Ileal pouch-anal anastomosis for chronic ulcerative colitis and familial polyposis coli complicated by adenocarcinoma

Of 518 patients undergoing the ileal pouch-anal anastomosis (IPAA), 17 (13 with chronic ulcerative colitis [CUC] and four with familial polyposis coli [FPC] ) also had a total of 22 cancers of the colorectum. Tumors were concentrated distally (rectum 6; sigmoid colon 5; proximal colon 11) and were diagnosed preoperatively in eight patients. Histologic grade and stage were as follows: grade I, 36 percent; II, 23 percent; III, 23 percent; IV, 18 percent; stage A, 5 percent; B1, 32 percent; B2, 18 percent; C1 and C2, 45 percent. Median hospital stay was 17 days with no operative mortality. Relaparotomy was required in 35 percent (sepsis in four patients; obstruction in two) and minor procedures were done in 12 percent (anastomotic dilatation in one; rectovaginal fistula in one). Mean frequency of defecation was 6.4/day, 1.0/night; incidence of minor seepage, 17 percent (day), 50 percent night); incidence of pouchitis, 8 percent; intermittent dyspareunia, 17 percent of six women. One patient died from hepatic metastases nine months after operation. IPAA should be considered in favorable cancers complicating CUC or FPC, although it may be contraindicated in advanced rectal cancer, and may be unsuitable in advanced proximal cancer.

Roux-Y stasis syndrome after gastrectomy

The aim of the present study was to determine which factors lead to upper gastrointestinal stasis after Roux-Y reconstruction. Among the 214 patients with Roux-Y reconstructions performed between 1961 and 1983, follow-up data were obtained for 187 (87 percent) after a mean of 6.2 years. Patients with vomiting of food but not bile, postprandial pain, and nausea were considered to have the Roux-Y stasis syndrome. The syndrome was found in 49 patients with gastrojejunostomy (30 percent of those at risk) but in only 2 patients with esophagojejunostomy (8 percent, p less than 0.05). The condition was more common in women than men (p less than 0.05), but it was equally common in patients with and without vagotomy. The mean length of the Roux-Y limb in patients with stasis was 41 cm, which was longer than the 36 cm in patients without stasis (p less than 0.001). When multiple logistic regression was used, the length of the Roux-Y limb emerged as the major risk factor (p less than 0.01). In conclusion, construction of Roux-Y limbs greater than about 40 cm in length may increase the incidence of the Roux-Y stasis syndrome.

Trends in peptic ulcer surgery. A population-based study in Rochester, Minnesota, 1956-1985

We evaluated trends in peptic ulcer surgery among residents of Rochester, Minnesota, where medical care delivered to the population by all providers is well documented. The incidence of elective operations on previously unoperated patients declined dramatically during the 30-yr study period, from 49/100,000 population per year in 1956-1960 to 6/100,000 per year in 1981-1985. The decline was greatest for men with duodenal ulcer, less for men and women with gastric ulcer, and least for women with duodenal ulcer. These trends were established long before the introduction of H2-receptor drug therapy in 1977. In contrast to elective operations, the incidence of emergent operations remained at about 10/100,000 population per year. Perhaps because of an increasing proportion of emergency operations, overall survival appeared to worsen from the first decade of study to the last; but, after adjustment for age at operation and sex, no difference in survival over time was detected.

Young age as a prognostic factor in cervical cancer: analysis of population based data from 10,022 cases

The effect of young age on survival in cervical cancer is not fully known, although evidence has suggested that it is a poor prognostic factor and that young patients should therefore be treated differently from older patients. All 10,022 cases of invasive cervical cancer in the west Midlands during 1957-81, which comprised 10% of the cases in England and Wales, were analysed to determine the prognostic effect of age. Univariate analysis showed a median survival time of 54 months for all cases, with survival rates at five years of 69% for patients aged under 40 and 45% for those aged 40 or older (chi 1(2) (log rank) = 331.4; p less than 0.0001). This difference remained significant after stratification for stage (chi 1(2) (log rank) = 7.1; p = 0.008). Cox regression analysis with nine covariables, including age and year of registration, reaffirmed the importance of conventional prognostic factors such as stage of disease, size of tumour, state of lymph nodes, and differentiation of the tumour. After allowance was made for the effects of other prognostic factors young age was found to be a small but significant favourable factor that did not change during the period of the study. Estimated survival distributions obtained from the Cox model showed that for women presenting with the common characteristics associated with stage Ib disease who were treated with radical radiotherapy the survival rate at five years fell non-linearly from 71% in the group aged 25-29 to 65% in the group aged 65-69. Young age alone is not a reason to alter existing policies for treatment for patients with invasive cervical cancer.

