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Yen HH, Wu JF, Wang HY, Chang TA, Chang CH, Chang CW, Chao TH, Chou JW, Chou YH, Chuang CH, Hsu WH, Hsu TC, Huang TY, Hung TI, Le PH, Lin CC, Lin CC, Lin CP, Lin JK, Lin WC, Ni YH, Shieh MJ, Shih IL, Shun CT, Tsai TJ, Wang CY, Weng MT, Wong JM, Wu DC, Wei SC. Management of ulcerative colitis in Taiwan: consensus guideline of the Taiwan Society of Inflammatory Bowel Disease updated in 2023. Intest Res 2024; 22:213-249. [PMID: 39099217 PMCID: PMC11309818 DOI: 10.5217/ir.2023.00050] [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: 04/03/2024] [Revised: 04/25/2024] [Accepted: 04/29/2024] [Indexed: 08/06/2024] Open
Abstract
Ulcerative colitis (UC) is a chronic inflammation of the gastrointestinal tract and is characterized by alternating periods of inflammation and remission. Although UC incidence is lower in Taiwan than in Western countries, its impact remains considerable, demanding updated guidelines for addressing local healthcare challenges and patient needs. The revised guidelines employ international standards and recent research, emphasizing practical implementation within the Taiwanese healthcare system. Since the inception of the guidelines in 2017, the Taiwan Society of Inflammatory Bowel Disease has acknowledged the need for ongoing revisions to incorporate emerging therapeutic options and evolving disease management practices. This updated guideline aims to align UC management with local contexts, ensuring comprehensive and context-specific recommendations, thereby raising the standard of care for UC patients in Taiwan. By adapting and optimizing international protocols for local relevance, these efforts seek to enhance health outcomes for patients with UC.
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Affiliation(s)
- Hsu-Heng Yen
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Division of Gastroenterology, Changhua Christian Hospital, Changhua, Taiwan
| | - Jia-Feng Wu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Horng-Yuan Wang
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
- MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
- MacKay Medical College, Taipei, Taiwan
| | - Ting-An Chang
- Department of Pathology, Taipei City Hospital, Renai-Branch, Taipei, Taiwan
| | - Chung-Hsin Chang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chen-Wang Chang
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
- MacKay Junior College of Medicine, Nursing and Management, Taipei, Taiwan
- MacKay Medical College, Taipei, Taiwan
| | - Te-Hsin Chao
- Division of Colon and Rectal Surgery, Department of Surgery, Chiayi and Wangiao Branch, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jen-Wei Chou
- Center for Digestive Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
- School of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Yenn-Hwei Chou
- Division of General Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Chiao-Hsiung Chuang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wen-Hung Hsu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan
| | - Tzu-Chi Hsu
- Division of Colon and Rectal Surgery, Department of Surgery, MacKay Memorial Hospital, MacKay Medical College, Taipei, Taiwan
| | - Tien-Yu Huang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tsung-I Hung
- Division of General Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Puo-Hsien Le
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Chang Gung Microbiota Therapy Center, Linkou Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Inflammatory Bowel Disease Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Chun-Che Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Chun-Chi Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Surgery, Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ching-Pin Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Jen-Kou Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Surgery, Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Chen Lin
- Division of Gastroenterology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Yen-Hsuan Ni
- Department of Pediatrics, National Taiwan University College of Medicine and Children’s Hospital, Taipei, Taiwan
| | - Ming-Jium Shieh
- Department of Oncology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - I-Lun Shih
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Tung Shun
- Department of Forensic Medicine and Pathology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pathology, Good Liver Clinic, Taipei, Taiwan
| | - Tzung-Jiun Tsai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Yi Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Meng-Tzu Weng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Medical Research, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Jau-Min Wong
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Deng-Chyang Wu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Gangshan Hospital, Kaohsiung, Taiwan
- Department of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shu-Chen Wei
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Kucharzik T, Dignass A, Atreya R, Bokemeyer B, Esters P, Herrlinger K, Kannengiesser K, Kienle P, Langhorst J, Lügering A, Schreiber S, Stallmach A, Stein J, Sturm A, Teich N, Siegmund B. Aktualisierte S3-Leitlinie Colitis ulcerosa (Version 6.2). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:769-858. [PMID: 38718808 DOI: 10.1055/a-2271-0994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Affiliation(s)
- T Kucharzik
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Städtisches Klinikum Lüneburg, Lüneburg, Deutschland
| | - A Dignass
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt, Deutschland
| | - R Atreya
- Medizinische Klinik 1 Gastroent., Pneumologie, Endokrin., Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - B Bokemeyer
- Interdisziplinäres Crohn Colitis Centrum Minden - ICCCM, Minden, Deutschland
| | - P Esters
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt, Deutschland
| | - K Herrlinger
- Innere Medizin I, Asklepios Klinik Nord, Hamburg, Deutschland
| | - K Kannengiesser
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Städtisches Klinikum Lüneburg, Lüneburg, Deutschland
| | - P Kienle
- Abteilung für Allgemein- und Viszeralchirurgie, Theresienkrankenhaus, Mannheim, Deutschland
| | - J Langhorst
- Klinik für Integrative Medizin und Naturheilkunde, Sozialstiftung Bamberg Klinikum am Bruderwald, Bamberg, Deutschland
| | - A Lügering
- Medizinisches Versorgungszentrum Portal 10, Münster, Deutschland
| | - S Schreiber
- Klinik für Innere Medizin I, Universitätsklinikum Schleswig Holstein, Kiel, Deutschland
| | - A Stallmach
- Klinik für Innere Medizin IV Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Jena, Jena, Deutschland
| | - J Stein
- Abteilung Innere Medizin mit Schwerpunkt Gastroenterologie, Krankenhaus Sachsenhausen, Frankfurt, Deutschland
| | - A Sturm
- Klinik für Innere Medizin mit Schwerpunkt Gastroenterologie, DRK Kliniken Berlin Westend, Berlin, Deutschland
| | - N Teich
- Internistische Gemeinschaftspraxis, Leipzig, Deutschland
| | - B Siegmund
- Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Charité Campus Benjamin Franklin - Universitätsmedizin Berlin, Berlin, Deutschland
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Orchard MR, Saracino A, Hooper J, Shabbir J. Ileorectal anastomosis in ulcerative colitis: what do surgeons and patients need to know? A systematic literature review. Ann R Coll Surg Engl 2024. [PMID: 38660816 DOI: 10.1308/rcsann.2024.0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
INTRODUCTION Ileal pouch-anal anastomosis (IPAA) is currently the gold standard for restoration of gastrointestinal continuity after colectomy for ulcerative colitis in the UK. However, with further experience of the risks relating to IPAA, the use of ileorectal anastomosis (IRA) is being revisited. Decisions regarding restorative surgery after colectomy are individual to every patient's circumstances, and this paper aims to provide a comprehensive review of the literature to guide a full discussion of the risks and benefits of IRA. METHODS A systematic literature review was conducted of papers published from 2000 onwards relating to IRA and ulcerative colitis, in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. The papers were reviewed by two independent surgeons for information it was felt that patients and surgeons would want to know about the operation (cancer risk, bowel function, sexual and urinary function, fecundity/fertility and postoperative complications). RESULTS Seventeen papers were identified for inclusion as they reported original data on one or more of the categories identified for discussion. The median ten-year cancer risk after IRA was 2.8% and the median failure rate at ten years was 21%. IRA was generally found to have lower postoperative complication rates and better bowel function than IPAA, with sexual function similar and fecundity not commented on in any paper. CONCLUSIONS For some patients, IRA can offer restorative surgery in the short or long term, with acceptable cancer risk, failure rate and postoperative complications, while avoiding the higher risks associated with IPAA.
