Funktionelle Schluckaktuntersuchungen mit der Elektronenstrahl- computertomographie

Zusammenfassung Videofluorographie und Kinematographie gelten derzeit als Goldstandard für die Abkl?rung von Schluckst?rungen. Methodisch bedingt ist jedoch keine überlagerungsfreie Darstellung der anatomisch wichtigen Strukturen des Pharynx m?glich, so da? bei manchen St?rungen nicht unterschieden werden kann, ob diese pathoanatomisch oder funktionell-neurogen bedingt sind. Anhand von 3 Fallbeispielen wird dargelegt, ob und in welchem Umfang die Elektronenstrahlcomputertomographie mit ihrem hohen r?umlichen und zeitlichen Aufl?sungsverm?gen (Millisekundenbereich) diese Nachteile kompensiert. Es ist uns gelungen zu zeigen, da? die vollst?ndige und symmetrische nasopharyngeale Abdichtung durch den Passavantschen Wulst und den weichen Gaumen gew?hrleistet wird. Durch die EBT konnte die genaue anatomische Lokalisation und Ausbreitung eines lateralen hypopharyngealen Pouches dargestellt werden. Durch den Nachweis einer Kompression des oberen ?sophagussphinkters durch einen kleinen zervikalen Spondylophyten konnte eine scheinbar nur funktionell bedingte Dysfunktion weiter abgekl?rt werden. Diese Beispiele zeigen, da? die Elektronenstrahlcomputertomographie die sich funktionell ?ndernde Anatomie w?hrend des Schluckens in der Transversalschicht darstellen kann, und legen es nahe, ihre Wertigkeit auf der Basis systemischer interdisziplin?rer Untersuchungen zu evaluieren.      

Long-Term Function After Restorative Proctocolectomy

PURPOSE Early functional outcome after restorative proctocolectomy and formation of an ileoanal pouch is known to be good, but there are minimal data on the long-term function of the pouch. The aim of this study was to look at the long-term functional outcome in patients who had undergone restorative proctocolectomy and formation of an ileoanal pouch.METHODS A total of 151 consecutive patients (96 males, 55 females) who underwent ileoanal pouch surgery between April 1983 and May 1993 were identified. Functional outcomes from the previous 12 months were appraised by a standardized questionnaire.RESULTS The median age at surgery was 31 years (range, 6–63 years), with a median follow-up of 142 months (range, 100–221 months). Eighteen patients have had their pouches excised, with another patient being defunctioned. Therefore 19 patients (13 percent) had suffered pouch failure. Altogether, 115 patients were available for follow-up, and 98 patients (85 percent) returned questionnaires. The median pouch-emptying frequency was five times (range, 1–17) during the day and one time (range, 0–6) at night. A total of 74 percent of patients had perfect continence during the day. Most of the patients had no life-style restrictions related to the pouch, and 98 percent of patients would recommend a pouch to others.CONCLUSIONS Long-term functional outcome after ileoanal pouch surgery is good in most patients. For patients requiring proctocolectomy, ileoanal pouch surgery can now be recommended as an excellent long-term option.Presented at the Association of Coloproctology of Great Britain and Ireland, Manchester, United Kingdom, July 2 to 5, 2002 Reprints are not available.     