Anal canal pressure and motility after ileoanal anastomosis

This study was done to determine the effect of mucosal rectectomy and ileal pouch to anal anastomosis (IAA) on pressure and motility of the anal canal. Fifty patients, 22 +/- 2 months after operation (mean plus or minus standard error of the mean), and 30 healthy control volunteers were studied. Twenty-eight patients had excellent continence, while 22 had episodic minor incontinence. The maximum resting pressure in the anal canal was reduced in patients with episodic incontinence compared with continent patients and control volunteers. The increase in pressure with squeeze was slightly greater in continent than in incontinent patients. The frequency of the anal slow waves was less after IAA than in control volunteers and the amplitude of the waves was greater. The frequency and amplitude, however, were not related to continence or resting pressure. In conclusion, decreased anal canal resting and squeeze pressures after ileal pouch to anal anastomosis are associated with episodic minor incontinence, while altered motility patterns in the anal canal are not.

Ileal pouch-anal anastomosis for chronic ulcerative colitis. Long-term results

The aim of this study was to determine the long-term outcome among 390 patients with ulcerative colitis who underwent ileal J pouch-anal anastomosis and whether patient or operative factors influenced results. The combined operative morbidity rate for the pouch-anal anastomosis and the subsequent closure of the temporary ileostomy was 29% (bowel obstruction, 22%; pelvic sepsis, 5%), with one death due to pulmonary embolus. The probability of a successful outcome at 5 years was 94%. Of the 24 patients who failed (6% of total), 18 did so within 1 year (4%), three during year 2 (1%), three during year 3 (1%), and none thereafter. Stool frequency (7 stools/24 h), the occurrence of pouchitis (14%), and satisfactory daytime continence (94% of patients) remained stable over 4 years after operation, whereas nocturnal fecal spotting decreased (51% of patients to 20%). Women had more spotting than men, whereas patients over 50 years old had more stools per day than those 50 years or younger. In conclusion, ileal pouch-anal anastomosis achieved a reasonable stool frequency and satisfactory continence in patients with ulcerative colitis over the long-term. These results support the ileal pouch-anal anastomosis as a safe, satisfactory alternative to permanent ileostomy.

Enteric transit and absorption after canine ileostomy. Effect of pacing

The aim was to determine whether retrograde jejunal pacing would slow gastroenteric transit and reduce stomal output of water and electrolytes in dogs with ileostomy. In five alert animals with an end ileostomy, and jejunal pacing and recording electrodes, 200 g of liver labeled with technetium Tc 99m and 50 mL of polyethylene glycol-labeled water were fed to each animal on eight occasions. In one half of the experiments, the jejunum was paced backward for the first three hours after the meal, while in the other half pacing was not done. Stomal output was collected for nine hours. In four other experiments per dog, gastric emptying of the meal was measured by scintigraphy and aspiration after three hours of pacing or control. Jejunal pacing delayed gastrointestinal transit of both liquids and solids, reduced stomal output, and increased fecal sodium concentration during the pacing period. Net postcibal absorption of water and electrolytes over nine hours, however, was not increased by pacing.

Speed of response to platinum-based chemotherapy: implications for the management of epithelial ovarian cancer

Seventy-nine patients with evaluable epithelial ovarian cancer following primary laparotomy and treated with one of three primary cis-platinum-containing regimens were studied to determine the rate at which clinical cytoreduction occurred and whether a rapid response to treatment was of prognostic significance by improving progression free interval (PFI) or survival. A rapid response to treatment improved PFI in patients treated with single agent cis-platinum (P = 0.04) and increased survival in patients treated with a sequential cis-platinum based combination regimen (P = 0.03). The rate of cytoreduction was not a significant variable, however, in a multiple regression analysis of prognostic factors. Over 75% of all clinical responses, regardless of the regimen, had begun by the completion of the third course of chemotherapy. We conclude that response to active chemotherapy is a rapid phenomenon in ovarian cancer and this has important implications in both the decision to change drug therapy and the timing of further surgical effort.

Total gastrectomy for benign disease

Among 37 patients who underwent total gastrectomy for nonmalignant disease, operative mortality was 4 per cent after 27 elective operations and 10 per cent after 10 emergency operations. Three other patients died 1 to 6 months after operation. Major postoperative complications occurred in 24 per cent. Long-term follow-up of 26 patients (81 per cent of survivors) after a mean +/- SEM of 8.4 +/- 1.1 years showed that 73 per cent of patients had no or only occasional, easily controlled, mild abdominal symptoms and good enough health to enable them to work or carry out normal activities for their age. The patients lost a mean of 15 per cent of their body weight, however, and about one third of them had weakness and diarrhea. A quarter of them had anemia despite iron and vitamin B12 therapy. Our conclusion was that total gastrectomy is a reasonable operation for benign diseases. Nonetheless, in view of the substantial postoperative mortality and morbidity, the operation should be used only when less extensive operations will not suffice.