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Affiliation(s)
- M R Orchard
- University Hospitals Bristol and Weston NHS Foundation Trust, UK
| | | | - J Hooper
- University Hospitals Bristol and Weston NHS Foundation Trust, UK
| | - J Shabbir
- University Hospitals Bristol and Weston NHS Foundation Trust, UK
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4
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Dunleavy KA, Santiago P, Forde G, Harmsen WS, McKenna NP, Coelho-Prabhu N, Shawki S, Raffals L. Total Proctocolectomy vs Subtotal/total Colectomy for Neoplasia in Patients With Inflammatory Bowel Disease and Primary Sclerosing Cholangitis. Inflamm Bowel Dis 2023:izad278. [PMID: 38142126 DOI: 10.1093/ibd/izad278] [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: 08/06/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC) frequently undergo restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for medically refractory disease or colonic dysplasia/neoplasia. Subtotal colectomy with ileosigmoid or ileorectal anastomosis may have improved outcomes but is not well studied. Due to increased risk for colorectal cancer in PSC-IBD, there is hesitancy to perform subtotal colectomy. We aim to describe the frequency of colorectal dysplasia/neoplasia following IPAA vs subtotal colectomy in PSC-IBD patients. METHODS We completed a retrospective study from 1972 to 2022 of patients with PSC-IBD who had undergone total proctocolectomy with IPAA or subtotal colectomy. We abstracted demographics, disease characteristics, and endoscopic surveillance data from the EMR. RESULTS Of 125 patients (99 IPAA; 26 subtotal), the indication for surgery was rectal sparing medically refractory disease (51% vs 42%), dysplasia (37% vs 30%) and neoplasia (11% vs 26%) in IPAA vs subtotal colectomy patients, respectively. On endoscopic surveillance of IPAA patients, 2 (2%) had low-grade dysplasia (LGD) in the ileal pouch and 2 (2%) had LGD in the rectal cuff after an average of 8.4 years and 12.3 years of follow-up, respectively. One (1%) IPAA patient developed neoplasia of the rectal cuff after 17.8 years of surgical continuity. No subtotal colectomy patients had dysplasia/neoplasia in the residual colon or rectum. CONCLUSIONS In patients with PSC-IBD, there was no dysplasia or neoplasia in those who underwent subtotal colectomy as opposed to the IPAA group. Subtotal colectomy may be considered a viable surgical option in patients with rectal sparing PSC-IBD if adequate endoscopic surveillance is implemented.
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Affiliation(s)
- Katie Ann Dunleavy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Priscila Santiago
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Gerard Forde
- Department of Gastroenterology, Galway University Hospital, Galway, Ireland
| | - W Scott Harmsen
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | | | | | - Sherief Shawki
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Laura Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Kabir M, Thomas-Gibson S, Tozer PJ, Warusavitarne J, Faiz O, Hart A, Allison L, Acheson AG, Atici SD, Avery P, Brar M, Carvello M, Choy MC, Dart RJ, Davies J, Dhar A, Din S, Hayee B, Kandiah K, Katsanos KH, Lamb CA, Limdi JK, Lovegrove RE, Myrelid P, Noor N, Papaconstantinou I, Petrova D, Pavlidis P, Pinkney T, Proud D, Radford S, Rao R, Sebastian S, Segal JP, Selinger C, Spinelli A, Thomas K, Wolthuis A, Wilson A. DECIDE: Delphi Expert Consensus Statement on Inflammatory Bowel Disease Dysplasia Shared Management Decision-Making. J Crohns Colitis 2023; 17:1652-1671. [PMID: 37171140 DOI: 10.1093/ecco-jcc/jjad083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND AND AIMS Inflammatory bowel disease colitis-associated dysplasia is managed with either enhanced surveillance and endoscopic resection or prophylactic surgery. The rate of progression to cancer after a dysplasia diagnosis remains uncertain in many cases and patients have high thresholds for accepting proctocolectomy. Individualised discussion of management options is encouraged to take place between patients and their multidisciplinary teams for best outcomes. We aimed to develop a toolkit to support a structured, multidisciplinary and shared decision-making approach to discussions about dysplasia management options between clinicians and their patients. METHODS Evidence from systematic literature reviews, mixed-methods studies conducted with key stakeholders, and decision-making expert recommendations were consolidated to draft consensus statements by the DECIDE steering group. These were then subjected to an international, multidisciplinary modified electronic Delphi process until an a priori threshold of 80% agreement was achieved to establish consensus for each statement. RESULTS In all, 31 members [15 gastroenterologists, 14 colorectal surgeons and two nurse specialists] from nine countries formed the Delphi panel. We present the 18 consensus statements generated after two iterative rounds of anonymous voting. CONCLUSIONS By consolidating evidence for best practice using literature review and key stakeholder and decision-making expert consultation, we have developed international consensus recommendations to support health care professionals counselling patients on the management of high cancer risk colitis-associated dysplasia. The final toolkit includes clinician and patient decision aids to facilitate shared decision-making.
