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Purpose: This study was designed to compare self-reported sexual function, body image, and quality of life outcomes among ulcerative colitis patients undergoing laparoscopic or open ileal pouch-anal anastomosis., Methods: Between 1978 and 2004, 100 laparoscopic and 189 open operations were performed in patients who were identified from a previously published cohort. Patients were surveyed one year after operation to evaluate sexual function, body image, and quality of life., Results: A total of 125 of 289 patients (43 percent) returned completed surveys. There were no significant differences in terms of demographics, complications, or long-term functional outcomes between those who completed the surveys and those who did not. There were no clinical differences in results between laparoscopic and open patients using the three survey instruments. Orgasmic function scores were lower in men who underwent laparoscopic ileal pouch-anal anastomosis (P < 0.05) compared with open ileal pouch-anal anastomosis. Overall, sexual function scores were equal to or better than normal values for men but were lower in women. Finally, overall body image and quality of life scores were above the means published for the United States., Conclusions: After ileal pouch-anal anastomosis, men and women reported excellent body image and high cosmetic and quality of life scores regardless of operative approach. Female sexual function was more adversely affected after ileal pouch-anal anastomosis than was male sexual function.

Introduction: Laparoscopic assisted (LA) colectomy has significant patient benefits but is technically challenging. Hand-assisted laparoscopic surgery (HALS) allows tactile feedback because the surgeon's hand assists in retraction and dissection. This may decrease the technical difficulty and shorten the learning curve associated with performing laparoscopic colectomy. We investigated the patient selection and short-term clinical outcomes of HALS and LA since the introduction of HALS to our minimally invasive colorectal practice., Methods: Prospectively collected data on 258 patients undergoing HALS (n = 109) or LA colectomy (n = 149) during a calendar year (2004) were analyzed. Patient and disease characteristics, operative parameters, and perioperative outcomes were compared., Results: HALS patients were similar to LA patients in age (51 vs. 54 yrs), gender (56 vs. 52% male), body mass index (26 vs. 26 kg/m2), comorbidities (84 vs. 85% with one or more), and diagnosis (83 vs. 80% benign), but differed in incidence of previous surgery (49 vs. 30%; P = 0.008). A significantly greater proportion of HALS patients underwent complex procedures and extensive resections. Conversion rates (15 vs. 11%, P = 0.44), intraoperative complications (4 vs. 1%, P = 0.17), 30-day morbidity (18 vs. 11%, P = 0.12) and surgical reinterventions (2 vs. 1%, P = 0.58) did not differ. Recovery measured by days to flatus was not different [mean (standard deviation) 3(2) vs. 3(2) days, P = 0.26], however HALS patients had longer operative times [276(96) vs. 211(107) minutes P < 0.0001] and 1 day longer stay in hospital [6(3) vs. 5 (3) days, P = 0.0009)]., Conclusions: Patients undergoing HALS underwent more-complex procedures than LA patients but retained the short-term benefits associated with LA colectomy. HALS facilitates expansion of a minimally invasive colectomy practice to include more challenging procedures while maintaining short-term patient benefits.

