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Gao Y, Hu B. Colonoscopy in the diagnosis and management of appendiceal disease. World J Gastrointest Endosc 2024; 16:187-192. [PMID: 38680200 PMCID: PMC11045350 DOI: 10.4253/wjge.v16.i4.187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/30/2024] [Accepted: 03/07/2024] [Indexed: 04/11/2024] Open
Abstract
In this editorial, we comment on the article published in the recent issue of the World Journal of Gastrointestinal Endoscopy. We focused on the understanding of appendiceal disease, and the various options for diagnosis and treatment via endoscopy. Some factors affecting the diagnosis and management of appendiceal diseases are also discussed. The existence of any organ has its natural rationality, and the appendix is such a magical organ. A growing number of experts and scholars have gradually come to a consensus that the appendix is not a useless evolutionary relic. There are many lymphocytes and lymph nodes in the appendix wall, which has a strong immune function, and this function is particularly important for children and adolescents. Many intestinal probiotics in the appendix are very helpful for maintaining the balance of the intestinal flora. With the continuous progress of endoscopic technology, endoscopic treatment involving preservation of the appendix has shown great advantages over surgery. In the diagnosis of appendiceal inflammation and neoplasms, colonoscopy, endoscopic retrograde appendicography and choledochoscopy help assess conditions of the appendix. Endoscopic retrograde appendicitis therapy, abscess drainage under colonoscopy, fenestration of abscess under colonoscopy, and endoscopic or natural orifice transluminal endoscopic surgery resection of appendiceal neoplasms are safe and effective endoscopic treatments for appendiceal disease. New breakthroughs in the application of endoscopy in the appendix are expected to occur in the near future.
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Affiliation(s)
- Yuan Gao
- Department of Gastroenterology and Hepatology/Medical Engineering Integration Laboratory of Digestive Endoscopy, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Bing Hu
- Department of Gastroenterology and Hepatology/Medical Engineering Integration Laboratory of Digestive Endoscopy, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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2
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Dai C, Huang YH. The Role of Appendicectomy in Ulcerative Colitis: True or Coincidental Association? Inflamm Bowel Dis 2022; 28:e149. [PMID: 36000973 DOI: 10.1093/ibd/izac190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Cong Dai
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Yu-Hong Huang
- Department of Gastroenterology, First Affiliated Hospital, China Medical University, Shenyang, China
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3
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Welsh S, Sam Z, Seenan JP, Nicholson GA. The Role of Appendicectomy in Ulcerative Colitis: Systematic Review and Meta-Analysis. Inflamm Bowel Dis 2022; 28:e147-e148. [PMID: 36018055 DOI: 10.1093/ibd/izac191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Silje Welsh
- Edinburgh Medical School: Clinical Sciences, University of Edinburgh, Edinburgh, Scotland, United Kingdom.,General Surgery and Gastroenterology Department, NHS Greater Glasgow and Clyde, Glasgow, Scotland, United Kingdom
| | - Zihao Sam
- Edinburgh Medical School: Clinical Sciences, University of Edinburgh, Edinburgh, Scotland, United Kingdom.,General Surgery and Gastroenterology Department, NHS Greater Glasgow and Clyde, Glasgow, Scotland, United Kingdom
| | - John Paul Seenan
- General Surgery and Gastroenterology Department, NHS Greater Glasgow and Clyde, Glasgow, Scotland, United Kingdom.,Medical School, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Gary A Nicholson
- General Surgery and Gastroenterology Department, NHS Greater Glasgow and Clyde, Glasgow, Scotland, United Kingdom.,Medical School, University of Glasgow, Glasgow, Scotland, United Kingdom
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Fantodji C, Jantchou P, Parent ME, Rousseau MC. Appendectomy and risk for inflammatory bowel disease: effect of age and time post appendectomy - a cohort study. BMJ Open Gastroenterol 2022; 9:bmjgast-2022-000925. [PMID: 35902208 PMCID: PMC9341190 DOI: 10.1136/bmjgast-2022-000925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 07/07/2022] [Indexed: 11/04/2022] Open
Abstract
Background and objective Appendectomy may modulate the risk of inflammatory bowel disease through an effect on the gut microbiota. This study investigated the associations between appendectomy and incidence of Crohn’s disease (CD) or ulcerative colitis (UC), with an emphasis on the influence of age and time post appendectomy. Methods This cohort study included 400 520 subjects born in Québec in 1970–1974 and followed until 2014. Administrative health data were used to ascertain appendectomy and cases of CD and UC. Cox proportional hazards models with time-dependent variables (appendectomy and time elapsed post appendectomy) allowed for the estimation of HRs and 95% CIs. Results A total of 2545 (0.6%) CD cases and 1134 (0.3%) UC cases were identified during follow-up. Appendectomy increased the risk of CD (HR=2.02; 95% CI: 1.66 to 2.44), especially when performed at 18–29 years of age. The risk of CD was increased in the first 2 years, and decreased significantly after ≥15 years post appendectomy. Appendectomy appeared to protect against UC (HR=0.39; 95% CI: 0.22 to 0.71). The risk of UC was not associated with age at appendectomy, but decreased with time elapsed post appendectomy (HR=0.21; 95% CI: 0.06 to 0.72, comparing ≥5 with 0–4 years after appendectomy). Conclusions The increased risk of CD related to appendectomy in young adults may result from detection bias, but physicians should have a low threshold for suspicion of CD in young symptomatic adults with a history of appendectomy. A strong protective effect of appendectomy against UC was observed after 5 years.
