Anastomotic integrity after operations for large-bowel cancer: a multicentre study.

Clinically evident anastomotic dehiscence was studied in 1466 patients who had undergone resection of a large-bowel adenocarcinoma. The overall incidence of anastomotic leakage was 13%, but the incidence varied between surgeons (range 0.5% to over 30%). Morbidity and mortality were significantly higher in those patients in whom the anastomosis failed to heal primarily. If these results are extrapolated to the national level, it should be possible by achieving results closer to those in patients without leakage to reduce overall post-operative mortality after resection of large-bowel cancer by 2% and to achieve an appreciable reduction in morbidity. Both factors are clinically important and, taken together, could result in appreciable saving of revenue.     

Irritable bowel syndrome and abdominoplasty

Irritable bowel syndrome is a chronic disease involving pain or discomfort relieved by defecation and associated with a change in frequency or consistency of the stools. The effect of abdominoplasty on patients with irritable bowel syndrome has not been elucidated, so advising patients with irritable bowel syndrome about the effects of surgery on their disease was difficult. One hundred female patients from a pool of 120 patients responded to a questionnaire relating to abdominoplasty surgery. Follow-up ranged from 6 months to 2 years. Patients completed questionnaires formulated on the basis of Rome II Diagnostic Criteria. Of the 100 patients, nine had true irritable bowel syndrome, nine had moderate symptoms and were receiving medication (not true irritable bowel syndrome), 16 had mild symptoms on occasional medication, and 66 had no symptoms of irritable bowel syndrome before surgery. Of the true irritable bowel syndrome patients, all had symptomatic improvement with decreased medication, eight of the nine patients with moderate symptoms improved markedly, and five of the 16 patients with mild symptoms improved significantly. No patient had any initiation or deterioration of symptoms. It is thus concluded that the symptoms of irritable bowel syndrome are certainly not worsened, in the short term, by surgery, and may be alleviated or improved in most significant cases.     

Mutagens in human faeces. Are they relevant to cancer of the large bowel?

1. Mutagenic activity has been detected in faecal extracts, prepared by a number of methods, from donors living under widely differing geographical, cultural and dietary circumstances. Faecal extracts cause point mutations in bacteria and chromosomal damage in cultured mammalian cells. 2. The claims that nitroso compounds are present in human faeces have been retracted, and the chemical nature of faecal mutagens is still unknown. Indirect evidence suggests the presence of several classes of mutagen. 3. The use of different methods of mutation assay gives conflicting estimates of the proportion of people who excrete mutagenic faeces. There is wide variation in mutagenic activity between different stool samples from one person, and between different stool samples from different people. There is conflicting evidence for inhibition or enhancement of the mutagenicity of reference mutagens by faecal extracts. The effects of air oxidation on the mutagenicity of faecal extracts have not been investigated in detail. 4. It has been claimed that the proportion of people excreting mutagenic faeces is higher in groups representing populations at high risk of large-bowel cancer than in groups at low risk of large-bowel cancer. For the reasons given in paragraph 3, these claims must be regarded as premature. 5. The part played by faecal mutagens in the aetiology of large-bowel cancer has yet to be determined.     

Histochemical alterations of mucin in normal colon, inflammatory bowel disease and colonic adenocarcinoma

Summary Loss of sialic acid o-acyl substitutions in colonic mucus was studied using specific histochemical techniques in individuals with a variety of large-bowel diseases and in a control population. Changes found included a focal or field (diffuse) loss of side-chain substitutions which were qualitatively similar in all groups studied. The results were tested statistically using a variety of assumptions that field and/or focal loss of o-acyl substitution may be either abnormal or a normal variant. No statistically significant differences in the prevalence of substitutions were detected between normal males and females or between normal individuals aged 0–29 years and 30–80 years. Significant differences were found between ascending and descending colon in both normal individuals and in the non-neoplastic mucosa of patients with cancer. There were also significant differences between the normal descending colon and cases with cancer of the descending colon. These differences seem unlikely to be due to non-specific factors, since for most assumptions there were also differences between colons containing cancer and those from patients with inflammatory bowel disease. In agreement with the work of other investigators, it seems likely that focal loss of o-acetylation results from an acquired gene mutation. It is not clear whether or not this plays a role in carcinogenesis. Deceased 21 May, 1994.     

