2002. Additional data were retrieved from electronic patient records. The primary outcome measures were mortality and rate of primary anastomosis following resection. RESULTS: There were 879 patients before and 1280 patients after subspecialization. Nonoperative management was undertaken in approximately 80% of cases. Total mortality fell from 3.3 to 1.5% (P = 0.008), attributable to reduced operative mortality (9.6 to 4.2%; P = 0.019). The primary anastomosis rate for all left colon resections increased from 50.3 to 77.9%; P < 0.0001. Stoma formation of any type fell from 46.6 to 27.7%; P < 0001). CONCLUSION: Emergency management of diverticulitis by subspecialist colorectal surgeons is associated with low overall and operative mortality whilst safely achieving high rates of primary anastomosis.

Fecal calprotectin predicts the clinical course of acute severe ulcerative colitis.

OBJECTIVES: Calprotectin is a granulocyte neutrophil-predominant cytosolic protein. Fecal concentrations are elevated in intestinal inflammation and may predict relapse in quiescent inflammatory bowel disease. We aim to investigate fecal calprotectin (FC) as a biomarker in predicting the clinical course of acute severe ulcerative colitis (ASUC). METHODS: In 90 patients with ASUC requiring intensive in-patient medical therapy (January 2005-September 2007), we investigated the discriminant ability of FC to predict colectomy and corticosteroid and infliximab nonresponse. All patients received parenteral corticosteroids as first-line treatment; 21 (23.3%) were also treated with infliximab (5 mg/kg), after failure of corticosteroid therapy. RESULTS: Of 90 patients, 31 (34.4%) required colectomy, including 11 (52.4%) of those treated with infliximab. Overall FC was high (1,020.0 microg/g interquartile range: 601.5-1,617.5). FC was significantly higher in patients requiring colectomy (1,200.0 vs. 887.0; P=0.04), with a trend toward significance when comparing corticosteroid nonresponders and responders (1,100.0 vs. 863.5; P=0.08), as well as between infliximab nonresponders and responders (1,795.0 vs. 920.5; P=0.06). Receiver-operator characteristic curve analysis yielded an area under the curve of 0.65 to predict colectomy (P=0.04), with a maximum likelihood ratio of 9.23, specificity 97.4%, and sensitivity 24.0% at a cutoff point of 1,922.5 microg/g. Kaplan-Meier analyses showed that using 1,922.5 microg/g over a median follow-up of 1.10 years, 87% of patients will need subsequent colectomy. CONCLUSIONS: This is the first data set to demonstrate that FC levels are dramatically elevated in severe UC. These data raise the possibility that this biomarker can predict response to first or second-line medical therapy in this setting.

Preoperative conditioning with oral carbohydrate loading and oral nutritional supplements can be combined with mechanical bowel preparation prior to elective colorectal resection.

OBJECTIVE: Preoperative conditioning with oral fluid and carbohydrate (CHO) loading allows the patient to undergo surgery in the fed state and is associated with reduced postoperative insulin resistance. Further benefit may accrue from oral nutritional supplements (ONS) to counteract the fasting associated with mechanical bowel preparation (MBP). In this study we assess the ability to prescribe, dispense and have patients comply with a protocol combining preoperative ONS and CHO/fluid loading during MBP. METHOD: One hundred and forty-seven patients undergoing elective left colonic or rectal resection were recruited to an Enhanced Recovery after Surgery (ERAS) programme. All patients were prescribed MBP (2 sachets Picolax). On the daytime prior to surgery, eligible patients were prescribed 2 x 200 ml of ONS (Fortijuice, Nutricia) and in the evening 800 ml oral CHO/fluid loading (Preop(R), Nutricia,). Patients were prescribed a further 400 ml of oral/CHO/fluid on the morning of surgery 2 h prior to induction of anaesthesia. Protocol compliance was audited prospectively. RESULTS: One hundred and forty-seven patients received MBP. Twenty-three patients were ineligible for oral CHO/fluid loading [diabetes (n = 22), allergy to lemon flavoured drinks (n = 1)]. Fourteen patients did not receive the preoperative CHO drinks due to failure to prescribe (n = 8) or dispense (n = 6). One hundred and ten patients were dispensed the combined ONS and CHO/fluid loading regimen, compliance rates were 83% with ONS, 80% with CHO/fluid loading and 74% with both. CONCLUSION: Approximately 74% of patients undergoing MBP can comply with preoperative conditioning with ONS and CHO/fluid loading. Prescription and dispensing requires close attention to detail.