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Affiliation(s)
- Misha Kabir
- Division of GI Services, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
| | - Siwan Thomas-Gibson
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Phil J Tozer
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Janindra Warusavitarne
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Omar Faiz
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Ailsa Hart
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Lisa Allison
- Department of Gastroenterology, Royal Free Hospital, London, UK
| | - Austin G Acheson
- Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Semra Demirli Atici
- Department of Surgery, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey
| | - Pearl Avery
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Mantaj Brar
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Michele Carvello
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Surgery, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Matthew C Choy
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia
- Division of Medicine, Dentistry and Health Sciences, University of Melbourne, Austin Academic Centre, Melbourne, VIC, Australia
| | - Robin J Dart
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Justin Davies
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Anjan Dhar
- Department of Gastroenterology, Darlington Memorial Hospital, County Durham & Darlington NHS Foundation Trust, Darlington, UK
- Department of Gastroenterology, Teesside University, UK, Middlesbrough, UK
| | - Shahida Din
- Edinburgh IBD Unit, NHS Lothian, Western General Hospital, Edinburgh, UK
| | - Bu'Hussain Hayee
- Department of Gastroenterology, King's College Hospital, London, UK
| | - Kesavan Kandiah
- Department of Gastroenterology, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Konstantinos H Katsanos
- Division of Gastroenterology, Department of Internal Medicine, University of Ioannina School of Health Sciences, Ioannina, Greece
| | - Christopher Andrew Lamb
- Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Gastroenterology, Royal Victoria Infirmary, Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Jimmy K Limdi
- Department of Gastroenterology, Northern Care Alliance NHS Foundation Trust, Greater Manchester, UK
- Department of Gastroenterology, University of Manchester , Manchester, UK
| | - Richard E Lovegrove
- Department of Surgery, Worcestershire Acute Hospitals NHS Trust , Worcester, UK
| | - Pär Myrelid
- Department of Surgery, Linköping University Hospital, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Nurulamin Noor
- Department of Gastroenterology, Cambridge University Hospitals, Addenbrooke's Hospital, Cambridge, UK
| | - Ioannis Papaconstantinou
- Department of Surgery, Aretaieion Hospital, National and Kapodistrian University of Athens, A thens, Greece
| | - Dafina Petrova
- Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain
- Escuela Andaluza de Salud Pública [EASP], Granada, Spain
- CIBER of Epidemiology and Public Health [CIBERESP], Madrid, Spain
| | - Polychronis Pavlidis
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Thomas Pinkney
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - David Proud
- Department of Surgery, Austin Health, Heidelberg Victoria, VIC, Australia
| | - Shellie Radford
- Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Rohit Rao
- Department of Gastroenterology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Shaji Sebastian
- Department of Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Jonathan P Segal
- Department of Gastroenterology, Northern Hospital Epping, University of Melbourne, Melbourne, VIC, Australia
| | - Christian Selinger
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Antonino Spinelli
- Faculty of Life Sciences and Medicine, King's College London, London, UK
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Kathryn Thomas
- Department of Surgery, Nottingham University Hospitals, UK
| | - Albert Wolthuis
- Department of Surgery, University Hospital Leuven, The Netherlands
| | - Ana Wilson
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
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6
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Druvefors E, Myrelid P, Andersson RE, Landerholm K. Female and Male Fertility after Colectomy and Reconstructive Surgery in Inflammatory Bowel Diesase: A National Cohort Study from Sweden. J Crohns Colitis 2023; 17:1631-1638. [PMID: 37158789 PMCID: PMC10637042 DOI: 10.1093/ecco-jcc/jjad079] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND AND AIMS Colectomy and reconstruction in patients with inflammatory bowel disease [IBD] may adversely affect fertility, but few population-based studies on this subject are available. METHODS Fertility was assessed in 2989 women and 3771 men with IBD and prior colectomy during 1964-2014, identified from the Swedish National Patient Register, and in 35 092 matched individuals. RESULTS Reconstruction with ileoanal pouch anastomosis [IPAA] was as common as ileorectal anastomosis [IRA] in ulcerative colitis [UC] and IBD-unclassified [IBD-U] but rare in Crohn's disease [CD]. Compared with the matched reference cohort, women with IBD had lower fertility overall after colectomy (hazard ratio [HR] 0.65, confidence interval [CI] 0.61-0.69), with least impact with leaving the rectum intact [HR 0.79, CI 0.70-0.90]. Compared with colectomy only, fertility in female patients remained unaffected after IRA [HR 0.86, CI 0.63-1.17 for UC, 0.86, CI 0.68-1.08 for IBD-U and 1.07, CI 0.70-1.63 for CD], but was impaired after IPAA, especially in UC [HR 0.67, CI 0.50-0.88], and after completion proctectomy [HR 0.65, CI 0.49-0.85 for UC, 0.68, CI 0.55-0.85 for IBD-U and 0.61, CI 0.38-0.96 for CD]. In men, fertility was marginally reduced following colectomy [HR 0.89, CI 0.85-0.94], regardless of reconstruction. CONCLUSIONS Fertility was reduced in women after colectomy for IBD. The least impact was seen when a deviated rectum was left intact. IRA was associated with no further reduction in fertility, whereas proctectomy and IPAA were associated with the strongest impairment. IRA therefore seems to be the preferred reconstruction to preserve fertility in selected female patients. Fertility in men was only moderately reduced after colectomy.
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Affiliation(s)
- Emma Druvefors
- Department of Surgery, County Hospital Ryhov, Jönköping, Sweden
- Department of Biomedical and Clinical Sciences, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | - Pär Myrelid
- Department of Biomedical and Clinical Sciences, Faculty of Health Sciences, Linköping University, Linköping, Sweden
- Department of Surgery, Linköping University Hospital, Linköping, Sweden
| | - Roland E Andersson
- Department of Surgery, County Hospital Ryhov, Jönköping, Sweden
- Department of Biomedical and Clinical Sciences, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | - Kalle Landerholm
- Department of Surgery, County Hospital Ryhov, Jönköping, Sweden
- Department of Biomedical and Clinical Sciences, Faculty of Health Sciences, Linköping University, Linköping, Sweden
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7
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Sica GS, Sensi B, Siragusa L, Blasi F, Crispino B, Pirozzi B, Angelico R, Biancone L, Khan J. Surgical management of colon cancer in ulcerative colitis patients with orthotopic liver transplant for primary sclerosing cholangitis. A systematic review. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106922. [PMID: 37210276 DOI: 10.1016/j.ejso.2023.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 03/13/2023] [Accepted: 04/27/2023] [Indexed: 05/22/2023]
Abstract
INTRODUCTION Colon cancer in ulcerative colitis patients with liver transplant (UCCOLT) due to primary sclerosing cholangitis carries significant treatment challenges. Aim of this literature search is to review management strategies and provide a framework to facilitate the decisional process in this clinical setting. METHODS PRISMA-compliant systematic search was followed by critical expert commentary of the results and development of a surgical management algorithm. Endpoints included surgical management, operative strategies, functional and survival outcomes. Technical and strategics aspects with particular regard to the choice of reconstruction were evaluated to tentatively develop an integrated algorithm. RESULTS Ten studies reporting treatment of 20 UCCOLT patients were identified after screening. Nine patients underwent proctocolectomy and end-ileostomy (PC) and eleven had restorative ileal pouch-anal anastomosis (IPAA). Reported results for perioperative outcomes, oncological outcomes, and graft loss were comparable for both procedures. There were no reports of subtotal colectomies and ileo-rectal anastomosis (IRA). CONCLUSIONS Literature in the field is scarce and decision-making is particularly complex. PC and IPAA have been reported with good results. Nevertheless, IRA may also be considered in UCCOLT patients in selected cases, reducing the risks of sepsis, OLT and pouch failure; furthermore, in young patients, it has the advantage of preserving fertility or sexual function. The proposed treatment algorithm may represent a valuable support in guiding surgical strategy.
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Affiliation(s)
- G S Sica
- Department of Surgical Science, University of Rome Tor Vergata, Rome, Italy.
| | - B Sensi
- Department of Surgical Science, University of Rome Tor Vergata, Rome, Italy
| | - L Siragusa
- Department of Surgical Science, University of Rome Tor Vergata, Rome, Italy
| | - F Blasi
- Department of Surgical Science, University of Rome Tor Vergata, Rome, Italy
| | - B Crispino
- Department of Surgical Science, University of Rome Tor Vergata, Rome, Italy
| | - B Pirozzi
- Department of Surgical Science, University of Rome Tor Vergata, Rome, Italy
| | - R Angelico
- Department of Surgical Science, University of Rome Tor Vergata, Rome, Italy
| | - L Biancone
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - J Khan
- Portsmouth Hospitals, NHS Trust, Portsmouth, UK
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8
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Georganta I, McIntosh S, Boldovjakova D, Parnaby CN, Watson AJM, Ramsay G. The incidence of malignancy in the residual rectum of IBD patients after colectomy: a systematic review and meta-analysis. Tech Coloproctol 2023; 27:699-712. [PMID: 36906886 PMCID: PMC10404177 DOI: 10.1007/s10151-023-02762-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 01/25/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) who have had a total colectomy remain with their rectum in situ, and are therefore at risk of rectal carcinoma. It is not clear how high the incidence of rectal cancer is in this cohort. The primary objective of this meta-analysis was to estimate the incidence of rectal cancer in patients with ulcerative colitis or Crohn's disease who have undergone colectomy but have a residual rectum, and to identify the risk factors for its development. In doing so, we explore the current recommendations for screening processes for these patients. METHODS A systematic review of the literature was performed. Five databases (Medline, Embase, Pubmed, Cochrane Library and Scopus) were searched from inception to 29 October 2021, to identify studies adhering to the population, intervention, control and outcomes (PICO) criteria. The included studies were critically appraised, and the relevant data was extracted. Cancer incidence was estimated from the reported information. Risk stratification was analysed using RevMan. A narrative approach was undertaken for the exploration of the existing screening guidelines. RESULTS Data from 23 of the 24 identified studies was suitable for analysis. The pooled incidence of rectal carcinoma was calculated to be 1.3%. Subgroup analysis showed an incidence of 0.7% and 3.2% for patients with a de-functioned rectal stump and ileorectal anastomosis, respectively. Patients with a history of a colorectal carcinoma were more likely to have a subsequent diagnosis of rectal carcinoma (RR 7.2, 95% CI 2.4-21.1). Patients with previous colorectal dysplasia were also at higher risk (RR 5.1, 95% CI 3.1-8.2). No universal standardised guidance regarding screening for this cohort could be identified in the available literature. CONCLUSIONS The overall risk of malignancy was estimated to be 1.3%, which is lower than previously reported. There is a need for clear and standardised screening guidance for this group of patients.
