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LAPAROSCOPIC APPENDECTOMY outpatient setting is, of course, part of The pouchitis was treated with a this overall plan. combination of metronidazole, 5- n the October 1995 issue of the acetylsalicylic acid and corticosteroids I Journal (pages 449 to 453), Karim E.J. Thomas, MD, FRCSC rectally and sulfasalazine, 5-acetylsali - and O’Regan reviewed a series of pa - Department of Surgery cylic acid and low-dose prednisone tients with appendicitis treated by la - McMaster University orally but failed to alleviate her symp - 1200 Main St. W paroscopic appendectomy. One of the Hamilton, Ont. toms. After 10 weeks of this regimen, advantages of this approach to sus - topical treatment was begun with pected appendicitis is listed as a reduc - short-chain fatty acids, given as ene - tion in hospital stay. mas. The enemas contained sodium The authors are to be congratu - acetate (60 mmoles), sodium pro - lated on the outcome of the patients SEVERE POUCHITIS pionate (30 mmoles) and sodium n- in their series, but, editorially, they SUCCESSFULLY TREATED butyrate (40 mmoles) made isotonic WITH SHORT -CHAIN FATTY should be further congratulated for by the addition of sodium chloride. A again demonstrating one of the most ACIDS 100-mL enema was instilled into the outstanding advantages of laparo - estorative proctocolectomy with pouch twice daily, and the patient re - scopic surgery, namely that general R an ileal pouch–anal anastomosis mained supine for 30 minutes there - surgeons are revising the criteria by is now an established alternative to after. After 4 weeks of this treatment which they keep patients in hospital. I permanent ileostomy in patients with the pouchitis was cured and did not would charge the authors and other severe ulcerative colitis and familial recur during 2 years of follow-up. general surgeons to recognize that pa - polyposis coli. The functional results The definition of pouchitis should tients subjected to open appendec - are generally good, but acute inflam - include clinical symptoms, macro - tomy (in a manner similar to that de - mation of the ileal reservoir mucosa scopic inflammatory lesions demon - scribed in the article) would, in most (pouchitis) remains a serious and strated endoscopically and histologic cases, be able to leave hospital within poorly understood complication, with evidence of intense acute inflamma - 48 hours of surgery and continue an incidence of up to 30%. tion of the reservoir mucosa. The their convalescence in a more com - A 48-year-old woman with a history cause is unknown but appears to be fortable domestic setting. The fact of colectomy and mucosal proctec - multifactorial. Several mechanisms that the references emphasizing hos - tomy who had an ileal S-pouch–anal have been postulated, including recur - pital stay are drawn from 1975 and anastomosis for ulcerative colitis was rent inflammatory bowel disease, bac - 1984 (before the laparoscopic alterna - admitted to our hospital with diarrhea, terial overgrowth or a nutritional defi - tive become available) follows the fever and bloody anal discharge. En - ciency of the pouch epithelium, general pattern of discussion when la - doscopy showed severe colitis. The especially because of a lack of short- paroscopic surgery is promoted on ac - mucosa was erythematous and friable, chain fatty acids. count of reduced hospital-bed occu - with multiple deep ulcerations. On his - Wischmeyer and colleagues 1 mea - pancy. Again, I would emphasize that tologic examination there was villous sured the concentration of fecal short- we need to review our indications for atrophy, crypt hyperplasia and superfi - chain fatty acids in 24 patients with keeping a patient in hospital and to cial mucosal ulceration. Also, intense ileal pouch–anal anastomosis. They discharge all patients whose use of the infiltration by plasma cells and a dense found that the 11 patients who had hospital as a hotel or for “babysitting” inflammatory infiltrate of lymphocytes pouchitis had only 23% of the total represents an irresponsible misuse of and polymorphonuclear leukocytes concentration of fecal short-chain expensive facilities. The need for com - were noted in the lamina propria. Mi - fatty acids measured in the 13 patients munity services to be embellished and crobiologic analysis of the pouch efflu - without pouchitis. The concentration to provide appropriate support in the ent excluded any infection. of propionic acid was similar in the

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CORRESPONDANCE

two groups. The concentrations of part, the result of a deficiency of short- References acetic and n-butyric acids, however, chain fatty acids. were markedly decreased in the pa - We suggest that the administration tients with pouchitis, supporting the of short-chain fatty acids is an alterna - 1. Wischmeyer PE, Tremaine WJ, Had - hypothesis that pouchitis may be the tive treatment for patients with therapy- dad AC et al: Fecal short chain fatty result of a deficiency of luminal short- resistant pouchitis. Current knowl - acids in patients with pouchitis after chain fatty acids. In a more recent pi - edge of the different metabolic pro - ileal pouch anal anastomosis. [ab - lot study by Wischmeyer, Pemberton perties of each class of these acids is stract] Gastroenterology 1991; 100: A848 and Phillips, 2 in which 19 patients limited. Continued research is needed with pouchitis were treated with bu - to determine the full potential of tyrate or glutamine suppositories, 6 of short-chain fatty acids as an intestinal 2. Wischmeyer P, Pemberton JH, 10 patients who received glutamine fuel. Phillips SF: Chronic pouchitis after ileal pouch–anal anastomosis: re - had no recurrence of symptoms, but Pieter Th. den Hoed, MD sponses to butyrate and glutamine only 3 of 9 patients who received bu - Jan J. van Goch, MD, PhD suppositories in a pilot study. Mayo tyrate had no recurrence. de Silva and Herman F. Veen, MD, PhD Clin Proc 1993; 68: 978–981 associates 3 used short-chain fatty acids Division of General Surgery to treat two patients with pouchitis Rob J.Th. Ouwendijk, MD, PhD but found no improvement of mu - Division of Gastroenterology 3. de Silva HJ, Ireland A, Kettlewell M cosal ulceration histologically. In con - Ikazia Hospital et al: Short-chain fatty acid irrigation trast, our observations support the hy - Rotterdam in severe pouchitis. [letter] N Engl J pothesis that pouchitis may be, in The Netherlands Med 1989; 321: 1416–1417

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