The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

Chirurgie des maladies inflammatoires chroniques de l’intestin et COVID-19 : étude européenne multicentrique (COVIBD-SURG)

But

Méthodes

Résultats

Conclusions

Simultaneous pelvic exenteration and liver resection for primary rectal cancer with synchronous liver metastases: results from the PelvEx Collaborative

AIM

At presentation, 15-20% of patients with rectal cancer already have synchronous liver metastases. The aim of this study was to determine the surgical and survival outcomes in patients with advanced rectal cancer who underwent combined pelvic exenteration and liver (oligometastatic) resection.

METHOD

Data from 20 international institutions that performed simultaneous pelvic exenteration and liver resection between 2007 and 2017 were accumulated. Primarily, we examined perioperative outcomes, morbidity and mortality. We also assessed the impact that margin status had on survival.

RESULTS

Of 128 patients, 72 (56.2%) were men with a median age of 60 years [interquartile range (IQR) 15 years]. The median size of the liver oligometastatic deposits was 2 cm (IQR 1.8 cm). The median duration of surgery was 406 min (IQR 240 min), with a median blood loss of 1090 ml (IQR 2010 ml). A negative resection margin (R0 resection) was achieved in 73.5% of pelvic exenterations and 66.4% of liver resections. The 30-day mortality rate was 1.6%, and 32% of patients had a major postoperative complication. The 5-year overall survival for patients in whom an R0 resection of both primary and metastatic disease was achieved was 54.6% compared with 20% for those with an R1/R2 resection (P = 0.006).

CONCLUSION

Simultaneous pelvic exenteration and liver resection is feasible, with acceptable morbidity and mortality. Simultaneous resection should only be performed where an R0 resection of both pelvic and hepatic disease is anticipated.

Correction to: Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn's disease

The affiliation of the author Silvio Danese has been incorrectly published in the original publication.

Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn's disease

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a position statement of Italian colorectal surgeons to address the surgical aspects of Crohn's disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of Crohn's disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.

Risk of permanent stoma in extensive Crohn's colitis: the impact of biological drugs

AIM

The overall risk of permanent stoma was determined in patients with extensive Crohn's colitis. An attempt was made to analyse whether biological drugs have modified the surgical approach in patients with anorectal involvement.

METHOD

In all, 233 patients with Crohn's disease colitis operated on between 1995 and 2010 were reviewed retrospectively. Fifty-one were treated before 2002 (prebiological era) and 182 after 2002 (biological era). The relationship was determined between the use of immunosuppressors, biological drugs, the presence of perianal disease and anorectal stenosis and the rate of permanent stoma formation.

RESULTS

In the prebiological era 23 (45.1%) patients without anorectal involvement underwent colectomy and ileorectal anastomosis, 17 (33.3%) with severe anorectal disease had proctocolectomy and 11 (21.6%) with anorectal involvement had abdominal colectomy with permanent ileostomy. In the biological era 73 (40.1%) patients without anorectal involvement underwent colectomy and ileorectal anastomosis, nine (5%) with severe anorectal involvement had proctocolectomy and 100 (54.9%) with anorectal involvement had colectomy with terminal ileostomy. Of these 100, 75 have subsequently been treated with biological drugs with full regression of anorectal lesions in 81.3%. Rates of permanent stoma in the prebiological and biological era were 60.8% and 19.2% (P < 0.001). Univariate and multivariate analysis showed that only the use of biological drugs was significantly associated with an increased rate of rectal preservation (P < 0.05).

CONCLUSION

The risk of a permanent stoma in patients with Crohn's colitis and anorectal involvement is significantly reduced with combined surgical and biological treatment.

Randomized controlled trials in pouchitis

Pouchitis is the most common complication of Proctocolectomy with ileal pouch-anal anastomosis (IPAA) in patients with ulcerative colitis (UC). The diagnosis of pouchitis requires the presence of symptoms, together with characteristic endoscopic and histological abnormalities. The exact cause of pouchitis is not known. Whereas 'acute' pouchitis can be treated rapidly and successfully in the majority of patients, "refractory" and 'chronic pouchitis' remain therapeutic challenges to patients and physicians. Metronidazole and Ciprofloxacin budesonide enemas and oral probiotic therapy with VSL#3 all appear to be effective therapies for acute and/or chronic pouchitis. The medical therapy of pouchitis remains largely empiric, and additional multicenter, randomized, double-blind, placebo-con- trolled, dose-ranging trials are needed. In future trials, treatment indications such as active acute or chronic pouchitis and maintenance of remission for acute or chronic pouchitis should be clearly defined.

Nutritional status of patients undergoing ileal pouch-anal anastomosis

The nutritional consequences of total colectomy and ileal pouch-anal anastomosis (IPAA) were assessed by evaluating 36 patients at the end of the defunctionalised stage (DS group) and 18 patients with recanalised IPAA (IPAA group). The changes in protein-calorie and zinc status occurring after the closure of the diverting ileostomy were evaluated also in 11 patients assessed both during the DS and the IPAA stage. The results were compared with those observed in 14 patients who underwent a Brooke-type permanent ileostomy (PI group). In the DS group there were protein-calorie malnutrition in 50% of cases characterised by body weight, TSF and AMC values lower than normal associated with normal serum protein levels; severe salt and water depletion with secondary aldosteronism in 90%; normal calcium-phosphorus balance in all but few cases, low values of parameters related to vitamin D and K, Fe, Zn and Cu status in 6-25% of cases and normal folate status. In the IPAA group all the anthropmetric parameters improved significantly after the closure of the protective ileostomy, but muscle mass (AMC) remained lower than normal in 40% of cases; mild salt depletion (urinary Na K ratio between 1 and 2) was observed in 1 3 of cases and of severe degree (urinary Na K < 1 ) in 20%; lower serum Zn occurred in 60% of patients probably due to greater requirements of the metal, secondary to increased muscle protein synthesis; parameters of calcium-phosphorus balance, vitamin D and K, folate, Fe and Cu status, were normal in almost all the cases. In the PI group, protein-calorie and salt and mineral nutritional status were similar to those of the IPAA group, whereas Zn status was normal in all the patients and erythrocytes folate levels and prothrombin time were significantly lower than in the IPAA group. These last two results might be explained by the different characteristics of the small bowel flora occurring in the two types of ileostomy.

Medical treatment and management of severe ulcerative colitis

Severe colitis is a life-threatening complication of ulcerative colitis. Early recognition of the severity of the colitis and intensive treatment and monitoring have all contributed to improved outcome. Since their introduction in the 1950s, corticosteroids are the first line therapy for severe active ulcerative colitis (UC). Several prognostic parameters (such as stools movement per day, C-reactive protein, increased amount of intestinal gas or small bowel dilation, hypoalbuminemia, fever, etc.) help the physician to quickly introduce infliximab or cyclosporine or to refer the patient to the surgeon. This decision requires a careful evaluation of the patient and a medical/surgical team.