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Affiliation(s)
- Canisius Fantodji
- Epidemiology and Biostatistics Unit, Centre Armand-Frappier Santé Biotechnologie, Institut national de la recherche scientifique, Laval, Quebec, Canada.,Centre de recherche, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
| | - Prévost Jantchou
- Centre de recherche, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada.,Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
| | - Marie-Elise Parent
- Epidemiology and Biostatistics Unit, Centre Armand-Frappier Santé Biotechnologie, Institut national de la recherche scientifique, Laval, Quebec, Canada.,Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montreal, Quebec, Canada
| | - Marie-Claude Rousseau
- Epidemiology and Biostatistics Unit, Centre Armand-Frappier Santé Biotechnologie, Institut national de la recherche scientifique, Laval, Quebec, Canada .,Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montreal, Quebec, Canada
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Welsh S, Sam Z, Seenan JP, Nicholson GA. The Role of Appendicectomy in Ulcerative Colitis: Systematic Review and Meta-Analysis. Inflamm Bowel Dis 2022; 29:633-646. [PMID: 35766795 DOI: 10.1093/ibd/izac127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND This updated systematic review and meta-analysis investigates the putative role of the appendix in ulcerative colitis as a therapeutic target. METHODS Ovid Medline, Embase, PubMed and CENTRAL were searched with MeSH terms ("appendectomy" OR "appendicitis" OR "appendix") AND ("colitis, ulcerative") through October 2020, producing 1469 references. Thirty studies, including 118 733 patients, were included for qualitative synthesis and 11 for quantitative synthesis. Subgroup analysis was performed on timing of appendicectomy. Results are expressed as odds ratio (OR) with 95% confidence intervals (CIs). RESULTS Appendicectomy before UC diagnosis reduces the risk of future colectomy (OR, 0.76; 95% CI, 0.65-0.89; I2 = 5%; P = .0009). Corresponding increased risk of colorectal cancer and high-grade dysplasia are identified (OR, 2.27; 95% CI, 1.11-4.66; P = .02). Significance is lost when appendicectomy is performed after disease onset. Appendicectomy does not affect hospital admission rates (OR, 0.87; 95% CI, 0.68-1.12; I2 = 93%; P = .27), steroid use (OR, 1.08; 95% CI, 0.78-1.49; I2 = 36%; P = .64), immunomodulator use (OR, 1.04; 95% CI, 0.76-1.42; I2 = 19%; P = .79), or biological therapy use (OR, 0.76; 95% CI, 0.44-1.30; I2 = 0%; P = .32). Disease extent and risk of proximal progression are unaffected by appendicectomy. The majority (71% to 100%) of patients with refractory UC avoid colectomy following therapeutic appendicectomy at 3-year follow-up. CONCLUSIONS Prior appendicectomy reduces risk of future colectomy. A reciprocal increased risk of CRC/HGD may be due to prolonged exposure to subclinical colonic inflammation. The results warrant further research, as consideration may be put toward incorporating a history of appendicectomy into IBD surveillance guidelines. A potential role for therapeutic appendicectomy in refractory left-sided UC is also identified.
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Affiliation(s)
- Silje Welsh
- Edinburgh Medical School: Clinical Sciences, University of Edinburgh, Edinburgh, Scotland.,General Surgery and Gastroenterology Department, NHS Greater Glasgow & Clyde, Glasgow, Scotland
| | - Zihao Sam
- Edinburgh Medical School: Clinical Sciences, University of Edinburgh, Edinburgh, Scotland.,General Surgery and Gastroenterology Department, NHS Greater Glasgow & Clyde, Glasgow, Scotland
| | - John Paul Seenan
- General Surgery and Gastroenterology Department, NHS Greater Glasgow & Clyde, Glasgow, Scotland.,Medical School, University of Glasgow, Glasgow, Scotland
| | - Gary A Nicholson
- General Surgery and Gastroenterology Department, NHS Greater Glasgow & Clyde, Glasgow, Scotland.,Medical School, University of Glasgow, Glasgow, Scotland
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Arjomand Fard N, Armstrong H, Perry T, Wine E. Appendix and Ulcerative Colitis: a Key to Explaining the Pathogenesis and Directing Novel Therapies? Inflamm Bowel Dis 2022; 29:151-160. [PMID: 35749298 PMCID: PMC9825289 DOI: 10.1093/ibd/izac106] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Indexed: 02/05/2023]
Abstract
The vermiform appendix is generally considered a redundant organ, but recent evidence suggests that the appendix could contribute to the pathogenesis of inflammatory bowel diseases, in particular ulcerative colitis (UC), and may even have a therapeutic role; however, mechanisms of the appendix involvement remain unclear. Here, we highlight current evidence on the link between the appendix and UC and consider plausible therapeutic implications. A literature search was conducted using PubMed and PubMed Central from inception to Nov 2021 using the terms "Appendix", "UC", "Appendix & UC," "Appendectomy", and "Peri-appendicular patch," including only articles published in English. Reference lists from the selected studies were manually searched and reviewed to gather additional related reports. Inflammation around the appendix ("peri-appendicular patch") has been frequently observed in UC patients without other cecal involvement, and this inflammation can even precede the onset of UC. Epidemiologic studies propose that appendectomy reduces the risk of developing UC or even the risk of flare after UC is diagnosed, although this remains controversial. We reviewed studies showing altered host-microbe interactions in the appendix in UC, which suggest that the appendix could act as a priming site for disease via alterations in the immune response and changes in microbiota carried distally to the colon. In summary, recent literature suggests a possible role for microbes and immune cells within the appendix; however, the role of the appendix in the pathogenesis of UC remains unclear. Further research could clarify the therapeutic potential related to this organ.
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Affiliation(s)
- Nazanin Arjomand Fard
- Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, AB, T6G 2X8, Canada,Department of Physiology, University of Alberta, Edmonton, AB T6G 1C9, Canada
| | - Heather Armstrong
- Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, AB, T6G 2X8, Canada,Department of Pediatrics, University of Alberta, Edmonton Clinic Health Academy, Room 4-577, 11405 87th Ave, Edmonton, AB T6G 1C9, Canada,Department of Internal Medicine, University of Manitoba, Winnipeg, MB R3E 3P4, Canada
| | - Troy Perry
- Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, AB, T6G 2X8, Canada,Department of Surgery, University of Alberta, Edmonton, AB T6G 1C9, Canada
| | - Eytan Wine
- Address correspondence to: Dr. Eytan Wine, Department of Pediatrics, University of Alberta, Edmonton Clinic Health Academy, Room 4-577, 11405 87th Ave, Edmonton, AB T6G 1C9, Canada ()
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Bernardes Antunes P, Gonçalves M, Leal T, Gonçalves B. One appendix too many: a severe IBD-U case in remission after appendectomy. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2022; 114:623-624. [PMID: 35410478 DOI: 10.17235/reed.2022.8809/2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
| | | | - Tiago Leal
- Gastroenterology , Hospital de Braga, Portugal
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Shaikh DH, Patel H, Munshi R, Sun H, Mehershahi S, Baiomi A, Alemam A, Pirzada U, Nawaz I, Naher K, Hanumanthu S, Nayudu S. Patients with Clostridium difficile infection and prior appendectomy may be prone to worse outcomes. World J Gastrointest Surg 2021; 13:1436-1447. [PMID: 34950432 PMCID: PMC8649559 DOI: 10.4240/wjgs.v13.i11.1436] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 08/29/2021] [Accepted: 09/17/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Clostridium difficile infection (CDI) occurs due to a dysbiosis in the colon. The appendix is considered a ‘safe house’ for gut microbiota and may help repopulate gut flora of patients with CDI.