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Affiliation(s)
- I Georganta
- Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB252ZD, UK
| | - S McIntosh
- Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB252ZD, UK
| | - D Boldovjakova
- Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB252ZD, UK
| | - C N Parnaby
- Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB252ZD, UK
| | - A J M Watson
- Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB252ZD, UK
| | - G Ramsay
- Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB252ZD, UK.
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9
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Lavryk OA, Holubar SD. Rectal Stump Management in IBD. Dis Colon Rectum 2023; 66:1051-1054. [PMID: 37235863 DOI: 10.1097/dcr.0000000000002954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Olga A Lavryk
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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10
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Kucharzik T, Dignass A, Atreya R, Bokemeyer B, Esters P, Herrlinger K, Kannengiesser K, Kienle P, Langhorst J, Lügering A, Schreiber S, Stallmach A, Stein J, Sturm A, Teich N, Siegmund B. Aktualisierte S3-Leitlinie Colitis ulcerosa (Version 6.1) – Februar 2023 – AWMF-Registriernummer: 021-009. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:1046-1134. [PMID: 37579791 DOI: 10.1055/a-2060-0935] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Affiliation(s)
- T Kucharzik
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Städtisches Klinikum Lüneburg, Lüneburg, Deutschland
| | - A Dignass
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt, Deutschland
| | - R Atreya
- Medizinische Klinik 1 Gastroent., Pneumologie, Endokrin., Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - B Bokemeyer
- Interdisziplinäres Crohn Colitis Centrum Minden - ICCCM, Minden, Deutschland
| | - P Esters
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt, Deutschland
| | - K Herrlinger
- Innere Medizin I, Asklepios Klinik Nord, Hamburg, Deutschland
| | - K Kannengiesser
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Städtisches Klinikum Lüneburg, Lüneburg, Deutschland
| | - P Kienle
- Abteilung für Allgemein- und Viszeralchirurgie, Theresienkrankenhaus, Mannheim, Deutschland
| | - J Langhorst
- Klinik für Integrative Medizin und Naturheilkunde, Sozialstiftung Bamberg Klinikum am Bruderwald, Bamberg, Deutschland
| | - A Lügering
- Medizinisches Versorgungszentrum Portal 10, Münster, Deutschland
| | - S Schreiber
- Klinik für Innere Medizin I, Universitätsklinikum Schleswig Holstein, Kiel, Deutschland
| | - A Stallmach
- Klinik für Innere Medizin IV Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Jena, Jena, Deutschland
| | - J Stein
- Abteilung Innere Medizin mit Schwerpunkt Gastroenterologie, Krankenhaus Sachsenhausen, Frankfurt, Deutschland
| | - A Sturm
- Klinik für Innere Medizin mit Schwerpunkt Gastroenterologie, DRK Kliniken Berlin Westend, Berlin, Deutschland
| | - N Teich
- Internistische Gemeinschaftspraxis, Leipzig, Deutschland
| | - B Siegmund
- Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Charité Campus Benjamin Franklin - Universitätsmedizin Berlin, Berlin, Deutschland
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11
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Akimenko E, Bjerrum JT, Iversen AT, Allin KH, Jess T. Rectal Cancer Risk After Colectomy in Patients With Inflammatory Bowel Disease-A Population-Based Danish Cohort Study 1978-2018. GASTRO HEP ADVANCES 2023; 2:853-859. [PMID: 39130114 PMCID: PMC11307601 DOI: 10.1016/j.gastha.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 05/08/2023] [Indexed: 08/13/2024]
Abstract
Background and Aims Selected patient groups with ulcerative colitis and Crohn's disease are at increased risk of colorectal cancer. Surveillance guidelines rarely cover patients after colectomy. We performed a nationwide population-based cohort study to estimate the risk of developing rectal cancer in patients with inflammatory bowel disease after subtotal colectomy. Methods Through the Danish Civil Registration System, a source population of all individuals living in Denmark between 1978 and 2018 was retrieved. The risk of rectal cancer in patients with diverted rectum was assessed using Cox regression analyses with comparison to both the individuals with inflammatory bowel diseases without subtotal colectomy and the background population. Results Rectal cancer occurred in 42 of 4931 patients (0.9%) after subtotal colectomy and diverted rectum, compared to 209 of 49,251 (0.4%) in the matched inflammatory bowel diseases cohort without colectomy and 941 of 246,550 (0.4%) in the background population. The hazard ratio (HR) for rectal cancer in patients with inflammatory bowel disease and diverted rectum vs patients without colectomy was 0.76 (95% CI, 0.28, 2.07) before 10 years and 7.56 (95% CI, 5.21, 10.86) 10 years after colectomy. The HR for patients with diverted rectum compared to the background population was 0.84 (95% CI, 0.31, 2.24) and 10.01 (95% CI, 7.20, 13.94) respectively. Conclusion In our nationwide population-based Danish cohort study, we found the risk of rectal cancer in the diverted rectum to be markedly increased 10 years postcolectomy. This calls for better long-term surveillance of colectomized patients with inflammatory bowel diseases.