Proximal gastric vagotomy and mucosal antrectomy: effect on gastric acid secretion, plasma gastrin, and experimental ulcerogenesis in the dog

The aim of this study was to determine whether mucosal antrectomy, which preserves antropyloric motility, would enhance the antiulcer properties of proximal gastric vagotomy (PGV). Hydrochloric acid and gastrin secretion were studied in five dogs before and after PGV and mucosal antrectomy, while the response to the Mann-Williamson operation (an ulcer-producing operation) was evaluated in four control dogs with intact stomachs, five dogs with PGV alone, and six dogs with PGV plus mucosal antrectomy. Proximal gastric vagotomy and mucosal antrectomy decreased mean +/- SEM basal and pentagastrin-stimulated acid secretion from 4.3 +/- 1.3 to 0.4 +/- 0.3 mEq/hr and from 21 +/- 0.7 to 7.4 +/- 1.8 mEq/hr, respectively (p less than 0.05). Basal plasma gastrin was altered little by the operation (68 +/- 9.7 pg/ml before, 58 +/- 11 pg/ml after; p greater than 0.05) but the 4-hour integrated plasma gastrin response to a 200 gm meat meal decreased from 13 +/- 1.8 to 3.3 +/- 0.7 ng X min/ml (p less than 0.05). Only one of six dogs with mucosal antrectomy and PGV developed peptic ulcer after the Mann-Williamson operation, whereas four of five with PGV alone and three of four controls developed ulcers (p less than 0.05, PGV alone versus PGV and mucosal antrectomy). In conclusion, PGV and mucosal antrectomy decreased acid secretion and postcibal gastrin response and provided greater protection against peptic ulcer than PGV alone.

Mechanisms of enhanced canine enteric absorption with intestinal pacing

Electrical pacing enhances absorption from the canine small bowel, but the mechanism of this effect is unknown. To explore the mechanism, conscious dogs with two Vella loops, a proximal jejunal and a distal ileal, each 50 cm long, were studied. Pacing the jejunal loop with 15-18 pulses/min entrained the pacesetter potentials of the jejunal loop and increased water, sodium, and glucose absorption from the jejunal loop. Jejunal pacing also increased water absorption from the unpaced, ileal loop. Conversely, ileal pacing did not entrain the ileal loop or enhance absorption from the ileal loop. However, it did enhance water absorption in the unpaced jejunal loop. After alpha-blockade with phentolamine or celiac and superior mesenteric ganglionectomy, jejunal pacing did not increase jejunal or ileal absorption. In contrast, after beta-blockade with propranolol, pacing still enhanced jejunal absorption in three out of four dogs. Vagotomy alone enhanced jejunal but not ileal absorption, but the enhancement was not further increased by pacing. In conclusion, electrical pacing of the small bowel elicited a local and distant increase in net water absorption; the effect was mediated in part by an alpha-adrenergic mechanism.

Determinants of stool frequency after ileal pouch-anal anastomosis

The aim of our study was to determine whether ileal pouch motility and evacuability and the 24 hour fecal output influence stool frequency after ileal pouch-anal anastomosis. In 23 patients, at a mean of 24 months postoperatively (range 22 to 26 months), ileal pouch motility was measured using an intraluminal bag and pressure-sensitive catheters. The pattern and efficiency of ileal pouch emptying was determined scintigraphically. A 24 hour stool collection was made and the stool output and stool frequency recorded. The volume of ileal pouch distention at which large amplitude propulsive waves appeared (the threshold volume) correlated closely with stool frequency. The larger the threshold volume, the fewer the stools per 24 hours (correlation coefficient -0.70; p less than 0.01). Also, the greater the 24 hour stool output, the greater the stool frequency (correlation coefficient 0.79, p less than 0.001). In contrast, the efficiency of ileal pouch evacuation was less strongly related to stool frequency (correlation coefficient -0.41, p = 0.05). We conclude that ileal pouch motility and stool output are major determinants of stool frequency after ileal pouch-anal anastomosis. Inefficient pouch emptying is less commonly associated with frequent bowel movements.

Influence of a jejunal fistula on gastric emptying

The aim was to determine whether a proximal jejunal fistula would speed gastric emptying after truncal vagotomy and Roux distal gastrectomy. Eight vagotomy-gastrectomy dogs were studied; 4 had a jejunal fistula, and 4 other dogs without a fistula served as controls. The rate of gastric emptying of 100 ml 25% dextrose in the fistula dogs with the fistula open (95 +/- 3 ml/20 min) was faster than in the same dogs with the fistula closed (62 +/- 10 ml/20 min; p less than 0.05) and faster than in dogs without a fistula (77 +/- 5 ml/20 min; p less than 0.05). The rate of emptying in dogs with the fistula closed, however, was similar to the rate in dogs without a fistula (p greater than 0.05). We concluded that diversion of the enteric content to the exterior through a proximal jejunal fistula increases the rate of gastric emptying of 25% dextrose solutions in dogs with truncal vagotomy and Roux gastrectomy.