AIM To study the impact of prior appendectomy on the severity and outcomes of CDI.
METHODS We retrospectively reviewed data of 1580 patients with CDI, admitted to our hospital between 2008 to 2018. Patients were grouped based on the presence or absence of the appendix. The primary aim was to (1) assess all-cause mortality and (2) the severity of CDI. Severity was defined as per the Infectious Diseases Society of America criteria. Logistic regression, and propensity score analysis using inverse probability of treatment weights (IPTW) was performed.
RESULTS Of the 1580 patients, 12.5% had a history of appendectomy. There was no statistical difference in mortality between patients with a prior appendectomy or without (13.7% vs 14%, P = 0.877). However, a history of appendectomy affected the severity of CDI [odds ratio (OR) = 1.32, 95% confidence interval: 1.01-1.75]. On IPTW, this association remained significant (OR = 1.59, P < 0.05). On multivariable analysis of secondary outcomes, prior appendectomy was also associated with toxic megacolon (OR = 5.37, P < 0.05) and colectomy (OR = 2.77, P < 0.05).
CONCLUSION Prior appendectomy may affect the severity of CDI, development of toxic megacolon and the eventual need for colectomy. Since treatment of CDI is governed by its severity, stronger antibiotic regimens or earlier use of fecal microbiota transplant may be a viable option for patients with prior appendectomy.
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Affiliation(s)
- Danial Haris Shaikh
- Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Harish Patel
- Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Rezwan Munshi
- Department of Medicine, Nassau University Medical Center, New York, NY 11554, United States
| | - Haozhe Sun
- Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Shehriyar Mehershahi
- Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Ahmed Baiomi
- Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Ahmed Alemam
- Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Usman Pirzada
- Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Iqra Nawaz
- Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Kamrun Naher
- Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Siddarth Hanumanthu
- Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Suresh Nayudu
- Division of Gastroenterology, Department of Medicine, BronxCare Health System, Bronx, NY 10457, United States
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Cai S, Fan Y, Zhang B, Lin J, Yang X, Liu Y, Liu J, Ren J, Xu H. Appendectomy Is Associated With Alteration of Human Gut Bacterial and Fungal Communities. Front Microbiol 2021; 12:724980. [PMID: 34603252 PMCID: PMC8483179 DOI: 10.3389/fmicb.2021.724980] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/19/2021] [Indexed: 12/12/2022] Open
Abstract
Recent research has revealed the importance of the appendix in regulating the intestinal microbiota and mucosal immunity. However, the changes that occur in human gut microbial communities after appendectomy have never been analyzed. We assessed the alterations in gut bacterial and fungal populations associated with a history of appendectomy. In this cross-sectional study, we investigated the association between appendectomy and the gut microbiome using 16S and ITS2 sequencing on fecal samples from 30 healthy individuals with prior appendectomy (HwA) and 30 healthy individuals without appendectomy (HwoA). Analysis showed that the gut bacterial composition of samples from HwA was less diverse than that of samples from HwoA and had a lower abundance of Roseburia, Barnesiella, Butyricicoccus, Odoribacter, and Butyricimonas species, most of which were short-chain fatty acids-producing microbes. The HwA subgroup analysis indicated a trend toward restoration of the HwoA bacterial microbiome over time after appendectomy. HwA had higher gut fungi composition and diversity than HwoA, even 5 years after appendectomy. Compared with those in samples from HwoA, the abundance correlation networks in samples from HwA displayed more complex fungal–fungal and fungal–bacterial community interactions. This study revealed a marked impact of appendectomy on gut bacteria and fungi, which was particularly durable for fungi.
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Affiliation(s)
- Shuntian Cai
- Department of Gastroenterology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, China.,School of Medicine, Institute for Microbial Ecology, Xiamen University, Xiamen, China
| | - Yanyun Fan
- Department of Gastroenterology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, China.,School of Medicine, Institute for Microbial Ecology, Xiamen University, Xiamen, China
| | - Bangzhou Zhang
- Department of Gastroenterology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, China.,School of Medicine, Institute for Microbial Ecology, Xiamen University, Xiamen, China
| | - Jinzhou Lin
- Department of Gastroenterology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, China
| | - Xiaoning Yang
- Department of Gastroenterology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, China
| | - Yunpeng Liu
- Department of Gastroenterology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, China
| | - Jingjing Liu
- Department of Gastroenterology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, China.,School of Medicine, Institute for Microbial Ecology, Xiamen University, Xiamen, China
| | - Jianlin Ren
- Department of Gastroenterology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, China.,School of Medicine, Institute for Microbial Ecology, Xiamen University, Xiamen, China
| | - Hongzhi Xu
- Department of Gastroenterology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, China.,School of Medicine, Institute for Microbial Ecology, Xiamen University, Xiamen, China
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10
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Liu S, Eisenstein S. State-of-the-art surgery for ulcerative colitis. Langenbecks Arch Surg 2021; 406:1751-1761. [PMID: 34453611 PMCID: PMC8481179 DOI: 10.1007/s00423-021-02295-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 08/04/2021] [Indexed: 12/11/2022]
Abstract
Ulcerative colitis (UC) is an autoimmune-mediated colitis which can present in varying degrees of severity and increases the individual’s risk of developing colon cancer. While first-line treatment for UC is medical management, surgical treatment may be necessary in up to 25–30% of patients. With an increasing armamentarium of biologic therapies, patients are presenting for surgery much later in their course, and careful understanding of the complex interplay of the disease, its management, and the patient’s overall health is necessary when considering he appropriate way in which to address their disease surgically. Surgery is generally a total proctocolectomy either with pelvic pouch reconstruction or permanent ileostomy; however, this may need to be spread across multiple procedures given the complexity of the surgery weighed against the overall state of the patient’s health. Minimally invasive surgery, employing either laparoscopic, robotic, or transanal laparoscopic approaches, is currently the preferred approach in the elective setting. There is also some emerging evidence that appendectomy may delay the progression of UC in some individuals. Those who treat these patients surgically must also be familiar with the numerous potential pitfalls of surgical intervention and have plans in place for managing problems such as pouchitis, cuffitis, and anastomotic complications.