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Affiliation(s)
- Elena Akimenko
- Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jacob Tveiten Bjerrum
- Department of Gastroenterology and Hepatology, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Aske Thorn Iversen
- Department of Clinical Medicine, Center for Molecular Prediction of Inflammatory Bowel Disease (PREDICT), Aalborg University, Copenhagen, Denmark
| | - Kristine H. Allin
- Department of Clinical Medicine, Center for Molecular Prediction of Inflammatory Bowel Disease (PREDICT), Aalborg University, Copenhagen, Denmark
- Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Tine Jess
- Department of Clinical Medicine, Center for Molecular Prediction of Inflammatory Bowel Disease (PREDICT), Aalborg University, Copenhagen, Denmark
- Department of Gastroenterology & Hepatology, Aalborg University Hospital, Aalborg, Denmark
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12
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Challine A, Voron T, O'Connell L, Chafai N, Debove C, Collard MK, Parc Y, Lefèvre JH. Does an Ileoanal Anastomosis Decrease the Rate of Successful Pregnancy Compared With an Ileorectal Anastomosis? A National Study of 1491 Patients. Ann Surg 2023; 277:806-812. [PMID: 35837902 DOI: 10.1097/sla.0000000000005569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Report the rate of successful pregnancy in a national cohort of women with either an ileal pouch anal (IPAA) or ileorectal (IRA) anastomosis constructed after colectomy for inflammatory bowel disease (IBD) or polyposis. BACKGROUND Fertility after IPAA is probably impaired. All available data are corroborated by only small sample size studies. It is not known whether construction of IPAA versus IRA influences the odds of subsequently achieving a successful pregnancy, especially with increased utilization of the laparoscopic approach. METHODS All women (age: 12-45 y) undergoing IRA or IPAA in France for polyposis or IBD, between 2010-2020, were included. A control population was defined as women aged from 12 to 45 years undergoing laparoscopic appendicectomy during the same period. The odds of successful pregnancy were studied using an adjusted survival analysis. RESULTS A total of 1491 women (IPAA=872, 58%; IRA=619, 42%) were included. A total of 220 deliveries (15%) occurred during the follow-up period of 71 months (39-100). After adjustment, the odds of successful pregnancy was not significantly associated with type of anastomosis (after IPAA: Hazard Ratio [HR]=0.79, 95% confidence interval=0.56-1.11, P =0.17). The laparoscopic approach increased the odds of achieving successful pregnancy (HR=1.79, 95% confidence interval=1.20-2.63, P =0.004). IRA and IPAA significantly impacted fertility when compared with the control population ( P <0.001). CONCLUSIONS In this large cohort study, total colectomy for polyposis or IBD was associated with reduced fertility compared with the general population. No difference in odds of achieving successful pregnancy was found between IRA and IPAA after adjustment. This analysis suggests laparoscopic surgery may be associated with greater likelihood of pregnancy.
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Affiliation(s)
- Alexandre Challine
- Department of Digestive Surgery, APHP, Hôpital Saint Antoine, Paris, France
- Sorbonne Université, Paris, France
- Centre de Recherche des Cordeliers, Inserm UMR 1138, Sorbonne Université, Université Paris Cité, Paris, France
| | - Thibault Voron
- Department of Digestive Surgery, APHP, Hôpital Saint Antoine, Paris, France
- Sorbonne Université, Paris, France
| | - Lauren O'Connell
- Centre for Colorectal Disease, St Vincent's University Hospital, Elm Park, Dublin, Ireland
| | - Najim Chafai
- Department of Digestive Surgery, APHP, Hôpital Saint Antoine, Paris, France
| | - Clotilde Debove
- Department of Digestive Surgery, APHP, Hôpital Saint Antoine, Paris, France
| | - Maxime K Collard
- Department of Digestive Surgery, APHP, Hôpital Saint Antoine, Paris, France
- Sorbonne Université, Paris, France
| | - Yann Parc
- Department of Digestive Surgery, APHP, Hôpital Saint Antoine, Paris, France
- Sorbonne Université, Paris, France
| | - Jérémie H Lefèvre
- Department of Digestive Surgery, APHP, Hôpital Saint Antoine, Paris, France
- Sorbonne Université, Paris, France
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13
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Risto A, Nordenvall C, Deputy M, Hermanson M, Lindforss U, Block M, Faiz O, Myrelid P. Colectomy reconstruction for ulcerative colitis in Sweden and England: a multicenter prospective comparison between ileorectal anastomosis and ileal pouch-anal anastomosis after colectomy in patients with ulcerative colitis. (CRUISE-study). BMC Surg 2023; 23:96. [PMID: 37085812 PMCID: PMC10122388 DOI: 10.1186/s12893-023-01984-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 04/04/2023] [Indexed: 04/23/2023] Open
Abstract
BACKGROUND There are no prospective trials comparing the two main reconstructive options after colectomy for Ulcerative colitis, ileal pouch anal anastomosis and ileorectal anastomosis. An attempt on a randomized controlled trial has been made but after receiving standardized information patients insisted on choosing operation themselves. METHODS Adult Ulcerative colitis patients subjected to colectomy eligible for both ileal pouch anastomosis and ileorectal anastomosis are asked to participate and after receiving standardized information the get to choose reconstructive method. Patients declining reconstruction or not considered eligible for both methods will be followed as controls. The CRUISE study is a prospective, non-randomized, multi-center, open-label, controlled trial on satisfaction, QoL, function, and complications between ileal pouch anal anastomosis and ileorectal anastomosis. DISCUSSION Reconstruction after colectomy is a morbidity-associated as well as a resource-intensive activity with the sole purpose of enhancing function, QoL and patient satisfaction. The aim of this study is to provide the best possible information on the risks and benefits of each reconstructive treatment. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05628701.
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Affiliation(s)
- Anton Risto
- Division of Surgery, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University Hospital Linköping, 581 85, Linköping, Sweden.
- Department of Surgery, County Council of Östergötland, Linköping, Sweden.
| | - Caroline Nordenvall
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Center for Digestive Disease, Division of Coloproctology, Karolinska University Hospital, Stockholm, Sweden
| | - Mohammed Deputy
- St Mark's Hospital and Academic Institute, Harrow, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Maria Hermanson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Ulrik Lindforss
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Center for Digestive Disease, Division of Coloproctology, Karolinska University Hospital, Stockholm, Sweden
| | - Mattias Block
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Omar Faiz
- Center for Digestive Disease, Division of Coloproctology, Karolinska University Hospital, Stockholm, Sweden
- St Mark's Hospital and Academic Institute, Harrow, UK
| | - Pär Myrelid
- Division of Surgery, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University Hospital Linköping, 581 85, Linköping, Sweden
- Department of Surgery, County Council of Östergötland, Linköping, Sweden
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14
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Post-endoscopy colorectal cancer after colectomy in inflammatory bowel disease patients: a population-based register study. Eur J Gastroenterol Hepatol 2023; 35:288-293. [PMID: 36708300 DOI: 10.1097/meg.0000000000002514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES Long-standing inflammatory bowel disease (IBD) colitis is an indication for endoscopic surveillance. Postcolonoscopy colorectal cancer (PCCRC), cancer detected after a negative colonoscopy, is a quality indicator for colonoscopy. In analogy with PCCRC, we aimed to assess postendoscopy CRC (PECRC) in individuals with IBD who had undergone colectomy. METHODS This register study included Swedish adults with an IBD diagnosis who had undergone colectomy and later were examined by either colonoscopy or sigmoidoscopy during 2001-2012. The final study population had a CRC diagnosis within 36 months of the index examination. Poisson regression was used to assess the relative risks (RR) of PECRC. RESULTS A total of 33 individuals, 12 with an ileorectal anastomosis and 21 with a rectal remnant, had a CRC diagnosis within 36 months of the index endoscopy. Eleven cancers were detected as CRCs, and 22 (67%) were PECRCs. Compared with individuals aged >70 years, individuals aged <30 years had an RR of 3.1 (P = 0.054) and individuals aged 30-50 years had a RR of 2.6 (P = 0.030). A longer interval between colectomy and index endoscopy (>10 vs. <10 years) was associated with a lower risk of PCCRC (RR = 0.5; P = 0.007). There was no significant difference between the risk for Crohn's disease vs. ulcerative colitis, or between ileorectal anastomosis and rectal remnant risks. CONCLUSIONS Continuous surveillance of IBD patients after colectomy is important. In the postcolectomy context, PECRC may be used as a quality indicator.