Relationship of backwash ileitis to ileal pouchitis after ileal pouch-anal anastomosis

To assess whether the presence of backwash ileitis predisposed to the subsequent development of ileal pouchitis after ileal pouch-anal anastomosis, 131 patients who had the operation were studied. Fifteen patients had nonspecific inflammation in the terminal ileum noted at the time of the operation, while 20 patients subsequently developed pouchitis. No correlation between the two conditions was found. Pouchitis developed in two of 15 patients (13 percent) with backwash ileitis and in 18 of 116 patients (16 percent) without the ileitis (P greater than 0.05). Among the 20 patients with pouchitis only two (10 percent) had had previous backwash ileitis. It is concluded that the presence of backwash ileitis does not predispose to later development of pouchitis, and so does not contraindicate use of the inflamed terminal ileum for construction of the ileal pouch and anastomosis.

Effect of transection and pacing on human jejunal pacesetter potentials

The aim of this study was to determine whether transection and pacing alter the frequency of the human jejunal pacesetter potentials (PPs). In 8 patients undergoing Roux gastrectomy, three temporary bipolar electrodes were implanted on the jejunal seromuscularis at sites 5 cm proximal to and 10 and 20 cm distal to the jejunal transection. Three other patients not undergoing Roux transection (controls) had electrodes applied at similar sites. After recovery, the mean +/- SEM frequency of the jejunal PPs in Roux patients was slightly slower distal to the jejunal transection (11.0 +/- 0.2 cpm) than proximal to the transection (11.3 +/- 0.2 cpm, p less than 0.05), whereas the PP frequency in the two areas in control nontransected patients was identical (proximal, 12.0 +/- 0.3 cpm; distal, 12.0 +/- 0.3 cpm). In contrast to the change in frequency with transection, pacing with electric pulses (strength, 15 mA; duration, 50 ms; frequency, 0.2-1.0 cpm faster than native PP frequency) speeded the jejunal PP frequency in only 1 of 9 patients tested. We conclude that transection decreased the frequency of the human jejunal PPs, but only slightly. Pacing did not readily entrain the PPs in either intact or transected jejunum.

Sexual function in women after proctocolectomy

One hundred women who had undergone proctocolectomy with a continence-preserving procedure (50 Kock pouches, 50 ileoanal anastomoses) for ulcerative colitis or polyposis coli were interviewed regarding their preoperative and postoperative sexual function. Frequency of intercourse increased and the incidence of dyspareunia decreased after operation in both groups. Patients who had a Kock pouch had a greater incidence of persistent postoperative dyspareunia than patients who underwent an ileoanal procedure (38% vs. 18%, p less than 0.02). Only one patient in each group reported a postoperative disturbance in ability to achieve orgasm. Most women reported no change in their menstrual cycle, but patients with a Kock pouch had more episodic vaginal discharge than patients with an ileoanal anastomosis (18% vs. 0%, p less than 0.001). Postoperative fertility was minimally impaired. Overall, the majority of women in this study who underwent proctocolectomy for benign diseases experienced enhanced sexual function after operation, which they attributed mainly to improved health.

Enteric bacteriology, absorption, morphology and emptying after ileal pouch-anal anastomosis

The aim was to determine whether changes in enteric bacteriology, absorption, morphology, and emptying occur after ileal pouch-anal anastomosis for ulcerative colitis, and to relate any changes to the clinical result. Twenty patients were studied 26 +/- 2 months (mean +/- s.e.m.) after operation. Eight patients had a good result, six a poor result, and six a history of recurrent pouch ileitis. Anaerobic and aerobic overgrowth occurred in the jejunum of patients with a poor result, but not in those with a good result or with pouch ileitis. In contrast, ileal pouch bacterial overgrowth occurred in all patients regardless of the clinical result. Patients with jejunal overgrowth had increased 24 h stool volume and stool nitrogen, but other patients did not. The larger the stool volume, the greater the anaerobic overgrowth. Pouch biopsies showed chronic inflammation in all patients, while 45 per cent had colonic metaplasia. Neither the inflammation nor the metaplasia correlated with the clinical result, nor did the clinical result correlate with the efficiency of pouch emptying. In conclusion, jejunal bacterial overgrowth after ileal pouch-anal anastomosis was associated with an increased stool output, azotorrhoea, and a poor clinical result. A distinguishing bacterial, absorptive, morphological, or emptying abnormality was not found in patients with a history of recurrent pouch ileitis.

Prediction of ifosfamide/mesna associated encephalopathy

Ifosfamide and mesna were administered to 77 patients with advanced malignancies. Seven (9%) experienced a severe but reversible encephalopathy. In 56% of patients in whom EEG data was available, characteristic changes were seen with or without mild clinical toxicity. Discriminant analysis identified low serum albumin concentration, high serum creatinine concentration and the presence of pelvic disease as variables which predispose patients to the development of severe encephalopathy. A nomogram has been constructed which can be used to determine the probability that an individual patient may be given ifosfamide and mesna safely. This has important implications for the clinical use of a highly active chemotherapy regimen.

