Transanal endoscopic microsurgery: clinical and functional results

OBJECTIVE

Transanal endoscopic microsurgery (TEM) has become increasingly common in the management of rectal adenomas and also in selected cases of rectal carcinomas. The aim of this study was to assess the results in a consecutive series of patients after introducing the TEM technique.

PATIENTS AND METHODS

All 58 patients operated with TEM from January 1996 to January 1999 were evaluated in a retrospective review. Forty-eight patients answered a clinically validated questionnaire a median of 22 months after TEM. Eighty patients who had undergone transanal excision and 12 who had undergone York Mason's procedure served as a reference group with respect to recurrence rates.

RESULTS

The complication rate was 5% (immediate) and 14% (long-term). The overall 30-day mortality rate was zero. An impairment of continence was seen in 18 (37%) patients. Of these, all 18 experienced varying degree of incontinence to liquid stool, 14 also to flatus and 5 of them even to solid stool. The recurrence rate was 11% in adenomas and 14% in cancers; T1, 1 (10%) recurrence and T2, 1 (50%) recurrence. There was a correlation between operating time and impairment of continence as well as recurrence rate.

CONCLUSION

TEM is a safe procedure, having a low recurrence rate and an acceptable functional outcome.

Proctocolectomy and pelvic pouch--is a diverting stoma dangerous for the patient?

OBJECTIVE

A diverting loop ileostomy was previously considered mandatory for minimizing the effects of septic complications in pelvic pouch surgery. During the past decade there has been a trend towards omission of the loop ileostomy without obvious signs of increased numbers of pouch complications or impaired long-term function. The aim of the present study was to evaluate the risk of complications associated with the construction and closure of the loop ileostomy itself.

PATIENTS AND METHODS

Complications following diverting loop ileostomies in 143 patients subjected to restorative pelvic pouch surgery during the period 1983-97 were studied retrospectively by evaluation of case records.

RESULTS

In the period between discharge after pelvic pouch surgery and closure of the loop ileostomy, 20 (14%) patients were hospitalized because of excessive stoma flow and 19 (13%) patients were treated for other surgical complications, of whom 10 (7%) required surgical intervention. In the early postoperative period (within 30 days) after closure of the loop ileostomy, 18 (13%) patients suffered complications necessitating surgery. Another 12 (8%) patients were hospitalized because of intestinal obstruction that could be treated conservatively.

CONCLUSION

The proportion of complications associated with diverting loop ileostomies in pelvic pouch surgery was considerable. A randomised controlled multicentre study is ethically defensible and is recommended.

Human neutrophil lipocalin is a unique marker of neutrophil inflammation in ulcerative colitis and proctitis

BACKGROUND AND AIM

Accumulation and infiltration by neutrophil granulocytes is a prominent feature in the local inflammatory process in ulcerative colitis (UC). The present study was performed to evaluate human neutrophil lipocalin (HNL) as a specific neutrophil marker in the inflamed lesions of the colon and rectum in patients with colitis and proctitis.

METHODS

The activity of intestinal neutrophils with respect to release of granule proteins was studied in 18 patients with UC (10 with colitis and eight with isolated proctitis) and in 18 healthy controls using perfusion fluid and biopsies from the sigmoid colon and rectum. The released amounts of the neutrophil granule proteins HNL and myeloperoxidase (MPO) were determined by radioimmunoassays, and the location of HNL and MPO in biopsies from colonic mucosa was examined by immunohistochemistry.

RESULTS

Mucosal release of HNL and MPO was increased 10-55-fold in patients with colitis and proctitis compared with controls. Their bowel biopsies demonstrated that only neutrophils were stained with anti-HNL. We also found correlations between HNL and levels of granulocyte/macrophage-colony stimulating factor (GM-CSF) and interleukin 8 (IL-8) in perfusion fluids from the sigmoidal segments of patients with proctitis, between HNL and GM-CSF in rectal segments in patients with proctitis, and in sigmoidal segments in patients with colitis.

