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Extent of colitis in surgical outcome
1920
What’s New in GI
Extent of Colitis and Surgical Outcome Hassan I, Horgan AF, Nivatvongs S, et al. Outcome of patients undergoing ileal pouch-anal anastomosis for leftsided chronic ulcerative colitis. J Gastrointest Surg 2003;7:567–71. The extent of disease in patients with chronic ulcerative colitis ranges from ulcerative proctitis to pancolitis. Almost one half of patients with ulcerative proctitis will maintain fairly localized disease, whereas the other half will experience progression into more diffuse pancolitis. It remains controversial whether patients who maintain limited proctocolitis have a disease entity that is distinct from that in individuals who develop more extensive disease. Extensive colon involvement may be associated with differences in metabolic and immunological function. In addition, patients with more limited proctocolitis seem to have a lower risk of malignancy, fewer systemic complications, and a lower requirement for colectomy than patients with more extensive disease. The issue addressed in this article was whether patients with more limited colitis have different preoperative characteristics and a different postoperative clinical course after undergoing an ileal pouch–anal anastomosis. Hassan et al. performed a retrospective review of 565 patients undergoing ileal pouch–anal anastomosis for chronic ulcerative colitis over a 6-yr period. They identified 111 patients who had primarily left-sided involvement and 283 patients who had pancolitis. Of the patients, 124 were excluded because they had undergone previous colectomy, had coexistent cancer, were ⬍16 yr of age, had inadequate follow-up data, or there were concerns about the pathological diagnosis. Left-sided colitis was defined as occurring up to the splenic flexure. Patients with left-sided colitis were slightly older (37 yr vs 34 yr, p ⫽ 0.01) and had a longer median duration of disease (8.7 yr vs 7.7 yr,
AJG – Vol. 98, No. 9, 2003
p ⫽ 0.05) compared to patients with pancolitis. Postoperative complication rates were similar except for a higher incidence of small bowel obstruction in patients with left-sided colitis at 5 yr (27% vs 13%, p ⫽ 0.002). However, there were no significant differences in the incidence of pouchitis (43% vs 39% at 5 yr) or in the long term functional results and quality of life assessment. The authors conclude that although patients with left-sided colitis were older, had longer duration of disease, and perhaps had an increased risk of small bowel obstruction, their long term outcome after ileal pouch–anal anastomosis was similar to that of individuals with more extensive disease. This study supports a clinical approach in which patients with leftsided colitis who require surgery are believed to be appropriately treated in a fashion similar to that of individuals with pancolitis. Although the authors suggest that these findings support the concept that left-sided colitis and pancolitis are the same disease with a different extent of involvement rather than different disease entities, this, of course, will remain controversial and will require further study. Jon S. Thompson, M.D.
Antral Overload and Symptoms in Functional Dyspepsia Caldarella MP, Azpiroz F, Malagelada J-R. Antro-fundic dysfunctions in functional dyspepsia. Gastroenterology 2003;124:1202–29. The stomach can be divided functionally into proximal and distal parts. Proper coordination between the two parts is essential for normal gastric function. Although symptoms in patients with functional dyspepsia (FD) have generally been attributed to impaired activity of the proximal stomach, recent studies suggest that abnormalities in the distal stomach may
also contribute. Caldarella et al. hypothesized that dysfunction occurring in patients with FD affects both regions of the stomach, thereby causing discoordination and the generation of dyspeptic symptoms. To test their hypothesis, they conducted a comprehensive investigation involving 30 patients with FD and 22 healthy subjects in two sequential studies. In the first part of the study, conducted with the subject in an upright position, the proximal and distal stomach were distended by balloons containing air or water, respectively, while perception and fundic relaxation in response to antral distension were measured. In the second part, with the subjects placed on their right and left sides, air-filled balloons positioned in similar locations and connected to a tensostat were selectively distended while perception, compliance, and responses to intestinal nutrient infusion were measured. They found that: 1) hypersensitivity to luminal distension of both the proximal and distal stomach was present in FD patients, with antral hypersensitivity being further magnified by luminal nutrients; and 2) although fundic and antral fasting tone was normal, reflex fundic relaxation induced by either antral distension or intestinal nutrient infusion was impaired in FD patients. The investigators conclude that antral and fundic dysfunctions (namely, antral hypersensitivity and impaired fundic accommodation) may interact to cause an alteration in the intragastric distribution of contents, thereby producing a situation of “antral overload,” which then contributes to the generation of dyspeptic symptoms. This ambitious study has demonstrated the complex relationship between the parts of the stomach; in so doing, it may provide a more comprehensive explanation of symptom generation in FD and may also lead to alternative therapeutic options. John K. DiBaise, M.D.
