PURPOSE: The aim of the present study was to assess the integrity of the anal sphincters after handsewn pouch- anal anastomosis performed with the help of a Scott retractor. For this purpose the anal sphincters were v...PURPOSE: The aim of the present study was to assess the integrity of the anal sphincters after handsewn pouch- anal anastomosis performed with the help of a Scott retractor. For this purpose the anal sphincters were visualized with threedimensional endoanal ultrasonography. METHODS: Patients undergoing a colonic pouch- anal anastomosis or an ileal pouchanal anastomosis were included. Before and six months after the procedure, the length and volume of both sphincters were assessed with three- dimensional endoanal ultrasonography, and anal manometry was performed. Continence scores were determined using the Fecal Incontinence Severity Index (FISI). RESULTS: Fifteen patients with a colonic pouch and 13 patients with an ileal pouch were examined. Six months after the procedure, three- dimensional endoanal ultrasonography showed significant alterations of the internal anal sphincter in eight patients with a colonic pouch- anal anastomosis (53 percent) and in eight patients with an ileal pouch- anal anastomosis (62 percent). These alterations were characterized by asymmetry or thinning. No defects were seen in the colonic pouch group, but, in two patients with an ileal pouch, a small defect in the internal anal sphincter was found. A decrease in internal anal sphincter volume was seen only in patients with a colonic pouch- anal anastomosis (P = 0.009). In both groups the length of the internal anal sphincter and the length, thickness, and volume of the external anal sphincter remained the same. After the procedure a reduction of maximum anal resting pressure was found in both groups (colonic pouch: P < 0.001, ileal pouch: P = 0.001). Maximum anal squeeze pressure was reduced in only patients with an ileal pouch- anal anastomosis (P = 0.006). The observed alterations of the internal anal sphincter and the manometric findings showed no correlation with the postoperative Fecal Incontinence Severity Index scores. CONCLUSION: Handsewn pouch- anal anastomosis, performed with the help of a Scott retractor, only rarely leads to internal anal sphincter defects, but three- dimensional endoanal ultrasonography shows alterations of the internal anal sphincter in 57 percent of the patients. No correlation was observed between these alterations and the functional outcome.展开更多
Transanal advancement flap repair has been advocated as the treatment of choice for transsphincteric perianal fistulas, because it enables the healing of almost all fistulas without sphincter damage and consequent con...Transanal advancement flap repair has been advocated as the treatment of choice for transsphincteric perianal fistulas, because it enables the healing of almost all fistulas without sphincter damage and consequent continence disturbance. After initial promising reports, recently less favorable results have been reported. It remains unclear why there is such a large variety in the reported healing rates. Recently, it has been suggested that impaired wound healing caused by a diminished rectal mucosal perfusion in patients who smoke may lead to the breakdown of the advancement flap in patients undergoing flap repair for perianal fistulas. This study was designed to investigate the difference in blood flow in rectal mucosa between patients who smoke and those who do not smoke. Furthermore, we assessed the impact of the creation of a mucosa advancement flap and the difference in blood flow in the flap between smoking and nonsmoking patients. Between July 2001 and July 2002, 23 consecutive patients (19 males; median age, 46 (range, 26- 69) years) with a perianal fistula of cryptoglandular origin underwent surgery for a perianal fistula. Among them were 13 patients who smoked cigarettes. All patients underwent intraoperative laser Doppler flowmetry. Median blood flow before transanal advancement flap repair was 35 (range, 8- 70) volts in patients who did not smoke. In patients who smoked the median blood flow before transanal advancement flap repair was 18 (range, 7- 35) volts. Blood flow was significantly lower in patients who smoked (P = 0.018; Mann-Whitney). In conclusion, it seems likely that impaired wound healing caused by a diminished rectal mucosal perfusion is a contributing factor in the breakdown of advancement flaps in patients who smoke cigarettes.展开更多
