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The progress of adaptive changes in the left colon after diverting colostomy was studied in rats using stereological techniques. Standardised segments of left colon proximal and distal to the colostomy was examined after 0, 1, 2, 4, or 12 weeks. In excluded colon the mucosal weight was reduced by 37% (p<0-01) and the luminal surface area by 47% (p<0.01) after four weeks and reached a steady state at this point of time, as no further reduction was seen from 4 to 12 weeks. The number of proliferating crypt cells was determined immunohistochemically after in vivo labelling with bromodeoxyuridine and was compared with the total number of colonocytes. Total bowel rest leads to a reduction in the number of proliferating epithelial cells and not to a reduced average life span. The weight of the muscularis propria decreased by 32% after four weeks (p<0.01) and by 48% after 12 weeks (p<0.001), whereas the weight of the submucosa was unchanged. No adaptive changes were found in segments proximal to the colostomy. These results show that the wall composition of defunctioned colon in rats is radically changed resulting from a mucosal and muscular atrophy, and from a reduction in luminal surface area. (Gut 1994; 35: 1275-1281 Multistage procedures that include a temporary colostomy have become the standard approach in the surgical treatment of many emergency and some elective colonic conditions. Although the performance of a colostomy later followed by colostomy closure is regarded as a safe procedure, the latter is still associated with a significant rate of morbidity and mortality.1 2 The complications include anastomotic leak, faecal fistula, and anastomotic obstruction.3 When the faecal stream is surgically divided, the luminal environment and the mechanical stimulation of the colon is radically changed. Although complications after colostomy closure may be related to trophic changes in the defunctioned bowel wall only few studies have been performed to characterise the overall colonic response to surgical defunctioning.Luminal bulk is considered to be important for normal mucosal growth in the entire gastrointestinal tract. Profound mucosal hypoplasia has been found in biopsy specimens taken from the defunctioned rectum in humans,4 and in rat colon reductions in the mucosal cell proliferation and mucosal mass have been shown after total parenteral nutrition,5 fasting,6 and faecal diversion.7-9 The morphometric information in these studies was, however, obtained mainly from isolated crypts, and consequently they did not fulfil modem stereological requirements regarding uniform specimen sampling.'0 Blomquist et alhas shown a decrease in collagen synthesis and collagen content of the entire wall of excluded colon in rats.11 These data show that the atrophic changes occur in all layers after defunctioning the large bowel, but at the present no morphometric information exist to support these findings.The aim of this experimental study was, by means of new and unbiased stereological techniques, to investigate and quan...

Existing data on morphological adaptation after small bowel resection are obtained by potentially biased methods. Using stereological techniques, we examined segments of bowel on days 0, 4, 7, 14, and 28 after 80% jejunoileal resection or sham operation in rats and correlated intestinal growth with plasma levels of glucagon-like peptide-2 (GLP-2). In the jejunum and ileum of the resected rats, the mucosal weight increased by 120 and 115% during the first week, and the weight of muscular layer increased by 134 and 83%, compared with sham-operated controls. The luminal surface area increased by 190% in the jejunum and by 155% in the ileum after 28 days. The GLP-2 level was increased by 130% during the entire study period in the resected rats. Small bowel resection caused a pronounced and persistent transmural growth response in the remaining small bowel, with the most prominent growth occurring in the jejunal part. The significantly elevated GLP-2 level is consistent with an important role of GLP-2 in the adaptive response.

BackgroundCombined intra-operative ablation and resection (CARe) is proposed to treat extensive colorectal liver metastases (CLM). This multicenter study was conducted to evaluate overall survival (OS), local recurrence-free survival (LRFS), hepatic recurrence-free survival (HRFS) and progression-free survival (PFS), to identify factors associated with survival, and to report complications.Materials and MethodsFour centers combined retropectively their clinical experiences regarding CLM treated by CARe. CLM characteristics, pre- and post-operative chemotherapy regimens, surgical procedures, complications and survivals were analyzed.ResultsOf the 288 patients who received CARe, 210 (73%) had synchronous and 255 (88%) had bilateral CLM. Twenty-two patients (8%) had extrahepatic disease. Median follow-up was 3.17 years (95%CI 2.83–4.08). Median OS was 3.33 years (95%CI 3.08–4.17) and 5-year OS was 37% (95%CI 29–45). One- and 5-year LRFS from ablated lesions were 87.9% (95%CI 83.3–91.2) and 78.0% (95%CI 71–83), respectively. Median HRFS and PFS were 14 months (95%CI 11–18) and 9 months (95%CI 8–11), respectively. One hundred patients experienced complications: 29 grade I, 68 grade II–III–IV, and three deaths. In the multivariate models adjusted for center, the occurrence of complications was confirmed as a major independent factor associated with 3-year OS (HR 1.80; P = 0.008). Five-year OS was 25.6% (95%CI 14.9–37.6) for patients with complications and 45% (95%CI 33.3–53.4) for patients without.ConclusionsRecent strategies facing advanced CLM include non-anatomic resections, portal-induced hypertrophy of the future remnant liver and aggressive medical preoperative treatments. CARe has the qualities of an approach that allows effective tumor clearance while maintaining good tolerance for the patient.