Vaginal Delivery After Ileal Pouch-Anal Anastomosis: A Word of Caution

PURPOSE This study was designed to evaluate the impact of childbirth on anal sphincter integrity and function, functional outcome, and quality of life in females with restorative proctocolectomy and ileal pouch-anal anastomosis.METHODS The patients who had at least one live birth after ileal pouch-anal anastomosis were asked to return for a comprehensive assessment. They were asked to complete the following questionnaires: the Short Form-36, Cleveland Global Quality of Life scale, American Society of Colorectal Surgeons fecal incontinence severity index, and time trade-off method. Additionally, anal sphincter integrity (endosonography) and manometric pressures were measured by a medical physician blinded to the delivery technique. Anal sphincter physiology also was evaluated with electromyography and pudendal nerve function by nerve terminal motor latency technique.RESULTS Of 110 eligible females who had at least one live birth after ileal pouch-anal anastomosis, 57 participated in the study by returning for clinical evaluation to the clinic and 25 others by returning the quality of life and functional outcome questionnaires. Patients were classified into two groups: patients who had only cesarean section delivery after ileal pouch-anal anastomosis (n = 62) and patients who had at least one vaginal delivery after ileal pouch-anal anastomosis (n = 20). The mean follow-up from the date of the most recent delivery was 4.9 years. The vaginal delivery group had significantly higher incidence of an anterior sphincter defect by anal endosonography (50 percent) vs. cesarean section delivery group (13 percent; P = 0.012). The mean squeeze anal pressure was significantly higher in the patients who had only cesarean section delivery (150 mmHg) after restorative proctocolectomy than patients who had at least one vaginal delivery (120 mmHg) after restorative proctocolectomy (P = 0.049). Quality of life evaluated by time trade-off method also was significantly better in the cesarean section delivery group (1) vs. vaginal delivery group (0.9; P < 0.001).CONCLUSIONS The risk of the sphincter injury and quality of life measured by time trade-off method are significantly worse after vaginal delivery compared with cesarean section in patients with ileal pouch-anal anastomosis. In the short-term, this does not seem to substantially influence pouch function or quality of life; however, the long-term effects remain unknown, thus obstetric concern may not be the only factor dictating the type of delivery in this group of patients. A planned cesarean section may eliminate these potential and factual concerns in ileal pouch-anal anastomosis patients.Podium presentation at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004.     

Functional and Physiologic Assessment of the Colonic Reservoir or Side-to-End Anastomosis After Low Anterior Resection for Rectal Cancer: A Two-Year Follow-Up

PURPOSE Functional disturbances are common after anterior resection for rectal cancer. This study was designed to compare functional and physiologic outcome after low anterior resection and total mesorectal excision with a colonic J-pouch or a side-to-end anastomosis.METHODS Functional and physiologic variables were analyzed in patients randomized to a J-pouch (n = 36) or side-to-end anastomosis (n = 35). Postoperative functional outcome was investigated with questionnaires. Anorectal manometry was performed preoperatively and at six months, one year, and two years postoperatively.RESULTS There was no statistical difference in functional outcome between groups at two years. Maximum neorectal volume increased in both groups but was approximately 40 percent greater at two years in pouches compared with the side-to-end anastomosis. Anal sphincter pressures volumes were halved postoperatively and did not recover during follow-up of two years. Male gender, low anastomotic level, pelvic sepsis, and the postoperative decrease of sphincter pressures were independent factors for more incontinence symptoms.CONCLUSIONS Colonic J-pouch and side-to-end anastomosis gives comparable functional results two years after low anterior resection. Neorectal volume had no detectable influence on function. There was a pronounced and sustained postoperative decrease in sphincter pressures.Supported by the Stockholm County Council, Public Health and Medical Services Committee and the Swedish Research Council, grant #09101.Reprints are not available.     

Persistent Perineal Sinus After Ileoanal Pouch Excision in Inflammatory Bowel Diseases: Incidence,Risk Factors,and Clinical Course

Purpose  This study was designed to determine the incidence of persistent perineal sinus after pouch excision in inflammatory bowel disease, risk factors, and long-term clinical course. Methods  The study included 35 consecutive patients who underwent pouch excision at St. Mark’s Hospital, London, between 1996 and 2006. Incidence of persistent perineal sinus and its long-term clinical course were reported. Sixteen variables were analyzed to determine their association with persistent perineal sinus. Results  There were 17 men and 18 women with median age of 37 (range, 20–57) years. The final diagnosis was ulcerative colitis in 28 and Crohn’s disease in 7 patients. The indications for pouch excision included pelvic or perineal sepsis in 60 percent, pouchitis in 23 percent, and poor pouch function in 17 percent. Persistent perineal sinus was diagnosed in 14 patients (40 percent). Pouch excision for fistula or abscess in the pelvis or perineum (odds ratio, 8; 95 percent confidence interval, 1.4–45.5) was an independent predictor for persistent perineal sinus. Twenty-six procedures were performed in patients with persistent perineal sinus and resulted in healing in 64 percent. Curettage was the most common procedure used. Conclusions  Pouch excision for pelvic or perineal sepsis was an independent predictor for persistent perineal sinus. Poster presentation at the meeting of the Association of Coloproctology of Great Britain and Ireland, Birmingham, United Kingdom, June 30 to July 3, 2008. Reprints are not available.     