Short-term treatment with infliximab in chronic refractory pouchitis and ileitis

BACKGROUND

Chronic refractory pouchitis is a long-term complication after ileal pouch-anal anastomosis and it may be associated with ileal inflammation.

AIM

To determine the efficacy of infliximab in treatment of chronic refractory pouchitis complicated by ileitis, using a wireless capsule endoscopy.

METHODS

Sixteen patients with chronic refractory pouchitis complicated by ileitis were enrolled. Pouchitis was diagnosed by clinical, endoscopic and histological criteria. Ileitis was documented using wireless capsule endoscopy. Duodenum-jejunum and proximal-middle ileum were evaluated and the presence of small lesions and large lesions were noted. Crohn's disease, intestinal infections were excluded in all patients. Patients were treated with infliximab and clinical response was recorded. Wireless capsule endoscopy was repeated at week 10 and Pouchitis Disease Activity Index score was determined.

RESULTS

Ten patients were enrolled and completed the study. Clinical remission was achieved in nine patients. At wireless capsule endoscopy and pouch endoscopy, a complete recovery of lesions was observed in eight patients. One patient presented four small lesions of the ileum at the 6 weeks of treatment and one patient did not show any modification. Clinical and endoscopic remission was maintained in these eight patients at least 6 months.

CONCLUSION

These preliminary results indicate that infliximab may be recommended for the treatment of chronic refractory pouchitis complicated by ileitis.

Controlled study using wireless capsule endoscopy for the evaluation of the small intestine in chronic refractory pouchitis

BACKGROUND

Pouchitis is a common long-term complication after ileal pouch anal anastomosis for ulcerative colitis. Chronic refractory pouchitis is a treatment-resistant condition that affects 5-15% of patients.

AIM

To test the hypothesis of a small bowel involvement using wireless capsule endoscopy.

MATERIAL AND METHODS

This is a single-blind, prospective, cohort study. Twenty-four patients: 16 were patients with chronic refractory pouchitis and eight, with a macroscopically and histologically normal ileal pouch, were considered as control subjects. Diagnosis of pouchitis was confirmed using the pouchitis disease activity index. All subjects were submitted to wireless capsule endoscopy procedure. Within 2 weeks before wireless capsule endoscopy, patients underwent a pouch endoscopy and a small bowel follow-through. Re-examination of the colonic surgical and histological specimens was also performed.

RESULTS

One patient with chronic pouchitis was excluded because of incomplete bowel cleaning. At small bowel follow-through of 16 patients, two subjects (13%) showed only a focal ectasia of the middle ileum and a substenosis of the pouch. At wireless capsule endoscopy all the 15 evaluable patients with chronic pouchitis (100%) showed diffuse lesions from duodenum to ileum consisting of aphthae, erosions, erythema, atrophy, cobblestone, deep/fissural ulcers.

CONCLUSIONS

This enteropathy needs further research, and wireless capsule endoscopy could be useful to show involvement of small bowel in patients with chronic pouchitis.

Surgical outcome and long-term follow up after laparoscopic rectosigmoid resection in women with deep infiltrating endometriosis

The aim of this study was to assess the long-term outcome of treating severely symptomatic women with deep infiltrating intestinal endometriosis by laparoscopic segmental rectosigmoid resection. Detailed intraoperative and postoperative records and questionnaires (preoperatively, 1 month postoperatively and every 6 months for 3 years) were collected from 22 women. The estimated blood loss during surgery was 290 +/- 162 ml (range 180-600), and average hospital stay was 8 days (range 6-19). One woman required blood transfusion after surgery. Two cases were converted to laparotomy. One woman had early dehiscence of the anastomosis. Six months after surgery, there was a significant reduction of symptom scores (greater than 50% for most types of pain) related to intestinal localisation of endometriosis (P < 0.05). Score improvements were maintained during the whole period of follow up. Noncyclic pelvic pain scores showed significant reductions (P < 0.05) after 6 and 12 months, but there was a high recurrence rate later. Dysmenorrhoea and dyspareunia improved in 18/21 and 14/18 women with preoperative symptoms, respectively. Constipation, diarrhoea and rectal bleeding improved in all affected women for the whole period of follow up. Laparoscopic segmental rectosigmoid resection seems safe and effective in women with deep infiltrating colorectal endometriosis resulting in significant reductions in painful and dysfunctional symptoms associated with deep bowel involvement.

Oral budesonide in the treatment of chronic refractory pouchitis

BACKGROUND

Pouchitis is the major long-term complication after ileal-pouch nal anastomosis for ulcerative colitis. Ten to 15% of patients develop a chronic pouchitis, either treatment responsive or treatment refractory.

AIM

To evaluate the efficacy of oral budesonide in inducing remission and improving quality of life in patients with chronic refractory pouchitis.

METHODS

Twenty consecutive patients with active pouchitis, not responding after 1 month of antibiotic treatment were treated with budesonide controlled ileal release 9 mg/day for 8 weeks. Symptomatic, endoscopic and histological evaluations were undertaken before and after treatment according to Pouchitis Disease Activity Index. Remission was defined as a combination of Pouchitis Disease Activity Index clinical score of < or = 2, endoscopic score of < or = 1 and total Pouchitis Disease Activity Index score of < or = 4. The quality of life was assessed with the Inflammatory Bowel Disease Questionnaire.

RESULTS

Fifteen of 20 patients (75%) achieved remission. The median total Pouchitis Disease Activity Index scores before and after therapy were, respectively, 14 (range 9-16) and 3 (range 2-10) (P < 0.001). The median Inflammatory Bowel Disease Questionnaire score also significantly improved from 105 (range 77-175) to 180 (range 85-220) (P < 0.001).

CONCLUSION

Eight-week treatment with oral budesonide appears effective in inducing remission in patients with active pouchitis refractory to antibiotic treatment in this open-label study.

Impact of surgery on the development of duodenal cancer in patients with familial adenomatous polyposis

PURPOSE

Precancerous duodenal lesions in patients with familial adenomatous polyposis can be detected with duodenoscopy and treatment may prevent the development of cancer. We proposed to determine the frequency, natural history, cumulative risk, and risk factors of the precancerous duodenal lesions in a series of patients diagnosed in northern Italy.

