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Biomedical subjects

N J Mortensen

Publications and source records attributed to N J Mortensen.

At least 19 recordsLinked to original sources
PubMed2006

Inflammatory bowel disease: the view of the surgeon.

Despite advances in medical therapy, surgery is required in approximately 30-40% of patients with ulcerative colitis (UC) and 70-80% of patients with Crohn's disease (CD) at some point during their lifetime. For patients with UC, surgery may be curative, whereas recurrence of CD following surgery is common due to the potentially pan-enteric distribution of the disease. As a result, the indications and surgical management of the disease may be quite different. For UC, the surgeon is involved in the identification of new cases, management of severe disease, recognition of dysplasia and restorative proctocolectomy. Most of the advances in surgery for UC have been in novel techniques relating to the ileal pouch-anal anastomosis, which can now be performed safely for UC with a 10% pouch failure rate long term. For CD, the surgeon is involved in the management of small bowel and ileo-colonic disease, Crohn's colitis and perianal disease. Advances in the surgical management of CD include strictureplasty for extensive small bowel disease, laparoscopic ileo-caecal resection and a combined medical and surgical approach to perianal disease. For both CD and UC close liaison between the gastroenterologist and colorectal surgeon is essential.

Anastomosis, Surgical↗
PubMed2006

European evidence based consensus on the diagnosis and management of Crohn's disease: current management.

This second section of the European Crohn's and Colitis Organisation (ECCO) Consensus on the management of Crohn's disease concerns treatment of active disease, maintenance of medically induced remission, and surgery. The first section on definitions and diagnosis includes the aims and methods of the consensus, as well as sections on diagnosis, pathology, and classification of Crohn's disease. The third section on special situations in Crohn's disease includes postoperative recurrence, fistulating disease, paediatrics, pregnancy, psychosomatics, extraintestinal manifestations, and alternative therapy for Crohn's disease.

Adrenal Cortex Hormones↗
PubMed2001

Cyclosporin for severe ulcerative colitis does not increase the rate of perioperative complications.

PURPOSE: Cyclosporin is used in severe ulcerative colitis that is refractory to intravenous steroids. Cyclosporin is a potent immunosuppressant and can cause side effects such as opportunistic infections. This study aimed to investigate the incidence of perioperative complications in patients treated with intravenous cyclosporin and steroids compared with patients treated with intravenous steroids alone. METHODS: We retrospectively reviewed the case notes of 44 patients with severe ulcerative colitis who underwent total abdominal colectomy and ileostomy. Twenty-five patients were treated with intravenous steroids and 19 patients were treated with intravenous cyclosporin and steroids. Details were recorded with respect to age, length of illness, extent of disease, Truelove and Witt's criteria, hemoglobin and albumin at surgery, surgical procedure, and perioperative morbidity. RESULTS: Twenty-four percent of patients treated with intravenous steroids alone and 15.8 percent of patients treated with intravenous cyclosporin and steroids had major surgical complications. Sixteen percent of patients treated with intravenous steroids alone and 5.2 percent of patients treated with intravenous cyclosporin and steroids had minor surgical complications. Eight percent of patients treated with intravenous steroids alone and 10.5 percent of patients treated with intravenous cyclosporin and steroids had major medical complications. There was no mortality in either group. CONCLUSIONS: There is no increased incidence of perioperative complications associated with the use of intravenous cyclosporin in addition to steroids in acute severe ulcerative colitis provided cyclosporin treatment is for a defined period and surgery is not delayed.

Acute Disease↗
PubMed2001

Impotence after mesorectal and close rectal dissection for inflammatory bowel disease.

PURPOSE: Close rectal dissection is a surgical technique used by some surgeons in inflammatory bowel disease. It is performed within the mesorectum, close to the rectal muscle wall, with the aim of minimizing damage to the pelvic sexual nerves. Other surgeons dissect in the more anatomical mesorectal plane. Our aim was to determine whether close rectal dissection is more protective of the pelvic sexual nerves than mesorectal dissection. METHOD: Patients undergoing surgery for inflammatory bowel disease were entered prospectively into a database. Male patients were mailed a standardized, validated, urologic impotence questionnaire: the International Index of Erectile Function. RESULTS: There was an 81 percent response rate. Six of 156 assessable patients were totally impotent (3.8 percent). They were all in the 50-year-old to 70-year-old age group, with no impotence in patients younger than 50 years old. Twenty-one patients complained of minor diminution of erectile function (13.5 percent), where sexual activity was still possible. There was no statistical difference in the rate of complete (2.2 percent vs. 4.5 percent, P = 0.67) or partial (13.5 percent vs. 13.3 percent, P = 0.99) impotence between close rectal and mesorectal dissection (Fisher's exact test). There were no ejaculatory difficulties. The time elapsed since surgery ranged from 2.7 months to 192.7 months, with a median of 74.5 months. CONCLUSION: Rectal excision for inflammatory bowel disease can be conducted with low rates of impotence. Minor degrees of erectile dysfunction may be more common than currently recognized. We could not demonstrate that close rectal dissection significantly protects the patient from impotence compared with operating in the anatomical mesorectal plane. Age appears to be the most important risk factor for postoperative impotence.