Purpose: This study was designed to assess the impact of pelvic radiotherapy on the incidence of complications and colostomy-free survival of patients after a coloanal anastomosis for rectal cancer., Methods: A total of 192 patients underwent a coloanal anastomosis between 1982 and 2001: 87 patients did not receive pelvic radiotherapy; 105 patients received pelvic radiotherapy (39 preoperative and 66 postoperative). Early and late complications requiring surgical intervention and the colostomy-free survival rate were assessed by retrospective review of patient records., Results: After a median follow-up of 62 months, 151 patients were alive. The most frequent complication was development of an anastomotic stricture (5-year rate of a stricture, 16 percent; 95 percent confidence interval, 10-21). Patients receiving pelvic radiotherapy had a higher rate of complications other than anastomotic strictures, including fecal incontinence, fistulas, abscesses, and bowel obstructions compared with patients not receiving pelvic radiotherapy (5-year rate: 20 percent (95 percent confidence interval, 10-29) vs. 5 percent (95 percent confidence interval, 0-10); P = 0.001). Patients receiving pelvic radiotherapy had a lower colostomy-free survival than did patients not receiving pelvic radiotherapy (5-year colostomy-free rate: 72 percent (95 percent confidence interval, 62-84) vs. 92 percent (95 percent confidence interval, 86-98); P < 0.001). There was no significant difference in the colostomy-free survival of patients receiving preoperative and postoperative pelvic radiotherapy., Conclusions: After coloanal anastomosis, a significant number of patients will have complications requiring surgical intervention, and some will require a permanent colostomy. Pelvic radiotherapy, whether it is administered preoperatively or postoperatively, significantly increases the need for a permanent colostomy.

Surgery is the primary treatment of rectal cancer. However, variability in surgical outcomes led to development of combined therapies including pelvic radiation and systemic chemotherapy. The evolution of these therapies both individually and combined, their successes and limitations is discussed in the context of an evolving understanding of rectal cancer biology. The impact of standardized optimal surgery on the need for additional therapy and trends in treating complete responders to neoadjuvant therapy is also reviewed., (2007 Wiley-Liss, Inc)

Modern management of locally advanced rectal cancer requires a multimodality approach. This includes radical surgery, pelvic radiotherapy, and systemic chemotherapy. It can require a permanent colostomy and result in significant bowel, sexual, and urinary dysfunction. In order to determine the effectiveness of various multimodality regimens it is important to not only assess conventional oncologic outcomes but also the impact on patient's quality of life., (2007 Wiley-Liss, Inc)

Crohn's disease is a chronic inflammatory disease of the intestinal tract that often results in the need for surgical intervention to treat complications of the disease. The transmural nature of the inflammation can lead to intestinal perforation, intraabdominal abscesses, intestinal strictures, and fistula development. Because there is no cure for Crohn's disease, many patients will require multiple operations during their lifetime. Index surgery and reoperative surgery in these patients is often complex and challenging. There are many preoperative planning and technical aspects of Crohn's surgery that can be helpful in achieving a successful clinical outcome. In this paper, we will review some of the important principles in operative and reoperative Crohn's surgery that can assist the surgeon when approaching these challenging cases.

Background: The aim of this analysis was to determine the impact of complicated and uncomplicated diverticulitis on conversion rates and complications in patients undergoing laparoscopic surgery (LS) for diverticular disease., Methods: Between 1993 and 2004, 125 patients underwent LS [91 laparoscopic-assisted (LA) and 34 hand-assisted (HA) colectomy for diverticular disease, 79 uncomplicated and 46 complicated]. Cases not completed laparoscopically were considered converted. Complicated diverticulitis was defined as diverticular disease associated with abscess, fistula, bleeding or stricture., Results: The mean age was 59 years with 67 (54%) men with a mean follow-up of 23 months. The conversion rate was 26% (33 patients). The only factor independently associated with conversion was a history of previous abdominal surgery (37% vs. 14%, p = 0.004). Among the subset of patients undergoing surgery for uncomplicated diverticulitis, the number of diverticulitis episodes (DE), the time between the first and last DE, and the time between the last DE and surgery, were not significantly associated with conversion. Early complications (<30 days from surgery) occurred in 30 (25%) patients. Twenty-one long-term complications (>30 days from surgery) occurred in 20 patients and the one and two-year cumulative probabilities of these complications were 14% and 22%, respectively. Early complications were significantly higher among patients requiring conversion (44% vs. 24%, p = 0.04) but were not significantly higher among patients with complicated diverticulitis (39% vs. 24%, p = 0.11). The rates of long-term complications were not significantly higher among patients that required conversion or had complicated diverticulitis (one-year rate 23% vs. 11%, p = 0.47; 18% vs. 13%, p = 0.70)., Conclusions: A previous history of abdominal surgery was associated with a higher conversion rate in patients undergoing laparoscopic surgery for diverticular disease. Long-term patient outcomes are not adversely impacted by laparoscopic surgery for complicated diverticulitis or laparoscopic surgery requiring conversion to an open procedure.