METHODS

A prospective, endoscopic, follow-up protocol was performed in 50 patients examined by gastroduodenoscopy at two years of interval or less. The presence and severity of precancerous lesions of the duodenal mucosa were evaluated by Spigelman score. Twenty-five patients (50 percent) had proctocolectomy and ileoanal anastomosis, 15 (30 percent) had colectomy and ileorectal anastomosis, and 5 (10 percent) had proctocolectomy and definitive ileostomy from 0 to 3 years before the admission to the surveillance program. All patients showed more than a thousand adenomas in the colorectal mucosa. No patients with attenuated polyposis were found.

RESULTS

At the first endoscopy, duodenal adenomas could be detected in 19 of 50 patients (38 percent), whereas at the end of the follow-up, 43 (86 percent) had duodenal lesions. The final mean Spigelman score increased during the follow-up period (P<0.001 respect to baseline values). No duodenal cancer could be detected. Eleven patients had or developed severe precancerous duodenal lesions (Stage IV) treated with endoscopic or surgical resection. The distribution of patients with Stage IV according to the surgery of the colon was: 2 of 25 treated with ileoanal anastomosis and 8 of 15 with ileorectal anastomosis (P=0.0024, Fisher's exact test).

CONCLUSIONS

Patients with familial adenomatous polyposis are at risk of significant neoplasia. The natural history of precancerous lesions might be related to surgical treatment of colorectal neoplasms.

CT-guided percutaneous pelvic abscess drainage in Crohn's disease

BACKGROUND

Percutaneous abscess drainage (PAD) is the current therapy for abdominal or pelvic collections. PAD has poorer curative rate for abscesses in Crohn's disease (CD), commonly complicated by wide fistulas and multiloculations.

METHODS

We retrospectively evaluated abscess cure rate, complications and final outcome in 87 CD patients, 70 with spontaneous and 17 with postoperative pelvic abscesses, all treated with CT-guided PAD during the last 7 years.

RESULTS

A 77% primary success rate and an 84.3% secondary success rate were obtained without major complications. The higher success rate for PAD was for postoperative (88.2%) rather than spontaneous abscesses (74.2%). Seventy-two percent of treated patients did not develop recurrent abscesses and underwent elective surgery up to 40 months later.

CONCLUSION

PAD in pelvic abscess complicating CD is an effective alternative to early surgery with satisfactory curative success rates. In unsuccessful cases, due to wide fistulas or postoperative anastomotic dehiscence, PAD helped in planning elective surgery, reducing surgical complications.

Combined carriership of TLR9-1237C and CD14-260T alleles enhances the risk of developing chronic relapsing pouchitis

AIM

To investigate the single nucleotide polymorphisms (SNPs) in genes involved in bacterial recognition and the susceptibility to pouchitis or pouchitis severity.

METHODS

Analyses of CD14 -260C>T, CARD15/NOD2 3020insC, Toll-like receptor (TLR)4 +896A>G, TLR9 -1237T>C, TLR9+2848G>A, and IRAKM + 22148G>A SNPs were performed in 157 ileal-pouch anal anastomosis (IPAA) patients (79 patients who did not develop pouchitis, 43 infrequent pouchitis patients, 35 chronic relapsing pouchitis patients) and 224 Italian Caucasian healthy controls.

RESULTS

No significant differences were found in SNP frequencies between controls and IPAA patients. However, a significant difference in carriership frequency of the TLR9-1237C allele was found between the infrequent pouchitis and chronic relapsing pouchitis groups [P = 0.028, oddos ratio (OR) = 3.2, 95%CI = 1.2-8.6]. This allele uniquely represented a 4-locus TLR9 haplotype comprising both studied TLR9 SNPs in Caucasians. Carrier trait analysis revealed an enhanced combined carriership of the alleles TLR9 -1237C and CD14 -260T in the chronic relapsing pouchitis and infrequent pouchitis group (P = 0.018, OR = 4.1, 95%CI = 1.4 -12.3).

CONCLUSION

There is no evidence that the SNPs predispose to the need for IPAA surgery. The significant increase of the combined carriership of the CD14 -260T and TLR9 -1237C alleles in the chronic relapsing pouchitis group suggests that these markers identify a subgroup of IPAA patients with a risk of developing chronic or refractory pouchitis.

Local injection of Infliximab for the treatment of perianal Crohn's disease

PURPOSE

Perianal disease is a serious complication of Crohn's disease and its surgical management is still controversial. It has been suggested that the local injection of infliximab has resulted in some potential benefit. This pilot study analyzed the feasibility and safety of such therapy in selected patients with severe perianal Crohn's disease.

METHODS

The study included 15 patients with complex perianal Crohn's disease in which sepsis was not controllable using surgical and medical therapy. Among them, four had previously undergone intravenous infusion of infliximab with no significant response, nine had contraindications for intravenous infusion, and two had associated stenosing ileitis and severe coloproctitis. The injection of 15 to 21 mg of infliximab, associated with surgical treatment, was performed at the internal and external orifices and along the fistula tract. Efficacy was measured by a complete morphologic evaluation using a personal score.

RESULTS

No major adverse effects were reported. Ten of 15 patients healed after 3 to 12 infusions.

CONCLUSIONS

Local injection of infliximab adjacent to the fistula tract of perianal Crohn's disease is safe and may help in fistula healing. A controlled, randomized trial is required to prove the value.

Once daily high dose probiotic therapy (VSL#3) for maintaining remission in recurrent or refractory pouchitis

BACKGROUND

Ten to 15% of patients with pouchitis experience refractory or recurrent disease. The aim of this study was to evaluate the effectiveness of a single daily high dose probiotic preparation (VSL#3) in maintaining antibiotic induced remission, and quality of life (QOL), for one year in such patients.

METHODS

Patients with pouchitis at least twice in the previous year or requiring continuous antibiotics, associated with a pouchitis disease activity index (PDAI) > or =7 (0 = perfect; 18 = worst), in whom remission was induced by four weeks of combined metronidazole and ciprofloxacin, were randomised to receive VSL#3 6 g or placebo once daily for one year or until relapse. Symptomatic, endoscopic, and histological evaluations were made before, and two and 12 months after randomisation or at the time of relapse. Remission was defined as a clinical PDAI < or =2 and endoscopic PDAI < or =1. Relapse was defined as an increased clinical PDAI score > or =2 and increased endoscopic PDAI score > or =3. QOL was assessed using the inflammatory bowel disease questionnaire (IBDQ).

RESULTS

Thirty six patients were randomised: 20 to VSL#3 and 16 to placebo. Remission was maintained at one year in 17 patients (85%) on VSL#3 and in one patient (6%) on placebo (p<0.0001). The IBDQ score remained high in the VSL#3 group (p = 0.3) but deteriorated in the placebo group (p = 0.0005).