Adolescent↗
PubMed2001

Connective tissue changes in ileal Crohn's disease: relationship to disease phenotype and ulcer-associated cell lineage.

PURPOSE: Abnormalities of enteric collagen and smooth-muscle cell content have been documented in Crohn's disease. We studied the relationships among connective tissue changes, disease "type," and other disease features using immunohistochemistry and image analysis. METHODS: Twenty consecutive ileal resections for Crohn's disease and ten normal terminal ileal specimens were evaluated using conventional histopathologic examination. Monoclonal antibodies to smooth-muscle actin and Type III collagen fibers were used to determine the percentage area of the submucosa occupied by these constituents using image analysis. RESULTS: There were no significant differences in smooth-muscle content among stenosed, perforated, and ulcerated specimens. There was a significantly increased submucosal Type III collagen content in stenosed vs. other types. The only factor that correlated with smooth-muscle cell content was the amount of ulcer-associated cell lineage present. CONCLUSIONS: Increased deposition of Type III collagen fibers rather than smooth-muscle proliferation is associated with a stenotic phenotype. Loss of Type III collagen fibers may play a role in the development of perforating complications. We have found no evidence that smooth-muscle cells are the source of Type III collagen fiber production although there is evidence that ulcer-associated cell lineage may be related to the stimulus leading to submucosal neomuscularization.

Cell Division↗
PubMed2001

Immune therapy in inflammatory bowel disease and models of colitis.

BACKGROUND: A proliferation of animal models has not only improved our understanding of inflammatory bowel disease, it has also formed the basis of new treatment strategies. METHODS: A search was conducted using the National Library of Medicine for articles discussing immune therapies for inflammatory bowel disease. This was supplemented by findings from the authors' own laboratory. RESULTS: An overview of the different animal models is presented. These models are used to highlight the recent human trials of immune therapies. Potential future therapies are also discussed. CONCLUSION: Immune therapies have altered the management of patients with inflammatory bowel disease. In future they will influence not only the indications for surgery but also its timing and outcome.

Animals↗
PubMed2001

The pharmacology of the internal anal sphincter and new treatments of ano-rectal disorders.

Surgical options for faecal incontinence in the presence of intact sphincters are limited. Furthermore, in patients with fissures, lateral sphincterotomy reduces anal sphincter hypertonia but there has been concern about complications. A greater understanding of the basic pharmacology of the internal anal sphincter has led to the development of novel treatments for both these disorders. A Medline review was undertaken for internal anal sphincter pharmacology, anal fissures and faecal incontinence. This review is based on these articles and those found by further cross-referencing. Nitric oxide released from non-adrenergic non-cholinergic nerves is the main inhibitory agent in the internal anal sphincter. Relaxations are also mediated through beta-adrenoceptors and muscarinic receptors. Stimulation of alpha-receptors results in contraction. Calcium and its entry through L-type calcium channels is important for the maintenance of tone. Nitric oxide donors produce reductions in resting anal tone and heal fissures but are associated with side-effects. Muscarinic agents and calcium channel antagonists show promise as low side-effect alternatives. Botulinum toxin appears more efficacious than other agents in healing fissures. To date, alpha-receptor agonists have been disappointing at improving incontinence. Further understanding of the pharmacology of the internal anal sphincter may permit the development of new agents to selectively target the tissue with greater efficacy and fewer side-effects.

Adrenergic alpha-Agonists↗
PubMed2001

Lessons from laparoscopic surgery-a fresh look at post-operative management after major colorectal procedures.