Incidence and natural history of dysplasia of the anal transitional zone after ileal pouch-anal anastomosis

PURPOSE: Preservation of the anal transitional zone during ileal pouch-anal anastomosis is still controversial because of the risk of dysplasia and the theoretical risk of associated cancer. Without long-term follow-up data, the natural history and optimal treatment of anal transitional zone dysplasia are unknown. The aim of this study was to determine the long-term risk of dysplasia in the anal transitional zone and to evaluate the outcome of a conservative management policy for anal transitional zone dysplasia. METHODS: Two hundred ten patients undergoing anal transitional zone-sparing ileal pouch-anal anastomosis for ulcerative or indeterminate colitis between 1987 and 1992 and who were studied with serial anal transitional zone biopsies for at least five years postoperatively were included. Median follow up was 77 (range, 60–124) months. RESULTS: Anal transitional zone dysplasia developed in seven patients 4 to 51 (median, 11) months postoperatively. There was no association with gender, age, preoperative disease duration or extent of colitis, but the risk of anal transitional zone dysplasia was significantly increased in patients with prior cancer or dysplasia in the colon or rectum. Dysplasia was high grade in one and low grade in six. Two patients each with low-grade dysplasia detected on three separate occasions underwent mucosectomy 29 and 38 months after detection of low-grade dysplasia, but no cancer was found. The five other patients with dysplasia on one or two occasions were treated expectantly and were apparently dysplasia-free for a median of 72 (range, 48–100) months. CONCLUSIONS: Anal transitional zone dysplasia after ileal pouch-anal anastomosis is infrequent, is most common in the first two to three years postoperatively and may apparently disappear on repeated biopsy. Anal transitional zone preservation did not lead to the development of cancer in the anal transitional zone after five to ten years of follow-up. Long-term surveillance is recommended to monitor dysplasia. If repeat biopsy confirms persistent dysplasia, anal transitional zone excision with neoileal pouch-anal anastomosis is recommended.Presented at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio, Texas, May 2 to 7, 1998.     

Three-Year Experience of Pouch Dilatation and Slippage Management after Laparoscopic Adjustable Gastric Banding

Purpose

Pouch dilatation and band slippage are the most common long-term complications after laparoscopic adjustable gastric banding (LAGB). The aim of the study is to present our experience of diagnosis and management of these complications.

Materials and Methods

The pars flaccida technique with anterior fixation of the fundus was routinely used. All band adjustments were performed under fluoroscopy. We analyzed the incidence, clinico-radiologic features, management, and revisional surgeries for treatment of these complications. We further presented the outcome of gastric plication techniques as a measure for prevention of these complications.

Results

From March 2009 to March 2012, we performed LAGB on 126 morbidly obese patients. Among them, 14 patients (11.1%) were diagnosed as having these complications. Four patients (3.2%) had concentric pouch dilatations, which were corrected by band adjustment. Ten (7.9%) had eccentric pouch with band slippage. Among the ten patients, there were three cases of posterior slippage, which were corrected by reoperation, and seven cases of eccentric pouch dilatation with anterior slippage. Three were early anterior slippage, which was managed conservatively. Two were acute anterior slippage, one of whom underwent a revision. There were two cases of chronic anterior slippage, one of whom underwent a revision. The 27 patients who underwent gastric plication did not present with eccentric pouch with band slippage during the follow-up period.

Conclusion

The incidence of pouch dilatation with/without band slippage was 11.1%. Management should be individualized according to clinico-radiologic patterns. Gastric plication below the band might prevent these complications.     

Risk of ileal pouch neoplasms in patients with familial adenomatous polyposis

Restorative proctocolectomy is the most common surgical option for patients with familial adenomatous polyposis(FAP). However,adenomas may develop in the ileal pouch mucosa over time,and even carcinoma in the pouch has been reported. We therefore reviewed the prevalence,nature,and treatment of adenomas and carcinoma that develop after proctocolectomy in the ileal pouch mucosa in patients with FAP. In 25 reports that were reviewed,the incidence of adenomas in the ileal pouch varied from 6.7% to 73.9%. Several potential factors that favor the development of pouch polyposis have been investigated,but many remain controversial. Nevertheless,it seems certain that the age of the pouch is important. The risk appears to be 7%to 16% after 5 years,35% to 42% after 10 years,and75% after 15 years. On the other hand,only 21 cases of ileal pouch carcinoma have been recorded in the literature to date. The diagnosis of pouch carcinoma was made between 3 to 20 years(median,10 years) after pouch construction. Although the risk of malignant transformation in ileal pouches is probably low,it is not negligible,and the long-term risk cannot presently be well quantified. Regular endoscopic surveillance,especially using chromoendoscopy,is recommended.