Background: Patient education is known to improve satisfaction in and participation with treatment. A careful assessment of internet use by inflammatory bowel disease (IBD) patients to gather information has not been reported. Our aim was to evaluate internet use to gather general health- and disease-specific information in patients presenting to an IBD clinic., Methods: A cross-sectional anonymous survey using a convenience sample of patients (N = 175) at a tertiary-care institution's IBD clinic was performed., Results: In all, 169 surveys (97%) were returned for analysis. The median age was 46 (17-84), 83 men and 81 women (5 missing). In known IBD patients (87%), 85 (50%) had Crohn's disease and 62 (37%) ulcerative colitis; 81% of patients had home internet access. The most common information sources were: gastroenterologists (59%), internet (54%), and primary-care physicians (54%). Ninety-two patients (54%) used the internet to gather IBD-specific information. Age-specific use (<40, 40-65, >65) was 73%, 48%, 37.5%, respectively. There was a significant positive association between level of education and internet use (P < 0.0001), but not with income. Internet sites most commonly visited were organization- or institution-specific. Factors that most influenced a user's choice of an internet site were noncommercial status (59%) and ease of use (53%). The majority of patients (57%) rated internet information "trustworthy" to "very trustworthy.", Conclusions: Over half of patients in an IBD clinic used the internet to gather IBD-specific information. Use was inversely associated with age and positively correlated with education level. There was no income association. These findings suggest web-based IBD information may become increasingly important in the future.

Complex pilonidal disease, an uncommon manifestation of an anorectal condition, is characterized by chronic or recurrent abscesses with extensive, branching sinus tracts. Definitive treatment requires wide excision of all involved tissue followed by secondary intention healing or reconstructive surgery. All treatment options have unique advantages and disadvantages. Following recent reports that negative pressure wound therapy after surgery for complex pilonidal disease may be a useful alternative to moist saline dressing treatments, five patients (three men and two women, median age 21 years [range: 16 to 63 years]) with complex pilonidal disease (symptom duration range 6 months to 30 years) were treated on an outpatient basis. Following wide excision under general anesthesia, a portable negative pressure wound therapy device was applied. Mean wound defect size after excision was 11 cm x 4 cm x 5 cm, or 205 cm(3) (range 90 cm(3) to 410 cm(3)). Negative pressure wound therapy was used for an average of 6 weeks (range 4 to 9 weeks) and mean time to complete epithelialization was 12 weeks (range 9 to 22 weeks), including use of moist saline dressings post negative pressure wound therapy. Treatment was discontinued in one patient due to skin irritation. No other complications were observed. Long-term follow-up is required to assess the risk of recurrent pilonidal disease or wound failure following negative pressure wound therapy. Additional studies of negative pressure wound therapy in the management of pilonidal disease are warranted.