Stability of Methanobrevibacter smithii populations in the microbial flora excreted from the human large bowel

Total anaerobic bacteria and Methanobrevibacter smithii populations were enumerated in fecal specimens from two individuals over 10- and 13-month periods. The ratio of M. smithii to total anaerobic count varied between the individuals, but it was a relatively constant proportion of the large-bowel microbial flora within each individual. Neither a barium enema examination of one subject nor a radical change in the diet of the other had any long-term effect on the methanogen populations.     

Towards positive diagnosis of the irritable bowel.

A questionnaire to establish the presence of 15 symptoms thought to be typical of the irritable bowel syndrome (IBS) was given to 109 unselected patients referred to gastroenterology or surgery clinics with abdominal pain or a change in bowel habit or both. Review of case records 17--26 months later established a definite diagnosis of IBS in 32 patients and of organic disease in 33. Four symptoms were significantly more common among patients with IBS--namely, distension, relief of pain with bowel movement, and looser and more frequent bowel movements with the onset of pain. Mucus and a sensation of incomplete evacuation were also common in these patients. The more of these symptoms that were present the more likely was it that the patient''s pain or altered bowel habit, or both, was due to IBS. We conclude that a careful history can increase diagnostic confidence and reduce the amount of investigation in many patients with chronic abdominal pain.     

Stability of Methanobrevibacter smithii Populations in the Microbial Flora Excreted from the Human Large Bowel

Total anaerobic bacteria and Methanobrevibacter smithii populations were enumerated in fecal specimens from two individuals over 10- and 13-month periods. The ratio of M. smithii to total anaerobic count varied between the individuals, but it was a relatively constant proportion of the large-bowel microbial flora within each individual. Neither a barium enema examination of one subject nor a radical change in the diet of the other had any long-term effect on the methanogen populations.     

Clinical and Diagnostic Significance of Enteroclysis Through Nasointestinal Decompression Intubation

To study the clinical and diagnostic significance of enteroclysis through nasointestinal decompression intubation, thirty-five patients with small bowel obstruction were enrolled. A nasointestinal catheter of 300 cm was placed through the nasal cavity then pushed to the upper jejunum under X-ray realtime monitoring. The patients underwent intra-small-intestinal suction therapy reducing or relieving the obstruction after 3 days. As the catheter reached the lesions, we conducted selective imaging. Using fluoroscopy, we injected 20–100 ml meglumine diatrizoate 76 % and 50–200 ml air via the decompression suction port to produce a double-contrast radiography. The catheter was then retrieved to the upper jejunum, and the X-ray of the small intestine was obtained. All 35 patients had successful intubations. The decompression treatment resolved symptoms in 20 cases and alleviated symptoms in 15 cases. Ten cases underwent surgery. The images obtained by infusing meglumine diatrizoate through the decompression catheter were of good quality. Among the 35 cases, six were absent of any distinct abnormal signs on the X-ray, 15 had adhesive ileus, four had small bowel tumor (three metastatic tumor, one small bowel cancer), three had Crohn’s disease, three had radiation enteritis (one of the three was mistaken for small bowel metastatic tumor), two had enteric intussusception, one had a polyp in the small intestine, one had ascending colon cancer. The nasointestinal decompression intubation under X-ray monitoring serves a dual function for patients with intestine obstruction, by decompressing the small bowel and examining the small intestinal radiographically. The X-rays can confirm the obstruction and provide guidelines for surgery.     

CT平扫对肠坏死诊断价值

目的:探讨CT平扫对肠坏死诊断价值,总结肠管坏死征象。方法:分析98例可疑肠坏死患者CT平扫图像,所有患者均经手术证实或未能及时治疗死亡患者CT平扫影像,总结、分析影像特点。结果:全部患者中40例患者存在肠坏死,肠壁厚度改变,包括29例肠壁增厚,8例肠壁菲薄,5例表现为肠壁密度减低,3例表现为肠壁密度增加,25例表现肠管扩张,8例表现肠管塌陷,36例肠管内积液,其中34例见气液平面,4例仅见积气,5例肠壁内见气泡影,38例见腹腔积液,10例见系膜水肿,2例见肠系膜血管密度增高,1例肠系膜静脉内气体,1例门静脉内气体,5例见腹腔游离气体。结论:多排螺旋CT平扫对肠坏死部位及范围的评价有较高的价值,同时CT平扫能明确病因,为及早治疗打下良好基础。     

Tritrichomonas foetus and not Pentatrichomonas hominis is the etiologic agent of feline trichomonal diarrhea

Recently, several investigators have reported large-bowel diarrhea in cats associated with intestinal trichomonad parasites. These reports have presumptively identified the flagellates as Pentatrichomonas hominis, a n organism putatively capable of infecting the intestinal tracts of a number of mammalian hosts, including cats, dogs, and man. The purpose of the present study was to determine the identity of this recently recognized flagellate by means of rRNA gene sequence analysis; restriction enzyme digest mapping; and light, transmission, and scanning electron microscopy (SEM).     