CONCLUSION

We conclude that the increased release of HNL and MPO in colorectal perfusion fluids indicates neutrophil involvement in the local inflammatory process, and suggest that HNL may serve as a specific marker of intestinal neutrophil activation in UC. GM-CSF, and to some extent IL-8, may play a role in neutrophil accumulation and priming in this disease.

Allopurinol as prophylaxis against pouchitis following ileal pouch-anal anastomosis for ulcerative colitis. A randomized placebo-controlled double-blind study

BACKGROUND

Pouchitis is the major long-term complication of restorative proctocolectomy for ulcerative colitis (UC). Allopurinol is a scavenger of oxygen-derived free radicals, which it is suggested play a role in the development of UC and pouchitis. The first aim was to test the hypothesis that the incidence of pouchitis can be reduced by prophylactic Allopurinol, and secondly to evaluate if Allopurinol influences the overall pouch function.

METHODS

273 patients with UC who were planned for proctocolectomy and ileal pouch-anal anastomosis at 12 centres in Sweden between October 1994 and June 1997 were offered the opportunity to participate. 184 patients (67%) were randomized to receive postoperative prophylactic Allopurinol 100 mg twice daily or placebo. All 273 patients had clinical and endoscopic follow-up at 1, 3, 6, 12, 18, 24 months after surgery.

RESULTS

Of the 184 randomized patients, 94 were randomized to Allopurinol and 90 to placebo; 116 patients (63%) completed follow-up and the crude incidence of pouchitis among those patients fullfilling the protocol was 31% in the Allopurinol group and 28% in the placebo group (ns). The cumulative risk for a first attack of pouchitis was 30% and 26% after 24 months (ns). The overall pouch function improved over time and did not differ significantly between the two groups.

CONCLUSIONS

Prophylactic Allopurinol did not reduce the risk of a first attack of pouchitis.

IL-5 and TNF-alpha participate in recruitment of eosinophils to intestinal mucosa in ulcerative colitis

There is an increased influx of activated eosinophils to the intestinal mucosa in active ulcerative colitis, and an increased release of eosinophil-derived proteins, such as ECP, has also been observed. These findings indicate that eosinophils may contribute to tissue damage and intestinal inflammation in this disease. The relative importance of different chemotactic factors and the impact of steroid treatment on their effect in active ulcerative colitis are not known. We measured the eosinophil chemotactic activity in perfusion fluids from 11 patients with ulcerative colitis before and after steroid treatment and from 7 control patients. The effect of neutralizing antibodies to IL-5 and -8, RANTES, eotaxin, MCP-3, TNF-alpha, GM-CSF was investigated. The chemotactic activity was higher in perfusion fluids from patients than from controls (P = 0.0043). Anti-IL-5 (P = 0.005) and -TNF-alpha (P = 0.017) inhibited the activity in perfusion fluids obtained before treatment. Steroid treatment prevented the effect of all antibodies but had no significant effect on the chemotactic activity. The chemotactic activity correlated with the levels of eosinophil granule proteins in the perfusion fluids. In conclusion, in ulcerative colitis, eosinophils are attracted to the intestinal tissue by chemotactic factors, of which IL-5 and TNF-alpha may be the most prominent steroid-sensitive ones. The steroid-insensitive chemotactic activities remain unidentified.

Neutrophil and eosinophil granule proteins as markers of response to local prednisolone treatment in distal ulcerative colitis and proctitis

OBJECTIVE

The pathophysiological role of neutrophil and eosinophil granulocytes in relation to steroid enema treatment was studied in patients with distal ulcerative colitis and proctitis.

METHODS

The rectal release of the neutrophil (myeloperoxidase, MPO), and eosinophil (eosinophilic cationic protein, ECP and eosinophil peroxidase, EPO) granule constituents were measured in 11 patients using intraluminal segmental perfusion of the rectum. The released amounts of MPO, ECP, and EPO in the perfusion fluids were determined by radioimmunoassays before and during prednisolone enema treatment and related to clinical, endoscopical, and histopathological data in addition to treatment outcome.