Background: Total proctocolectomy and ileal pouch anal anastomosis (IPAA) is the preferred operation for patients with chronic ulcerative colitis (CUC) refractory to medical therapy. Infliximab (IFX), an antitumor necrosis factor-alpha antibody, has demonstrated efficacy in medical management of CUC. The aim of this study is to determine if IFX before IPAA impacts short-term outcomes., Study Design: A prospective institutional database was retrospectively reviewed for short-term complications after IPAA for CUC. Postoperative outcomes were compared between patients who received pre-IPAA IFX and those who did not., Results: Between 2002 and 2005, 47 patients received IFX before IPAA, and 254 patients received none. There were no gender (p = 0.16) or body mass index (p = 0.07) differences between groups. IFX patients were younger than non-IFX patients (mean age 28.1 to 39.3 years) (p < 0.001). In IFX patients, 70% were receiving preoperative IFX, azathioprine, and corticosteroids. Mortality was nil. Overall surgical morbidity was similar: 61.7% and 48.8%, IFX and non-IFX, respectively (p = 0.10). Anastomotic leaks (p = 0.02), pouch-specific (p = 0.01) and infectious (p < 0.01) complications were more common in IFX patients. Multivariable analysis revealed IFX as the only factor independently associated with infectious complications (odds ratio [OR] = 3.5; CI, 1.6-7.5). In a separate analysis, incorporating age, high-dose corticosteroids, azathioprine, and severity of colitis, IFX remained significantly associated with infectious complications (OR = 2.7; CI, 1.1-6.7)., Conclusions: CUC patients treated with IFX before IPAA have substantially increased the odds of postoperative pouch-related and infectious complications. Additional prospective studies are required to determine if IFX alone or other factors contribute to the observed increases in infectious complications.

Pilonidal disease is a common anorectal problem that typically affects young people. Numerous surgical procedures have been described, but treatment failure and disease recurrence are frequent, leading to considerable morbidity in these otherwise healthy patients. To manage this problem successfully, surgeons must consider the pathogenesis and presentation of the disease and weigh the advantages and disadvantages of any operation. Discussed in this article are the pathogenesis of pilonidal disease and basic treatment options for acute pilonidal abscesses, sinus tracts, and chronic or recurrent pilonidal disease.

Purpose: This study was designed to evaluate the long-term functional and quality-of-life outcomes of patients after coloanal anastomosis for distal rectal cancer., Methods: A total of 192 patients underwent coloanal anastomosis between 1982 and 2001 at two tertiary referral institutions. Standardized and validated questionnaires to assess functional and quality-of-life outcomes were mailed to 151 patients, of which 121 patients responded (median follow-up, 65 months)., Results: Patients receiving pelvic radiotherapy had more bowel function problems than patients who did not receive pelvic radiotherapy. No significant differences in relevant functional and quality-of-life outcomes were seen among patients who received preoperative or postoperative pelvic radiotherapy. Patients requiring permanent diversion as a result of complications of the surgery had decreased quality of life., Conclusions: Coloanal anastomosis for distal rectal cancer has favorable long-term outcomes. Pelvic radiotherapy has an adverse effect on subsequent bowel function (whether given preoperatively or postoperatively) in patients who maintain intestinal continuity. Loss of intestinal continuity after a coloanal anastomosis is associated with diminished quality of life.

Objective: To compare safety and short-term outcomes of 100 laparoscopic ileal pouch-anal anastomosis (IPAA) versus 200 conventional open IPAA patients., Summary Background Data: Outcomes of laparoscopic IPAA (LAP-IPAA) have been incompletely characterized. Previous reports are characterized by small numbers of patients and rarely include case-matched or randomized trial methodology. This report describes 100 LAP-IPAA patients case matched to 200 open IPAA patients., Methods: Between 1998 and 2004, 100 consecutive LAP-IPAA patients (75 laparoscopic assisted, 25 hand assisted) were identified and case matched to 200 open IPAA control patients by age, operation, gender, date of operation, and body mass index. Operative and postoperative outcomes at 90 days were compared., Results: A total of 300 patients (180 female) with a median age of 32 years (range, 17-66 years), and a median body mass index of 23 kg/m (range, 16-34 kg/m) underwent IPAA (100 LAP-IPAA, 200 open IPAA). Diagnosis (chronic ulcerative colitis 97%, familial adenomatous polyposis 3%) and previous operative history were equivalent between groups. One intraoperative complication occurred in each group. Overall, the laparoscopic conversion rate was 6%. Median operative time was longer for the LAP-IPAA group (333 minutes versus 230 minutes, P < 0.0001). LAP-IPAA patients had shorter median time to regular diet (3 versus 5 days), time to ileostomy output (2 versus 3 days), length of stay (4 versus 7 days), and decreased IV narcotic use (all P < 0.05. Postoperative morbidity was equivalent (LAP-IPAA = 33%, open IPAA = 37%), mortality was nil, and readmission rates were equal (LAP-IPAA = 21%, open IPAA = 22%). Reoperation was required in 3% of LAP-IPAA and 6.5% of open IPAA patients (P < 0.2) during the first 3 months., Conclusion: LAP-IPAA is equivalent to open IPAA in terms of safety and feasibility. In addition, LAP-IPAA provides significant improvements in short-term recovery outcomes.