The specialty of colon and rectal surgery: its impact on patient care and role in academic medicine

The specialty of colon and rectal surgery, a specialty of general surgery, has evolved from the field of proctology. Clinical care has demonstrated decreased number of patients requiring intestinal stomas, improved quality of life in patients with benign anorectal disorders, and more favorable results in patients afflicted with primary and recurrent colorectal cancer. Basic science investigations have spawned from clinical questions such as the molecular biology of colorectal cancer, use of cyclooxygenase inhibitors and polyp regression, and novel cytokine antagonists in inflammatory bowel disease. Medical students are exposed to surgeons with expertise in anorectal anatomy and physiology, mechanisms of carcinogenesis and the importance of screening for detection of colorectal cancer, and novel therapies for inflammatory bowel disease. Surgical residents benefit by having a colorectal surgeon on the faculty by repetitive exposure to anorectal surgery, low pelvic anastomoses, stoma creation and closure, and surgery involving the small intestine. Senior colorectal surgeons will develop critical pathways for the healthcare delivery of patients afflicted with colorectal disease. The specialty of colorectal surgery will continue to translate into improved patient care and positively impact in academic medicine by providing expertise into student and resident training and generate highly sophisticated clinical and basic science investigations.     

Carcinoma of Large Bowel in the Young

The incidence of large-bowel carcinoma in young people seems to be increasing. Twenty-one cases occurring between the ages of 13 and 25 are reviewed. Most cases were found to be in an advanced state of the disease. High grade malignant growths were found to be twice as common in the young as in adults. The mode of presentation is no different from that in adults and a plea is made for improving results of treatment by earlier diagnosis, which can be established by an increased awareness of the disease in children and young adults.     

Effects of bacterial colonization on mucosal structure of the large bowel of neonatal rats

Micro-anatomical changes in colonic and caecal epithelia of infant rats between birth and weaning appear to be the outcome of the effects of bacterial colonization, superimposed on the natural postnatal ontogeny of the mucous membranes. Conventional rat pups between 15 and 22 days of age showed development of subepithelial spaces in both caecum and colon, rupture of the overlying epithelium and loss of whole enterocyte plaques. Antibiotic-treated animals retained the large-bowel mucosal morphology of the 10-day-old rat, without any of the lesions described in conventional infants. Mucosal lesions were typical of ischaemic damage, possibly triggered by lumen anoxia during colonization.     

Effect of epidermal growth factor on intestinal adaptation after allogeneic small bowel transplantation in rats

We reported that epidermal growth factor (EGF) stimulated graft adaptation in a rat model of syngeneic small bowel transplantation. However, graft rejection is a severe problem with clinical small bowel transplantation, because small intestinal wall contains large amounts of lymphoid tissue. Studies were performed to investigate the effect of EGF on allogeneic graft adaptation after small bowel transplantation in rats treated with an immunosuppressant FK506. The transplanted animals received intraperitoneally EGF or saline (untreated) after surgery and were examined for analysis one week later. EGF-treated group markedly enhanced the water absorption and induction of sodium glucose cotransporter (SGLTI) as compared with EGF-untreated group. EGF-treated group also increased the mucosal crypt depth and its cell proliferating rate, although there was no significant difference in the mucosal villus height between the two groups. These results indicate that EGF accelerates intestinal allograft adaptation in part by the recovery of mucosal structure and function after small bowel transplantation in rats. EGF may have relevance to promote graft function in clinical small intestinal transplantation.     

Malignant Carcinoid Tumour with Gangrene of the Small Intestine

Four patients with a malignant carcinoid tumour of the small bowel (three had the carcinoid syndrome) developed gangrene of the small intestine. Attention is drawn to this seldom recognized complication, as early surgery may be life saving.     

