Basic Sciences, Miscellaneus : Coloproctology

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

July

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

June

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

May

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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