During acute exacerbations of inflammatory bowel diseases, oxidants are generated through the interactions of bacteria in the lumen, activated granulocytes, and cells of the colon mucosa. In this study we explored the ability of one such class of oxidants, represented by monochloramine (NH(2)Cl), to serve as agonists of Ca(2+) and Zn(2+) accumulation within the colonocyte. Individual colon crypts prepared from Sprague-Dawley rats were mounted in perfusion chambers after loading with fluorescent reporters fura 2-AM and fluozin 3-AM. These reporters were characterized, in situ, for responsiveness to Ca(2+) and Zn(2+) in the cytoplasm. Responses to different concentrations of NH(2)Cl (50, 100, and 200 microM) were monitored. Subsequent studies were designed to identify the sources and mechanisms of NH(2)Cl-induced increases in Ca(2+) and Zn(2+) in the cytoplasm. Exposure to NH(2)Cl led to dose-dependent increases in intracellular Ca(2+) concentration ([Ca(2+)](i)) in the range of 200-400 nM above baseline levels. Further studies indicated that NH(2)Cl-induced accumulation of Ca(2+) in the cytoplasm is the result of release from intracellular stores and basolateral entry of extracellular Ca(2+) through store-operated channels. In addition, exposure to NH(2)Cl resulted in dose-dependent and sustained increases in intracellular Zn(2+) concentration ([Zn(2+)](i)) in the nanomolar range. These alterations were neutralized by dithiothreitol, which shields intracellular thiol groups from oxidation. We conclude that Ca(2+)- and Zn(2+)-handling proteins are susceptible to oxidation by chloramines, leading to sustained, but not necessarily toxic, increases in [Ca(2+)](i) and [Zn(2+)](i). Under certain conditions, NH(2)Cl may act not as a toxin but as an agent that activates intracellular signaling pathways.

Purpose: Functional outcomes in laparoscopic-assisted ileal pouch-anal anastomosis have been incompletely studied. More than one-year follow-up has rarely been reported in these patients. This study was designed to assess operative, functional, and quality of life outcomes in patients with ulcerative colitis or familial adenomatous polyposis a minimum of one year after., Methods: Thirty-three laparoscopic-assisted ileal pouch-anal anastomosis and 33 open ileal pouch-anal anastomosis patients, with a median of 13 months and minimum of 12 months follow-up, were identified from a prospective, laparoscopic database. Functional outcome was prospectively assessed by using a standardized survey. These cohorts were matched by individual patient for year of surgery, age, gender, body mass index, and indication., Results: Median age was 27 years (open) and 28 years (laparoscopic). There were 27 females and 6 males in each group. All operations occurred between 1999 and 2001. Median body mass index was 22.3 (open) and 21.7 (laparoscopic) groups. There were no significant differences in diagnosis, use of diversion, and anastomotic technique. Postoperative morbidity occurred in 6 percent of the laparoscopic cases and 12 percent of the open cases. Functional outcome after a minimum of one year revealed equivalent median day and median nocturnal number of stools of six to seven and one to two respectively. Consistency of stool, medication usage, and continence were no different between groups. Daytime and nocturnal incontinence was similar. Quality of life in regard to social, home life, family, travel, sports, recreation, and sex life were equivalent., Conclusions: The function and quality of life outcomes for patients undergoing laparoscopic-assisted ileal pouch-anal anastomosis seem to be equivalent to our open experience. Laparoscopic-assisted ileal pouch-anal anastomosis offers selected patients a safe, feasible, and durable alternative.