Outcomes of the rectal remnant following colectomy for ulcerative colitis.

OBJECTIVE: Controversy surrounds the optimal surgical management of the distal rectal remnant during colectomy for ulcerative colitis (UC) and the potential benefit from the placement of a rectal catheter for remnant drainage. This study reviews the clinical outcomes of patients who have undergone colectomy for UC with intra-peritoneal closure of the rectal remnant. METHOD: Analysis of prospective data lodged on Lothian Surgical Audit databases from patients treated in a tertiary coloproctology unit over 11 years. RESULTS: One hundred and fifty-nine patients were identified, the mean age was 41.9 years, 63% were men. Failure of maximal medical therapy necessitated surgery for 78.1% patients, while 12.6% had acute perforation and 11.9% had toxic megacolon. Complications included five (3.1%) stump dehiscences, eight (5.0%) intra-abdominal/pelvic collections, four (2.5%) significant wound infections, three (1.9%) small bowel obstructions and three (1.9%) deaths. Within the follow-up period, 62.3% patients had an ileo-pouch anal anastomosis (IPAA), 7.5% patients had a completion proctectomy, 10.1% patients within the series had a retained rectal remnant after 1 year follow up, the remaining patients had less than 1 year follow up. CONCLUSION: The intra-peritoneal rectal stump following colectomy for UC is associated with low rates of pelvic sepsis and a high proportion of patients successfully proceeding to IPAA.

A retrospective evaluation of rectal irrigation in the treatment of disorders of faecal continence.

OBJECTIVES: The aim of this study was, firstly, to evaluate the efficacy and acceptability of rectal irrigation in the treatment of patients with disorders of faecal continence that have not responded to other treatment modalities. Secondly, to see if standard anorectal physiology measures can identify patients who might have successful treatment with rectal irrigation. PATIENTS AND METHODS: All patients who had been treated with rectal irrigation, between 1998 and 2000, were sent a postal questionnaire. Patients were asked to quantify their symptoms (before and after rectal irrigation) using a visual analogue scale to determine the efficacy of rectal irrigation. An increase of 10 (10 mm) in this score was regarded as successful treatment and incontinence scores obtained. The acceptability of rectal irrigation was determined using a Quality of Life questionnaire. Data regarding presenting symptoms, previous therapies, pretreatment anorectal physiology measurements were obtained from a retrospective case note and database review. RESULTS: Completed questionnaires were obtained from 48 (52%) of 92 patients, 39 patients had had previous medical and/or surgical treatment before trying rectal irrigation. At the time of the questionnaire 44 of 48 patients were still using rectal irrigation. Using the linear analogue scores 24 of 48 (50%) reported an improvement in their symptoms using rectal irrigation. Most patients found the treatment acceptable. Incontinence scores and anorectal physiology measures did not predict those patients who responded successfully to rectal irrigation. CONCLUSION: Rectal irrigation can offer symptomatic improvement to patients with faecal evacuatory disorders where other therapies have failed. Most patients find the treatment acceptable. Standard anorectal physiology measures and incontinence scores do not predict those patients likely to have successful treatment.

Safety of primary anastomosis in emergency colo-rectal surgery.

BACKGROUND: The surgical management of left-sided large bowel emergency patients remains controversial. There has been an increasing trend towards primary reconstructive surgery. The main dilemma remains appropriate patient selection for primary anastomosis. METHODS: The records of 323 patients who presented as acute emergencies and underwent surgery between January 1990 and December 2000 for left-sided colorectal cancer and diverticular disease were reviewed, to compare the outcome of resection and primary anastomosis with Hartmann's procedure. Patients were stratified into 3 groups according to whether the presentation was with localized or generalized peritonitis, or with obstruction. RESULTS: Resection and anastomosis was carried out in 176 (55.7%) patients with a 30-day mortality of 5.7%. Anastomotic dehiscence occurred in 9 (5.1%) patients, with no difference between the three groups. Wound sepsis occurred in 8 (4.5%) patients, and the median hospital stay was 13 days. Hartmann's resection was associated with a higher incidence of systemic and surgical morbidity (39.5% and 24.3%, respectively). The mortality rates in those selected for primary anastomosis (5.7%) compared favourably with those undergoing Hartmann's resections (20.4%) (P < 0.001). CONCLUSION: Emergency primary anastomosis in left-sided disease can be performed with a low morbidity and mortality in selected patients, even in the presence of a free perforation with diffuse peritonitis. Patients selected for staged resection, were those with major comorbid disease.