CONCLUSION

The once daily high dose probiotic VSL#3 is effective in maintaining antibiotic introduced remission for at least a year in patients with recurrent or refractory pouchitis. This is associated with a high level of quality of life.

Colorectal cancer and high grade dysplasia complicating ulcerative colitis in Italy. A retrospective co-operative IG-IBD study

BACKGROUND

Ulcerative colitis is a well-known risk factor for colorectal cancer.

AIM

To take a census of the cases of colorectal cancer in ulcerative colitis patients observed in Italy and to evaluate the clinical presentation of neoplastic complication.

PATIENTS AND METHODS

Experts from 28 Italian centres specialised in the management of inflammatory bowel disease or malignancies participated to the study. They were invited to send clinical data of patients with ulcerative colitis complicated by colorectal cancer or high-grade dysplasia consecutively observed between 1985 and 2000. One hundred and twelve patients (92 with cancer and 20 with high-grade dysplasia) were collected. Fourteen of them had undergone colectomy and ileo-rectal anastomosis for ulcerative colitis. Data of surgical patients were analysed separately.

RESULTS

The mean age at diagnosis of ulcerative colitis and colorectal cancer patients was 39.3 and 53.2 years, respectively, and the mean duration between diagnosis of ulcerative colitis and cancer was 13.9 years (range 0-53). Inflammation was proximal to the splenic flexure in 71 cases (76.3%). One hundred and three colorectal cancers were registered (93 patients with single lesion and five patients with two synchronous cancers), with 76.7% of cancers being located in the left colon. As to the surgical patients, the mean age at diagnosis of ulcerative colitis and cancer was 28.9 and 47.0 years, respectively, and the mean diagnostic interval for ulcerative colitis and cancer was 18.1 years. Only 51 out of 112 patients were in follow-up. An early diagnosis of neoplasia (high grade dysplasia, stage A or B sec. Dukes) occurred in 72.5% of patients who were subjected to endoscopic surveillance and in 48.0% of patients who did not undergo endoscopic surveillance (p=0.02).

CONCLUSIONS

These data show an earlier diagnosis of cancer in patients who had undergone endoscopic surveillance. The poor compliance to the follow-up program, however, reduces its effectiveness. Moreover, total colectomy allows an easier follow-up, with only the rectum being controlled. Colectomy with ileo-rectal anastomosis or proctocolectomy with ileo-anal anastomosis, could represent a valid alternative in patients at high risk of cancer who refuse endoscopic surveillance.

A new model of strictureplasty for multiple and long stenoses in Crohn's ileitis: side-to-side diseased to disease-free anastomosis

Conservative surgery has become the treatment of choice for diffuse jejunoileal Crohn's Disease. Previous research described a conservative approach both for multiple strictures located in close proximity to each other and for long stenoses. The side-to-side enteroenteric anastomosis has gained popularity and has lead to nonresectional surgery even for those patients who, until now, were considered suitable only for resection. This technique however, presents in our hands some disadvantages represented mainly by early restenosis at the two edges of the strictureplasty, probably caused by the sutures between the diseased and the thickened part of the bowel. We propose a new technique called "side-to-side diseased to disease-free anastomosis," which consists of dividing the bowel and the mesentery at the beginning of the stenoses and suturing the disease-free bowel above the stenoses to the diseased bowel. This procedure could avoid early restenosis at the two ends of the strictureplasty. Moreover, it is faster and safer to perform because the knots of the sutures are tied to the normal bowel with less risk of bleeding.

Review article: indication and type of surgery in Crohn's disease

The large majority of patients affected by Crohn's disease require surgery during their clinical history. Radical resection originally advocated for Crohn's disease does not decrease the recurrence rate, and repeated resections predispose patients to the development of short-bowel syndrome. Over the last few years, conservative surgery has become accepted by many authors as a safe means of treating obstructive Crohn's disease. In this review article we analyse the efficacy and safety of conservative techniques, in comparison with resective surgery. Indications, advantages and technical aspects of resective and conservative surgery are reported. The experience with 489 patients treated for complicated or treatment refractory Crohn's disease in our Institution suggests that strictureplasty is a safe and effective procedure in many cases, as reported by other authors. The risk of cancer in areas of active disease as in stenosis treated with strictureplasty seems to be negligible. Resective surgery still represents the 'gold standard' in patients with perforating Crohn's disease; however, conservative surgery, usually contraindicated in perforating Crohn's disease, can be advocated in patients with localized perforating disease presenting an actual risk of short bowel syndrome.

Four-week open-label trial of metronidazole and ciprofloxacin for the treatment of recurrent or refractory pouchitis

BACKGROUND

Preliminary data suggest that short-term antibiotic therapy with a single drug is effective for the treatment of patients with pouchitis. However, some patients are resistant to treatment.

AIM

To evaluate the therapeutic efficacy of a prolonged course of a combination of two antibiotics in patients with refractory or recurrent pouchitis, as well as its impact on their quality of life.

METHODS

Patients with active refractory or recurrent pouchitis were recruited. This was defined as both: (i) a history of pouchitis at least twice in the last 12 months or persistent pouchitis requiring continual intake of antibiotics; and (ii) a Pouchitis Disease Activity Index score 3 7 (best to worst pouchitis=0-18) at the beginning of therapy. Treatment consisted of a combination of metronidazole, 400 or 500 mg twice daily, and ciprofloxacin, 500 mg twice daily, for 28 days. Symptomatic, endoscopic and histological evaluations were undertaken before and after antibiotic therapy using the Pouchitis Disease Activity Index score. Remission was defined as a combination of a Pouchitis Disease Activity Index clinical score of <or= 2, endoscopic score of <or= 1 and total score of <or= 4. The quality of life was assessed with the Inflammatory Bowel Disease Questionnaire, which encompasses bowel, systemic and emotional symptoms as well as social function (worst to best=32-224).

RESULTS

Forty-four patients (24 male, 20 female; median age, 37.5 years) entered the trial and completed treatment. Thirty-six (82%) went into remission. The median Pouchitis Disease Activity Index scores before and after therapy were 12 (range, 8-17) and 3 (range, 1-10), respectively (P < 0.0001). The median Inflammatory Bowel Disease Questionnaire score also significantly improved from 96.5 (range, 74-183) to 175 (range, 76-215) with this therapy (P < 0.0001). The eight patients (five male, three female) who did not go into remission were significantly older (median 47.5 vs. 35 years; P=0.007), had a longer history of pouchitis (95.5 vs. 26 months; P=0.0008), had a greater proportion with chronic pouchitis (chronic/relapsing: 6/2 vs. 9/27; relative risk, 1.6; 95% confidence interval, 1.0-2.4) and tended to have a higher Pouchitis Disease Activity Index score before treatment (median 14.5 vs. 12; P=0.13) than those who went into remission. Even in these eight patients, the median Pouchitis Disease Activity Index score significantly improved from 14.5 (range, 8-16) to 9.5 (range, 7-10) (P=0.0078), as did the Inflammatory Bowel Disease Questionnaire score from 95.5 (range, 74-134) to 127 (range, 76-187) (P=0.039). The Inflammatory Bowel Disease Questionnaire score strongly correlated with the Pouchitis Disease Activity Index score (r=0.79, P < 0.0001), and was significantly related to the patients' overall assessment of satisfaction (P < 0.0001). No serious side-effects were noted.