RESULTS

Clinical activity and particularly endoscopic activity correlated well with intraluminal MPO concentrations both before and during treatment. At the end of the study, eight of 11 patients fulfilled predefined response criteria; all responding patients had significant decrease of MPO concentrations (p < 0.01). This decline of MPO concentration was seen after 7 days of treatment (p < 0.05) in the response group and often occurred before clinical improvement. There was a nonsignificant trend toward a decrease in the concentrations of ECP and EPO at the end of treatment in responders.

Evidence of local eosinophil activation and altered mucosal permeability in collagenous colitis

The local release of the inflammatory mediators eosinophil cationic protein and myeloperoxidase and the permeability marker albumin was studied in collagenous colitis using a new technique for segmental perfusion of the rectum and descending colon. Perfusion of both segments was successful in 19/25 (76%) of patients with collagenous colitis and controls with noninflammatory conditions. The concentration of myeloperoxidase was increased in the perfusion fluids from both segments in only one patient with collagenous colitis and in none of the controls. On the other hand, concentrations of eosinophil cationic protein and albumin in the perfusate from the rectum were significantly increased in collagenous colitis compared with controls, and similar trends were seen in the perfusates from the descending colon. Furthermore, there was a significant correlation between the increased concentrations of eosinophil cationic protein and albumin, indicating a possible relation between eosinophil activation and disturbed mucosal permeability in collagenous colitis.

Trimethoprim-sulphamethoxazole and metronidazole as prophylaxis in colorectal surgery: a study of bioavailability after an oral single dose

OBJECTIVE

To evaluate oral single dose prophylaxis in colorectal surgery.

DESIGN

Prospective study.

SETTING

University hospital, Sweden.

SUBJECTS

24 patients (13 women; 11 men; mean age 57 years, range 27-81) listed for elective colorectal operations.

INTERVENTION

At 0630 on the day of the operation all patients were given an oral dose of trimethoprim-sulphamethoxazole (TMP 160 mg and SMZ 800 mg) and metronidazole (2 g). The serum concentrations of TMP and SMZ were analysed in venous samples taken at the start and end of each operation.

RESULTS

The earliest operation started at 0830 and the last finished at 1700. The median (range) serum concentrations of TMP were 1.4 (0.7-2.6) mg/L (start) and 1.3 (1.0-2.8) mg/L (end), and of SMZ 35 (15-65) mg/L (start) and 33 mg (13-70) mg/L (end). The individual values were above or equal to the minimal inhibitory concentration (TMP 0.8 mg/L; SMZ 15.2 mg/L) for relevant gram-negative species.

CONCLUSION

Oral TMP/SMZ in the morning gives satisfactory serum concentrations independently of when the operation is done during the day. The regimen is simple and has the potential for being an effective alternative to intravenous prophylaxis.

Factors influencing the functional outcome of restorative proctocolectomy in ulcerative colitis

BACKGROUND

Restorative proctocolectomy is considered to be the procedure of choice in the operative treatment of ulcerative colitis. The aim of this study was to evaluate the functional outcome following operation and to identify possible predictive factors.

METHODS

Some 168 patients (median age 32 years, 102 men) with ulcerative colitis underwent restorative proctocolectomy. The functional outcome was evaluated by a symptom index created from a questionnaire at a median of 29 (13-123) months of follow-up. The records of these patients were reviewed, and preoperative, peroperative and postoperative variables were registered and related to outcome.

RESULTS

The response rate to the questionnaire was 155 (92 per cent) of 168. The symptom index was related to patients' overall assessment of outcome. In spite of a perceived good result many patients experienced a number of symptoms. Age over 50 years (P < 0.01), presence of extraintestinal manifestations (P < 0.05) and late complications, such as anastomotic stricture (P < 0.05), pouchitis (P < 0.01) and anal pain (P < 0.05), were related to a less favourable outcome.

CONCLUSION

While preoperative data may help in selecting patients suitable for restorative proctocolectomy, prevention of late complications seems most important in improving the functional outcome.

