Emergency primary anastomosis in left-sided disease can be performed with a low morbidity and mortality in selected patients, even in the presence of a free perforation with diffuse peritonitis. Patients selected for staged resection, were those with major comorbid disease.

ObjectiveThe authors determined the effect of glutamine-supplementation of TPN on postoperative peripheral blood T-cell response and proinflammatory cytokine production in patients undergoing colorectal resection. Summary Background DataSeveral vital tissues, including the immune system, are very dependent on glutamine; however, this amino acid, which may be essential in conditions of stress, only now is becoming formulated suitably for incorporation into TPN. The effects of such supplementation on the immune function of stressed surgical patients is unknoWn. MethodsPatients (n = 20) were randomized to receive conventional TPN (0.2 g nitrogen/kg/d) or an isonitrogenous/isocaloric regimen with 0.18 g of glutamine/kg/d from days 1 to 6 postoperatively. T-cell DNA synthesis and interleukin (IL)-2 production and peripheral blood mononuclear cell IL-6 and tumor necrosis factor (TNF) production were measured in vitro preoperatively and on days 1 and 6 postoperatively. ResultsT-cell DNA synthesis after 5 days of TPN was increased compared with preoperative values in the glutamine-supplemented group (median preoperative tritiated thymidine uptake: 78.3 X 103 cpm, day 6: 95.0 X 103 cpm, p < 0.05). There was no such increase in the control TPN group (preoperative: 89.0 X 103 cpm, day 6: 69.4 X 103 cpm, p > 0.05). Glutamine supplementation did not influence IL-2 production or the production of TNF or IL-6. ConclusionsGlutamine supplementation may be a method of enhancing T-cell function in the surgical patient receiving TPN. 212

To compare the methods of abdominal rectopexy and to elucidate the mechanism by which rectopexy restores continence in patients with rectal prolapse, the role of sphincter recovery, rectal morphological changes and improved rectal sensation were assessed in 68 patients (eight men, 60 women) of median age 63 (range 18-83) years undergoing resection rectopexy (n = 29), anterior and posterior Marlex rectopexy (n = 20), posterior Ivalon rectopexy (n = 9) or suture rectopexy (n = 10). Preoperative and postoperative manometry, radiology and electrosensitivity measurements were made. Age and duration of follow-up were similar in all groups and the prolapse was controlled in all patients. Significantly improved continence was seen in all but the Ivalon group. There was no evidence of increasing postoperative constipation. Sphincter length and voluntary contraction were unaltered, but improved resting tone was seen in the resection and suture groups. This was not seen in the prosthetic groups. Improved continence correlated with recovery of resting pressure. Upper and sensation was improved in all groups. Radiological changes did not correlate with improved continence. We conclude that continence is improved by all rectopexy procedures but seems better without prosthetic material. Sphincter recovery seems to be the most important factor.

Early experience with an artificial anal sphincter has demonstrated that continence can be restored with acceptable morbidity in patients with severe fecal incontinence.

Internal anal sphincter relaxation occurs on fewer occasions in patients with chronic anal fissures that have failed to heal in comparison to patients with hemorrhoids and normal controls. This evidence further supports the hypothesis that internal sphincter hypertonia may be relevant to the pathogenesis of this disorder.