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Affiliation(s)
- Shanglei Liu
- Department of Surgery, UC San Diego Health System, 3855 Health Sciences Dr. #0987, La Jolla, CA, 92093, USA
| | - Samuel Eisenstein
- Department of Surgery, UC San Diego Health System, 3855 Health Sciences Dr. #0987, La Jolla, CA, 92093, USA.
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11
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Zou J, Liu C, Jiang S, Qian D, Duan J. Cross Talk between Gut Microbiota and Intestinal Mucosal Immunity in the Development of Ulcerative Colitis. Infect Immun 2021; 89:e0001421. [PMID: 33526559 PMCID: PMC8370674 DOI: 10.1128/iai.00014-21] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Ulcerative colitis (UC), a nonspecific inflammatory disease, is characterized by inflammation and mucosal damage in the colon, and its prevalence in the world is increasing. Nevertheless, the exact pathogenesis of UC is still unclear. Accumulating data have suggested that its pathogenesis is multifactorial, involving genetic predisposition, environmental factors, microbial dysbiosis, and dysregulated immune responses. Generally, UC is aroused by inappropriate immune activation based on the interaction of host and intestinal microbiota. The relationship between microbiota and host immune system in the pathogenesis of UC is complicated. However, increasing evidence indicates that the shift of microbiota composition can substantially influence intestinal immunity. In this review, we primarily focus on the delicate balance between microbiota and gut mucosal immunity during UC progression.
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Affiliation(s)
- Junfeng Zou
- Jiangsu Collaborative Innovation Center of Chinese Medicinal Resources Industrialization, Nanjing University of Chinese Medicine, Nanjing, People’s Republic of China
| | - Chen Liu
- Jiangsu Collaborative Innovation Center of Chinese Medicinal Resources Industrialization, Nanjing University of Chinese Medicine, Nanjing, People’s Republic of China
| | - Shu Jiang
- Jiangsu Collaborative Innovation Center of Chinese Medicinal Resources Industrialization, Nanjing University of Chinese Medicine, Nanjing, People’s Republic of China
| | - Dawei Qian
- Jiangsu Collaborative Innovation Center of Chinese Medicinal Resources Industrialization, Nanjing University of Chinese Medicine, Nanjing, People’s Republic of China
| | - Jinao Duan
- Jiangsu Collaborative Innovation Center of Chinese Medicinal Resources Industrialization, Nanjing University of Chinese Medicine, Nanjing, People’s Republic of China
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Human gut-associated lymphoid tissues (GALT); diversity, structure, and function. Mucosal Immunol 2021; 14:793-802. [PMID: 33753873 DOI: 10.1038/s41385-021-00389-4] [Citation(s) in RCA: 147] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/05/2021] [Accepted: 02/06/2021] [Indexed: 02/07/2023]
Abstract
Gut-associated lymphoid tissues (GALT) are the key antigen sampling and adaptive immune inductive sites within the intestinal wall. Human GALT includes the multi-follicular Peyer's patches of the ileum, the vermiform appendix, and the numerous isolated lymphoid follicles (ILF) which are distributed along the length of the intestine. Our current understanding of GALT diversity and function derives primarily from studies in mice, and the relevance of many of these findings to human GALT remains unclear. Here we review our current understanding of human GALT diversity, structure, and composition as well as their potential for regulating intestinal immune responses during homeostasis and inflammatory bowel disease (IBD). Finally, we outline some key remaining questions regarding human GALT, the answers to which will advance our understanding of intestinal immune responses and provide potential opportunities to improve the treatment of intestinal diseases.
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13
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Song MY, Ullah S, Yang HY, Ahmed MR, Saleh AA, Liu BR. Long-term effects of appendectomy in humans: is it the optimal management of appendicitis? Expert Rev Gastroenterol Hepatol 2021; 15:657-664. [PMID: 33350352 DOI: 10.1080/17474124.2021.1868298] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Appendectomy remains the gold standard for treating uncomplicated and complicated appendicitis. However, the vermiform appendix may play a significant role in the immune system (secondary immune function) and maintain a reservoir of the normal microbiome for the human body. The aim of this study was to summarize the long-term effects after appendectomy and discuss whether appendectomy is suitable for all appendicitis patients. AREAS COVERED A comprehensive and unbiased literature search was performed in PubMed. The terms 'appendix,' 'appendicitis,' 'appendectomy,' and 'endoscopic retrograde appendicitis therapy' were searched in the title and/or abstract. This review summarizes the long-term effects of appendectomy on some diseases in humans and describes three methods including appendectomy, medical treatment, and an 'organ-sparing' technique, named endoscopic retrograde appendicitis therapy (ERAT) to treat appendicitis. EXPERT OPINION Appendectomy remains the first-line therapy for appendicitis. The patient's problem is appendix, not appendicitis. If we treat appendicitis, the problem should be resolved. During COVID-19, an initial antibiotic treatment of mild appendicitis represents a promising strategy. For patients who are worried about the long-term adverse effect after appendectomy and have a strong desire to preserve the appendix and are aware of the risk of appendicitis recurrence, medical treatment, or ERAT could be proposed.