OBJECTIVE: Laparoscopy holds promise of exciting advances in colorectal surgery, yet the data we require to draw appropriate evidence-based conclusions on its apparent advantages are sadly lacking. In the meantime, our focus on improved recovery after major colorectal resections has changed the way we manage patients after open surgery. METHODS: A literature review was undertaken to collect published data on laparoscopic colorectal surgery. In addition, data on newer developments in open colorectal surgery were collected. RESULTS: Although there are many published data in laparoscopic colorectal surgery, very few are randomized and controlled. It is clear that, at least in the short to medium term, oncological outcomes are comparable to open surgery. There are data suggesting advantages, including less immune suppression, faster recovery with earlier feeding, less ileus, shorter length of stay and earlier return to normal activity. CONCLUSION: Unfortunately, due to study design the data are largely not comparable with open surgery data, and open surgery itself has changed to some extent recently. We must encourage recruitment of patients into current ongoing randomized controlled trials of laparoscopic and open surgery and await the results.

Journal Article↗
PubMed2001

Hypermethylation of the promoter region of the E-cadherin gene (CDH1) in sporadic and ulcerative colitis associated colorectal cancer.

BACKGROUND: Ulcerative colitis associated colorectal cancer (UCACRC) has several distinctive clinicopathological and genetic features which differ from sporadic colorectal cancer (SCRC). Hypermethylation of the E-cadherin gene (CDH1) has not been described previously in colorectal cancer. AIMS: A panel of SCRC and UCACRC were investigated for mutations in CDH1, and for hypermethylation of the promoter region of CDH1. SUBJECTS AND METHODS: DNA was available from 14 patients with UCACRC and from 14 with SCRC. All exons of CDH1 were amplified with the polymerase chain reaction (PCR) and screened using single strand conformational polymorphism and direct sequencing. Hypermethylation of the CDH1 promoter region was determined by methylation specific PCR following bisulphite modification, and compared with E-cadherin protein expression from a previous immunohistochemistry study. RESULTS: Thirteen of 28 cancers (46%) were hypermethylated in the CDH1 promoter region-eight cancers (57%) in the UCACRC group and five cancers (36%) in the SCRC group (NS)-and this correlated with reduced E-cadherin expression (p<0.05). There was a trend for methylation to be associated with a more advanced stage of cancer although this did not reach statistical significance. There were no mutations in CDH1 in either group although there were several polymorphisms. CONCLUSION: We have demonstrated hypermethylation of the promoter region in CDH1 in 46% of colorectal cancers studied. There was no difference between the UCACRC and SCRC groups. Just as there are specific differences in the genetic changes between UCACRC and SCRC, there is also likely to be a large degree of overlap among the genetic pathways of these cancers.

Cadherins↗
PubMed2001

Topical adhesive as a wound dressing for elective abdominal surgery.

The choice of wound dressing after abdominal surgery is not always easy. We describe a simple technique using acyanoacrylate wound adhesive to provide a water resistant, flexible, sealed dressing which is simple to use, requires no nursing time to 'maintain' and is particularly useful in the presence of stomas or open drains.

Abdomen↗
PubMed2000

Persistent pain and faecal urgency after stapled haemorrhoidectomy.

INTRODUCTION: Haemorrhoidectomy usually cures haemorrhoids. Day surgery is feasible, and is associated with high patients' satisfaction and few complications, but patients take an average of 2 weeks off work after surgery. Stapled haemorrhoidectomy has the potential to decrease postoperative pain and time off work. However, data on long-term efficacy and function are lacking. METHODS: 22 patients underwent stapled haemorrhoidectomy: seven in a pilot study, and 15 in a randomised controlled trial to compare the new stapled operation with diathermy haemorrhoidectomy in a day-case setting. All operations were done by one consultant surgeon. RESULTS: 16 patients were followed up for longer than 6 months, five of whom (31% [95% CI 8.5-54.0%]) developed symptoms of pain and faecal urgency which persisted for up to 15 months postoperatively. The randomised trial was suspended, and patients were investigated with endoanal ultrasonography, anorectal physiology, and examination under anaesthetic. All five affected patients were reviewed by two independent surgeons experienced in the stapled operation. In one patient, a fibroepithelial polyp was found adjacent to an anodermal ulcer; in the other patients, no abnormality was found. Four of the five affected patients had some muscle incorporated into the doughnut, compared with only one of 11 of the unaffected patients (p=0.012, Fisher's exact test). No other significant differences in operative variables were identified between patients with and without symptoms. INTERPRETATION: Persistent severe pain and faecal urgency has been found in a disturbingly high proportion of patients after stapled haemorrhoidectomy. The mechanism behind this phenomenon is unclear, although muscle incorporation in the doughnut may have a role. Other groups who have studied stapled haemorrhoidectomy urgently need to audit their long-term results to assess the frequency of this problem.