Breast Milk Substitute: A Bacteriological Study

The increased susceptibility of infants fed on cows'' milk preparations has been attributed, at least in part, to differences in the nature of the large-bowel content—owing to the acidity of the faeces and their high content of Lactobacillus bifidus. In an attempt to mimic these features of the breastfed infant in one who is fed artificially, a breast milk substitute was devised which resembles breast milk in several important ways. When this material was fed to newborn infants the faeces developed the characteristics of those of the breast-fed child.     

Radiation Enteropathy of the Small Bowel

The features of radiation injury of the small bowel are reviewed to focus attention on this uncommon but persistent problem which usually arises in women undergoing treatment for gynecological malignancy and which may be confused with recurrence of the malignant growth. Intestinal perforation, bleeding, obstruction and fistulas have all been observed in patients with radiation enteropathy. Three cases in which these complications occurred are reported. Early excisional surgery is considered to be the preferred treatment, although conservative surgical procedures have been used for patients who are very ill or for those with diffuse bowel changes. Medical measures alone have not been successful but have been utilized in preoperative preparation.     

肠镜下置入支架治疗左半结肠癌性梗阻的临床疗效分析

目的:探讨肠镜下置入支架治疗左半结肠癌性梗阻的应用价值。方法:对我院54例左半结肠癌性梗阻的患者行肠镜下支架置入术,恢复肠道通畅性。结果:24例患者永久性植入结肠内支架以姑息的治疗,30例患者暂时植入结肠支架,并行肠道准备,择期外科手术。术后患者无死亡,无相关并发症的发生,均痊愈出院。结论:肠镜下置入支架在治疗左半结肠癌性梗阻中有临床应用价值,既可作为姑息疗法,也可作为术前准备的一部分。     

An unusual presentation of a malignant jejunal tumor and a different management strategy

BACKGROUND: Malignant small bowel tumors are very rare and leiomyosarcoma accounts for less than 15% of the cases. Management of these tumors is challenging in view of nonspecific symptoms, unusual presentation and high incidence of metastasis. In this case report, an unusual presentation of jejunal sarcoma and management of liver metastasis with radiofrequency ablation (RFA) is discussed. CASE PRESENTATION: A 45-year-old male presented with anemia and features of small bowel obstruction. Operative findings revealed a mass lesion in jejunum with intussusception of proximal loop. Resection of bowel mass was performed. Histopathological findings were suggestive of leiomyosarcoma. After 3-years of follow-up, the patient developed recurrence in infracolic omentum and a liver metastasis. The omental mass was resected and liver lesion was managed with radiofrequency ablation. CONCLUSION: Jejunal leiomyosarcoma is a rare variety of malignant small bowel tumor and a clinical presentation with intussusception is unusual. We suggest that an aggressive management approach using a combination of surgery and a newer technique like RFA can be attempted in patients with limited metastatic spread to liver to prolong the long-term survival in a subset of patients.     

Systemic and local secretions of cytokines and nitric oxide in massive bowel resected rats with or without small bowel segment reversal

Our previous study suggested that small bowel segment reversal stimulates jejunal hyperplasia, but that the elevated serum interleukin (IL-)6 eliminates whole-body anabolism in massive bowel resected rats. The aim of this study was to investigate systemic and local secretions of cytokines and nitric oxide (NO) in relation to whole-body and tissue responses in rats that underwent massive bowel resection with small bowel segment reversal. Seventy percent small bowel resection was performed in Wistar rats with (REV) or without (CON) a 5 cm reversed small bowel segment. Sham operation (SHAM) was performed on a third group of rats. Twelve days after surgery the REV group had significantly lower weight gain and greater serum levels of NO, IL-2 and IL-6 than the CON and SHAM groups. The weights of the livers in the REV and CON groups were significantly heavier, but these groups had lower levels of protein, tumour-necrosis factor-alpha, IL-2 and IL-6 than the SHAM group. The cecum weights of the REV group were significantly higher with increased protein and NO levels, but decreased IL-6 levels compared with the CON and SHAM groups. In the proximal small intestine the REV group had significantly increased protein levels and mucosal dry weights, but decreased interferon-gamma and IL-2 compared with the CON and SHAM groups. Our results suggested that cytokines and NO may have endocrine and paracrine/autocrine actions in regulating whole-body and tissue responses.