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Affiliation(s)
- Ming-Yang Song
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,The Academy of Medical Science, Zhengzhou University, Zhengzhou, China
| | - Saif Ullah
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hui-Yu Yang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Md Robin Ahmed
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | | | - Bing-Rong Liu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Kobayashi T, Siegmund B, Le Berre C, Wei SC, Ferrante M, Shen B, Bernstein CN, Danese S, Peyrin-Biroulet L, Hibi T. Ulcerative colitis. Nat Rev Dis Primers 2020; 6:74. [PMID: 32913180 DOI: 10.1038/s41572-020-0205-x] [Citation(s) in RCA: 664] [Impact Index Per Article: 166.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/21/2020] [Indexed: 02/07/2023]
Abstract
Ulcerative colitis (UC) is a chronic inflammatory bowel disease of unknown aetiology affecting the colon and rectum. Multiple factors, such as genetic background, environmental and luminal factors, and mucosal immune dysregulation, have been suggested to contribute to UC pathogenesis. UC has evolved into a global burden given its high incidence in developed countries and the substantial increase in incidence in developing countries. An improved understanding of the mechanisms underlying UC has led to the emergence of new treatments. Since the early 2000s, anti-tumour necrosis factor (TNF) treatment has significantly improved treatment outcomes. Advances in medical treatments have enabled a paradigm shift in treatment goals from symptomatic relief to endoscopic and histological healing to achieve better long-term outcomes and, consequently, diagnostic modalities have also been improved to monitor disease activity more tightly. Despite these improvements in patient care, a substantial proportion of patients, for example, those who are refractory to medical treatment or those who develop colitis-associated colorectal dysplasia or cancer, still require restorative proctocolectomy. The development of novel drugs and improvement of the treatment strategy by implementing personalized medicine are warranted to achieve optimal disease control. However, delineating the aetiology of UC is necessary to ultimately achieve disease cure.
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Affiliation(s)
- Taku Kobayashi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan.
| | - Britta Siegmund
- Division of Gastroenterology, Infectiology and Rheumatology, Charite-Universitatsmedizin, Berlin, Germany
| | - Catherine Le Berre
- Department of Gastroenterology, Nancy University Hospital, Inserm U1256 NGERE, Lorraine University, Lorraine, France
| | - Shu Chen Wei
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Marc Ferrante
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Bo Shen
- Center for Inflammatory Bowel Diseases, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
| | - Charles N Bernstein
- University of Manitoba IBD Clinical and Research Centre and Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Silvio Danese
- Humanitas Clinical and Research Center - IRCCS - and Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, Nancy University Hospital, Inserm U1256 NGERE, Lorraine University, Lorraine, France
| | - Toshifumi Hibi
- Center for Advanced IBD Research and Treatment, Kitasato University Kitasato Institute Hospital, Tokyo, Japan.
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15
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Acute appendicitis: Will a novel endoscopic "organ-sparing" approach change the treatment paradigm? Gastrointest Endosc 2020; 92:190-191. [PMID: 32145285 DOI: 10.1016/j.gie.2020.02.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 02/28/2020] [Indexed: 02/06/2023]
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16
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Franko J, Ferrel B, Pierson P, Raman S, Frankova D, Rearigh LM, Afroze A, Guevara Hernandez MA, Terrero-Salcedo D, Kermode D, Gorvet M. Influence of prior appendectomy and cholecystectomy on Clostridioides difficile infection recurrence and mortality. Am J Surg 2020; 220:203-207. [DOI: 10.1016/j.amjsurg.2019.10.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 10/13/2019] [Accepted: 10/18/2019] [Indexed: 11/15/2022]
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17
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Chen J, Sali A, Vitetta L. The gallbladder and vermiform appendix influence the assemblage of intestinal microorganisms. Future Microbiol 2020; 15:541-555. [DOI: 10.2217/fmb-2019-0325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Surgical procedures for the symptomatic removal of the gallbladder and the vermiform appendix have been posited to adversely shift the assemblage of the intestinal microbiome increasing the risk of disease. The associated mechanisms have been linked with dysbiosis of the gut microbiota. Cholecystectomy causes changes of bile acid compositions and bile secretion patterns as bile acids interact with the intestinal microbiota in a bidirectional capacity. An appendectomy precludes the further recolonization of the proximal colon with a commensal biofilm that could maintain a stable intestinal microbiome. Epidemiological studies indicate that there is an increased risk of disease rather than causality following a cholecystectomy and appendectomy. This narrative review summarizes studies that report on the role that bile salts and the appendix, contribute to the assemblage of the intestinal microbiome in health and disease.
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Affiliation(s)
- Jiezhong Chen
- Research Department, Medlab Clinical Ltd, Sydney, 2015, Australia
| | - Avni Sali
- National Institute of Integrative Medicine, Melbourne, 3022, Australia
| | - Luis Vitetta
- Research Department, Medlab Clinical Ltd, Sydney, 2015, Australia
- Faculty of Medicine & Health, The University of Sydney, Sydney, 2006, Australia
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18
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Stellingwerf ME, Sahami S, Winter DC, Martin ST, D'Haens GR, Cullen G, Doherty GA, Mulcahy H, Bemelman WA, Buskens CJ. Prospective cohort study of appendicectomy for treatment of therapy-refractory ulcerative colitis. Br J Surg 2019; 106:1697-1704. [DOI: 10.1002/bjs.11259] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 05/06/2019] [Accepted: 05/12/2019] [Indexed: 12/19/2022]
Abstract
Abstract
Introduction
Appendicectomy may reduce relapses and need for medication in patients with ulcerative colitis, but long-term prospective data are lacking. This study aimed to analyse the effect of appendicectomy in patients with refractory ulcerative colitis.
Methods
In this prospective multicentre cohort series, all consecutive patients with refractory ulcerative colitis referred for proctocolectomy between November 2012 and June 2015 were counselled to undergo laparoscopic appendicectomy instead. The primary endpoint was clinical response (reduction of at least 3 points in the partial Mayo score) at 12 months and long-term follow-up. Secondary endpoints included endoscopic remission (endoscopic Mayo score of 1 or less), failure (colectomy or start of experimental medication), and changes in Inflammatory Bowel Disease Questionnaire (IBDQ) (range 32–224), EQ-5D™ and EORTC-QLQ-C30-QL scores.