Achieving enteric continence: principles and applications

Continence may be defined broadly as the ability to defer the passage of enteric content voluntarily to a socially acceptable time and place. In health, continence is provided by the anorectum; several factors interplay to achieve control. When the colon and rectum are removed because of intractable inflammatory bowel disease, a Brooke ileostomy that is incontinent of stool and gas is traditionally constructed, and control of the stoma is provided by an external appliance. Although the functional results after a Brooke ileostomy are good, we believe that restoration of continence would enhance the quality of life. The methods by which continence is restored surgically have undergone evolutionary changes based on an expanding knowledge of the principles of continence gained in the laboratory. In this report, we detail the current status of our understanding of anorectal continence mechanisms and of the principles of ileal continence, in order to examine how "ileo-anal" continence has been achieved in patients who require proctocolectomy.

Canine mucosal antrectomy

Our primary aim was to determine whether mucosal antrectomy decreases postcibal serum gastrin and gastric acid secretion. In four dogs with proximal gastric vagotomy and a Heidenhain pouch, mucosal antrectomy decreased the integrated postcibal serum gastrin response from a mean +/- SEM of 2.0 +/- 0.2 ng X h/mL before antrectomy to 0.8 +/- 0.1 ng X h/mL after antrectomy, while it decreased postcibal output of hydrochloric acid from the pouch from 9.5 +/- 3.3 mEq/7 h (9.5 +/- 3.3 mmol/7 h) to 4.3 +/- 2.2 mEq/7 h (4.3 +/- 2.2 mmol/7 h). However, these decreases were temporary in two of the four dogs. In five additional dogs without vagotomy, the distal, antral, mucosal gastrin level increased from 1 +/- 1 micrograms/g of tissue before mucosal antrectomy to 5 +/- 1 micrograms/g of tissue after the antrectomy. Moreover, gastrin and G cells were present in corporal mucosa transferred to the antrum in three of five dogs after the antrectomy, where none had been present in the corporal mucosa before the antrectomy. The conclusion was that mucosal antrectomy decreased serum gastrin and hydrochloric acid output from the stomach, but that these changes were counteracted in part by hyperplasia of residual G cells and G-cell neogenesis after the operation.

Temporary ileostomy for ileal pouch-anal anastomosis. Function and complications

The function and complications associated with temporary ileostomies were reviewed in patients undergoing ileal pouch-anal anastomosis. A series of 180 patients had temporary ileostomies established (157 loop, 23 Brooke). Patients with incomplete fecal diversion had a significantly higher incidence of pouch-anal anastomotic complications (44 percent) than did those with complete diversion (14 percent). Patients with loop ileostomies were more likely than patients with Brooke ileostomies to develop technique-related complications (18 percent vs. 13 percent) and peristomal irritation (54 percent vs. 26 percent). The most frequent complications after take-down of the ileostomy were transient bowel obstruction (13 percent) and peritonitis (7 percent). These complications could not be related to the type of stoma used or the interval to closure. Temporary diversion of a pouch-anal anastomosis decreased the incidence of anastomotic complications. These ileostomies, however, are associated with a significant risk of complications, which can be minimized by meticulous surgical technique.

Increasing antidumping effect of intestinal pacing with motor-active agents

The aim was to determine whether cholecystokinin-octapeptide (CCK-OP), bethanechol Cl, or metoclopramide HCl would increase the antidumping effect of intestinal pacing in five dogs with truncal vagotomy and Roux gastrectomy. While recording electrical activity from the conscious animals, the amount of a 100-ml, 25% dextrose gastric instillate emptied in 20 min was determined during control tests, during tests with CCK-OP (500 ng/kg/hr), bethanechol (80 micrograms/kg/hr), or metoclopramide alone (600 micrograms/kg/hr) given intravenously or during tests using combinations of pacing and drugs. In other tests, intraluminal gastrointestinal pressure was measured during control and drug infusions. CCK-OP, which relaxed the proximal stomach, slowed emptying of the dextrose instillates (mean +/- SEM emptied, no pacing, no drug = 74 +/- 5 ml; CCK-OP alone = 34 +/- 5 ml; P less than 0.05). CCK-OP also enhanced the slowing effect produced by pacing (pacing alone = 41 +/- 7 ml; pacing plus CCK-OP = 19 +/- 8 ml; P less than 0.05). In contrast, bethanechol and metoclopramide, which did not alter proximal gastric motility, did not alter emptying or augment or diminish the effect of pacing. The conclusion was that the combination of pacing and CCK-OP slowed gastric emptying of the dextrose more than pacing alone and thus had a greater antidumping effect. In contrast, neither bethanechol nor metoclopramide enhanced the pacing effect.