CONCLUSIONS

Four-week treatment with a combination of metronidazole and ciprofloxacin is highly effective in patients with active recurrent or refractory pouchitis, objectively improving the inflammation and quality of life. The Inflammatory Bowel Disease Questionnaire is a sensitive tool for evaluating patients with pouchitis, and correlates well with disease activity.

Adenocarcinoma below ileoanal anastomosis for ulcerative colitis: report of a case and review of the literature

BACKGROUND

Restorative proctocolectomy with hand-sewn ileoanal anastomosis and mucosectomy is warranted in patients with dysplasia and/or cancer on ulcerative colitis to prevent subsequent neoplastic changes in the retained mucosa. However, complete excision of the colonic mucosa cannot be obtained reliably. We report a case of anal canal adenocarcinoma after handsewn anastomosis with mucosectomy.

METHODS

A 47-year-old patient, previously submitted to ileorectal anastomosis for colonic cancer on ulcerative colitis, underwent completion proctectomy and handsewn ileoanal anastomosis with mucosectomy for recurrent anastomotic cancer. Two years later, we submitted the patient to pouch removal with permanent ileostomy for a mucinous adenocarcinoma of the anal canal (T2N2Mx) found at follow-up pouch endoscopy.

CONCLUSIONS

Only four cases of adenocarcinoma after handsewn anastomosis have been reported in the literature. This new case we report confirms that the risk of malignancy after ileoanal anastomosis with mucosectomy, although small, is real, despite the surgeon taking care with this particular step of the procedure. Careful surveillance is needed in patients with surgical treatment for long-term ulcerative colitis or dysplasia.

Oral bacteriotherapy as maintenance treatment in patients with chronic pouchitis: a double-blind, placebo-controlled trial

BACKGROUND & AIMS

Pouchitis is the major long-term complication after ileal pouch-anal anastomosis for ulcerative colitis. Most patients have relapsing disease, and no maintenance treatment study has been performed. We evaluated the efficacy of a probiotic preparation (VSL#3) containing 5 x 10(11) per gram of viable lyophilized bacteria of 4 strains of lactobacilli, 3 strains of bifidobacteria, and 1 strain of Streptococcus salivarius subsp. thermophilus compared with placebo in maintenance of remission of chronic pouchitis.

METHODS

Forty patients in clinical and endoscopic remission were randomized to receive either VSL#3, 6 g/day, or an identical placebo for 9 months. Patients were assessed clinically every month and endoscopically and histologically every 2 months or in the case of a relapse. Fecal samples were collected for stool culture before and after antibiotic treatment and each month during maintenance treatment.

RESULTS

Three patients (15%) in the VSL#3 group had relapses within the 9-month follow-up period, compared with 20 (100%) in the placebo group (P < 0.001). Fecal concentration of lactobacilli, bifidobacteria, and S. thermophilus increased significantly from baseline levels only in the VSL#3-treated group (P < 0.01).

CONCLUSIONS

These results suggest that oral administration of this new probiotic preparation is effective in preventing flare-ups of chronic pouchitis.

[Immediate and long-term results in ileoanastomosis with reservoir in 335 consecutive cases]

Restorative proctocolectomy with ileal pouch anal anastomosis is the first choice procedure for the treatment of ulcerative colitis and familial adenomatous polyposis. The introduction of the stapled technique has shortened the duration of the procedure and reduced the complication rates. Data on 335 consecutive patients undergoing ileal pouch anal anastomosis for ulcerative colitis (277 pts), Indeterminate colitis (20 pts) and familial adenomatous polyposis (38 pts) between 1984 and 1998 were prospectively collected. Parameters evaluated included diagnosis, surgical technique, functional outcome, early and late complications and their management and results. Twenty-nine patients (8.6%) presented with pelvic sepsis. Twelve patients (3.5%) experienced late perianal fistulas. The pouch failure rate was 3.4%. Six patients required a re-do pouch procedure, with 75.9% preservation of sphincter function. No correlation was found between complication rates and diagnosis. The mean number of stools was 5.2/24 h. The study confirmed the safety and effectiveness of the procedure. In particular, morbidity rates are comparable to those of major abdominal procedures and the long-term functional results are satisfactory. However, a number of technical aspects, such as the anastomosis technique, the need for temporary ileostomy and the treatment of indeterminate colitis, still remain controversial.

Oral rehydration solution containing rice maltodextrins in patients with total colectomy and high intestinal output

Oral rehydration solutions containing rice maltodextrins (R-ORS) have been reported to be more effective than glucose-based ORS in reducing intestinal losses in infectious diarrhea. To evaluate the effect of R-ORS in patients with total colectomy and high intestinal output, a perspective open noncontrolled study was performed on 13 adult patients who consumed 1 l/day of R-ORS for 7 days. Body weight, daily ileal and urinary output, serum electrolytes, aldosterone and renin activity were measured the day before (day 0) and on the last day of the study (day 7). Net changes (mean +/- SE) from day 0-7 showed an increase of urine Na (40 +/- 16 mmol/day, p < 0.04) and K (24 +/- 8 mmol/day, p < 0.02). Body weight increased in seven patients. Serum renin activity decreased (-0.60 +/- 0.26 ng/ml/min) in these patients but not in the six patients in whom body weight remained unchanged (0.19 +/- 0.07 ng/ml/min; p < 0.03). Ileal and urinary volume remained stable. In patients with high ileal output, R-ORS supplementation improved Na and K balance. The association of increased body weight with decreased serum renin concentrations suggests that a positive water balance also occurred.

Antibiotic combination therapy in patients with chronic, treatment-resistant pouchitis

BACKGROUND

Pouchitis is the major long-term complication after ileal pouch-anal anastomosis for ulcerative colitis. About 15% of patients have a chronic, treatment-resistant disease.

AIMS

To evaluate the efficacy of an antibiotic combination for chronic active, treatment-resistant pouchitis.

