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Recurrence and reoperation for Crohn's disease
1048
They tested the ability of these patients to mount a serologic response to the intravenous particulate antigen ~bX174, and demonstrated a marked impairment in the primary and secondary responses to this antigen. The clinical importance of this is that the impaired immunity associated with hyposplenism may subject these patients to increased risk of sepsis at the time of surgery. The authors have noted a correlation of pneumococeal septicemia and gram-negative endotoxemia occurring in the postoperative period in patients with hyposplenism undergoing colectomy for inflammatory bowel disease.--Richard R. Ricketts Miliary Crohn's Disease. Stephen L. Werlin and Marvin
Glicklich. Am J Gastroenterol 75:48-51, (January), 1981. Miliary Crohn's disease describes an unusual variant of Crohn's disease, in which macroscopic miliary nodules stud the serosal surface of the small intestine. An 11 5/12-yr-old boy, who presented with poor weight gain and abdominal pain, is described. Repeat upper gastrointestinal series demonstrated nodularity of the jejunum and duodenum. A diagnosis of Crohn's disease was entertained but, because of the possibility of lymphoma, an exploratory laparotomy was performed. White nodules studded the serosal surfaces of the duodenum and jejunum. Jejunal biopsy demonstrated transmural inflammation and noncaseating granulomas in the mucosa, submucosa, and serosa. A mesenteric lymph node also demonstrated noncaseating granulomas; cultures and stains were negative for bacteria, fungi or acid-fast bacilli. The patient was treated with total parenteral nutrition and sulfasalazine with resolution of his diarrhea and abdominal pain. Six previous cases of miliary Crohn's disease have been presented. In three of these, as in the present case, the disease was primarily located in the proximal small bowel. The differential diagnosis of a patient with nodular defects in the proximal small bowel is lymphoma, tuberculosis, or miliary Crohn's disease. Skin testing will help in the diagnosis of tuberculous enteritis; however, an operation with biopsy will be required to differentiate lymphoma from miliary Crohn's disease so that proper therapy can be instituted.--Richard R. Ricketts. Recurrence and Reoperation for Crohn's Disease. M. R.
Lock, R. G. Farmer, 1I. IV. Fazio, D. G. Jagelman, 1. C. Lavery and F. L. Weakley. N Engl J Med 304:1586, 1981. The authors evaluated 361 patients operated upon for Crohn's disease. There were 108 (30%) with small bowel disease only, 107 (30%) with large bowel disease only, and 146 (40%) with ileocolic disease, of which 92 had ileocecal disease and 54 had ileal disease with extensive colon involvement. Need for reoperation and further resection due to recurrence was noted in 123 patients (34%). The incidence of reoperation was lowest in large bowel (24.3%) and small bowel (28.5%) disease and highest in patients with initial ileocolic disease (43.8%--p < 0.005). Second reoperations were required in 43 patients (35%); ileocolic disease accounted for 26 (60%) of these cases. The authors recommend that extent and localization of disease be used to group patients in determining prognosis and treatment.--E. S. Wiener
ABSTRACTS
Prophylaxis and Therapy of Recurrent Ileus by External Splinting of Small Bowel With Butyl-Cyanoacrylate.
C. Janneck. Z Kinderchir 32:305-310, 1981. The authors report their experiences with a new method for the prevention of further bowel obstruction in 12 children with recurrent bowel obstructions following laparotomy. After detachment of adhesions the bowel loops are adapted like in Child's procedure and glued together with the tissue adhesive butyl-cyanoacrylate. Additional appendectomy if not performed yet is recommended. Postoperative courses were uneventful in any case. The short time of operation and the simplicity of procedure are regarded as the main advantages with respect to other techniques.--Thomas A. Angerpointner. Ileocecal Valve Replacement. J. Careskey, T. R. Weber, and J. L. Grosfeld. Arch Surg 116:618-622, (May), 1981.