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15
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A systematic review of outcomes and quality of life after ileorectal anastomosis for ulcerative colitis. Arab J Gastroenterol 2023:S1687-1979(23)00008-4. [PMID: 36813579 DOI: 10.1016/j.ajg.2023.01.007] [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: 05/23/2022] [Revised: 09/14/2022] [Accepted: 01/15/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND AND STUDY AIMS Ileorectal anastomosis (IRA) is one option for restoring bowel continuity in patients who have undergone subtotal colectomy for ulcerative colitis (UC). This systematic review aims to assess short- and long-term outcomes after IRA for UC, including anastomotic leak rates, IRA failure (as defined by conversion to pouch or end stoma), cancer risk in the rectal remnant, and quality of life (QoL) post-IRA surgery. MATERIALS & METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analysis checklist was used to demonstrate the search strategy. A systematic review of PubMed, Embase, Cochrane library, and Google Scholar from 1946 to August 2022 was undertaken. RESULTS This systematic review included 20 studies, representing 2538 patients who underwent IRA for UC. The mean age ranged from 25 to 36 years and the mean postoperative follow-up ranged between 7 and 22 years. The overall leak rate reported across 15 studies was 3.9 % (n = 35/907) ranging from 0 % to 16.7 %. The failure of IRA (requiring conversion to pouch or end stoma) as reported across 18 of the studies was 20.4 % (n = 498/2447). The risk of developing cancer in the remaining rectal stump following IRA was reported by 14 studies and was accumulatively 2.4 % (n = 30/1245). Five studies reported on patient QoL using a variety of different instruments and 66.0 % of patients (n = 235/356) reported a "high" QoL score. CONCLUSION IRA was associated with a relatively low leak rate and a low risk of colorectal cancer in the rectal remnant. However, it does carry a significant failure rate which invariably requires conversion to an end stoma or the formation of an ileoanal pouch. IRA provided a QoL to most of the patients.
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16
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Berghog J, Hermanson M, de la Croix H, Bengtson J, Block M. Ileo-rectal anastomosis in ulcerative colitis-Long-term outcome, failure and risk of cancer at a tertiary centre. Colorectal Dis 2022; 24:1535-1542. [PMID: 35768885 PMCID: PMC10084240 DOI: 10.1111/codi.16237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 06/05/2022] [Accepted: 06/16/2022] [Indexed: 01/07/2023]
Abstract
AIM Ileo-rectal anastomosis (IRA) is an option to restore bowel continuity after colectomy in patients with ulcerative colitis (UC). Concerns that the remaining rectum may serve as a site for continuing proctitis with subsequent poor function and IRA failure and the fear of development of dysplasia and cancer have led to the abandonment of IRA in large parts of the world. This study investigated the outcome of IRA in a large patient cohort with UC and IRA with regard to failure of IRA and development of dysplasia and cancer. METHODS This was a retrospective data gathering of patients with UC and IRA enrolled at the Department of Colorectal Surgery, Surgical Clinic, Sahlgrenska University Hospital/Östra, Gothenburg, 1972-2019. End-points were IRA failure, rectal dysplasia and cancer. IRA survival analysis and the cumulative probability of rectal cancer were calculated. RESULTS In total, 183 patients (121 men) were included in the study. The IRA failure rate was 34% and the estimated cumulative IRA failure rates were 25% and 35% at 5 and 10 years respectively. Four patients developed rectal cancer and the estimated cumulative probability of rectal cancer was 3% and 6% at 10 and 15 years respectively. CONCLUSION Ileo-rectal anastomosis remains a restorative option after colectomy for UC, even if the failure rate raises some concern. Further knowledge is needed for optimal patient selection to avoid early IRA failures. With increasing probability of rectal cancer over time a vigilant surveillance protocol is mandatory.
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Affiliation(s)
- John Berghog
- Department of Surgery, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden.,Institute of Clinical Sciences, Sahlgrenska Academy Gothenburg University, Gothenburg, Sweden
| | - Maria Hermanson
- Department of Surgery, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden.,Institute of Clinical Sciences, Sahlgrenska Academy Gothenburg University, Gothenburg, Sweden
| | - Hanna de la Croix
- Department of Surgery, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden.,Institute of Clinical Sciences, Sahlgrenska Academy Gothenburg University, Gothenburg, Sweden
| | - Jonas Bengtson
- Department of Surgery, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden.,Institute of Clinical Sciences, Sahlgrenska Academy Gothenburg University, Gothenburg, Sweden
| | - Mattias Block
- Department of Surgery, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden.,Institute of Clinical Sciences, Sahlgrenska Academy Gothenburg University, Gothenburg, Sweden
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17
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DeLeon MF, Stocchi L. Elective and Emergent Surgery in the Ulcerative Colitis Patient. Clin Colon Rectal Surg 2022; 35:437-444. [PMID: 36591393 PMCID: PMC9797282 DOI: 10.1055/s-0042-1758134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Ulcerative colitis (UC) requires surgical management in 20 to 30% of patients. Indications for surgery include medically refractory disease, dysplasia, cancer, and other complications of UC. Appropriate patient selection for timing and staging of surgery is paramount for optimal outcomes. Restorative proctocolectomy is the preferred standard of care and can afford many patients with excellent quality of life. There have been significant shifts in the treatment of UC-associated dysplasia, with less patients requiring surgery and more entering surveillance programs. There is ongoing controversy surrounding the management of UC-associated colorectal cancer and the techniques that should be used. This article reviews the most recent literature on the indications for elective and emergent surgical intervention for UC and the considerations behind the surgical options.