[Peroral antibiotic prophylaxis in upper gastrointestinal surgery. A study of biological availability]

Sixteen patients undergoing elective upper gastrointestinal surgery with presumed normal gastrointestinal function received peroral trimethoprim-sulfamethoxazole (TMP/SMZ 160/800 mg) and metronidazole (2 g) in the morning regardless of what time the operation was to be started. The concentration of SMZ in plasma was measured before and after the operation. Only 37 per cent of the patients were found to have adequate levels of SMZ concentration. Patients with grave obesity or malignant disease of the liver, biliary tract or pancreas had concentrations below the minimal inhibitory concentrations for species of Enterobacteriacae. Peroral antibiotic prophylaxis is therefore not suitable in all types of upper gastrointestinal surgery.

Intestinal mucosal secretion of basic fibroblast growth factor in patients with ulcerative colitis

BACKGROUND

Basic fibroblast growth factor (bFGF) promotes angiogenesis and several other biologic processes, including proliferation of mesenchymal cells and tumor progression. We investigated whether bFGF could be detected in the intraluminal secretion of the small intestine, sigmoid colon, and rectum in healthy individuals and in patients with ulcerative colitis.

METHODS

We used endoscopic perfusion techniques to obtain samples from well-defined intestinal segments. The perfusion fluid concentrations of bFGF, biochemical markers of inflammation, myeloperoxidase (MPO), interleukin-6 (IL-6), and permeability (albumin) were determined with immunochemical methods.

RESULTS

In the perfusion fluids the albumin concentration, which reflects passive diffusion, was less than 1% of the plasma concentration, whereas the intestinal concentration of bFGF was similar to that in plasma. Among healthy subjects the concentration of bFGF was eightfold higher in the jejunum and twofold higher in the rectum than in the sigmoid colon. The perfusion fluid from colorectal segments in patients with ulcerative colitis had a significantly higher mean concentration of bFGF than that from healthy individuals; an almost 10-fold difference was found in rectal segments. There were strong correlations between the concentration of bFGF and the concentrations of MPO and IL-6.

CONCLUSIONS

The high concentrations of bFGF in the intestinal perfusion fluid reflect either a local synthesis or an active secretion of bFGF within the mucosa. The bFGF concentration differs in intestinal anatomic location and increases significantly in patients with ulcerative colitis in close relationship with biochemical markers of inflammation and permeability.

Increased intraluminal release of eosinophil granule proteins EPO, ECP, EPX, and cytokines in ulcerative colitis and proctitis in segmental perfusion

OBJECTIVE

The role of the eosinophil granulocyte in bowel mucosa in inflammatory bowel disease still remains obscure. The present study was performed in order to elucidate the local eosinophil activity and activating cytokines in the inflamed lesions of colon and rectum in patients with ulcerative colitis and proctitis.

METHODS

The activity of intestinal eosinophils with respect to the release of granule proteins was studied in 18 patients (10 with colitis and 8 with isolated proctitis) and 18 healthy controls, using intraluminal segmental perfusion of the sigmoid colon and rectum. The released amounts of eosinophil granule proteins: eosinophil cationic protein (ECP), eosinophil peroxidase (EPO), and eosinophil protein X (EPX) to perfusion fluid were determined by radioimmunoassays. The intraluminal release of possible eosinophil priming cytokines granulocyte/macrophage-colony stimulating factor (GM-CSF) and interleukin 8 (IL-8), were analyzed by immunoassays.

RESULTS

The mucosal release of ECP, EPO, and EPX was increased 10- to 20-fold in patients with colitis and proctitis compared with controls. The intraluminal release of GM-CSF and IL-8, was several-fold enhanced in patients with colitis and proctitis. We also found a correlation between all three eosinophil granule proteins and the levels of IL-8/GM-CSF in the sigmoidal segments of patients with colitis.