Assessment of ileoanal pouch inflammation by interleukin 1beta and interleukin 8 concentrations in the gut lumen.

PURPOSE: The cytokines interleukin 1beta and interleukin 8 have previously been shown to be present in mucosal biopsy specimens from inflamed ileoanal pouches. Our aim was to use the method of whole gut lavage fluid to measure cytokine concentrations and relate these to disease activity. METHODS: Forty-two patients with ulcerative colitis were recruited (23 males). Their ages ranged from 20 to 73 years (median 39). A questionnaire was completed and whole gut lavage, pouchoscopy, and biopsy were performed. RESULTS: Both interleukin 1beta and interleukin 8 were present in the whole gut lavage fluid of ileoanal pouches, with concentrations ranging from 4 to 143 pg/ml (median 6.3 pg/ml) for whole gut lavage fluid interleukin 1beta and from 18 to 1000 pg/ml (median 53.7 pg/ml) for whole gut lavage fluid interleukin 8. Whole gut lavage fluid interleukin 1beta and interleukin 8 were simultaneously detectable in 24 patients. These included the five patients with pouchitis, who had higher levels of interleukin 1beta (75 pg/ml vs. 8 pg/ml, P < 0.005) and interleukin 8 (668 pg/ml vs. 106 pg/ml, P < 0.005) compared with the rest of the patients with detectable cytokines (n = 19). The sensitivity of whole gut lavage fluid interleukin 8 (>200 pg/ml) in the diagnosis of pouchitis was 1, and the specificity was 0.86. There was a significant positive correlation of both whole gut lavage fluid interleukin 1beta and interleukin 8 with all the gut protein loss markers (immunoglobulin G, albumin, alpha1-antitrypsin). CONCLUSION: Cytokine interleukin 1beta and interleukin 8 concentrations, along with other parameters of inflammation, are raised in pouchitis in the whole gut lavage. The results also suggest a spectrum of severity of "pouchitis," with clinical pouchitis fulfilling Moskowitz criteria at the severe end of the spectrum.

Proctalgia fugax.

Proctalgia fugax is a benign, self-limiting pain experienced in the perineum. It is common, but most sufferers do not seek medical advice. The aetiology is unclear, but a variation of irritable bowel syndrome, pelvic floor myalgia, and internal anal sphincter spasm have all been suggested. A careful history can elicit the characteristic history, and simple reassurance is often all that is necessary. For persistent symptoms, therapies that induce internal anal sphincter relaxation are of value.

Hemorrhoids.

Understanding of hemorrhoidal pathology and treatment has come a long way. The theory of a sliding anal canal lining and the knowledge that hemorrhoidal cushions are a normal part of the anal anatomy should encourage symptom control rather than radical removal of tissue. Techniques that fix the cushions back in position can be performed in outpatients with reasonable success rates. When required, surgery should be aimed at symptomatic hemorrhoids. It is hoped that new developments such as circular stapling and better pain management will promote increased day surgery, better pain control, and less time off work for patients.

Pouchitis following restorative proctocolectomy for ulcerative colitis: incidence and therapeutic outcome.

