(Gut 2000;47:415-422)

Serum IL-6 and IL-10 may not be ideal measures for evaluation of the degree of tissue trauma in laparoscopic-assisted and open resections in Crohn's disease, probably because of interference with disease-specific cytokine interactions. In contrast, granulocyte elastase has to be considered a strong marker discriminating the different severity of surgical trauma induced by laparoscopic-assisted vs. open resection in Crohn's disease.

No abstract

Patients were referred to our neurophysiological department in order to investigate anorectal function. By the means of magnetic stimulation the total motor conduction can be determined. Only patients with normal latency of the pudendal nerve and normal EMG of the external anal sphincter were examined. Stimulation was carried out above the motor cortex with a MO between 80 and 100%. The recording was carried out in 22 patients with concentric needle electrodes and in the other 18 patients with surface electrodes. The mean latency in the group with surface electrodes was 19.4 ms (SD 1.7), and in the group with needle electrodes 23.4 ms (SD 4). Our results suggest, that in magnetic stimulation above the motor cortex and recording with a concentric needle electrode, the range and the mean was higher than with surface electrodes. In our opinion surface electrodes are preferable to needle electrodes in determining motor conduction time to the external anal sphincter.

Background Continent ileostomy (CI) aims to provide control of gas and faecal evacuation; however, it is rarely performed. This paper reports on outcomes of CI in a large single-surgeon series. Methods All consecutive patients who underwent CI between 1986 and 2015 were reviewed. Patients were classified according to the CI procedure (single stage versus two stage) and according to the underlying disease conditions (inflammatory bowel disease (IBD) versus no IBD). Primary outcome measures were early mortality and complications requiring surgical revision within 30 days (group Ia), those requiring surgical revision within 1–12 months (group Ib), and long-term complications after more than 12 months (group II). Secondary outcome measures were pouch survival and quality of life (QoL) assessed using questionnaires for occupational, sports, sexual, and travel activities; patients undergoing CI after conversion from ileostomy. Analyses were performed using descriptive statistics and Kaplan–Meier curves for the long-term outcomes. Results Sixty-two consecutive patients (28 men, 34 women) who underwent CI were reviewed, including 48 with IBD, and 14 without inflammatory conditions. Mean(s.d.) follow-up was 14.4 (9.5) (range 1–30) years. Twenty-seven patients (44 per cent) developed group I complications, of which 25 were corrected successfully. Two patients dropped out of the analysis: one who died from sepsis and the other owing to pouch loss attributed to unsolvable nipple complications. Of the remaining 60 patients, 23 (38 per cent) developed between one and five group II complications. The cumulative probability of reoperation was 54. per cent at 25 years. Overall, pouch survival was achieved in 90 per cent. The two-stage approach led to significantly fewer complications in group Ia (single stage versus two stage: 8 of 25 versus 2 of 37; P = 0.005), whereas complication rates in group Ib (5 of 23 versus 14 of 37) and group II (9 of 23 versus 14 of 37) were similar. Four CIs failed because of IBD complications. CI pouch and function were preserved in all patients without IBD, whereas in the group with IBD 2 of 31 with ulcerative colitis and 2 of 17 with Crohn’s colitis lost the CI owing to severe intractable inflammatory complications. In 16 patients who had conversion from ileostomy to CI, QoL improved significantly above precolectomy levels in all domains Conclusions CI remains an alternative to conventional ileostomy. Although affected by high reoperation rates, it has the benefit of a high rate of pouch survival.

Minor structural changes of ileoanal pouch mucosa develop early as an adaptive response to a new environment. Only in a small group of patients with chronic pouchitis does severe villous atrophy and crypt hyperplasia of the ileoanal pouch mucosa develop, most likely as a consequence of mucosal inflammation.

After ileostomy construction for Crohn's disease reoperations due to ileal recurrences are thought to be unusually rare, whereas reconstructions of the ileostomy due to stoma complications are considered to be unusually frequent. It remains unclear why the natural course of a disease as well as outstanding results of a standardized surgical procedure should be perverted. Therefore reconstructions of the ileostomy in 92 patients colectomized during a 12.5-year period and followed up for 5.4 years were analyzed concerning preoperative indication and postoperative histology. In 28 patients (30.4%) a total of 42 reoperations were necessary. The clinical indication was prestomal recurrence in 5 reoperations (11.9%) and stoma complications in 37 (88.1%). In contrast, ileal recurrence was demonstrated histologically in 28 specimens (66.7%) and healthy ileum in the rest. There was a statistically significant association between fibrotic recurrence and stoma stenosis/retraction and a trend for association between penetrating recurrence and peristomal ulceration. The cumulative risk for a first reoperation due to clinical recurrence was calculated at 3.3% and 14.0% at 5 and 10 years postoperatively, whereas the corresponding figures for stoma complications were 25.7% and 40.0%. In contrast, the cumulative risk that a recurrence was found histologically on the occasion of the reoperation was 23.0% and 35.0%, while the probability that the ileum was healthy in the case of a stoma complication remained low. In conclusion, most reoperations after ileostomy-construction in Crohn's disease are associated histologically with recurrent inflammation. The accentuation of the inflammatory recrudescence at the stoma itself or the prestomal ileum is decisive for the clinical presentation as stoma complication or intestinal complication. These findings reinforce both well known characteristics of the inflammatory disease and of established surgery.

Necrotizing fasciitis is a synergistic aerobical-anaerobical infection that rapidly spreads from its origin leading to foudroyant increasing soft tissue gangrene and systemic sepsis. In the perineal, perianal and genital regions it is referred to as Fournier's gangrene constituting a clinical entity with the gangrene of the abdominal wall. After a short presentation of the own experience with 17 patients the surgical approach to the life-threatening disease is presented reviewing the former and the recent literature. There is a worldwide consensus that immediate radical excision of the gangrene should be accompanied by intensive care measures. Functional and cosmetic defects are to be reconstructed in a second stage. However, morbidity and mortality remain high in spite of consequent treatment due to often associated significant co-morbidity of affected patients.