PATIENTS AND METHODS

Eighteen patients were treated orally with rifaximin 1 g b.d. + ciprofloxacin 500 mg b.d. for 15 days. Symptoms assessment, endoscopic and histological evaluations were performed at screening and after 15 days using the Pouchitis Disease Activity Index (PDAI). Improvement was defined as a decrease of at least 3 points in PDAI score, and remission as a PDAI score of 0. Systemic absorption of rifaximin was determined by high performance liquid chromatography. Faecal samples were collected before and after antibiotic treatment for stool culture.

RESULTS

Sixteen out of 18 patients (88.8%) either improved (n=10) or went into remission (n=6); the median PDAI scores before and after therapy were 11 (range 9-17) and 4 (range 0-16), respectively (P < 0.002). No side-effects were reported. Rifaximin plasma levels and urinary excretion were negligible, confirming its mainly topical activity. A significant decrease in total anaerobes and aerobes, enterococci, lactobacilli, bifidobacteria and bacteroides in faecal samples was observed, while the reduction in number of coliforms and Clostridium perfringens did not reach a statistical significance.

CONCLUSIONS

A combination of rifaximin and ciprofloxacin was effective in patients with active chronic, treatment-resistant pouchitis, suggesting the need, in these patients, for treatment using antibiotic agents with wide antibacterial spectrum of activity.

Review--antibiotic treatment in inflammatory bowel disease: rifaximin, a new possible approach

The etiology of inflammatory disease is still unknown, but a body of evidence from clinical and experimental observation indicates a role for intestinal microflora in the pathogenesis of this disease. Reduction of microflora using antibiotics, bowel rest and fecal diversion decreases activity in Crohn's disease and in ulcerative colitis. Several trials have been carried out on the use of antibiotic treatment in patients with active ulcerative colitis with contrasting results. A number of trials have been carried out using Rifaximin, a non-absorbable broad-spectrum antibiotic, confirming the absence of systemic bioavalaibility of the drug even when administered at very high doses and for prolonged periods. It may therefore be useful in treatment of ulcerative colitis and pouchitis, since its absorption through inflamed mucosa is negligible, it maintains a topical action without systemic effects and the lack of resistant bacterial strains may allow prolonged and repeated treatments.

Conservative surgical management of perforating Crohn's disease: side-to-side enteroenteric neoileocolic anastomosis: report of two cases

Conservative surgical management of jejunoileal Crohn's disease is the first-choice treatment in plurioperated patients with high risk of small-bowel syndrome. Treatment is more controversial in patients with a limited disease and no previous surgery, especially in those with terminal ileitis. Even in those cases we advocate conservative surgical management because we have demonstrated regression of both symptoms and morphologic lesions. Contraindications to nonresectional surgery include the presence of abscesses and fistulas. Impending short-bowel syndrome represents a partial exception to this approach. In this article two cases of conservative surgery performed in plurioperated patients with perianastomotic perforating recurrent disease are presented. We have named this procedure "side-to-side enteroenteric neoileocolic anastomosis," which is a combination of small resections and conservative procedure. This operative strategy leads us to believe that nonresectional surgery could be selectively performed even in patients with perforating Crohn's disease.

Long-term efficacy of bismuth carbomer enemas in patients with treatment-resistant chronic pouchitis

BACKGROUND

Mucosal inflammation of the ileal pouch (pouchitis) is the major long-term complication after ileal pouch-anal anastomosis for ulcerative colitis. Broad-spectrum antibiotics are the mainstay of treatment, however, 15% of patients with pouchitis have a chronic, treatment-resistant disease.

AIM

To determine the safety and efficacy of bismuth carbomer enemas in achieving and maintaining remission in treatment-resistant chronic pouchitis.

METHODS

Twelve patients with treatment-resistant chronic pouchitis were treated nightly for 45 days with enemas containing elemental bismuth complexed with carbomer. Diagnosis of pouchitis and response to treatment were evaluated with the Pouchitis Disease Activity Index (PDAI), which includes clinical, sigmoidoscopic and histological criteria. Serum bismuth concentrations were determined by atomic absorption.

RESULTS

Ten of 12 patients (83%) went into remission, with a significant decrease of mean total PDAI score from 12 (range 9-15) to 6 (4-15) (P < 0.002), and were continued on bismuth carbomer enemas administered every third night for 12 months. Patients were monitored clinically, sigmoidoscopically and histologically every 2 months for evidence of recurrence (increase > or = 2 in the clinical symptom portion of the PDAI). Six of 10 patients (60%) were able to maintain remission throughout the 12-month trial; 4/10 had an exacerbation, two of which occurred soon after discontinuing daily treatment. Serum bismuth levels were negligible in all patients and no side-effects were registered.

CONCLUSIONS

Our findings suggest that bismuth carbomer enemas are safe and effective in achieving and maintaining remission in patients with treatment-resistant chronic pouchitis.

Reducing the occupational risk of infections for the surgeon: multicentric national survey on more than 15,000 surgical procedures

The objective of this study was to find the incidence of accidental exposures to blood and body fluids among surgeons during operations and to describe their dynamics. A probabilistic model was also used to predict the cumulative 30-year risk to the surgeon of contracting hepatitis B and C viruses (HBV, HCV) or human immunodeficiency virus (HIV) infection and estimate the effect of preventive strategies in reducing this risk. A multicentric prospective survey, based on self-administered questionnaires, was conducted during a period of 6 months in 39 Italian hospitals. As accidental exposure to blood or body fluids occurred in 9.2% of 15,375 operations. In about 2% of procedures a parenteral-type injury, such as actual skin puncture or eye contamination, was suffered by the operating surgeon. A needle-stick injury was the commonest accident, and its occurrence was found to vary with the phase of the procedure and its length. The current lifetime risk of acquiring HBV, HCV, and HIV infection in our regions was estimated to be as high as 42.7%, 34.8%, and 0.54%, respectively. The adoption of preventive strategies is expected to reduce this risk to 21% for HBV, 16.6% for HCV, and 0.23% for HIV infection. Active immunization of surgeons against HBV is strongly recommended. The case is also made for the use of a face-shield combined with a permanent change in our surgical practice capable of reducing the current high rate of parenteral injuries.

Duodenal involvement of Crohn's disease: three different clinicopathologic patterns

PURPOSE

This study was designed to assess clinical and pathologic features of duodenal Crohn's disease (CD) and address its management according to different patterns of disease.

METHODS

Twelve cases of duodenal involvement in CD are reported out of 336 patients treated between 1978 and 1993. They represent 3.6 percent of all cases. Three patients had a duodenal fistula, and nine had an intrinsic duodenal lesion. The duodenal fistula was in all cases a manifestation of recurrent CD involving an ileocolic anastomosis and the third portion of the duodenum.