Numerous experimental and clinical techniques have been proposed to increase intestinal absorption by prolonging transit time following massive enterectomy. All experimental models have been in larger laboratory animals; none to the authors knowledge have been performed in smaller species with a small-bowel diameter that resembles that of the premature or newborn infant. Sixty-five Spraque-Dawley rats underwent one of three procedures: (1) laparotomy without resection; (2) 75% distal small bowel resection, including the ileocecal valve; and (3) 75% small bowel resection, including the ileocecal valve, and construction of a jejunal valve. There was no mortality in group one, 84% mortality in group two, and 28% in group three after 3 too. Rats with resection alone lost 29% of their initial weight, whereas rats with jejunal valves gained 24% of their initial weight. Transit time was three times slower in animals with valves. The valve is created by eversion of the distal small bowel and subsequent telescoping of valve into the proximal small bowel. The possible factors responsible for delay in transit time observed in group three rats include a partial small bowel obstruction, electromechanical dissociations of the peristaltic wave, or a true sphincters mechanism. The authors suggest that although these experimental observations have been encouraging, further laboratory investigation of this technique is obviously indicated prior to its being recommended for use in humans.--George A. Rowe. Neonatal Necrotizing Enterocolitis: A 10 Year Experience.
J. R. Gregory, J. R. Campbell, M. W. Harrison, and T. J. Campbell. Am J Surg 141:562-567, (May), 1981. This study reviews 42 of 5030 infants admitted to two pediatric units between January 1971 and June 1980 who developed necrotizing enterocolitis on physical, radiologic, and pathologic findings. The physical criteria used to define NEC were evidence of gastrointestinal mucosal injury or dysfunction with accompanying radiologic signs of intramural gas, portal vein gas, or an adynamic loop of bowel. The patients were divided into three groups: those with birth weight over 2500 g, those weighing 1501-2500 g, and those less than 1500 g. The time course of the appearance of NEC, incidence, risk factors, feeding history, symptoms, radiographic signs and therapy were recorded. One of seven
They tested the ability of these patients to mount a serologic response to the intravenous particulate antigen ~bX174, and demonstrated a marked impairment in the primary and secondary responses to this antigen. The clinical importance of this is that the impaired immunity associated with hyposplenism may subject these patients to increased risk of sepsis at the time of surgery. The authors have noted a correlation of pneumococeal septicemia and gram-negative endotoxemia occurring in the postoperative period in patients with hyposplenism undergoing colectomy for inflammatory bowel disease.--Richard R. Ricketts Miliary Crohn's Disease. Stephen L. Werlin and Marvin
Glicklich. Am J Gastroenterol 75:48-51, (January), 1981. Miliary Crohn's disease describes an unusual variant of Crohn's disease, in which macroscopic miliary nodules stud the serosal surface of the small intestine. An 11 5/12-yr-old boy, who presented with poor weight gain and abdominal pain, is described. Repeat upper gastrointestinal series demonstrated nodularity of the jejunum and duodenum. A diagnosis of Crohn's disease was entertained but, because of the possibility of lymphoma, an exploratory laparotomy was performed. White nodules studded the serosal surfaces of the duodenum and jejunum. Jejunal biopsy demonstrated transmural inflammation and noncaseating granulomas in the mucosa, submucosa, and serosa. A mesenteric lymph node also demonstrated noncaseating granulomas; cultures and stains were negative for bacteria, fungi or acid-fast bacilli. The patient was treated with total parenteral nutrition and sulfasalazine with resolution of his diarrhea and abdominal pain. Six previous cases of miliary Crohn's disease have been presented. In three of these, as in the present case, the disease was primarily located in the proximal small bowel. The differential diagnosis of a patient with nodular defects in the proximal small bowel is lymphoma, tuberculosis, or miliary Crohn's disease. Skin testing will help in the diagnosis of tuberculous enteritis; however, an operation with biopsy will be required to differentiate lymphoma from miliary Crohn's disease so that proper therapy can be instituted.--Richard R. Ricketts. Recurrence and Reoperation for Crohn's Disease. M. R.