PURPOSE: Pouchitis is the major long-term complication after ileal pouch-ana l anastomosis for ulcerative colitis. Metronidazole and ciprofloxacin are common ly used for treatment; however, nothing is known about the ...PURPOSE: Pouchitis is the major long-term complication after ileal pouch-ana l anastomosis for ulcerative colitis. Metronidazole and ciprofloxacin are common ly used for treatment; however, nothing is known about the effects on the pouch flora during and after pouchitis episodes. This study was designed to evaluate t he effect of both antibiotics on eradication of pathogens and the restoration of normal pouch flora. METHODS: The fecal flora obtained from 13 patients with ulc erative colitis was examined at the beginning of a pouchitis episode before trea tment, during treatment with metronidazole or ciprofloxacin, and during pouchiti s-free periods. Some patients experienced more than one pouchitis episode. Ther efore, a total of 104 samples was obtained. Each sample was cultured under aerob ic and anaerobic conditions and the isolated bacteria were identified. Furthermo re, the clinical response to both antibiotics was compared using the Pouchitis D isease Activity Index score. RESULTS: During pouchitis-free periods, the patien ts had a flora characterized by high numbers of anaerobes and no or low numbers of pathogens. This flora resembles normal colon flora. During pouchitis episodes , we found a significant decrease of anaerobes (P = 0.01), a significant increas e of aerobic bacteria (P = 0.01), and significantly more numbers of pathogens, s uch as Clostridium perfringens (in 95 percent of the samples; P< 0.01) and hemol ytic strains of Escherichia coli (in 57 percent of the samples; P = 0.05). Treat ment with metronidazole resulted in a complete eradication of the anaerobic flor a, including C. perfringens. However, no changes in the numbers of E. coli were found. In contrast, when the patient was treated with ciprofloxacin, not only C. perfringens, but also all coliforms including hemolytic strains of E. coli disa ppeared. The larger part of the anaerobic flora was left undisturbed during the administration of ciprofloxacin. Patients treated with ciprofloxacin experienced significant larger reductions in Pouchitis Disease Activity Index score compare d with patients treated with metronidazole (P = 0.04). CONCLUSIONS: This study s trongly suggests a role of pathogenic bacteria (C. perfringens and/or hemolytic strains of E. coli) in pouchitis. From a microbiologic and a clinical point of v iew, ciprofloxacin is preferable to metronidazole, because treatment with ciprof loxacin eradicates both pathogens and results in an optimal restoration of norma l pouch flora.展开更多
文摘PURPOSE: The aim of the present study was to assess the integrity of the anal sphincters after handsewn pouch- anal anastomosis performed with the help of a Scott retractor. For this purpose the anal sphincters were visualized with threedimensional endoanal ultrasonography. METHODS: Patients undergoing a colonic pouch- anal anastomosis or an ileal pouchanal anastomosis were included. Before and six months after the procedure, the length and volume of both sphincters were assessed with three- dimensional endoanal ultrasonography, and anal manometry was performed. Continence scores were determined using the Fecal Incontinence Severity Index (FISI). RESULTS: Fifteen patients with a colonic pouch and 13 patients with an ileal pouch were examined. Six months after the procedure, three- dimensional endoanal ultrasonography showed significant alterations of the internal anal sphincter in eight patients with a colonic pouch- anal anastomosis (53 percent) and in eight patients with an ileal pouch- anal anastomosis (62 percent). These alterations were characterized by asymmetry or thinning. No defects were seen in the colonic pouch group, but, in two patients with an ileal pouch, a small defect in the internal anal sphincter was found. A decrease in internal anal sphincter volume was seen only in patients with a colonic pouch- anal anastomosis (P = 0.009). In both groups the length of the internal anal sphincter and the length, thickness, and volume of the external anal sphincter remained the same. After the procedure a reduction of maximum anal resting pressure was found in both groups (colonic pouch: P < 0.001, ileal pouch: P = 0.001). Maximum anal squeeze pressure was reduced in only patients with an ileal pouch- anal anastomosis (P = 0.006). The observed alterations of the internal anal sphincter and the manometric findings showed no correlation with the postoperative Fecal Incontinence Severity Index scores. CONCLUSION: Handsewn pouch- anal anastomosis, performed with the help of a Scott retractor, only rarely leads to internal anal sphincter defects, but three- dimensional endoanal ultrasonography shows alterations of the internal anal sphincter in 57 percent of the patients. No correlation was observed between these alterations and the functional outcome.
