Heppell, Jacques

AbstractBackgroundThe aim of the present study was to examine the early outcome in patients undergoing intestinal resection for Crohn’s disease (CD) while they are receiving perioperative immunosuppressive medication.MethodsWe reviewed patients with CD undergoing intestinal surgery from 1999 to 2007. Demographics and relevant perioperative information, including medication, were extracted from patient charts. Statistical analysis was performed using Fisher’s exact test.ResultsDuring the course of the study period 112 with Crohn’s disease underwent intestinal resection, and 69 of them were receiving perioperative medication (47, corticosteroids; 39, immunomodulators; and 17, anti‐tumor necrosis factor‐α antibodies). There were no deaths. Median blood loss was 137 ml. Twenty‐two of the patients using perioperative medication (32%) experienced complications, 10 of which were major. The major complications occurred in 3 of the 43 patients (7%) who were not receiving perioperative medications, in 5 of 38 patients (13%) who were receiving one drug, 4 of 28 patients (14%) receiving two drugs, and 1 of 3 patients (33%) receiving three drugs. Thus the occurrence of major complications was not significantly greater in patients receiving perioperative medication. Risk factors for a major complication were intraoperative blood loss >400 ml (P < 0.003) and emergency surgery (P < 0.005).ConclusionsThe occurrence of complications in Crohn’s disease patients undergoing intestinal resection was not associated with the use of immunosuppressive medication. However, emergency surgery and blood loss were risk factors, and reflect the difficulty of surgery in this group of patients.

AbstractPurposeManagement of anal fistula represents a balance between curing the condition and maintaining anal continence. Recent reports of the results of the porcine anal fistula plug have demonstrated excellent fistula healing rates without reporting significant complications.MethodsThe outcome of patients who underwent treatment for anal fistula with the Surgisis® anal plug was retrospectively reviewed.ResultsTwenty patients were treated; three underwent concomitant anal advancement flap at the time of plug placement. Seventeen patients had a trans‐sphincteric fistula, and three had an anoperineal fistula. Ten patients had previously undergone failed surgical therapy to cure their fistula, including anal advancement flap in four, muscle interposition flap in two, fistulotomy in two, and cutting seton placement in two. Mean follow‐up was 7.4 months. Only 4 of 17 (24%) patients treated with the plug alone had closure of their fistula. Acute postoperative sepsis was seen in 5 of 17 (29%) patients treated with the plug alone. Four developed perianal abscesses that required incision and drainage, and one intersphincteric abscess was treated with antibiotics. Two of the patients who underwent concomitant anal advancement flaps and plug placement healed successfully.ConclusionsContrary to other published series, the use of the Surgisis® anal plug was associated with a low rate of fistula healing and a high incidence of perianal sepsis. The addition of a transanal advancement flap to the procedure may improve success rates.

The purpose of this study was to evaluate the short-term outcomes after laparoscopic and conventional parastomal hernia repairs. A retrospective review of parastomal hernia repairs was performed. Conventional repairs included primary suture repair, stoma relocation, and mesh repair. Laparoscopic repairs included the Sugarbaker and keyhole techniques. Forty-nine patients underwent repair of symptomatic parastomal hernias: 19 ileostomies, 13 colostomies, and 17 urostomies. Thirty patients underwent 39 conventional repairs. Nineteen patients underwent laparoscopic surgical repairs. Operative times were longer for laparoscopic repair (208 ± 58 vs 162 ± 114 minutes, P = .06). The mean length of stay was 6 days for both groups ( P = .74). The mean follow-up was shorter in the laparoscopic group (20 vs 65 months, P ≤ .001). There were no significant differences in the incidence of surgical site infections (11% laparoscopic vs 5% conventional, P = .60) or complication rates (63% laparoscopic vs 36% conventional, P = .67). Laparoscopic parastomal hernia repair is a feasible operation with similar short-term outcomes to conventional repairs.

BACKGROUND Chronic ulcerative conditions in the gastrointestinal tract result in the appearance of the ulcer associated cell lineage (UACL). The glands of this new cell lineage secrete epidermal growth factor, transforming growth factor α, and the trefoil factor family (TFF) peptides, which are known to participate in repair processes. Pouchitis is the most frequent complication of ileal pouch-anal anastomosis. AIM Our aim was to determine whether the mucosal ulceration present in pouchitis can induce the development of UACL glands. METHODS Biopsies from ileal pouches with pouchitis (n=10), healthy pouches (n=5), and normal terminal ileum (n=5) were studied. Expression of TFF mRNA was assessed by in situ hybridisation. TFF1 and TFF2 proteins were localised by immunochemistry. RESULTS UACL glands containing TFF1 and TFF2 were observed in six patients with pouchitis. In some glands, there was TFF3 mRNA as has been reported for Crohn's UACL. None of the biopsies from ileal reservoirs without pouchitis showed UACL glands (p<0.05). Neither TFF1 nor TFF2 expression was detected in ileal reservoirs without pouchitis. CONCLUSION UACL glands arise de novo in ileal pouch mucosa of patients with pouchitis and express all three TFF peptide genes. Chronic inflammation alone, present in healthy pouches, is not enough to stimulate the growth of the UACL, and additional stimuli consequent on ulceration may be needed.