CONCLUSIONS

We conclude that the increased release of ECP, EPO, and EPX to colorectal perfusion fluid indicate eosinophil involvement in the local disease in patients with colitis and proctitis. IL-8 and GM-CSF may play a role in eosinophil accumulation and priming in colitis.

Eosinophil activation in ulcerative colitis: studies on mucosal release and localization of eosinophil granule constituents

Activation of eosinophil granulocytes (eosinophils) seems to contribute to the pathophysiology of several inflammatory conditions. This process was evaluated in 18 patients with ulcerative colitis and in 18 healthy controls using intraluminal segmental perfusion of the sigmoid colon and rectum and immunoanalysis for eosinophil cationic protein (ECP) in the perfusate. Immunohistochemistry for eosinophils and neutrophils was made in simultaneously taken biopsies and in biopsies from surgical specimens taken from additional 10 patients. The mucosal release of ECP was increased severalfold in patients with UC. The bowel biopsies demonstrated a lamina propria infiltrated with eosinophils. The degree of eosinophil activation/degranulation was related to the intensity of the inflammatory reaction. Activated eosinophils and extracellular deposits of ECP were, in particular, seen in crypt abscesses and in areas with damaged surface epithelium. Since ECP is highly cytotoxic, its release at the site of inflammatory bowel lesions might reflect a potential pathophysiological mechanism.

Randomized trial of a biofragmentable bowel anastomosis ring in high-risk colonic resection

BACKGROUND

Biofragmentable anastomosis ring (BAR) has been proven to be a safe anastomotic device in elective surgery. The use of this anastomotic ring in high-risk patients has not been established.

METHODS

During a 5-year period (1990-1995), 100 high-risk patients undergoing colonic resection and suitable for a primary anastomosis were allocated randomly to a standard suture technique or to anastomosis performed with a BAR. High risk was defined as large bowel obstruction, complicated diverticular disease, Crohn's disease, local cancer recurrence, previously irradiated colon, and trauma to the colon or rectum. The patients were equally distributed to the two groups regarding sex, age, emergency surgery and concomitant diseases.

RESULTS

In three patients allotted to the BAR group, the device could not be used. There were three (6 per cent) postoperative deaths in each group; none was related to anastomotic problems. Three anastomotic dehiscences were diagnosed, two (4 per cent) in the BAR group and one (2 per cent) in the suture group. Postoperative complications and postoperative recovery were similar.

CONCLUSION

This study shows that the BAR anastomosis probably is as safe as the standard band-sewn anastomosis in high-risk colorectal surgery. As the cost of a BAR anastomosis is substantially higher than that for a hand-sewn anastomosis, the latter technique is still the preferred method in the authors' unit.

Small intestinal mucosal pH and lactate production during experimental ischemia-reperfusion and fecal peritonitis in pigs

The aim of this study was to investigate mucosal pH and lactate production in a porcine model of ischemia/reperfusion and sepsis using both tonometry and a technique for segmental intestinal perfusion. Eighteen pigs (17-23 kg) were anesthetized and mechanically ventilated. They were divided into three groups and followed for 4 h. Group C (n = 6) served as controls. In the ischemia/reperfusion group (I/R; n = 6), the superior mesenteric artery was totally occluded for 60 min. In group P (n = 6), sepsis was induced by fecal peritonitis. Cardiac index (CI) was determined by thermodilution and blood flow in the superior mesenteric artery (QSMA), using a Transonic flow probe. Intramucosal pH (pHi) was calculated using tonometry. A special balloon tube for segmental perfusion was introduced in the midileum for lactate measurement. Lactate and oxygen saturation were measured in arterial blood and in the superior mesenteric vein. CI, QSMA, pHi, and lactate in blood and perfusate remained unchanged in controls. Occlusion of intestinal blood flow induced a fall in pHi from 7.28 +/- .02 to 6.76 +/- .04, a marked rise in lactate in the perfusate, and an increased arteriovenous lactate difference. During reperfusion, pHi tended to return to baseline values. Lactate in the perfusate and the arteriovenous lactate difference decreased. In sepsis there was a continuous reduction in CI and QSMA to 45 +/- 13% and 40 +/- 20% of baseline, respectively. pHi decreased moderately from 7.22 +/- .09 to 6.98 +/- .25. Lactate remained unchanged in blood and perfusate. Microscopic mucosal injury was observed in all animals subjected to ischemia/reperfusion and in three of six pigs in group P. A good association between pHi and lactate production was seen in ischemia/reperfusion. However, in sepsis, lactate in superior mesenteric venous blood or in intestinal perfusate did not increase, despite the fall in pHi. The mechanism causing ischemic mucosal injury has different characteristics in sepsis and in ischemia caused by arterial occlusion.