BACKGROUND: Pouchitis is a significant sequel of restorative proctocolectomy. This study was undertaken to document the incidence of pouchitis at the Edinburgh Royal Infirmary and to assess outcome of treatment with metronidazole. METHODS: Patients who developed pouchitis following restorative proctocolectomy for ulcerative colitis form the basis of this study. Pouchitis was suspected if patients developed diarrhoea with or without blood, mucus or pus. Diagnosis was confirmed with pouch endoscopy and biopsy. RESULTS: From 1990 to 1999 (10 years) 139 patients underwent restorative proctocolectomy and ileo-anal pouch anastomosis (135 J pouches and 4 W pouches). Their median age was 35 years (range 13-74). There were 68 females and 71 males. The indication for operation was failed medical treatment in 104 patients and toxic megacolon in 35. Forty-seven patients (34%) developed pouchitis (21 females and 26 males). Symptoms were diarrhoea (35), diarrhoea, mucus and pus (5) and diarrhoea and blood (7). Symptoms of pouchitis started at an average of 33.51 + 29.2 months (range 2-102, median 18). All patients were treated with metronidazole for a minimum of one month. Thirty-six patients (77%) resolved on metronidazole alone. Nine patients (19%) went on to develop chronicity and were managed by long-term metronidazole (and/or ciprofloxacin). A further 2 patients (4%) had treatment resistant pouchitis and required pouch excision. CONCLUSION: Pouchitis is common following restorative proctocolectomy for ulcerative colitis. Treatment with metronidazole is associated with improvement in the majority of cases. In patients with chronic pouchitis maintenance of remission is possible with antibiotics. A high index of suspicion is advocated in patients who develop severe diarrhoea following this procedure.

Comparison of the Moskowitz criteria and the pouchitis disease activity index (PDAI) for diagnosis of ileoanal pouch inflammation.

OBJECTIVE: To prospectively compare two indices for diagnosis of pouchitis: Moskowitz criteria and pouchitis disease activity index (PDAI). PATIENTS AND METHODS: Fifty-six consecutive patients with an ileoanal pouch for ulcerative colitis were recruited. A clinical questionnaire was composed and the Oresland functional score calculated. Pouchoscopy and biopsy were performed after cleansing of the pouch. RESULTS: Seven patients had pouchitis according to both Moskowitz and PDAI ('positive' group). Five patients had PDAI > or = 7, but did not fulfil the Moskowitz criteria ('negative' group). The pouchoscopy and Oresland functional scores were similar between the two groups. The biopsy neutrophilia and ulceration were more prominent in the 'positive' group (chi2=5.18, P < 0.05), whereas urgency (chi2=8.4, P < 0.001), evacuation difficulties (chi2=5.18, P < 0.05) and history of bleeding per pouch (chi2=4.18, P < 0.05) were more pronounced in the 'negative' group. CONCLUSION: Moskowitz criteria may be broadly in agreement with the PDAI; these, however, cannot be regarded as interchangeable.

Luminal neutrophil migration in ileoanal pouches studied by whole gut lavage.

OBJECTIVE: White cell scintigraphy has shown that neutrophils migrate into the gut wall and lumen in ileoanal pouches. We aimed to establish whether whole gut lavage fluid can be used to investigate intestinal neutrophil migration in ileoanal pouches. DESIGN: A prospective single centre study recruiting consecutive patients. METHODS: Whole gut lavage with polyethylene glycol electrolyte solution was performed in 56 (32 men, 24 women) ileoanal pouch patients who had undergone colectomy for ulcerative colitis; the first clear effluent was collected, processed and stored at -70 degrees C. The fluid was assayed for neutrophil granulocyte elastase using a specific colorimetric assay, IgG, albumin, alpha1-antitrypsin, haemoglobin and cytokines IL-1beta and IL-8 using previously described techniques. Patients' disease activity was characterized following pouchoscopy and biopsy. RESULTS: Patients with pouchitis had significantly higher levels of granulocyte elastase in whole gut lavage fluid compared with those without pouchitis. Patients with detectable granulocyte elastase had higher pouchoscopy score, more severe mucosal neutrophil infiltration and protein loss and bleeding. These patients had significantly higher levels of cytokines IL-1beta and IL-8 in the whole gut lavage fluid, compared with patients with undetectable granulocyte elastase. CONCLUSION: Whole gut lavage fluid samples may provide a useful investigative tool to study mucosal inflammation and luminal neutrophil migration in ileoanal pouches.

Immunoglobulin G and albumin levels in whole gut lavage fluid provide an objective measure of pouch ileitis.