Adult↗
PubMed2000

The relationship between inflammatory and serosal connective tissue changes in ileal Crohn's disease: evidence for a possible causative link.

The relationship between the gross connective tissue and inflammatory changes in ileal Crohn's disease remains unclear. This study investigated 20 patients undergoing ileal resection for Crohn's disease and 20 normal controls. The specimens were blocked in 1 cm serial sections and fully examined, including fresh morphometry and documentation of a range of pathological features. Pathological features of disease showed uniform distributions within affected segments, although specimens showed different patterns and severity of affliction. Serosal fat wrapping (FW) was present in all cases and was significantly greater than normals [mean 63.5% (SD 27. 8) vs. 21.0% (6.4), p<0.001], as was mesenteric thickening (MTh) [mean 18.0 mm (SD 11.1) vs. 5.9 mm (2.2), p<0.001]. The extent of FW correlated significantly with the degree of acute and chronic inflammation (r()=0.32 and 0.23 respectively, p<0.01), particularly the extent of transmural inflammation in the form of lymphoid aggregates (r()=0.35, p<0.01). MTh did not correlate with any features studied. These findings support the hypothesis that serosal connective tissue changes in Crohn's disease are related to the local effects of underlying chronic inflammatory infiltrates. Full thickness, radial samples from a grossly affected area are representative of the histopathological features present in a diseased segment as a whole.

Acute Disease↗
PubMed2000

Successful resection of an ileoanal pouch mesenteric desmoid without pouch sacrifice: report of a case.

PURPOSE: Intra-abdominal desmoid tumors are associated with familial adenomatous polyposis and may compromise ileoanal pouch function after restorative proctocolectomy, particularly if the pouch mesentery is involved. This usually necessitates pouch excision. The aim of this report was to describe the first known case of pouch salvage after surgery for a desmoid tumor arising from the pouch mesentery. METHODS: The management of a desmoid tumor involving an ileoanal pouch in a 21-year-old female is described and the literature reviewed. RESULTS: The tumor was successfully excised completely after failed medical therapy, and pouch function was fully preserved. CONCLUSIONS: This is a unique case highlighting the possibility of pouch salvage when affected by desmoid tumor.

Adenomatous Polyposis Coli↗
PubMed2000

Laparostomy for severe intra-abdominal infection complicating colorectal disease.

PURPOSE: The aim of this study was to evaluate the use of laparostomy in the management of patients with severe intra-abdominal infection resulting from colorectal disease. METHODS: Seven patients, four with inflammatory bowel disease, two with colorectal carcinoma, and one with diverticular perforation, underwent laparostomy during a six-year period for postoperative, severe, intra-abdominal infection. RESULTS: The median age was 42 years, the mean Acute Physiology and Chronic Health Evaluation II score was 22.7, and the observed mortality was 28.6 percent (2/7 patients). In one patient the laparostomy was closed at 11 days; in all the others the wound was left to heal by granulation and contraction, and two of these later required reconstructive surgery. The median follow-up was three years and seven months. CONCLUSION: Laparostomy is an effective and practical method of managing patients with severe intra-abdominal infection as a result of colorectal disease.

APACHE↗
PubMed2000

Aneuploidy and columnar cuff surveillance after stapled ileal pouch-anal anastomosis in ulcerative colitis.

PURPOSE: A stapled pouch-anal anastomosis without mucosectomy is widely used in restorative proctocolectomy. Uncertainty exists about the longer-term outcome of retaining a columnar cuff of epithelium in the anal canal and about the need for surveillance of the columnar cuff. The aim of this article was to assess the ability to obtain biopsies of the columnar cuff, to assess the risk of dysplasia, and to search for the presence of aneuploidy as an early of marker of dysplasia in nondysplastic epithelium. METHOD: A total of 457 biopsy specimens were taken during 203 examinations of 113 patients. All biopsy specimens were stained with hematoxylin and eosin and examined by microscopy. One hundred thirty-two of these biopsy specimens from 67 patients were frozen and analyzed by flow cytometry for aneuploidy. RESULTS: Mean follow-up after pouch formation was 2.5 years, and the time after diagnosis of ulcerative colitis was 10.1 years. Successful columnar cuff biopsies were done on 93 percent of patients. There was no dysplasia. Two biopsy specimens from one patient had aneuploidy. CONCLUSION: To date, neoplastic change in the columnar cuff is rare. A selective policy of surveillance biopsies is recommended that includes patients greater than ten years after the diagnosis of ulcerative colitis and patients with dysplasia or cancer in their proctocolectomy specimen, but long-term follow-up data are needed.

Anal Canal↗