RESULTS

Treatment consisted of resection of the fistula's source and primary closure of duodenal breach. Of nine patients with intrinsic CD, five had stenosis and the remaining four had peptic ulcer-like lesions. Duodenal stenosis was treated with strictureplasty in three cases and duodenojejunostomy in two. No patient with ulcer-like lesions underwent surgery.

CONCLUSIONS

Differences encountered in intrinsic duodenal lesions apparently reflect two different clinical patterns. Stenosis is not usually associated with multifocal disease and is often the first evidence of disease. Ulcer-like lesions are not specific; they do not evolve into stenosis as do ulcers in other sites of the disease, spontaneously disappear and relapse, and do not require surgery, except for complications. They are always associated with other locations of the disease.

Conservative surgical management of terminal ileitis: side-to-side enterocolic anastomosis

PURPOSE

Terminal ileitis is the most frequent presentation of Crohn's disease. Resection of the terminal ileum and cecum with ileocolic anastomosis has always been considered the "gold standard" in the surgical treatment of this condition. This study illustrates an alternative technique referred to as "side-to-side enterocolic anastomosis."

METHODS

It consists of a longitudinal section of the terminal ileum starting 1 to 2 cm away from the beginning of the stricture and continued for a similar length on the ascending colon. A side-to-side anastomosis is then fashioned, in a kind of Finney-shaped strictureplasty. A series of five patients is reported.

RESULTS

Average length of the anastomosis was 18.4 (range, 12-25) cm. Postoperative course was uneventful. Colonoscopy and large-bowel enema performed on some patients six months after surgery revealed a complete morphologic regression of the disease. All patients are presently in good condition, with no evidence of recurrence after an average follow-up of 8.9 (range, 6-15) months.

CONCLUSIONS

"Side-to-side enterocolic anastomosis" can be a possible alternative option for the surgical management of Crohn's disease of the terminal ileum, providing at least regression of the morphologic aspects of the disease. Contraindications are presence of abscesses, fistulas, or rigid and fibrotic stricture. This technique can be considered a further example of nonresectional surgery such as strictureplasty. This makes it possible to conceive surgical treatment of Crohn's disease without resection in selected cases for the whole length of the small bowel and suggests the introduction of the new definition of "conservative surgical management of small-bowel Crohn's disease."

Factors affecting recurrence in Crohn's disease. Results of a prospective audit

It has been suggested that certain clinical and morphological features can modify the outcome of Crohn's disease, particularly regarding recurrence after surgery. A series of 233 patients was followed prospectively. They underwent a resectional surgical procedure for both primary and recurrent Crohn's disease during a fifteen-year period with a minimum follow-up of eighteen months. Possible risk factors for recurrence were studied. They included duration of disease before primary surgery, the type of clinical presentation at onset (whether "Perforating" or "Non-perforating"), the initial anatomical location, the presence of microscopic disease at the resection edges, the type of surgical procedure (anastomosis vs stoma), post-operative surgical complications and the age of the patient. The duration of the disease before the initial operation was the only significant factor related to the recurrence rate.

Functional outcome in handsewn versus stapled ileal pouch-anal anastomosis

Eighty-eight of 119 patients who underwent ileal pouch-anal anastomosis for ulcerative colitis were evaluated. Forty patients had a handsewn anastomosis (Hs) with mucosectomy, and 48 had a stapled anastomosis (St). In each patient, we evaluated operative, morphologic, functional, and manometric features. The results in the Hs and St groups were similar when the anastomosis was within 1 cm of the dentate line. In particular, there was no correlation between the type of anastomosis and the number of bowel movements in a 24-hour period, the presence of the urge to defecate, and the use of antidiarrheal drugs. Leakage was significantly higher in the Hs group, even when the anastomosis was less than 1 cm from the dentate line. Pouchitis was more frequent in the Hs group, and, within this group, among those with a short distance between the anastomosis and the dentate line. No correlations were found between the presence of columnar epithelium or active colitis in the mucosa below the anastomosis, the functional outcomes, and the incidence of pouchitis.

Mucosal concentrations of interleukin-1 beta, interleukin-6, interleukin-8, and tumor necrosis factor-alpha in pelvic ileal pouches

Concentrations of interleukin-1 beta (IL-1 beta), interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor-alpha (TNF-alpha) were determined by solid-phase ELISA in tissue homogenates of mucosal biopsy specimens obtained from pelvic ileal pouches in 13 patients with pouchitis (reservoir ileitis) and 17 with pouches without pouchitis. Normal ileal mucosa was used as a control. IL-1 beta was detected in all tissue homogenates from patients with pouchitis compared with only 29% from pouches without pouchitis and none from controls. IL-6 and IL-8 were present in all pouchitis specimens, in 70% of the specimens from nonpouchitis and only 30% of specimens from controls. TNF-alpha was undetectable in all specimens examined. The concentrations of IL-1 beta, IL-6, and IL-8 were significantly greater (P < 0.001) in biopsy specimens from pouchitis compared to those from pouches without pouchitis or normal ileal mucosa and in patients with pouchitis tissue levels of IL-1 beta significantly correlated with IL-6 (P < 0.05) and IL-8 (P < 0.01). Furthermore IL-1 and IL-8 levels were significantly higher in tissue specimens from nonpouchitis pouches than in those from normal ileal mucosa (P < 0.02). These results suggest that an enhanced cellular immunity operates in vivo at the mucosal level in pouchitis as in the case of ulcerative colitis.

[Acute inflammation of ileal reservoir after restorative ileoanal anastomosis]

Ileo-anal anastomosis (IAA) is a suitable surgical treatment for selected patients with ulcerative colitis or familial adenomatous polyposis. Acute inflammation of the ileal reservoir (pouchitis) is the most frequent late complication and is characterized by endoscopic and histological changes of acute inflammation similar to ulcerative colitis with abdominal and sometimes systemic symptoms. Between May 1984 and April 1993, 160 patients (103 male and 57 female) aged between 7 and 64 years (mean age 32.6) underwent IAA; twenty of these for familial adenomatous polyposis, 138 for ulcerative colitis and 2 for indeterminate colitis. After a mean follow-up of 41.8 months (range 1-108), 138 patients (86.3%) were symptoms free and twenty-two (16 male and 6 female-13.7%) who underwent IAA for ulcerative colitis, had pouchitis. Clinical, biochemical, endoscopic and histologic findings suggest pouchitis as a chronic recurrent disease similar to inflammatory bowel disease. In conclusion, the etiopathology of this new entity is unknown. Bacterial overgrowth is one of the most popular hypothesis, but the onset of the acute inflammation observed by us only in patients with previous ulcerative colitis and in some cases during the period of protective ileostomy suggests a multifactorial pathogenesis.