Vertical gastroplasty for morbid obesity: clinical experience

Our objective was to develop an operation for morbid obesity that would be simple, safe, and effective and yet have few long-term adverse physiologic effects. Vertical gastroplasty was chosen. A small proximal gastric pouch was fashioned by stapling vertically beginning 5 cm distal to the cardia along the lesser curvature of the stomach and ending just lateral to the esophagogastric junction along the greater curvature. A 1.1-cm channel through the staple line was left near the lesser curvature of the stomach. No gastric incisions, enterostomies, or anastomoses were necessary. Among 57 patients (with a mean +/- SEM preoperative weight of 136 +/- 4.5 kg) operated on since January 1981, no deaths occurred and no gastric reoperations were done. The hospital stay was short (mean, 9 days). In 32 patients who were followed up for 1 year or longer, the mean percentage of excess weight lost was 39% at 6 months, 43% at 12 months, and 34% at 24 months. Two patients had disruption of the staple line and regained weight by 24 months postoperatively. Channel stenosis occurred within 6 months after operation in seven patients, all of whom were managed successfully with endoscopic dilation. We conclude that vertical gastroplasty is a simple, safe operation for morbid obesity with few adverse sequelae, but the percentage of excess weight lost during a 1- to 4-year follow-up exceeded 50% in only 31% of our patients.

Familial and individual influences on blood pressure

Although familial aggregation of blood pressure is well documented, few studies have considered the changing contribution of genetic and environmental influences during adulthood. Applying maximum likelihood model fitting to blood pressure covariation in balanced pedigrees including both parents and their young adult twin offsprings (25 MZ, 32 DZ, aged between 16 and 24 years), it is shown that the increased variation in parents is explained by such developmental changes. For DBP, an apparent reduction in heritability from 68% to 38% from young adulthood to middle age results from the increasing impact of individual environmental experience (E1), with little or no influence from shared family environmental (E2). For SBP, shared environmental effects may play a part. Given the relatively small size of the present sample, the conclusions are to be seen as tentative. An augmented family study, incorporating middle aged twins and their young adult offspring, will clarify the causation of these developmental changes.

Scintigraphic assessment of neorectal motor function

Colectomy, mucosal rectectomy, and ileal pouch-anal anastomosis have become alternatives to proctocolectomy and ileostomy for patients with ulcerative colitis or polyposis coli. The aim of this study was to develop a scintigraphic technique for assessment of the "neorectal" motor function of such patients. An artificial stool, consisting of a 7.5% dispersion of aluminum magnesium silicate in water, was labeled with 1 mCi [99mTc]sulfur colloid and instilled into the neorectum. Static pre- and postevacuation scans and dynamic acquisition scans during evacuation were taken with the patient seated on a commode. The imaging provided good anatomic definition of the pouch and quantitated the usual rate and percentage of neorectal evacuation at about 10 ml stool/sec and 60% of instilled stool, respectively. This technique appeared to be a safe, simple, useful tool for assessing the neorectal motor function of patients with ileal pouch-anal anastomosis.

Graded mental arithmetic as an active psychological challenge

A computer-operated mental arithmetic task is outlined which presents questions at a level of difficulty continuously determined by subjects' accuracy of response on the previous question. The programme incorporates 5 levels of difficulty, and all questions concern the addition or subtraction of two numbers which vary in digit-span according to the current level of difficulty. Response requirements are manual rather than verbal so that, in addition to monitoring heart rate, subjects' exhaled air may be collected throughout the task in order to determine oxygen consumption.

Anal and neorectal function after ileal pouch-anal anastomosis

Bowel function varies markedly among patients with colectomy and ileal pouch-anal anastomosis. Little is known of the mechanisms controlling fecal continence and frequency of defecation after operation. The aim of this study was to determine which features of the anal sphincter and neorectum accounted for the variation in clinical outcome. Twenty patients were studied 4 to 35 months after operation and compared to 12 healthy volunteers. Despite several patients exhibiting impaired fecal continence, anal sphincteric length and pressures and ileal pouch capacity and distensibility were similar in patients and controls. Patients with poor results, however, had rapid filling of their ileal pouch, which resulted in early onset of high amplitude propulsive pressure waves in the pouch. As these waves became more frequent, defecation resulted. Patients with poor results also were not able to empty adequately their pouch. The poorer the completeness of evacuation, the more frequent the defecation (r = 0.62, p less than 0.01). The authors conclude that rapid pouch filling and impaired pouch evacuation can lead to increased stool frequency in patients after ileal pouch-anal anastomosis.

Ileal pouch-anal anastomosis without temporary, diverting ileostomy

Of two hundred patients undergoing proctocolectomy with ileal pouch-anal anastomosis, all but nine have had temporary diverting ileostomies. Of these nine patients, eight had successful results. One patient developed abdominal sepsis due to jejunal volvulus and perforation after she had returned home, and at surgery the pouch was excised. Ileal pouch-anal anastomosis without a temporary diverting ileostomy can be performed safely by surgeons experienced with this procedure in carefully selected patients.

Temporal and inter-task consistency of heart rate reactivity during active psychological challenge: a twin study

Heart rate was monitored while 22 pairs of young male monozygotic and 29 pairs of young male dizygotic twins were exposed to a video game and a mental arithmetic task. The heart rate reactions of the monozygotic twins showed much greater concordance than those of the dizygotic twins. Analysis of the data for the 102 individuals demonstrated reliable inter-task consistency of heart rate reaction. In addition, comparison of the heart rate reactions of ten pairs of monozygotic and ten pairs of dizygotic twins who had been tested more than a year earlier and their present reactivities revealed impressive temporal consistency.