Results
A total of 28 patients (13 women; median age 40·5 years) underwent appendicectomy. The mean baseline IBDQ score was 127·0, the EQ-5D™ score was 0·65, and the EORTC-QLQ-C30-QL score was 41·1. At 12 months, 13 patients had a clinical response, five were in endoscopic remission, and nine required a colectomy (6 patients) or started new experimental medical therapy (3). IBDQ, EQ-5D™ and EORTC-QLQ-C30-QL scores improved to 167·1 (P < 0·001), 0·80 (P = 0·003) and 61·0 (P < 0·001) respectively. After a median of 3·7 (range 2·3–5·2) years, a further four patients required a colectomy (2) or new experimental medical therapy (2). Thirteen patients had a clinical response and seven were in endoscopic remission. The improvement in IBDQ, EQ-5D™ and the EORTC-QLQ-C30-QL scores remained stable over time.
Conclusion
Appendicectomy resulted in a clinical response in nearly half of patients with refractory ulcerative colitis and a substantial proportion were in endoscopic remission. Elective appendicectomy should be considered before proctocolectomy in patients with therapy-refractory ulcerative colitis.
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Affiliation(s)
- M E Stellingwerf
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - S Sahami
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - D C Winter
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - S T Martin
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - G R D'Haens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - G Cullen
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - G A Doherty
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - H Mulcahy
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - W A Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - C J Buskens
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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19
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Zhao M, Burisch J. Impact of Genes and the Environment on the Pathogenesis and Disease Course of Inflammatory Bowel Disease. Dig Dis Sci 2019; 64:1759-1769. [PMID: 31073736 DOI: 10.1007/s10620-019-05648-w] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Crohn's disease and ulcerative colitis constitute two major subgroups of inflammatory bowel diseases (IBD), a group of complex polygenic diseases characterized by chronic and progressive inflammation in the gastrointestinal tract. In recent years, methodological advances in genetic analysis have greatly expanded our understanding of the genetic background of IBD. So far, more than 240 genetic risk loci have been identified for IBD. However, these risk alleles explain less than 30% of the susceptibility to disease development, suggesting that environmental factors contribute considerably. The increasing occurrence of IBD in Eastern countries following their 'westernization', as well as the increased risk of disease among those who migrate to high-incidence regions, also suggest that the environment is key in the pathogenesis of IBD. In this review, we summarize the current evidence on the role of genetic and environmental factors in the susceptibility to, and disease course of, IBD, and we suggest how these findings might be applied to clinical practice.
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Affiliation(s)
- Mirabella Zhao
- Gastro Unit, Hvidovre University Hospital, Kettegaard Alle 30, 2650, Hvidovre, Denmark
| | - Johan Burisch
- Gastro Unit, Hvidovre University Hospital, Kettegaard Alle 30, 2650, Hvidovre, Denmark.
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20
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Cheung KS, Leung WK, Seto WK. Application of Big Data analysis in gastrointestinal research. World J Gastroenterol 2019; 25:2990-3008. [PMID: 31293336 PMCID: PMC6603810 DOI: 10.3748/wjg.v25.i24.2990] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/14/2019] [Accepted: 04/29/2019] [Indexed: 02/06/2023] Open
Abstract
Big Data, which are characterized by certain unique traits like volume, velocity and value, have revolutionized the research of multiple fields including medicine. Big Data in health care are defined as large datasets that are collected routinely or automatically, and stored electronically. With the rapidly expanding volume of health data collection, it is envisioned that the Big Data approach can improve not only individual health, but also the performance of health care systems. The application of Big Data analysis in the field of gastroenterology and hepatology research has also opened new research approaches. While it retains most of the advantages and avoids some of the disadvantages of traditional observational studies (case-control and prospective cohort studies), it allows for phenomapping of disease heterogeneity, enhancement of drug safety, as well as development of precision medicine, prediction models and personalized treatment. Unlike randomized controlled trials, it reflects the real-world situation and studies patients who are often under-represented in randomized controlled trials. However, residual and/or unmeasured confounding remains a major concern, which requires meticulous study design and various statistical adjustment methods. Other potential drawbacks include data validity, missing data, incomplete data capture due to the unavailability of diagnosis codes for certain clinical situations, and individual privacy. With continuous technological advances, some of the current limitations with Big Data may be further minimized. This review will illustrate the use of Big Data research on gastrointestinal and liver diseases using recently published examples.
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Affiliation(s)
- Ka-Shing Cheung
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
- Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, Guangdong Province, China
| | - Wai K Leung
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Wai-Kay Seto
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
- Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen 518053, Guangdong Province, China
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21
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Macaluso FS, Cavallaro F, Felice C, Mazza M, Armuzzi A, Gionchetti P, Vecchi M, Orlando A. Risk factors and timing for colectomy in chronically active refractory ulcerative colitis: A systematic review. Dig Liver Dis 2019; 51:613-620. [PMID: 30826279 DOI: 10.1016/j.dld.2019.01.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 01/20/2019] [Accepted: 01/21/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND In patients with chronic refractory ulcerative colitis (UC) the precise timing for indication to colectomy is unclear. AIMS We performed a systematic review of the literature on the risk factors for colectomy in patients with chronic refractory UC in the biologic era. METHODS PubMed Central/Medline and Embase were systemically searched for records published between January 2000 and December 2017. Current evidence was summarized and filtered by expert opinion. RESULTS 70 studies were included in the qualitative synthesis. Several factors were found to be associated with a higher or reduced risk for colectomy, including variables at baseline - such as progression from proctitis/left-sided to extensive colitis, extensive colitis at diagnosis, high baseline C Reactive Protein or erythrocyte sedimentation rate, male gender, and younger age at diagnosis - previous medical history, and factors arising during therapy with biologics, including the absence of clinical response after induction with infliximab or adalimumab, and the lack of mucosal healing during therapy with anti-TNFs. CONCLUSIONS Two main points may help physicians to decide when the surgical option may be considered in patients with chronic refractory UC: (1) a first risk stratification can be obtained by analyzing factors at baseline and medical history, including the previous exposure to anti-TNFs; (2) during therapy with biologics, the early assessment (after 12-16 weeks of treatment) of clinical and endoscopic response is a strong predictor of the subsequent risk of colectomy.