What’s New in GI
Extent of Colitis and Surgical Outcome Hassan I, Horgan AF, Nivatvongs S, et al. Outcome of patients undergoing ileal pouch-anal anastomosis for leftsided chronic ulcerative colitis. J Gastrointest Surg 2003;7:567–71. The extent of disease in patients with chronic ulcerative colitis ranges from ulcerative proctitis to pancolitis. Almost one half of patients with ulcerative proctitis will maintain fairly localized disease, whereas the other half will experience progression into more diffuse pancolitis. It remains controversial whether patients who maintain limited proctocolitis have a disease entity that is distinct from that in individuals who develop more extensive disease. Extensive colon involvement may be associated with differences in metabolic and immunological function. In addition, patients with more limited proctocolitis seem to have a lower risk of malignancy, fewer systemic complications, and a lower requirement for colectomy than patients with more extensive disease. The issue addressed in this article was whether patients with more limited colitis have different preoperative characteristics and a different postoperative clinical course after undergoing an ileal pouch–anal anastomosis. Hassan et al. performed a retrospective review of 565 patients undergoing ileal pouch–anal anastomosis for chronic ulcerative colitis over a 6-yr period. They identified 111 patients who had primarily left-sided involvement and 283 patients who had pancolitis. Of the patients, 124 were excluded because they had undergone previous colectomy, had coexistent cancer, were ⬍16 yr of age, had inadequate follow-up data, or there were concerns about the pathological diagnosis. Left-sided colitis was defined as occurring up to the splenic flexure. Patients with left-sided colitis were slightly older (37 yr vs 34 yr, p ⫽ 0.01) and had a longer median duration of disease (8.7 yr vs 7.7 yr,
AJG – Vol. 98, No. 9, 2003
p ⫽ 0.05) compared to patients with pancolitis. Postoperative complication rates were similar except for a higher incidence of small bowel obstruction in patients with left-sided colitis at 5 yr (27% vs 13%, p ⫽ 0.002). However, there were no significant differences in the incidence of pouchitis (43% vs 39% at 5 yr) or in the long term functional results and quality of life assessment. The authors conclude that although patients with left-sided colitis were older, had longer duration of disease, and perhaps had an increased risk of small bowel obstruction, their long term outcome after ileal pouch–anal anastomosis was similar to that of individuals with more extensive disease. This study supports a clinical approach in which patients with leftsided colitis who require surgery are believed to be appropriately treated in a fashion similar to that of individuals with pancolitis. Although the authors suggest that these findings support the concept that left-sided colitis and pancolitis are the same disease with a different extent of involvement rather than different disease entities, this, of course, will remain controversial and will require further study. Jon S. Thompson, M.D.
Antral Overload and Symptoms in Functional Dyspepsia Caldarella MP, Azpiroz F, Malagelada J-R. Antro-fundic dysfunctions in functional dyspepsia. Gastroenterology 2003;124:1202–29. The stomach can be divided functionally into proximal and distal parts. Proper coordination between the two parts is essential for normal gastric function. Although symptoms in patients with functional dyspepsia (FD) have generally been attributed to impaired activity of the proximal stomach, recent studies suggest that abnormalities in the distal stomach may
also contribute. Caldarella et al. hypothesized that dysfunction occurring in patients with FD affects both regions of the stomach, thereby causing discoordination and the generation of dyspeptic symptoms. To test their hypothesis, they conducted a comprehensive investigation involving 30 patients with FD and 22 healthy subjects in two sequential studies. In the first part of the study, conducted with the subject in an upright position, the proximal and distal stomach were distended by balloons containing air or water, respectively, while perception and fundic relaxation in response to antral distension were measured. In the second part, with the subjects placed on their right and left sides, air-filled balloons positioned in similar locations and connected to a tensostat were selectively distended while perception, compliance, and responses to intestinal nutrient infusion were measured. They found that: 1) hypersensitivity to luminal distension of both the proximal and distal stomach was present in FD patients, with antral hypersensitivity being further magnified by luminal nutrients; and 2) although fundic and antral fasting tone was normal, reflex fundic relaxation induced by either antral distension or intestinal nutrient infusion was impaired in FD patients. The investigators conclude that antral and fundic dysfunctions (namely, antral hypersensitivity and impaired fundic accommodation) may interact to cause an alteration in the intragastric distribution of contents, thereby producing a situation of “antral overload,” which then contributes to the generation of dyspeptic symptoms. This ambitious study has demonstrated the complex relationship between the parts of the stomach; in so doing, it may provide a more comprehensive explanation of symptom generation in FD and may also lead to alternative therapeutic options. John K. DiBaise, M.D.