BACKGROUND: Gut protein loss is a characteristic of inflammatory bowel disease (IBD), and immunoglobulin (Ig) G, albumin and alpha1-antitrypsin concentrations in whole gut lavage fluid (WGLF) correlate with clinical disease activity. If inflammation in ileoanal pouches is similar to IBD, then measurement of protein-losing enteropathy by analysis of WGLF may provide an objective assessment of disease activity in pouches. METHODS: Forty-two patients who had restorative proctocolectomy for ulcerative colitis underwent whole gut lavage with a polyethylene glycol-electrolyte solution. The first clear effluent was filtered, processed by the addition of protease inhibitors and stored at - 70 degrees C. IgG, albumin and alpha1-antitrypsin were assayed in WGLF. The Pouchitis Disease Activity Index (PDAI) was calculated after pouchoscopy and biopsy; the Moskowitz criteria for pouchitis were also applied. RESULTS: There was a significant correlation of the pouchoscopy score and the PDAI with the concentration of WGLF IgG. All patients with 'pouchitis' according to the Moskowitz criteria had a WGLF IgG concentration greater than 10 microg/ml. The WGLF albumin level also showed a significant correlation with the PDAI, but alpha1-antitrypsin concentration did not. CONCLUSION: Analysis of WGLF for IgG and albumin may be useful in the assessment of disease activity in pouch inflammation.

Open study of low-dose amitriptyline in the treatment of patients with idiopathic fecal incontinence.

INTRODUCTION: Amitriptyline, a tricyclic antidepressant agent with anticholinergic and serotoninergic properties has been used empirically in the treatment of idiopathic fecal incontinence with good results. METHODS: An open study was conducted to test the response to amitriptyline 20 mg daily for four weeks by 18 patients (2 males) of median age 66 years with idiopathic fecal incontinence Incontinence scores, number of bowel movements, computerized ambulatory anorectal pressures, and pudendal nerve terminal motor latencies were evaluated before and after four weeks of therapy. Twenty-four control subjects (10 males) of median age 61 years were also assessed RESULTS: Amitriptyline improved incontinence scores (median pretreatment score = 16 vs. median posttreatment score = 3; P < 0.001) and reduced the number of bowel movements per day (P < 0.001). Amitriptyline also decreased the frequency (median pretreatment frequency = 4.5 per hour vs. median immediate posttreatment frequency = 1.2 per hour (P < 0.05); control median frequency = 0.3 per hour) and the amplitude of rectal motor complexes (median pretreatment rectal pressure = 94 cm H2O vs. median immediate posttreatment rectal pressure = 58 cm H2O (P < 0.05); control median rectal pressure = 36 cm H2O) and improved anal pressures during these events (P < 0.001). CONCLUSIONS: Amitriptyline improved symptoms in 89 percent of patients with fecal incontinence. The data support that the major change with amitriptyline is a decrease in the amplitude and frequency of rectal motor complexes. The second conclusion is that drug increases colonic transit time and leads to the formation of a firmer stool that is passed less frequently. These in combination may be the source of the improvement in continence.

Preliminary results of a multicentre trial of the electrically stimulated gracilis neoanal sphincter.

BACKGROUND: The electrically stimulated gracilis neoanal sphincter was initially developed to treat refractory incontinence. Good early results were reported from the two centres that pioneered the technique. The aim of this study was to assess the operation in a prospective multicentre setting. METHODS: The procedure was performed on 64 patients from seven centres worldwide and was performed in stages. All patients were evaluated clinically and manometrically before and after operation. RESULTS: There was a high incidence of infective and hardware-related complications. At a median of 10 months following closure of the defunctioning stoma 56 per cent had experienced a good functional result. The major functional problems comprised evacuatory difficulties experienced by 25 per cent. CONCLUSION: The technique is effective in treating otherwise refractory incontinence. It is, however, a complex procedure and the morbidity rate may be high, particularly during the learning curve, factors that necessitate careful patient selection. Presented to the Association of Surgeons of Great Britain and Ireland in Bournemouth, UK, April 1997 and the European Council of Coloproctology in Edinburgh, UK, June 1997; and published in abstract form as Br J Surg 1997; 88(Suppl): 39 and Int J Colorectal Dis 1997; 12: 144