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Affiliation(s)
| | - Flaminia Cavallaro
- Gastroenterology & Digestive Endoscopy Unit, IRCCS Policlinico San Donato, Milano, Italy
| | - Carla Felice
- IBD Unit, "Presidio Columbus" Foundation Hospital "A. Gemelli IRCCS" - Sacro Cuore Catholic University, Rome
| | - Marta Mazza
- Department of Medical and Surgical Sciences (DIMEC), Policlinico S.Orsola-Malpighi, University of Bologna, Italy
| | - Alessandro Armuzzi
- IBD Unit, "Presidio Columbus" Foundation Hospital "A. Gemelli IRCCS" - Sacro Cuore Catholic University, Rome
| | - Paolo Gionchetti
- Department of Medical and Surgical Sciences (DIMEC), Policlinico S.Orsola-Malpighi, University of Bologna, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Organ Transplantation, University of Milan, Italy
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22
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Stellingwerf ME, de Koning MA, Pinkney T, Bemelman WA, D'Haens GR, Buskens CJ. The Risk of Colectomy and Colorectal Cancer After Appendectomy in Patients With Ulcerative Colitis: A Systematic Review and Meta-analysis. J Crohns Colitis 2019; 13:309-318. [PMID: 30335149 DOI: 10.1093/ecco-jcc/jjy163] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Appendectomy decreases the risk of developing ulcerative colitis [UC], and is suggested to have a beneficial effect on the clinical course of established UC. However, recent studies showed no significantly decreased colectomy rate, and moreover an apparently increased risk of colorectal cancer [CRC]. We aimed to investigate the suggested correlation in a meta-analysis and to analyse possible confounding factors. METHODS A systematic review and meta-analysis were performed using MEDLINE, EMBASE, and the Cochrane Library. Data from studies describing the influence of appendectomy on colectomy and CRC were extracted from published reports. Exclusion criteria were patients aged <18 years, non-UC, and animal studies. RESULTS From 891 studies, 13 studies evaluating 73323 UC patients [appendectomy n = 2859] were included. All studies, except one, were rated as poor quality. Overall, colectomy rate in appendectomised and non-appendectomised patients was not significantly different (odds ratio [OR] 1.25, 95% confidence interval [CI] 0.88-1.77, I2 = 53%). The proportion of colectomies undertaken for CRC or high-grade dysplasia [HGD] was significantly higher after appendectomy [OR 2.85, 95% CI 1.40-5.78, I2 = 32%], with 50% of the colectomies indicated for CRC/HGD compared with 9.4% in non-appendectomised patients. Possible additional confounding factors were a longer UC disease duration, less medication use, and a higher prevalence of primary sclerosing cholangitis [PSC] in appendectomised patients. CONCLUSIONS Appendectomy in established UC is associated with apparently higher rates of subsequent CRC/HGD, but this appears to be due to inequalities in at-risk exposure between groups, presumably secondary to positive clinical effects of appendectomy on disease symptoms. This finding emphasises the importance of regular endoscopic surveillance in this patient group.
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Affiliation(s)
| | - Marlou A de Koning
- Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands
| | - Thomas Pinkney
- Academic Department of Surgery, University of Birmingham, Birmingham,UK
| | - Willem A Bemelman
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - Geert R D'Haens
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
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23
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Sahami S, Wildenberg ME, Koens L, Doherty G, Martin S, D'Haens GRAM, Cullen G, Bemelman WA, Winter D, Buskens CJ. Appendectomy for Therapy-Refractory Ulcerative Colitis Results in Pathological Improvement of Colonic Inflammation: Short-Term Results of the PASSION Study. J Crohns Colitis 2019; 13:165-171. [PMID: 30285094 DOI: 10.1093/ecco-jcc/jjy127] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS The objective of this study was to examine the modulating effect of an appendectomy on the disease course of therapy-refractory ulcerative colitis [UC] patients, and to analyse appendiceal pathological characteristics predictive of pathological response. METHODS Patients with therapy-refractory UC, and referred for proctocolectomy, were invited to undergo laparoscopic appendectomy first. The primary end points were clinical response after 3 and 12 months. Secondary end points were endoscopic remission, failure, and pathologic response. Appendiceal specimens, and pre- and post-operative biopsies were histologically graded according to the validated Geboes score. RESULTS Thirty patients [53% male] with a median age of 40 (interquartile range [IQR], 33-47) underwent appendectomy, with a median preoperative total Mayo score of 9 [IQR, 8-11]. After 12 months, 9 patients [30%] had lasting clinical response, of whom 5 [17%] were in endoscopic remission. Pathological evaluation was possible in 28 patients. After a median of 13.0 weeks [range 7-51], pathological response was seen in 13 patients [46%], with a median decrease of 2 points [range 1-3]. Appendiceal inflammation was highly predictive of pathological response when compared with no inflammation or extensive ulcerations [85% vs 20%, p = 0.001]. CONCLUSIONS Appendectomy was effective in one-third of therapy-refractory UC patients, with a substantial proportion of patients demonstrating complete endoscopic remission after 1 year. Pathological response was seen in almost 50% of patients and was related to active inflammation in the appendix, limited disease, and shorter disease duration. These early results suggest that there is a UC patient group that may benefit from appendectomy.