Urinary pseudouridine excretion in myelomatosis

Urinary psi excretion is independent of the main indices of tumour activity in myelomatosis (serum paraprotein, serum beta 2-microglobulin, serum creatinine and urinary light chain production). The mean (+/- s.d.) psi at presentation was 40.7 +/- 22.6 nmol. mumol ucr-1, compared to 25.4 +/- 4.8 nmol. mumol ucr-1 in controls. Urinary psi levels at presentation are significantly related to prognosis, the higher the level the poorer the prognosis. However, when these levels have been stratified according to the corresponding level of serum beta 2m, the level adds little as a prognostic factor.

Ileal "J" pouch-anal anastomosis. Clinical outcome

One hundred eighty-eight patients undergoing abdominal colectomy with distal mucosal proctectomy and endorectal ileal pouch-anal anastomosis were reviewed to assess long-term functional results and to identify factors that might influence them. There was no postoperative mortality, but 10 patients (5.3%) required permanent ileostomy because of postoperative complications or the development of unsuspected Crohn's disease. Immediate postoperative complications, including pelvic sepsis, small bowel obstruction requiring surgery, anastomotic stricture, and ileostomy dysfunction, were observed in 11%, 9%, 14% and 9% of patients, respectively. No males were impotent but nine (9%) developed retrograde ejaculation. Pouchitis occurred in 8% of patients. Among 157 patients assessed at least 60 days after ileostomy closure (mean +/- SD, 375 +/- 216 days), all evacuated their neorectum spontaneously, and stool frequency was 6.0 +/- 2.6 daily and 1.2 +/- 1.3 nightly. While continence was generally good, 2.5% of patients during waking hours and 4.5% during sleep had occasional frank soilage. Moreover, seepage was noted in 25 and 47% of patients during daytime and nighttime, respectively. Both stool frequency and degree of continence improved with time. Patients less than 50 years of age and those with polyposis coli had fewer stools and better continence than those older than 50 or those with ulcerative colitis. It is concluded that ileal "J" pouch-anal anastomosis can be performed safely and will provide acceptable anorectal function without late deterioration.

Anal sphincter electromyography after colectomy, mucosal rectectomy, and ileoanal anastomosis

Electromyography (EMG) was used to evaluate the external anal sphincter in 27 patients following colectomy, distal mucosal rectectomy, and ileoanal anastomosis. The studies were conducted four months to 58 months (mean, 20 months) following the restoration of intestinal continuity. Nine patients underwent endoanal rectal mucosal stripping, while in 18 patients the rectum was everted to facilitate the stripping. Postoperative continence varied widely, from perfect to frequent and severe mucous of fecal leak. Abnormal motor-unit potentials were identified by EMG in nine patients and this finding was usually associated with poor continence. The sex of the patient, technique of mucosal stripping, and type of anastomosis did not influence the EMG result, but patients at least 40 years old all had abnormal EMGs. We conclude that poor continence after ileoanal anastomosis correlates with an abnormal EMG of the external anal sphincter. The cause of the EMG abnormality is unclear.

Motility of the small intestine after proctocolectomy and ileal pouch-anal anastomosis

Though the mechanisms of continence after proctocolectomy and ileal pouch-anal anastomosis have been studied, functions of the small intestine have received little attention. However, frequent stools and urgency plague some patients who are otherwise quite continent. Motility of the jejunum and ileum was assessed in eight patients with ulcerative colitis who were studied 4 to 24 months after proctocolectomy and ileal pouch-anal anastomosis; these findings were compared to those in six healthy volunteers. Continuous manometric recordings from the small bowel were obtained in both groups for 16 to 23 hours of fasting; postprandial recordings were made for 6 hours following a mixed meal (800 kcal, 20% protein, 40% fat, 40% carbohydrate) in the ileoanal patients. The duration, velocity of propagation, and periodicity of the migrating motor complex did not differ between the groups (P greater than 0.05). Discrete bursts of clustered contractions were recorded from all of the controls and in five of eight patients. Likewise, we recorded from all controls and five of eight patients large amplitude, prolonged waves of pressure which propagated distally. However, in controls these large amplitude waves were confined to the terminal ileum, but in patients these were detected in the jejunoileum, up to 125 cm proximal to the ileal pouch. We conclude that jejunoileal motility is not greatly altered by proctocolectomy with ileal pouch-anal anastomosis. However, the appearance of the large amplitude, rapidly propagating waves in the proximal jejunoileum after operation may be a response to increased storage within and distention of the distal bowel.

Serological differences in Legionella pneumophila infections

Guinea pigs were infected with two subtypes of Legionella pneumophila serogroup 1 (UH1 and RH1). Seroconversion by indirect fluorescent-antibody assay was demonstrated in 94 to 97% of guinea pigs when the challenge strain was used as the antigen. The standard Philadelphia 1 antigen demonstrated seroconversion in 94% UH1-challenged animals, but in only 66% of RH1-challenged animals.