Hypothesis: Functional outcome and quality of life in older patients (>55 years) undergoing ileal pouch-anal anastomosis (IPAA) for ulcerative colitis or familial adenomatous polyposis have been incompletely studied. Our aim was to update our understanding on how the age of the patient at the time of surgery influences functional outcome and quality of life after IPAA., Methods: From January 1, 1981, to December 31, 2000, two thousand two patients who underwent IPAA were studied. Patients were grouped by age at operation: 45 years or younger (n = 1688), between 46 and 55 years (n = 249), and older than 55 years (n = 65). Mean age was 33.5 years. Postoperative complications, function, and quality of life were assessed with a questionnaire administered annually., Results: Follow-up for patients older than 55 years was a mean +/- SD of 8.1 +/- 4.8 years. Overall, follow-up was a mean of 10.1 +/- 5.7 years. The pouch failure rate for patients older than 55 years was 1.6% at 10 years. No statistically significant difference in pouch failure between age groups was observed. Overall, frequent daytime and nighttime incontinence, respectively, occurred in 5.6% and 13.3% of the patients at 10 years. Incontinence was more common in older patients (P = .002 at 3 years). Quality of life as assessed by social activities, work, travel, sexual activity, family relationships, and sports and recreation was not significantly different among age groups. Most patients felt that their condition had improved or that they had no restrictions after IPAA., Conclusions: Postoperative complications after surgery seem to be unrelated to age at the time of surgery. Although incontinence may occur more frequently in older patients, IPAA does not adversely affect quality of life in patients older than 55 years.

Purpose: Prostate brachytherapy is gaining wide popularity as an alternative to resection for the treatment of locally advanced prostate cancer. Rectal-urethral fistula after prostate brachytherapy is a rare but serious complication, and its incidence, presentation, risk factors, and clinical management have not been well described., Methods: From January 1997 to October 2002, seven patients with rectal-urethral fistulas were referred to two institutions (Brigham and Women's Hospital and West Roxbury Veteran's Administration Hospital) of a major teaching referral center. Clinical presentation, risk factors, prostate staging, and clinical management were examined in a retrospective fashion., Results: Seven rectal-urethral fistulas developed from roughly 700 (1 percent) patients treated with prostate brachytherapy for prostate cancer. The average patient age was 67.7 years, preimplant prostate-specific antigen was 7.1, and Gleason score was 3+3. Symptoms occurred at a mean of 27.3 months after prostate brachytherapy was started and included anorectal pain (57 percent), clear mucous discharge (57 percent), diarrhea (43 percent), and rectal ulceration (43 percent). Coronary artery disease was a common comorbidity (71 percent). Previous transurethral resection of prostate (28 percent) and pelvic irradiation or external beam radiation therapy (14 percent) were not associated with increased risk of rectal-urethral fistula. All patients underwent a diverting colostomy (86 percent) or ileostomy (14 percent), and four patients went on to have definitive therapy. Definitive resection was performed between 5 and 43 months after diverting ostomy and was chosen on the basis of comorbid disease, quality of life, and degree of operation. Two patients required a second diversion after definitive resection because of anorectal pain and a colocutaneous fistula. Postoperative complications included myocardial infarction (14 percent), blood transfusion (14 percent), and bowel perforation (14 percent). Patients became symptom-free nine months after surgery. Six patients are alive and well today; one died from an unrelated cause., Conclusions: Rectal-urethral fistula after prostate brachytherapy is a rare but devastating complication. Patients should be followed for at least three years after prostate brachytherapy because symptoms can develop late in the course. Although diversion of fecal stream does not heal the fistula, all patients diagnosed with rectal-urethral fistula should first undergo diverting ostomy to alleviate symptoms. Then, one should consider definitive resection and ostomy closure.