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Affiliation(s)
- S Sahami
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands.,Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - M E Wildenberg
- Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, The Netherlands.,Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Amsterdam, The Netherlands
| | - L Koens
- Department of Pathology, Academic Medical Centre, Amsterdam, The Netherlands
| | - G Doherty
- Department of Gastroenterology and Hepatology, St. Vincent's Hospital, Dublin, Ireland
| | - S Martin
- Department of Gastroenterology and Hepatology, St. Vincent's Hospital, Dublin, Ireland
| | - G R A M D'Haens
- Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - G Cullen
- Department of Gastroenterology and Hepatology, St. Vincent's Hospital, Dublin, Ireland
| | - W A Bemelman
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - D Winter
- Department of Surgery, St. Vincent's Hospital, Dublin, Ireland
| | - C J Buskens
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
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24
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The vermiform appendix: an immunological organ sustaining a microbiome inoculum. Clin Sci (Lond) 2019; 133:1-8. [PMID: 30606811 DOI: 10.1042/cs20180956] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 11/29/2018] [Accepted: 12/04/2018] [Indexed: 12/12/2022]
Abstract
The hominoid vermiform appendix has been characterized as a diverticulum of the caecum and describes an entity at the juxtaposition of the colon in the confluence of tanias. The independent development of the lymphoid follicle centres of the appendix is progressed at birth in the presence of the intestinal commensal microbiome, an obligatory prompt for the diversification of intestinal and extra-intestinal mucosal immunological tissue. In the vermiform appendix, this activity is centred on further developing the inventory of primary antibodies and the maturation of T- and B-lymphocyte cells in the follicles within the lymphoid tissue. Furthermore, the columnar epithelia, enterocytes and goblet cells comprise the complement of cells that occupy the lamina propria and muscularis mucosae of the vermiform appendix's mucosa, while macrophages and an abundance of immunoglobulin A and immunoglobulin G generating plasma cells seed the lamina propria Intraepithelial immune cells consisting predominantly of specific CD8+ T regulatory lymphocytes occupy sites in the appendix analogous to those present in the intestinal epithelia of the caecal colon. The complement of bacterial genera concealed in the vermiform appendix is posited extant as a biofilm inoculum of the intestinal commensal microbiome. This facilitates re-inoculation of the proximal colon and to a lesser degree the terminal ilium post an intestinal perturbation such as occurs with daily lifestyle stressors, dietary choices and the short-term administration of antibiotics rather than an infectious fulminant colitis. A plausible appreciation results of the importance of multiple immunological aspects of a healthy vermiform appendix and the provision of a commensal biofilm to the gut that repairs a dysbiotic microbiome contributing to balancing intestinal pro- and anti-inflammatory activity for maintaining homeostasis in the gut. Since the composition of the gut microbiome can vary over the short-term and long-term, it is plausible that the appendix inoculum may be instrumental in maintaining the intestinal microbiome.
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25
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Effects of Appendectomy on the Onset and Course of Ulcerative Colitis in Chinese Patients. Gastroenterol Res Pract 2018; 2018:2927891. [PMID: 30524476 PMCID: PMC6247428 DOI: 10.1155/2018/2927891] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 10/09/2018] [Accepted: 10/15/2018] [Indexed: 12/15/2022] Open
Abstract
Background Previous epidemiological studies have suggested that appendectomy may be a protective factor against the development of ulcerative colitis (UC). However, the results of these studies were inconsistent, with rare studies in Chinese populations. Aim This study examined the associations between appendectomy performed before UC diagnosis and the occurrence and clinical course of UC in Chinese patients. Methods A case control study was conducted to compare the rate of appendectomy between UC patients and controls matched for age and sex at two Chinese hospitals. Clinical course of UC was compared between UC patients who underwent appendectomies before UC diagnosis and who did not. Results 402 UC patients and 402 controls were included. The percentage of appendectomy performed before UC diagnosis in UC patients did not differ significantly from controls (2.74% vs 3.98%, P = 0.442). Subgroup analysis on the basis of localization of UC patients did not find significant difference from controls. The extent of disease involvement in UC patients who underwent appendectomy was smaller than patients who did not (P = 0.009). Appendectomy was found to be significantly related to the location of the disease independent of smoking status in multivariate analysis (P < 0.001). Appendectomy did not influence severity of disease and need for immunosuppressive treatment or colectomy. Conclusion We did not find a significant negative association between appendectomy and the UC occurrence in Chinese patients. Appendectomy performed before UC diagnosis may reduce the extent of UC involvement.
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26
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Shin DS, Cheon JH, Park YE, Park Y, Park SJ, Kim TI, Kim WH. Extensive Disease Subtypes in Adult Patients with Ulcerative Colitis: Non-pancolitis Versus Pancolitis. Dig Dis Sci 2018; 63:3097-3104. [PMID: 30145694 DOI: 10.1007/s10620-018-5218-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 07/18/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND AIM Few studies have compared pancolitis and non-pancolitis E3 in adult patients with ulcerative colitis (UC). This study aimed to evaluate the natural disease courses and factors affecting outcomes between pancolitis and non-pancolitis E3. METHODS We retrospectively analyzed 117 patients, including 93 with extensive colitis (E3) and 24 with UC confined to the rectum or left-sided colon and appendiceal orifice inflammation at the time of diagnosis, who were regularly followed up for at least 1 year. Patients with E3 were divided into two groups according to the degree of disease extension: pancolitis group (disease extent up to the cecum or proximal ascending colon) and non-pancolitis E3 group (disease extent above the splenic flexure but not up to the proximal ascending colon). Clinical findings at diagnosis; comorbidity; medications; Mayo score; cumulative rates of corticosteroid, immunomodulator, and anti-tumor necrosis factor (anti-TNF) alpha use; relapse; and admission were compared between the pancolitis and non-pancolitis E3 groups. RESULTS The median follow-up duration of the 117 patients was 74 (range 15-158) months. Fifty-one patients (43.5%) had pancolitis. The Mayo score at initial diagnosis, cumulative relapse rate, and cumulative admission rate were significantly higher in the pancolitis group than in the non-pancolitis E3 group (P < 0.001, P = 0.023 and P = 0.007, respectively). However, there was no significant difference between the groups in the rates of cumulative immunomodulator and anti-TNF alpha use (P = 0.67 and P = 0.73, respectively). CONCLUSIONS In patients with extensive UC (E3), pancolitis was associated with higher probabilities of cumulative relapse or admission, indicating poor prognosis.
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Affiliation(s)
- Dong Suk Shin
- Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Jae Hee Cheon
- Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea. .,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea.
| | - Yong Eun Park
- Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Yehyun Park
- Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Jung Park
- Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Il Kim
- Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ho Kim
- Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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Girard-Madoux MJ, Gomez de Agüero M, Ganal-Vonarburg SC, Mooser C, Belz GT, Macpherson AJ, Vivier E. The immunological functions of the Appendix: An example of redundancy? Semin Immunol 2018; 36:31-44. [DOI: 10.1016/j.smim.2018.02.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 02/16/2018] [Indexed: 12/12/2022]
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Matsushita M, Fukata N, Omiya M, Nishio A, Seki T, Okazaki K. Pathophysiology of the Appendix in Ulcerative Colitis. Am J Gastroenterol 2018; 113:622. [PMID: 29610510 DOI: 10.1038/ajg.2017.506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
| | - Norimasa Fukata
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Mika Omiya
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Akiyoshi Nishio
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Toshihito Seki
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
| | - Kazuichi Okazaki
- Third Department of Internal Medicine, Kansai Medical University, Osaka, Japan
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