Previous abdominal colectomy affects functional results after ileal pouch-anal anastomosis

We assessed the effect of previous abdominal colectomy on functional results after ileal J pouch-anal anastomosis (IPAA) in patients with ulcerative colitis. Twenty-five patients with colectomy prior to IPAA were compared with 22 patients who underwent noncolonic abdominal operations prior to IPAA. No differences were observed in pre- or postoperative resting anal sphincter pressure, squeeze pressure, or rectal inhibitory reflex. Previous colectomy was associated with a greater incidence of postoperative small bowel obstruction. Mean ± SEM daily stool frequency at 1 and 12 months postoperatively, respectively, was 8.9±0.8 and 5.7±0.3 for patients who had undergone previous colectomy, and 8.2±0.7 and 6.0±0.5 for the no previous colectomy group (p=not significant). At the same postoperative intervals, nocturnal stool frequency was 1.9±0.3 and 1.1±0.2 for the colectomy group and 1.5±0.3 and 0.6±0.1 for the no colectomy group (p=0.05 at 1 year). More patients in the previous colectomy group had greater than or equal to 1 nocturnal stool after 1 year (71% versus 33%,p=0.03). Although pouch capacity at 1 year was not different in the 2 groups, pouch capacity was directly related to stool frequency in the no colectomy group (r²=0.48,p=0.01), but not in the previous colectomy group (r²= 0.08,p=not significant). We conclude that previous abdominal colectomy may be associated with a higher overall incidence of small bowel obstruction. Moreover, previous colectomy is a determinant of postoperative nocturnal stool frequency after IPAA, most likely due to altered ileal pouch function. When possible, single-stage colectomy, mucosal proctectomy, and endorectal ileal pouch-anal anastomosis should be performed in patients requiring colectomy for ulcerative colitis.

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Resumen Hemos valorado el efecto de una colectomía abdominal previa sobre los resultados funcionales después de anastomosis ileoanal de bolsa en J (AIAB) en pacientes con colitis ulcerativa. Veinticinco pacientes con colectomía previa a la AIAB fueron comparados con 22 pacientes sometidos a operaciones abdominales no colónicas antes de la AIAB. No se hallaron diferencias en cuanto a la presión en reposo del esfínter anal (preoperatoria o postoperatoria), a la presión de compresión, o al reflejo rectal inhibitorio. La colectomía previa apareció asociada con una mayor incidencia de obstrucción del intestino delgado. La frecuencia de defecación diaria a 1 y a 12 meses postoperatorios, respectivamente, fue 8.9±0.8 y 5.7±0.3 para los pacientes que habían sido sometidos a colectomía previa, y 8.2 ±0.7 y 6.0±0.5 para el grupo sin colectomía previa (p=NS). En los mismos períodos postoperatorios la frecuencia de defecación nocturna fue 1.9±0.3 y 1.1±0.2 para el grupo con colectomía previa y 1.5±0.3 y 0.6 ±0.1 para el grupo sin colectomía (p=0.05 a 1 año). Más pacientes en el grupo de colectomía previa presentó más de una o una deposición nocturna después de un año (71% versus 33%, p=0.03). Aunque la capacidad de la boisa a un ano no apareció diferente en los 2 grupos, la capacidad de la bolsa apareció directamente relacionada con la frecuencia de la deposición en el grupo sin colectomía (r²=0.48,p=0.01), pero no en el grupo con colectomía previa (r²=0.08,p=NS). Nuestra conclusión es que una colectomía abdominal previa puede estar asociada con una mayor incidencia de obstrucción del intestino delgado. Además, la colectomía previa aparece como un factor determinante de la frecuencia de defecación nocturna después de AIAB, muy probablemente por alteración de la función de la bolsa ileal. En cuanto sea posible, se debe realizar la colectomía, proctectomía mucosal, y anastomosis ileal endorrectal en una sola etapa en los pacientes que requieran colectomía por colitis ulcerativa.

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Résumé Nous avons chercher à savoir si le fait d'avoir déjà effectué une colectomie retentissait sur les résultats de fonctionnement de l'anastomose iléo-anale avec réservoir en J (AIAR) chez le patient avec rectocolite hémorragique. Vingt cinq patients ayant eu une colectomie avant d'être opérés de leur AIAR ont été comparés à 22 patients ayant une intervention abdominale sans colectomie avant d'être opérés de leur AIAR. Aucune différence dans la pression sphinctérienne au repos pré ou post-opératoire, dans la pression de contraction ou dans le réflexe inhibiteur rectal n'a été observée. La colectomie préalable était associée à une incidence élevée d'occlusion intestinale post-opératoire. Le nombre de selles à 1 et à 12 mois post-opératoires était de 8.9±0.8 et 5.7±0.3, respectivement, chez le patient sans chirurgie colique antérieure (NS). Aux mêmes intervalles, la fréquence de selles nocturnes était de 1.9 ±0.3 et de 1.1±0.2 pour le groupe à colectomie préalable et de 1.5±0.3 et 0.6±0.1 pour le groupe sans chirurgie colique préalable (p=0.05 à un an). Dans le groupe à colectomie préalable, il y avait plus de patients qui avaient une ou plusieurs selles nocturnes après la première année (71% versus 33%;p= 0.03). Bien que la capacité du réservoir ne différait pas à 1 an entre les 2 groupes, la capacité était directement en rapport avec la fréquence des selles dans le groupe sans chirurgie colique préalable (r²=0.48; p=0.01), mais sans rapport dans le groupe avec chirurgie colique préalable (r²=0.08, p=NS). Nous concluons que la colectomie préalable est asscoiée à une incidence d'occlusion post-opératoire supérieure. De plus, la colectomie préalable est associée à une fréquence plus élevée de selles nocturnes après AIAR, probablement liée à un dysfonctionnement du réservoir. Lorsque la colectomie totale avec mucosectomie rectale, avec anastomose iléo-anale et réservoir est indiquée chez le patient ayant une rectocolite hémorragique, il vaut mieux la faire en un seul temps.