Immunochemical properties of some monoclonal IgE antibodies to 4-hydroxy-3-nitrophenylacetyl (NP)

Several hybridoma cell lines secreting NP-specific, murine IgE antibodies were generated by fusion of P3-X20 (gamma, kappa) tumour cells with spleen cells from (BALB/c X C57B1/6)F1 (CB6F1) mice previously immunized with NP-ovalbumin. Four subclones (designated NP-epsilon-3.57, NP-epsilon-15.88, NP-epsilon-91.58 and NP-epsilon-95.31) were propagated in vivo and milligram quantities of the corresponding IgE antibodies were purified from ascitic fluid by gel filtration, ion exchange chromatography and affinity chromatography. Immunological analyses and sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE) indicated that NP-epsilon-15.88, NP-epsilon-91.58 and NP-epsilon-95.31 all possessed lambda 1 (or possibly lambda 3) light chains; and that NP-epsilon-3.57 possessed lambda 2 light chains; NP-epsilon-95.31 also expressed the P3-X20 derived, MOPC-21 kappa light chain. Radioallergosorbent test (RAST) titration curves, generated from the interaction of the four monoclonal IgE antibodies with NP-BSA attached to paper discs (NP-BSA-P) were found to be non-overlapping. Measurements of the relative amounts of NP-epsilon-aminocaproic acid (NP-CAP) and 4-hydro-3-iodo-5-nitrophenylacetyl-epsilon-aminocaproic acid (NIP-CAP) that were required to inhibit by 50% the binding of the 4 IgE antibodies to NP-BSA-P indicated that these antibodies were all heteroclitic, since their affinity for NIP appeared to be higher than their affinity for NP. These results, in conjunction with other findings reported in the literature, suggested that the V regions of NP-specific IgE antibodies are similar to the V regions of NP-specific IgM and IgG antibodies, produced by the same mouse strains. Finally, in vitro histamine release measurements demonstrated that two of these monoclonal IgE antibodies could mediate antigen induced histamine release from passively sensitized rat peritoneal mast cells.

An evaluation of high-dose medroxyprogesterone acetate (MPA) therapy in women with advanced breast cancer

The efficacy of high-dose intramuscular MPA therapy in controlling progressive measurable metastatic breast carcinoma was assessed in 32 women. In addition serial measurements of MPA blood levels were carried out in 20 of the patients and subjective effects of treatment were monitored in detail in 18 of the women. Overall 6 patients (19%) gained an objective response and a further 7 (22%) experienced disease stasis from 4-17 months whilst on treatment. Significant differences in serum MPA levels were seen between responders and non-responders, objective tumour shrinkage only being seen in those patients who rapidly attained, and sustained, blood levels in excess of 100 ng ml-1. Subjective assessment showed no evidence of a euphoriant effect of MPA therapy in the non-responders group.

Gastric influences on canine small intestinal myoelectric activity

The aim was to determine whether the canine stomach modulates interdigestive and digestive small intestinal myoelectric activity. In four conscious dogs with electrodes implanted chronically on the duodenum and jejunum, enteric myoelectric activity was recorded during fasting and after feeding a 200-g liver meal. The dogs then underwent total gastrectomy and esophagoduodenostomy, after which they were restudied. Gastrectomy did not alter the pattern of the enteric interdigestive myoelectric complexes; the occurrence, period, duration of phase III, and consistency of distal propagation of enteric IMCs remained unchanged. Gastrectomy also preserved both the postcibal inhibition of the enteric IMCs and the postcibal induction of the fed myoelectric pattern in the small bowel. However, the onset of the fed pattern occurred more promptly after gastrectomy than before gastrectomy. We concluded that the pattern of canine duodenal and jejunal interdigestive myoelectric activity was largely independent of the stomach. The more rapid onset of the fed pattern with feeding postgastrectomy may relate to more rapid entry of chyme into the small intestine.

The endorectal ileal pouch-anal anastomosis. Current clinical results

One hundred thirteen patients with either chronic ulcerative colitis (108 patients) or familial polyposis coli (five patients) received an ileal J pouch-anal anastomosis after sphincter-saving proctocolectomy. There were no postoperative deaths. Leaks (radiologic and/or clinical) from the pouch or ileoanal anastomosis occurred in 14 per cent of patients. Small-bowel obstruction, requiring operative correction, occurred in 7 per cent and 3 per cent, respectively, of patients after either proctocolectomy or closure of the loop ileostomy. All 66 patients whose diverting ileostomy had been closed for at least three months could defecate spontaneously and their mean (+/- SE) stool frequency per 24 hours was 9.0 +/- 1 at one month and 5.9 +/- at 12 months. Major fecal incontinence was observed in 3 per cent of patients, and two patients eventually required a permanent ileostomy. The ileal J pouch-anal anastomosis has become our procedure of choice in selected patients who require proctocolectomy.