Factors influencing recurrence in Crohn's disease. An analysis of a consecutive series of 353 patients treated with primary surgery

PURPOSE

This study was undertaken to investigate the factors that influenced the risk of symptomatic recurrence in patients with Crohn's disease who were treated with primary resective surgery.

METHODS

Data regarding age, gender, time from diagnosis to surgery, medication, preoperative infectious complications, laboratory values, emergency/elective surgery, location and extent of disease, and resection margins were analyzed in relation to recurrence in 353 patients who were undergoing a "curative" resection in 1969 to 1986.

RESULTS

Univariate analyses showed a higher risk of recurrence in women with ileal and ileocolonic disease than in men (P < 0.05), in patients with ileocolonic disease compared with those with isolated ileal disease (P < 0.05), and in ileal disease patients with an increased disease extent (P < 0.05). In a multivariate analysis performed on patients with ileal disease, increased disease extent, limited resection on the colonic side, and referral from other hospitals were three independent variables that indicated an increased risk of recurrence (P < 0.05). Length of disease-free resection margins did not influence the risk of recurrence either in univariate or in multivariate analysis (P > 0.05).

CONCLUSIONS

Disease extent has prognostic value regarding the risk of symptomatic recurrence in Crohn's disease, whereas the length of resection margins does not influence the risk of relapse. These results favor a conservative approach, particularly in patients with extensive disease.

Mucosal synthesis and release of prostaglandin E2 from activated eosinophils and macrophages in ulcerative colitis

OBJECTIVE

To study the synthesis and release of prostaglandin E2 (PGE2) in diseased and healthy areas of the colon in ulcerative colitis/proctitis (UC) patients.

METHODS

Perfusate fluid from rectal and sigmoid segments in patients with UC was analyzed for PGE2, eosinophil cationic protein, myeloperoxidase, and tumor necrosis factor-alpha concentrations. To further elucidate the cell-specific origin of mucosal PGE2 synthesis, double immunofluorescence staining as well as imaging analysis using antibodies reactive with prostaglandin H-synthase and cell-specific antigens were used on surgical colonic specimens from patients with active UC and from controls.

RESULTS

The concentrations of PGE2 were, on average, 10-fold higher in perfusates from diseased areas in patients with UC than in perfusates from healthy areas in patients and controls. The PGE2 values correlated well with the released concentrations of eosinophil cationic protein, myeloperoxidase, and tumor necrosis factor-alpha. In the tissue specimens, there was a prominent colocalization in the expression of prostaglandin H-synthase on the one hand and CD 68 (a macrophage marker) and EG1/EG2 (eosinophil cationic protein markers) on the other hand, in both UC patients and controls. This did not apply to prostaglandin H-synthase and antibodies against B and T lymphocytes, neutrophils, or epithelial cells.

CONCLUSION

The increased PGE2 production found in the inflamed mucosa in active UC may be caused by a fraction of activated eosinophils and macrophages.