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Presented at the Société Internationale de Chirurgie, Toronto, Ontario, Canada, September, 1989.     

A model of nonparticipation in alcohol treatment programs

Why do the vast majority of those who suffer harm from drinking fail to obtain treatment? Based on a review of research literature and educational and treatment program materials, a model of nonparticipation in treatment is proposed whereby particular population groups are separated out according to whether or not they exhibit specified characteristics related to both harm from drinking and attitudes towards treatment. Eleven groups have been identified in the model, each of which has different reasons for failing to seek and/or obtain treatment. It is suggested that differing educational program messages should be sent to each group. While the model does not purport to be wholly inclusive of all nonparticipation, it offers a basis for addressing the variety of disparate groups that suffer harm from drinking but do not obtain treatment.     

Is ergonomic intervention alone sufficient to limit musculoskeletal problems in nurses?

This study retrospectively surveyed 1,216 nurses at hospitalsin Belgium and The Netherlands. Data concerning workloads, musculoskeletalsymptoms, work loss and psychosocial factors were collectedby questionnaire. Lifetime prevalence rates for musculoskeletalproblems and low back trouble were significantly lower in theDutch hospitals than the Belgian hospitals, but a significantlyhigher proportion of Dutch nurses had ‘heavy’ workloads.Overall, symptoms and work loss in the previous 12 months werenot related to workload, nor was the perception that work wascausative; a change of duties because of symptoms was rare (<3%). The Dutch nurses differed strikingly from Belgian nurseson the psychosocial variables; they were less depressed andsignificantly more positive about pain, work and activity. Itis proposed that ergonomic interventions alone may be sub-optimalin controlling musculoskeletal problems among nurses The additionalprovision of psychosocoial information to challenge misconceptionsand encourage self-management is proposed.     

Partnering. A cooperative approach to dietary procurement

The Toledo Hospital has initiated many innovative quality programs. One initiated with the dietary department involved turning its wholesaler into a partner to provide better-quality products, lower costs and better service. Specific requirements were established in each of these areas including guaranteed mark-ups, price caps and performance reports. The hospital and the wholesaler also do joint negotiating with product manufacturers. Through these and other strategies, the hospital has reduced purchase prices for food items by over 4%, drastically reduced administrative costs of procurement and lead time, increased inventory turns to over 80 and given the dietary department a single resource for "one stop shopping."     

Serum dioxin and cancer in veterans of Operation Ranch Hand

We studied cancer prevalence and exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin (dioxin) in veterans of Operation Ranch Hand, the Air Force unit responsible for the aerial spraying of herbicides in Vietnam from 1962 to 1971. A comparison group of Air Force veterans who served in Southeast Asia during the same period and who were not involved with spraying herbicides was included. Comparison veterans were matched to Ranch Hand veterans on age, race, and military occupation. We measured dioxin in 1987 or 1992, extrapolated the result to the time of service in Southeast Asia, and assigned each Ranch Hand veteran to Background, Low, or High exposure categories. This study had low power to detect an effect for specific or rare cancers. The risk of cancer at sites other than the skin within 20 years of service was increased in the Low (odds ratio (OR) = 3.4, 95% confidence interval (CI) 1.5-8.0) and High (OR = 2.7, 95% CI 0.9-8.0) categories, but the pattern was inconsistent with another study, suggesting that the excess risk may not have been caused by dioxin exposure. Overall, we found no consistent evidence of a dose-response gradient and no significant increase in cancer risk in the High dioxin exposure category, the subgroup of greatest a priori interest.     

Information and advice to patients with back pain can have a positive effect. A randomized controlled trial of a novel educational booklet in primary care

STUDY DESIGN: A double-blind, randomized controlled trial of a novel educational booklet compared with a traditional booklet for patients seeking treatment in primary care for acute or recurrent low back pain. OBJECTIVE: To test the impact of a novel educational booklet on patients' beliefs about back pain and functional outcome. SUMMARY OF BACKGROUND DATA: The information and advice that health professionals give to patients may be important in health care intervention, but there is little scientific evidence of their effectiveness. A novel patient educational booklet, The Back Book, has been developed to provide evidence-based information and advice consistent with current clinical guidelines. METHODS: One hundred sixty-two patients were given either the experimental booklet or a traditional booklet. The main outcomes studied were fear-avoidance beliefs about physical activity, beliefs about the inevitable consequences of back trouble, the Roland Disability Questionnaire, and visual analogue pain scales. Postal follow-up response at 1 year after initial treatment was 78%. RESULTS: Patients receiving the experimental booklet showed a statistically significant greater early improvement in beliefs which was maintained at 1 year. A greater proportion of patients with an initially high fear-avoidance beliefs score who received the experimental booklet had clinically important improvement in fear-avoidance beliefs about physical activity at 2 weeks, followed by a clinically important improvement in the Roland Disability Questionnaire score at 3 months. There was no effect on pain. CONCLUSION: This trial shows that carefully selected and presented information and advice about back pain can have a positive effect on patients' beliefs and clinical outcomes, and suggests that a study of clinically important effects in individual patients may provide further insights into the management of low back pain.