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Affiliation(s)
| | - Luca Stocchi
- Department of Surgery, Mayo Clinic, Jacksonville, Florida
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18
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Kotze PG, Heuthorst L, Lightner AL, Damião AOMC, Bemelman WA. New insights on the surgical management of ulcerative colitis in the 21st century. Lancet Gastroenterol Hepatol 2022; 7:679-688. [DOI: 10.1016/s2468-1253(22)00001-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 12/19/2021] [Accepted: 12/21/2021] [Indexed: 10/18/2022]
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19
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Barnes EL, Holubar SD, Herfarth HH. Systematic Review and Meta-analysis of Outcomes After Ileal Pouch-anal Anastomosis in Primary Sclerosing Cholangitis and Ulcerative Colitis. J Crohns Colitis 2021; 15:1272-1278. [PMID: 33544128 DOI: 10.1093/ecco-jcc/jjab025] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The optimal restorative surgical management of patients with concomitant diagnoses of primary sclerosing cholangitis and ulcerative colitis [PSC-UC] who require colectomy is controversial, given that patients may have an increased risk for pouchitis after ileal pouch-anal anastomosis [IPAA]. We aimed to compare rates of pouchitis and pouch failure among patients with and without PSC by performing a systematic review and meta-analysis. METHODS A systematic search performed through August 18, 2020, identified 12 studies that compared the rates of pouchitis [n = 11] and/or pouch failure [n = 6] among patients with PSC-UC and UC alone. We then performed a meta-analysis using random effects modelling to estimate the odds of developing any episodes of pouchitis or pouch failure. RESULTS A total of 4108 patients underwent an ileal pouch-anal anastomosis after proctocolectomy for UC. Of these, 3799 [92%] were performed for UC alone and 309 [8%] were performed for PSC-UC. In a meta-analysis of 11 studies, patients with PSC-UC compared with UC alone were significantly more likely to develop any pouchitis (63% vs 30%, odds ratio [OR] 4.21, 95% confidence interval [CI] 2.86-6.18), chronic pouchitis [47% vs 15%, OR 6.37, 95% CI 3.41-11.9], and pouch failure [10% vs 7%, OR 1.85, 95% CI 1.08-3.17]. CONCLUSIONS Patients with PSC-UC were more likely to experience pouchitis and pouch failure than patients with UC alone. The risks of inflammatory complications after IPAA must be weighed against the potential complications with other surgical procedures, and future studies comparing outcomes among these procedures may inform decision making in this population.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stefan D Holubar
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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20
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Holubar SD, Lightner AL, Poylin V, Vogel JD, Gaertner W, Davis B, Davis KG, Mahadevan U, Shah SA, Kane SV, Steele SR, Paquette IM, Feingold DL. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Ulcerative Colitis. Dis Colon Rectum 2021; 64:783-804. [PMID: 33853087 DOI: 10.1097/dcr.0000000000002037] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Stefan D Holubar
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Vitaliy Poylin
- McGaw Medical Center of Northwestern University, Chicago, Illinois
| | - Jon D Vogel
- Colorectal Surgery Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Wolfgang Gaertner
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Bradley Davis
- Colon and Rectal Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | | | - Uma Mahadevan
- Department of Medicine, University of California, San Francisco, California
| | - Samir A Shah
- Department of Medicine, Brown University, Providence, Rhode Island
| | - Sunanda V Kane
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Scott R Steele
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Daniel L Feingold
- Section of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
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21
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Attauabi M, Zhao M, Bendtsen F, Burisch J. Systematic Review with Meta-analysis: The Impact of Co-occurring Immune-mediated Inflammatory Diseases on the Disease Course of Inflammatory Bowel Diseases. Inflamm Bowel Dis 2021; 27:927-939. [PMID: 32628745 DOI: 10.1093/ibd/izaa167] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Patients with inflammatory bowel diseases (IBDs) are at risk of developing a variety of other immune-mediated inflammatory diseases (IMIDs). The influence of co-occurring IMIDs on the disease course of IBD remains unknown. The aim of this study was therefore to conduct a systematic review and meta-analysis of the impact of IMIDs on phenotypic presentation and outcome in patients with IBD. METHODS PubMed and Embase were searched from their earliest records through December 2018 and updated in October 2019 for studies reporting proportions or ratios of IBD-related disease outcomes in patients with and without co-occurring IMIDs. Meta-analyses were performed to estimate summary proportions and risks of the main outcomes. PRISMA guidelines were used, and study quality was assessed according to the Newcastle-Ottawa Scale. RESULTS A total of 93 studies were identified, comprising 16,064 IBD patients with co-occurring IMIDs and 3,451,414 IBD patients without IMIDs. Patients with IBD and co-occurring IMIDs were at increased risk of having extensive colitis or pancolitis (risk ratio, 1.38; 95% Cl, 1.25-1.52; P < 0.01, I2 = 86%) and receiving IBD-related surgeries (risk ratio, 1.17; 95% Cl, 1.01-1.36; P = 0.03; I2 = 85%) compared with patients without IMIDs. Co-occurrence of IMIDs other than primary sclerosing cholangitis in patients with IBD was associated with an increased risk of receiving immunomodulators (risk ratio, 1.15; 95% Cl, 1.06-1.24; P < 0.01; I2 = 60%) and biologic therapies (risk ratio, 1.19; 95% Cl, 1.08-1.32; P < 0.01; I2 = 53%). CONCLUSION This meta-analysis found that the presence of co-occurring IMIDs influences the disease course of IBD, including an increased risk of surgery and its phenotypical expression.
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Affiliation(s)
- Mohamed Attauabi
- Gastrounit, Medical Division, Copenhagen University Hospital, Hvidovre, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mirabella Zhao
- Gastrounit, Medical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - Flemming Bendtsen
- Gastrounit, Medical Division, Copenhagen University Hospital, Hvidovre, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Johan Burisch
- Gastrounit, Medical Division, Copenhagen University Hospital, Hvidovre, Denmark
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22
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Horio Y, Uchino M, Kihara T, Bando T, Kuwahara R, Minagawa T, Kusunoki K, Watanabe K, Hirota S, Ikeuchi H. Potential problems of partial resection for colitis-associated cancer in a patient with ulcerative colitis: case report. J Surg Case Rep 2021; 2021:rjab086. [PMID: 33777355 PMCID: PMC7984846 DOI: 10.1093/jscr/rjab086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/16/2021] [Indexed: 11/14/2022] Open
Abstract
Total proctocolectomy and an ileal pouch-anal anastomosis are recommended as the standard procedure for ulcerative colitis (UC)-colitis-associated cancer (CAC). However, several studies have reported the partial colectomy and endoscopic resection of UC-CAC in recent years. We present a surgical case of UC-CAC that was detected at a site that had not been diagnosed preoperatively, and we report potential problems of partial colectomy and endoscopic resection through this case. Considerations of synchronous and metachronous cancer/dysplasia are important before partial resection is planned for CAC in UC. Moreover, it should be noted that endoscopic resection at the anal site can be a risk factor for pouch surgery failure due to fibrosis after resection.
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Affiliation(s)
- Yuki Horio
- Department of Inflammatory Bowel Disease Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Motoi Uchino
- Department of Inflammatory Bowel Disease Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Takako Kihara
- Department of Surgical Pathology, Hyogo College of Medicine, Hyogo, Japan
| | - Toshihiro Bando
- Department of Inflammatory Bowel Disease Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Ryuichi Kuwahara
- Department of Inflammatory Bowel Disease Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Tomohiro Minagawa
- Department of Inflammatory Bowel Disease Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Kurando Kusunoki
- Department of Inflammatory Bowel Disease Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Kenji Watanabe
- Division of Internal Medicine, Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Hyogo, Japan
| | - Seiichi Hirota
- Department of Surgical Pathology, Hyogo College of Medicine, Hyogo, Japan
| | - Hiroki Ikeuchi
- Department of Inflammatory Bowel Disease Surgery, Hyogo College of Medicine, Hyogo, Japan
