The hypothesis that abnormal fibronectin metabolism in Crohn's disease could be an important mechanism leading to stricture formation or postoperative infection was tested in three related studies. (1) Lower concentrations of plasma fibronectin (p<0.05) were found in 20 patients with small and large bowel Crohn's disease (mean 0.24 g/l) compared with 13 patients with more limited disease confined to only small or only large bowel (mean 0.27 g/l) or 20 healthy controls (mean 0.29 g/l). (2) In 25 patients followed for 10 days after operation for Crohn's disease, there was a significant fall in fibronectin concentrations of 43% (p<001, Wilcoxon's rank-sum test). This fall was maximal on the second postoperative day and was more marked in patients undergoing more major operative procedures. (3) The predictive value of plasma fibronectin for subsequent stricture formation or progression was studied for one year; during which 10 patients developed strictures requiring operative treatment. Higher plasma fibronectin concentrations were related to stricture formation, although there was not a complete, predictive relationship. In this study we found that plasma fibronectin concentrations were low in patients with extensive or severe Crohn's disease, fall after operation and may be related to the risk of stricture formation. This relationship is unlikely to be of clinical value, although it shows the potential significance of fibronectin in the pathogenesis of strictures.

Background Although surgery is the treatment of choice for rectal cancer, local recurrence is common even after apparently curative resection. We aimed to assess the role of postoperative radiotherapy in reducing rates of local recurrence, and improving disease-free and overall survival in patients with mobile Dukes' stage B and C rectal cancers.Methods We carried out a prospective, randomised trial of surgery alone (n=235) versus surgery followed 4-6 weeks later by radiotherapy (n=234), of 40 Gy in 20 fractions of 2 Gy over 4 weeks. The 469 patients, from 46 hospitals in the UK and the Republic of Ireland, were randomised between 1984 and 1989, and followed up for a minimum of 5 years or to death.Findings 284 patients died, 145 of 235 allocated surgery alone and 139 of 234 allocated postoperative radiotherapy. The hazard ratio for overall survival was 0.84 (95% CI 0.65-1.07, p=0.17). At 5 years' follow-up 79 patients who received surgery alone and 48 who received postoperative radiotherapy had had local recurrence (hazard ratio 0.54 [0.38-0.77], p=0.001). The corresponding numbers with distant recurrence were 83 and 75 (hazard ratio 0.85 [0.63-1.114], p=0.18). The hazard ratio for disease-free survival was 0.85 (0.65-1.08; p=0.18). Radiotherapy was generally well tolerated; assessment of late events showed serious late bowel complications to be rare and not significantly increased after radiotherapy, even when this followed anterior resection.Interpretation Our results have provided further evidence of the ability of postoperative radiotherapy to delay and prevent local recurrence of rectal cancer. Although the local recurrence rate in the control group is in keeping with other multicentre trials of the mid to late 1980s, it is undoubtedly higher than would be regarded as acceptable now. The combination of larger trials required to provide definitive answers on the impact that postoperative radiotherapy will have on survival.

We describe an anal disease activity index suitable for use in prospective studies of treatment and recording the natural history of anal disease. We studied 40 patients with perianal Crohn's disease (PACD), 14 patients with anal disease not related to Crohn's disease, and 10 normal individuals. Seven symptoms related to anal disease were measured using a linear analog scoring system, which proved easy for the patients to complete. Only three of the seven clinical parameters studied before and after treatment had a high discriminant value. On the basis of these findings, we conclude that a good index of response to therapy in patients with anal disease can be obtained from a linear analog scoring of three symptoms: spontaneous anal pain, pain following defecation, and inhibition of locomotion by pain. The index should be of value in comparing management options in PACD.

Crohn's disease is a panintestinal disease of unknown aetiology and a tendency to recrudescence throughout the patient's life. It is therefore impossible to cure Crohn's disease by medical therapy or surgical excision. In spite of this, the majority of patients can be managed through their disease and maintained in a good state of health by a combination of medical and surgical treatment. Early attempts at surgical management of Crohn's disease in the 1930's and 1940's involved bypass procedures which were marred with serious complications of sepsis, development of cancer and increased rate of recurrence. By the 1950's resection became the preferred operation but there soon arose a controversy about the amount of bowel that should be removed. There were some who advocated radical excision; removing all diseased bowel with a large margin of apparently normal tissue on each side of the resection. Others found less radical resection safer as it preserved gut and also had no apparent effect on the rate of recurrence of the disease. Although this argument continued, the balance gradually shifted towards less radical surgery. Furthermore, the wave of conservatism led to the evolution of the concept of minimal surgery.

In a prospective double-blind randomised trial, 200 patients undergoing elective colorectal surgery received ceftizoxime 2g with either placebo or a single dose of metronidazole 500mg followed by a single dose of ceftizoxime 2g two hours later in both treatment groups. There was no difference in the rate of wound infection (9 of 85 vs 7 of 89), distal site infection (16 of 85 vs 18 of 89) or noninfective complications between the 2 treatment groups. Duration of hospital stay was also similar for the 2 groups (mean 11.3 vs 12.3 days). The low incidence of wound infection in this study is particularly impressive, as 13 of 16 wound infections were delayed, minor superficial discharges occurring after the patient left hospital. These results suggest that intravenous ceftizoxime offers effective prophylaxis in colorectal surgery and may be used without metronidazole.