Lock, R. G. Farmer, 1I. IV. Fazio, D. G. Jagelman, 1. C. Lavery and F. L. Weakley. N Engl J Med 304:1586, 1981. The authors evaluated 361 patients operated upon for Crohn's disease. There were 108 (30%) with small bowel disease only, 107 (30%) with large bowel disease only, and 146 (40%) with ileocolic disease, of which 92 had ileocecal disease and 54 had ileal disease with extensive colon involvement. Need for reoperation and further resection due to recurrence was noted in 123 patients (34%). The incidence of reoperation was lowest in large bowel (24.3%) and small bowel (28.5%) disease and highest in patients with initial ileocolic disease (43.8%--p < 0.005). Second reoperations were required in 43 patients (35%); ileocolic disease accounted for 26 (60%) of these cases. The authors recommend that extent and localization of disease be used to group patients in determining prognosis and treatment.--E. S. Wiener
ABSTRACTS
Prophylaxis and Therapy of Recurrent Ileus by External Splinting of Small Bowel With Butyl-Cyanoacrylate.
C. Janneck. Z Kinderchir 32:305-310, 1981. The authors report their experiences with a new method for the prevention of further bowel obstruction in 12 children with recurrent bowel obstructions following laparotomy. After detachment of adhesions the bowel loops are adapted like in Child's procedure and glued together with the tissue adhesive butyl-cyanoacrylate. Additional appendectomy if not performed yet is recommended. Postoperative courses were uneventful in any case. The short time of operation and the simplicity of procedure are regarded as the main advantages with respect to other techniques.--Thomas A. Angerpointner. Ileocecal Valve Replacement. J. Careskey, T. R. Weber, and J. L. Grosfeld. Arch Surg 116:618-622, (May), 1981.
Numerous experimental and clinical techniques have been proposed to increase intestinal absorption by prolonging transit time following massive enterectomy. All experimental models have been in larger laboratory animals; none to the authors knowledge have been performed in smaller species with a small-bowel diameter that resembles that of the premature or newborn infant. Sixty-five Spraque-Dawley rats underwent one of three procedures: (1) laparotomy without resection; (2) 75% distal small bowel resection, including the ileocecal valve; and (3) 75% small bowel resection, including the ileocecal valve, and construction of a jejunal valve. There was no mortality in group one, 84% mortality in group two, and 28% in group three after 3 too. Rats with resection alone lost 29% of their initial weight, whereas rats with jejunal valves gained 24% of their initial weight. Transit time was three times slower in animals with valves. The valve is created by eversion of the distal small bowel and subsequent telescoping of valve into the proximal small bowel. The possible factors responsible for delay in transit time observed in group three rats include a partial small bowel obstruction, electromechanical dissociations of the peristaltic wave, or a true sphincters mechanism. The authors suggest that although these experimental observations have been encouraging, further laboratory investigation of this technique is obviously indicated prior to its being recommended for use in humans.--George A. Rowe. Neonatal Necrotizing Enterocolitis: A 10 Year Experience.
J. R. Gregory, J. R. Campbell, M. W. Harrison, and T. J. Campbell. Am J Surg 141:562-567, (May), 1981. This study reviews 42 of 5030 infants admitted to two pediatric units between January 1971 and June 1980 who developed necrotizing enterocolitis on physical, radiologic, and pathologic findings. The physical criteria used to define NEC were evidence of gastrointestinal mucosal injury or dysfunction with accompanying radiologic signs of intramural gas, portal vein gas, or an adynamic loop of bowel. The patients were divided into three groups: those with birth weight over 2500 g, those weighing 1501-2500 g, and those less than 1500 g. The time course of the appearance of NEC, incidence, risk factors, feeding history, symptoms, radiographic signs and therapy were recorded. One of seven