Fat-induced ileal brake in humans: a dose-dependent phenomenon correlated to the plasma levels of peptide YY

BACKGROUND

Upper gastrointestinal motility is regulated by the presence of nutrients in the distal gut. The present study evaluated whether lipid-induced ileal brake on gastric emptying (1) can be elicited by low fat concentrations; (2) is a dose-dependent phenomenon; and (3) is related to gastrointestinal peptide release.

METHODS

Seven patients were studied in the defunctionalized stage of total colectomy, on three separate occasions. On each study day, patients ate a meal labeled in the solid component; 30 minutes later, one of the following solutions was randomly infused into the ileal pouch: 0.9% saline, 2% oleic acid, and 20% oleic acid. Plasma concentrations of peptide YY (PYY), enteroglucagon, neurotensin, and motilin were measured.

RESULTS

Both oleic acid solutions slowed gastric emptying compared with saline (P < 0.001), the effect being dose dependent (P < 0.001). Ileal infusions did not modify neurotensin and enteroglucagon levels but induced a dose-dependent increase of PYY (P < 0.01) and a borderline decrease of motilin (P = 0.05) levels. Slower rates of gastric emptying were related to increased plasma concentrations of PYY (r = 0.615; P < 0.05).

CONCLUSIONS

This study shows that (1) the ileal brake on gastric emptying can be evoked by low doses of lipids in the distal ileum; (2) the delay of gastric emptying is related to the release of PYY; and (3) both phenomena are dose dependent.

Colo-anal anastomosis with colonic reservoir for cavernous hemangioma of the rectum

The authors report on the clinical history of, and the therapeutic choices for, cavernous hemangioma of the rectum diagnosed in a 27-year-old male admitted for repeated episodes of rectal bleeding. The hemangioma extended to the dentate line and consequently the surgical challenge was to carry out a sphincter-saving procedure. The low resting pressure of the sphincter did not rule out the use of the colo-anal anastomosis procedure, but did require the construction of a pre-anastomotic colonic reservoir. The diagnostic problems and the therapeutic choices related to the salvaging of the sphincter are discussed.

[Comparison of magnetic resonance (0,5 T), computed tomography, and endorectal ultrasonography in the preoperative staging of neoplasms of the rectum-sigma. Correlation with surgical and anatomopathologic findings]

Eighteen cases of rectal carcinoma were staged preoperatively with transrectal endosonography (EUS), CT and MRI (0.5 T). The results were compared with surgical specimens and histology to evaluate the accuracy of the imaging modalities in staging rectal carcinomas which had been quantified according to Astler-Coller's classification. All methods identified the lesion (100% sensitivity). EUS and MRI correctly staged 8 cases (44%) and CT 9 cases (50%). CT and MRI mistakes were relative to overstaging, whereas EUS understaged 4 cases (22%) and overstaged 6 cases (33%). In local tumor staging ("T" variable), CT and MRI understaged no lesions, thus exhibiting 100% sensitivity, which was higher than EUS sensitivity (92%). Conversely, CT and MRI more frequently overstaged the lesions, thus demonstrating lower sensitivity than EUS (55% and 50%, respectively, versus 76% for EUS). As for the "N" variable, EUS identified node metastases in one case only (25%) and misdiagnosed as positive 4 cases of negative node involvement. All the C-stage lesions were correctly diagnosed by CT and MRI (whose findings were in agreement) which also overstaged as C three cases with hyperplastic node enlargement. The diagnostic accuracy of EUS, which was highest for the A and B1 stages, progressively decreased for bigger lesions, clearly understaging node involvement. On the contrary, CT and MRI accuracy rates were lower in small tumors involving the rectal wall only, whereas they always identified tumor spread beyond the bowel wall into perirectal fat, and node metastases. Therefore, to conclude, EUS can be used first: in case of extraluminal tumor spread, CT is the method of choice, more accurate than MRI in identifying node involvement and equally effective in evaluating perirectal fat infiltration and pelvic structures involvement. Whenever the pelvic floor is involved, MRI is the best imaging method, thanks to its multiplanar capabilities, for better detailing of musculoskeletal involvement.

Redo pouches: salvaging of failed ileal pouch-anal anastomoses

From October 1, 1984 to December 31, 1991 at the Clinica Chirurgica II of the University of Bologna, 140 patients submitted to ileal pouch-anal anastomosis for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Nineteen patients (13.5 percent) developed septic complications. Of these, 11 patients (7.8 percent) had pelvic sepsis. Eight patients required further surgical intervention. Five patients underwent the redo pouch procedure. Another redo pouch was performed in a patient who had previously, in another hospital, had an ileal pouch-anal anastomosis placed and then removed because of ischemic necrosis of the reservoir. No deaths are reported in the reoperated patients. Currently, five of the six patients who underwent the redo pouch procedure have a well-functioning ileoanal anastomosis. The redo pouch procedure should always be attempted prior to the establishment of pelvic fibrosis.

Renal stone formation in patients with inflammatory bowel disease

Kidney stones are more common in patients with inflammatory bowel disease (IBD) than in the general population. The main lithogenetic risk factors were evaluated in patients affected by Crohn's disease and ulcerative colitis. Our results show the presence of several factors, besides hyperoxaluria, in patients with IBD although their behaviour appears different in Crohn's disease and ulcerative colitis at pre- and post-operative stages. Before surgery in patients with Crohn's disease we found a decreased citrate (p < 0.001) and magnesium (p < 0.005) excretion together with a low urinary volume (p < 0.001) and pH (p < 0.005). After surgery patients with Crohn's disease showed a further reduction of magnesium and citrate. Patients with ulcerative colitis before surgery showed a reduced citrate excretion (p < 0.05) and a more acidic pH (p < 0.05) than healthy subjects. Surgical treatment of proctocolectomy with ileal pouch-anal anastomosis seems to increase the risk of stone formation; in fact, after surgery we observed a relevant decrease of urinary volume (p < 0.001), pH (p < 0.0001) and urinary excretion of citrate (p < 0.0001) as well as magnesium (p < 0.005). Patients with IBD seem to be at greater risk of stone formation than patients with idiopathic calcium lithiasis; in fact, they show a lower excretion of citrate (p < 0.001) and magnesium (p < 0.001) together with a low urinary pH (p < 0.001) and volume (p < 0.001). Urinary volume reduction is probably one of the major risk factors together with the decrease of small molecular weight inhibitors that is a constant finding in all patients with IBD.