Journal Article Carbon dioxide insufflation in gastrointestinal surgery Get access J Cabrol, J Cabrol Department of Surgery, The General Hospital, Birmingham B4 6NH, UK Search for other works by this author on: Oxford Academic Google Scholar C Griffiths, C Griffiths Department of Surgery, The General Hospital, Birmingham B4 6NH, UK Search for other works by this author on: Oxford Academic Google Scholar J Alexander-Williams J Alexander-Williams Professor Department of Surgery, The General Hospital, Birmingham B4 6NH, UK Correspondence to: Professor J. Alexander-Williams Search for other works by this author on: Oxford Academic Google Scholar British Journal of Surgery, Volume 78, Issue 4, April 1991, Page 499, https://doi.org/10.1002/bjs.1800780436 Published: 08 December 2005 Article history Accepted: 26 August 1990 Published: 08 December 2005

We have determined the outcome of a defined policy for the management of distal ileal Crohn's disease using a prospective computer-based analysis of 139 patients diagnosed between 1970 and 1988 with a mean follow-up of 10 years. The policy in outline consists of conservative treatment for acute obstructive episodes, resection or strictureplasty for recurrent obstructive episodes, surgical treatment for abscess and fistula formation and specific medical treatment (corticosteroids, immunosuppressive therapy or metronidazole) for symptomatic non-obstructive disease. Twenty-nine patients had a benign course without resection. The remainder were treated surgically at some time but only 28 of these patients had specific treatment before operation. Thirty-three needed more than one resection and five needed more than three surgical procedures. Immediate, early or delayed surgical treatment did not affect the reoperation rates or the long-term outcome. Eleven patients died, ten of causes unrelated to Crohn's disease. Of the 128 living patients, 114 are fit and well, and only two are currently taking specific medication. Fourteen are unwell of whom six either need or have refused further surgery which could restore them to good health. This management policy has achieved excellent long-term results in nearly all patients, and our findings suggest that the timing of surgery and its nature are more important in determining outcome than specific medical therapy.

Within 6 months, three constipated patients have been seen with stercoral perforation of the colon associated with the ingestion of non-steroidal anti-inflammatory drug medications (NSAIDs). These drugs were taken regularly for painful musculoskeletal disorders 6, 8 and 12 months before admission. Constipation is thought to be the most significant contributory factor in the development of colonic stercoral perforation; however, it is unclear why it develops in so few of the many patients with severe constipation. NSAID medications have been associated with the perforation of colonic diverticula, but there are no reports of an association with stercoral perforations. If our finding of the association is substantiated by other reports there may be a need for greater awareness of lower gastrointestinal problems when prescribing such drugs to constipated patients.

Planning Association advice for a "missed pill" should be followed,27 and wearers of soft contact lenses warned that these may be permanently stained.Itching, rashes, and gastro- intestinal reactions may also occur.Contacts must be advised of the risk of late secondary disease occurring despite prophylaxis.We advocate the use of rifampicin at a dose of 20 mg/kg a day (up to a maximum of 600 mg daily) for four days for three groups of contacts of patients with invasive Haemophilus influenzae type b disease.With the exclusion of pregnant or breastfeeding women, anyone with severely impaired hepatic function, and children aged under 3 months, prophylaxis should be offered to (a) all household members in households where there is an index case of Haemophilus influenzae type b disease, irrespective of age, and another child aged under 3 years; (b) all classroom contacts -both teachers and children - where two or more cases of the disease have occurred within 120 days-that is, where spread of the organism may have occurred within the class; and (c) all index cases of the disease before discharge from hospital.Prophylaxis should not be offered routinely to household contacts when there are no other children aged under 3 years, to non-household contacts of single cases, or to ward contacts in hospital outbreaks.When prophylaxis is given all defined contacts must be identified and treatment started as early as possible.These recommendations are consistent with and amplify those of the British Paediatric Association.28A more detailed review of H influenzae type b chemoprophylaxis may be found in the Communicable Disease Report.29

We report an audit of outcome on 24 patients (16 females) who had a strictureplasty to treat ileo-colic anastomotic strictures. All except one patient had their original resection for Crohn's disease, and required reoperation because of symptoms of recurrent intestinal obstruction for a mean 9.3 months (range 1-36); the remaining patient was discovered to have ileo-colic anastomotic stricture before he underwent laparotomy for closure of loop ileostomy. At operation, four patients needed additional small bowel strictureplasties, two of whom also underwent small bowel resection for separate areas of phlegmonous disease. There was no post-operative mortality, three patients developed wound infection and one had a pelvic abscess, which settled on antibiotic therapy. Two patients have since died of unrelated disease. Five patients have since needed reoperation for recurrence; only one had a stricture at the site of previous strictureplasty. Over a mean follow-up of 70.8 months (range 18-393) all 22 living patients now have complete relief of symptoms.