Regional rectal perfusion: a new in vivo approach to study rectal drug absorption in man

BACKGROUND

In vivo permeability measurements of drugs in the colonic/rectal region in humans are difficult. A new instrument for the perfusion of a defined and closed segment in the colon/rectum was developed. The objective of this study was to evaluate its use for studying drug absorption mechanisms in the human rectum and to investigate the effect of transmucosal water absorption on drug permeability. Six healthy subjects participated at 2 separate occasions by using a modified system for segmental rectal perfusion. The system consisted of a multichannel tube with inflatable balloons and was endoscopically introduced into the rectum. The technique was considered acceptable by the following criteria; (a) high and reproducible recovery of PEG 4000, (b) stable residence time of the solution within the test segment, (c) flux of electrolytes that agrees with previous reports, (d) mass-balance absorption of antipyrine across the rectal barrier, (e) and good acceptability to the subjects. The permeability of antipyrine in the rectal region was increased by inducing net water absorption. D-glucose was not absorbed during any study periods. The present technique is valuable for studying drug absorption from the human rectum.

Enhanced intestinal synthesis of interleukin-6 is related to the disease severity and activity in ulcerative colitis

The concentration of interleukin-6 (IL-6) was measured in the perfusion fluid from investigated rectal and sigmoid segments in patients with ulcerative colitis (UC). The colorectal release of this substance from segments with active inflammation was greatly increased compared with that found in healthy controls and correlated to the mucosal damage defined by plasma protein leakage and endoscopic findings. The perfusate/serum ratio of IL-6 was significantly higher than the corresponding ratio of albumin, indicating that the increased amount of IL-6 detected in the perfusion fluid was synthesized in the inflamed colorectal mucosa. A strong correlation between the concentrations of IL-6 and of tumor necrosis factor-alpha in perfusion fluid suggests that macrophages/monocytes are cells of importance in the stimulated local synthesis of IL-6. The calculated total colorectal release of IL-6 was significantly correlated to the serum concentrations of C-reactive protein and alpha 1-antitrypsin, demonstrating that the acute phase response in patients with UC reflects the amount of locally produced IL-6.

Neutrophil mucosal involvement is accompanied by enhanced local production of interleukin-8 in ulcerative colitis

The concentration of myeloperoxidase, a neutrophil granule constituent, was measured in the perfusion fluid from sigmoid and rectal segments in patients with ulcerative colitis. The concentrations of myeloperoxidase were increased severalfold in the patients with ulcerative colitis compared with healthy controls pointing to an enhanced neutrophil activity. The release of myeloperoxidase correlated to an enhanced local release of the neutrophil activating peptide interleukin-8 (IL-8). Increased values of tumour necrosis factor (TNF-alpha) were also found during intestinal perfusion of the patients and correlated with those of IL-8. The results obtained are compatible with the hypothesis that local mucosal recruitment/activation of neutrophils in ulcerative colitis is mediated by an enhanced IL-8 synthesis. TNF-alpha may be one relevant factor as a stimulus to IL-8 synthesis.

A technique for segmental rectal and colonic perfusion in humans

To enable a better characterization of pathophysiologic processes in colon and rectum, we have developed a perfusion technique for collection of soluble substances and cells from standardized intestinal segments. A tube with balloons attached to its outer wall was endoscopically introduced into the rectum and sigmoid colon, and its position ascertained fluoroscopically. The balloons delimited two segments, one in the sigmoid colon and one in the rectum. The segments were simultaneously perfused by a buffer at 37 degrees C. After a 30-min rinsing period, perfusate and cells were collected at 20-min intervals. Of 51 attempted perfusions, 45 were successfully completed. Recovered volumes equaled those infused. Leakage from the proximal intestine to the segments was negligible. In 18 healthy volunteers, the mean perfusate concentration from the rectal segment was 57.5 (27.5-120.2) mg/L for albumin, 1.3 (1.0-1.7) micrograms/L for eosinophil cationic protein, 5.1 (2.8-9.5) ng/L for prostaglandin E2, and 61.7 (41.7-89.1) micrograms/L for hyaluronan, and all values were lower in the sigmoid segment. Steady state conditions were achieved from the second perfusion period. The perfusate contained 4-80 x 10(4) cells, more than 95% of which were epithelial cells. The technique is safe, has a good subject compliance, and seems to be a valuable tool in investigations on quantitative release of soluble substances and cells in, e.g., colorectal inflammation.