Chronic ulcerative colitis (CUC) is an inflammatory bowel disease limited to the mucosa of the rectum and colon. The inflammation begins in the rectum and progresses uninterrupted for variable distances. To date, no etiologic factor has been identified. However, population studies suggest there is both a genetic and environmental component contributing to the development of CUC. The natural history is one of a chronic inflammatory state, characterized by intermittent flares of disease activity. In a small number of patients, the initial presentation of CUC is of a fulminant nature. Medical therapy for the intestinal manifestations of CUC is directed at controlling symptoms through treatment of the underlying inflammatory process. Medical therapy is not curative for either the intestinal or extraintestinal manifestation of CUC. However, surgical removal of the colon and rectum cures the intestinal manifestations of the disease and eliminates or markedly reduces the associated risk of malignancy in longstanding CUC. The indications for surgical intervention are divided into two broad categories that influence the type of surgery performed: emergent and elective surgery. Emergency operations are directed at life-threatening complications of CUC and are not intended as definitive surgical treatment for CUC. Alternatively, elective surgery is intended as definitive treatment for the intestinal component of the disease. In appropriately selected patients, the best surgical treatment option is the total proctocolectomy with an ileal pouch-anal anastomosis (IPAA). The IPAA avoids the need for a permanent stoma and maintains the normal route of defecation. This is a technically demanding operation and should be performed by surgeons comfortable with the procedure. The severity and frequency of complications related to IPAA have decreased significantly since the introduction of the operations in the early 1980s. More importantly, long-term follow-up of IPAA patients has demonstrated that the functional results are durable and patient satisfaction remains high.

It is well recognized that ileostomy patients suffer from chronic depletion of Na(+) through the stoma effluent. In this study we evaluated the effects of ileostomy on messenger RNA levels that encode different Na(+)/H(+) exchanger isoforms (NHE-2 and NHE-3). Loop ileostomies were created in Sprague-Dawley rats. Segments of diverted ileum were harvested for quantitation of mRNA levels encoding these isoforms and the Na(+)/K(+) ATPase in mucosal scrapings and for immunofluorescence microscopy, specifically of the NHE-3 protein. Our studies indicate that as early as 8 days after diversion, NHE-3 gene expression is selectively attenuated in poststomal ileal mucosa. Mucosal morphology remains undisturbed, and the distribution of protein expression along the crypt/villus axis is not altered. Infusion of Na(+) or the enterocyte nutrient, glutamine, into the lumen of the diverted segment restores or even augments mRNA levels for NHE-3, again without altering the histologic appearance or distribution of the protein along the crypt/villus axis. These effects are specific because nonpolar osmolytes (mannitol) and related organic nutrients not specific for the enterocyte (i.e., butyrate) have no effect on mRNA levels of NHE-3. Further work is required to understand how the early changes in mRNA contribute to mucosal function and response to luminal diversion.

Surgery continues to be a central component in the treatment of patients with inflammatory bowel disease (IBD). The most important aspect of caring for patients with IBD is a close and ongoing interaction between the surgeon and gastroenterologist both before and after surgery. Surgery in patients with chronic ulcerative colitis (CUC) is curative. In the appropriate patient, we recommend proctocolectomy with ileal pouch anal anastomosis (IPAA). In contrast, patients with Crohn's disease cannot be cured with surgery. Instead, surgery is used in conjunction with maximal medical therapy to treat symptoms of the disease and improve the patient's quality of life. Surgical interventions should be limited in scope. Small bowel disease should be treated with either limited resection or strictureplasty, if possible, to conserve bowel length. For limited involvement of the colon, segmental resection yields good results. Minimal surgical intervention, drainage of abscesses, placing draining setons, and aggressive medical therapy is recommended as treatment of perianal Crohn's disease.