文摘Transanal advancement flap repair has been advocated as the treatment of choice for transsphincteric perianal fistulas, because it enables the healing of almost all fistulas without sphincter damage and consequent continence disturbance. After initial promising reports, recently less favorable results have been reported. It remains unclear why there is such a large variety in the reported healing rates. Recently, it has been suggested that impaired wound healing caused by a diminished rectal mucosal perfusion in patients who smoke may lead to the breakdown of the advancement flap in patients undergoing flap repair for perianal fistulas. This study was designed to investigate the difference in blood flow in rectal mucosa between patients who smoke and those who do not smoke. Furthermore, we assessed the impact of the creation of a mucosa advancement flap and the difference in blood flow in the flap between smoking and nonsmoking patients. Between July 2001 and July 2002, 23 consecutive patients (19 males; median age, 46 (range, 26- 69) years) with a perianal fistula of cryptoglandular origin underwent surgery for a perianal fistula. Among them were 13 patients who smoked cigarettes. All patients underwent intraoperative laser Doppler flowmetry. Median blood flow before transanal advancement flap repair was 35 (range, 8- 70) volts in patients who did not smoke. In patients who smoked the median blood flow before transanal advancement flap repair was 18 (range, 7- 35) volts. Blood flow was significantly lower in patients who smoked (P = 0.018; Mann-Whitney). In conclusion, it seems likely that impaired wound healing caused by a diminished rectal mucosal perfusion is a contributing factor in the breakdown of advancement flaps in patients who smoke cigarettes.
文摘PURPOSE: Pouchitis is the major long-term complication after ileal pouch-ana l anastomosis for ulcerative colitis. Metronidazole and ciprofloxacin are common ly used for treatment; however, nothing is known about the effects on the pouch flora during and after pouchitis episodes. This study was designed to evaluate t he effect of both antibiotics on eradication of pathogens and the restoration of normal pouch flora. METHODS: The fecal flora obtained from 13 patients with ulc erative colitis was examined at the beginning of a pouchitis episode before trea tment, during treatment with metronidazole or ciprofloxacin, and during pouchiti s-free periods. Some patients experienced more than one pouchitis episode. Ther efore, a total of 104 samples was obtained. Each sample was cultured under aerob ic and anaerobic conditions and the isolated bacteria were identified. Furthermo re, the clinical response to both antibiotics was compared using the Pouchitis D isease Activity Index score. RESULTS: During pouchitis-free periods, the patien ts had a flora characterized by high numbers of anaerobes and no or low numbers of pathogens. This flora resembles normal colon flora. During pouchitis episodes , we found a significant decrease of anaerobes (P = 0.01), a significant increas e of aerobic bacteria (P = 0.01), and significantly more numbers of pathogens, s uch as Clostridium perfringens (in 95 percent of the samples; P< 0.01) and hemol ytic strains of Escherichia coli (in 57 percent of the samples; P = 0.05). Treat ment with metronidazole resulted in a complete eradication of the anaerobic flor a, including C. perfringens. However, no changes in the numbers of E. coli were found. In contrast, when the patient was treated with ciprofloxacin, not only C. perfringens, but also all coliforms including hemolytic strains of E. coli disa ppeared. The larger part of the anaerobic flora was left undisturbed during the administration of ciprofloxacin. Patients treated with ciprofloxacin experienced significant larger reductions in Pouchitis Disease Activity Index score compare d with patients treated with metronidazole (P = 0.04). CONCLUSIONS: This study s trongly suggests a role of pathogenic bacteria (C. perfringens and/or hemolytic strains of E. coli) in pouchitis. From a microbiologic and a clinical point of v iew, ciprofloxacin is preferable to metronidazole, because treatment with ciprof loxacin eradicates both pathogens and results in an optimal restoration of norma l pouch flora.
