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Gut. 2007 July; 56(7): 1000.
PMCID: PMC1994337


Preventing short bowel in Crohn's: a novel surgical approach

[filled triangle] Michelassi F, Taschieri A, Tonelli F, et al. An international, multicenter, prospective, observational study of the side‐to‐side isoperistaltic strictureplasty in Crohn's disease. Dis Col Rectum 2007;50:277–284.

Extensive fibrostenotic jejunoileal disease presents a particular therapeutic problem in Crohn's disease. Conventional drug treatment is ineffective and biological agents contraindicated. Surgical resection is clearly possible, but adds the additional risk of leaving the patient with a short bowel. In selected cases, multiple short strictureplasties may be possible, but often the disease is virtually confluent and this approach is impossible. In 1992 Michelassi described an extended side‐to‐side ileoperistaltic strictureplasty (SSIS) which, as it suggests, allows long segments of disease to be dealt with without resection. In this article, they describe 184 patients with primary and recurrent disease from six centres in Europe and the US who have undergone SSIS. The average length of the diseased segment undergoing strictureplasty was 37.8 cm with a range of 7 to 121.9 cm. Gastrointestinal haemorrhage, leak and obstruction were the common complications and one patient died from a pulmonary embolus. However 89% of operations were complication free. Of the 184 patients, 41 required further surgery for recurrent disease with a mean interval of 35 months, but the cumulative operation free survival at 5 years was 77%. Preservation of bowel length in patients with extensive small bowel Crohn's disease is critically important. This novel surgical approach seems to safely achieve this aim and, while there are differences across the six centres, it also seems to be reproducible.

It's not difficult: in IBD look for C difficile!

[filled triangle] Rodermann JF, Debberke ER, Reske KA, et al. Incidence of Clostridium difficile infection in inflammatory bowel disease. Clin Gastro Hep 2007;5:339–44.

[filled triangle] Issa M, Vijayapal A, Graham MB, et al. Impact of Clostridium difficile on inflammatory bowel disease. Clin Gastro Hep 2007;5:345–51.

The frequency of Clostridium difficile in hospitalised patients is increasing dramatically and it is known that C difficile can occur in patients with inflammatory bowel disease (IBD), mimicking a disease flare or triggering a relapse. Previous studies have shown that 5–20% of patients admitted with an IBD flare will have C difficile infection.

Two single‐centre US studies provide useful data on C difficile infection in IBD. In the first study from St Louis, all inpatient C difficile infections were studied over 7 years. Incidence increased in both groups with time and were significantly more common in ulcerative colitis than Crohn's disease (in 2004 rates were 57.6/1000 and 22.3/1000 admissions, respectively). The median time to positive C difficile test was less than 1 day in IBD, compared with 4 days for patients without IBD, implying that most patients with IBD acquire their infection before entering hospital. Similarly, the Milwaukee study showed that three quarters of infections were community‐acquired. This study was a more detailed analysis of risk factors for C difficile in IBD. Only 61% had had antibiotic exposure in the past 2 months. Colonic disease, short duration of IBD and immunosuppressive treatment were risk factors for C difficile infection.

These studies show that C difficile infection must now be considered in clinic patients with a flare of disease, even in the absence of recent antibiotic treatment, particularly in patients with colonic disease or those receiving immunosuppressive treatment.

Saving Private Jawan

[filled triangle] Shrestha MP, Scott RM, Joshi DM, et al. Safety and efficacy of recombinant hepatitis E vaccine. N Engl J Med 2007;356:895–903.

Hepatitis E virus (HEV) is an important cause of acute hepatitis accounting for large water‐borne epidemics in endemic regions such as Asia. Shrestha et al evaluated the safety and efficacy of an HEV recombinant protein (rHEV) vaccine in a high‐risk population with no previous exposure to HEV (as indicated by low anti‐rHEV immunoglobulin levels). In a double‐blind, placebo‐controlled trial, 2000 healthy people (99.6% men) from Nepalese Army units were randomised to receive either the rHEV vaccine or placebo. Of these, 1794 subjects (898 in the vaccine group and 896 in the placebo group) received three vaccine doses at month 0, 1 and 6. During a median followup of 804 days, symptomatic hepatitis E (defined as jaundice or at least three recognised symptoms lasting for three days with laboratory tests confirming acute HEV infection) developed in 69 subjects, of whom 66 were in the placebo group. After three vaccine doses, the vaccine efficacy was 95.5% (95% CI 85.6 to 98.6). The proportion of subjects with adverse events was similar in the two study groups, except that injection‐site pain was increased in the vaccine group (p = 0.03).

It is encouraging that in a high‐risk population, the rHEV vaccine was effective in the prevention of symptomatic hepatitis E. How this vaccine may affect the reservoir of HEV and its transmission, thus determining the overall public health benefit, is yet be determined. The ethics of choosing army personnel (Jawan) as subjects in a clinical trial and the politics behind the US Army designing and monitoring a trial conducted in the Nepalese Army will be eagerly debated.

When Dr McCoy met Van Gogh…tales of the unexpected from the colon

[filled triangle] Kiesslich R, Goetz M, Lammersdorf K et al. Chromoscopy‐guided endomicroscopy increases the diagnostic yield of intraepithelial neoplasia in ulcerative colitis. Gastroenterology 2007;132:874–82.

The clinical bay on the Star Ship Enterprise was always the place to go if you had difficulty with a rare, but well‐reported, Klingon‐acquired disease…pardon the pun for a gastroenterologist! Dr McCoy would simply pass his hand‐held laser sensor over the entire body in seconds and the diagnosis would be made. Glorious 3D images at cellular level would be projected for close scrutiny before the doctor gave his mercy green antidote…clearly no syringes required! Well, perhaps McCoy's diagnostic and therapeutic medicine was not too ”off‐the‐wall” after all. The needle‐free “pen” for diabetics is currently under trial and now laser scanning confocal endomicroscopy can permit cellular resolution imaging in vivo with the ability to examine the mucosa “sub‐surface” down to 250 microns.

Kiesslich and colleagues have now reported their experience of intraepithelial neoplasia detection using this novel technology in screening for ulcerative colitis cancer. When considering the primary outcome analysis of histological‐confirmed intraepithelial neoplasia, chromoscopic endomicroscopy significantly improved the yield compared with controls (p<0.007) and was able to resolve discrete cellular structure in vivo. Furthermore, the presence of neoplastic change in this study could be predicted with a high overall accuracy (97.8%) and significantly reduced the number of biopsy specimens per patient without any decrease in yield of neoplasia (21.2 biopsies per patient vs 42.2 biopsies per patient (p<0.05)). All‐in‐all, a top study that proves the clinical worth of novel technology.

Articles from Gut are provided here courtesy of BMJ Group