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23
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Kucharzik T, Dignass AU, Atreya R, Bokemeyer B, Esters P, Herrlinger K, Kannengießer K, Kienle P, Langhorst J, Lügering A, Schreiber S, Stallmach A, Stein J, Sturm A, Teich N, Siegmund B. Aktualisierte S3-Leitlinie Colitis ulcerosa – Living Guideline. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2020; 58:e241-e326. [PMID: 33260237 DOI: 10.1055/a-1296-3444] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Torsten Kucharzik
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Klinikum Lüneburg, Lüneburg, Deutschland
| | - Axel U Dignass
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt am Main, Deutschland
| | - Raja Atreya
- Medizinische Klinik 1, Universitätsklinikum Erlangen, Deutschland
| | - Bernd Bokemeyer
- Gastroenterologische Gemeinschaftspraxis Minden, Deutschland
| | - Philip Esters
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt am Main, Deutschland
| | | | - Klaus Kannengießer
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Klinikum Lüneburg, Lüneburg, Deutschland
| | - Peter Kienle
- Allgemein- und Viszeralchirurgie, Theresienkrankenhaus und Sankt Hedwig-Klinik GmbH, Mannheim, Deutschland
| | - Jost Langhorst
- Klinik für Integrative Medizin und Naturheilkunde, Klinikum am Bruderwald, Bamberg, Deutschland
| | - Andreas Lügering
- Medizinisches Versorgungszentrum Portal 10, Münster, Deutschland
| | | | - Andreas Stallmach
- Gastroenterologie, Hepatologie und Infektiologie, Friedrich Schiller Universität, Jena, Deutschland
| | - Jürgen Stein
- Innere Medizin mit Schwerpunkt Gastroenterologie, Krankenhaus Sachsenhausen, Frankfurt/Main, Deutschland
| | - Andreas Sturm
- Klinik für Innere Medizin mit Schwerpunkt Gastroenterologie, DRK Kliniken Berlin Westend, Berlin, Deutschland
| | - Niels Teich
- Internistische Gemeinschaftspraxis für Verdauungs- und Stoffwechselkrankheiten, Leipzig, Deutschland
| | - Britta Siegmund
- Medizinische Klinik I, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Deutschland
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24
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Horio Y, Uchino M, Bando T, Sasaki H, Goto Y, Kuwahara R, Minagawa T, Takesue Y, Ikeuchi H. Incidence, Risk Factors and Outcomes of Cancer of the Anal Transitional Zone in Patients with Ulcerative Colitis. J Crohns Colitis 2020; 14:1565-1571. [PMID: 32365200 DOI: 10.1093/ecco-jcc/jjaa089] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Performing a mucosectomy with a hand-sewn ileal pouch-anal anastomosis [IPAA] for ulcerative colitis [UC] theoretically reduces the risk of carcinoma arising from the anal transitional zone [ATZ]. Although current guidelines suggest a stapled anastomosis due to the low incidence of cancer after pouch surgery in UC patients, only a few small series have addressed the oncological advantage of mucosectomy. Therefore, we aimed to investigate the incidence of ATZ/pouch cancer. METHODS A total of 1970 UC patients who underwent surgery between April 1987 and December 2018 were included. We retrospectively analysed the incidences of primary ATZ cancer in the original operative specimen and de novo ATZ/pouch cancer after surgery. Possible risk factors for primary ATZ cancer and the pouch survival rate were assessed. RESULTS Fourteen [6.4%] primary ATZ cancers developed in 220 UC-colorectal cancer [CRC] cases. Multiple (odds ratio [OR] = 8.79, 95% confidence interval [CI] 2.77-27.83, p < 0.01) and rectal [OR = 6.48, 95% CI 1.41-29.7, p = 0.01] cancers were identified as independent risk factors for primary ATZ cancer. Four of 1970 [0.2%] patients developed de novo ATZ/pouch cancer and dysplasia. The 10-year estimated cumulative pouch survival rate was not significantly different between stapled IPAA and hand-sewn IPAA cases [95.9% and 97.3%, p = 0.25]. CONCLUSION The risk of de novo ATZ/pouch cancer and dysplasia was rare. The decision to perform a hand-sewn or a stapled IAA should be made on a case-by-case basis. However, the relatively high incidence of primary ATZ cancer in UC patients with CRC suggests that mucosectomy should be recommended for this patient group.
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Affiliation(s)
- Yuki Horio
- Department of Inflammatory Bowel Disease, Division of Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Motoi Uchino
- Department of Inflammatory Bowel Disease, Division of Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Toshihiro Bando
- Department of Inflammatory Bowel Disease, Division of Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Hirofumi Sasaki
- Department of Inflammatory Bowel Disease, Division of Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Yoshiko Goto
- Department of Inflammatory Bowel Disease, Division of Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Ryuichi Kuwahara
- Department of Inflammatory Bowel Disease, Division of Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Tomohiro Minagawa
- Department of Inflammatory Bowel Disease, Division of Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Yoshio Takesue
- Infection Control and Prevention, Hyogo College of Medicine, Hyogo, Japan
| | - Hiroki Ikeuchi
- Department of Inflammatory Bowel Disease, Division of Surgery, Hyogo College of Medicine, Hyogo, Japan
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25
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Ileorectal Anastomosis Versus IPAA for the Surgical Treatment of Ulcerative Colitis: A Markov Decision Analysis. Dis Colon Rectum 2020; 63:1276-1284. [PMID: 32472777 DOI: 10.1097/dcr.0000000000001686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Ileorectal anastomosis in patients with ulcerative colitis results in decreased postoperative morbidity and better functional outcome but leads to increased risk for rectal cancer compared with IPAA. OBJECTIVE This study aims to compare ileorectal anastomosis with IPAA in ulcerative colitis by using a decision model. DESIGN A Markov simulation model was designed to simulate clinical events of ileorectal anastomosis and IPAA over a time horizon of 40 years with time cycles of 1 year. All probabilities and utilities were derived from observational studies, identified after a systematic literature search using MEDLINE. Primary outcomes were life-years and quality-adjusted life-years. Deterministic and probabilistic sensitivity analyses were performed. SETTINGS A decision model using Markov simulation was designed. PATIENTS The base case was a 35-year-old patient with ulcerative colitis and a relatively preserved rectum. MAIN OUTCOMES MEASURES The primary outcome measures were (quality-adjusted) life-years. RESULTS The model resulted in lower life-years (36.22 vs 37.02) and higher quality-adjusted life-years (33.42 vs 31.57) for ileorectal anastomosis. This was confirmed after probabilistic sensitivity analysis. The model was sensitive to the utility of ileorectal anastomosis, IPAA, and end-ileostomy. A higher proportion of patients with ileorectal anastomosis will develop rectal cancer (7.6% vs 3.2%) and 43.5% of all patients with ileorectal anastomosis will end with an ileostomy as opposed to 23.0% of all patients with IPAA. LIMITATIONS The study was limited by characteristics inherent to modeling studies, including assumptions necessary to build the model, data input based on best available but often limited evidence, and unavoidable extra- and interpolation of data. CONCLUSIONS Ileorectal anastomosis was the preferred treatment option when quality-adjusted life-years were the outcome, with higher life-years for IPAA. This model highlights that both surgical strategies are useful in patients who have ulcerative colitis with a relatively spared rectum. See Video Abstract at http://links.lww.com/DCR/B249. ANASTOMOSIS ILEORRECTAL VERSUS ANASTOMOSIS ANAL CON RESERVORIO ILEAL EN EL TRATAMIENTO QUIRÚRGICO DE LA COLITIS ULCEROSA: ANÁLISIS DE DECISIÓN DE MARKOV: Las anastomosis ileorrectales en pacientes con colitis ulcerosa se encuentran asociadas con la disminución de la morbilidad postoperatoria y un mejor resultado funcional, pero conducen a un mayor riesgo de cáncer de recto cuando se las compara con casos de confección de un reservorio íleo-anal.Comparar las anastomosis ileorrectales con la anastomosis de un reservorio íleo-anal en casos de colitis ulcerosa, utilizando un modelo de procesos de decisión.Se diseñó un modelo de proceso de Markov para simular eventos clínicos en casos de anastomosis ileorrectales y anastomosis de reservorios íleo-anales en un horizonte temporal de 40 años comprendiendo ciclos temporales de 1 año. Todas las probabilidades y utilidades se derivaron de estudios observacionales, identificados después de una búsqueda sistemática de literatura usando MEDLINE. Los resultados primarios fueron años de vida y los años ajustados a la calidad de vida. Se realizaron los análisis de sensibilidad determinada y de probabilística.Se diseñó un modelo de decisión utilizando el proceso de simulación de Markov.El caso base fue el de un paciente de 35 años con colitis ulcerosa y con un recto relativamente sano.El resultado principal fué la medida de los años de vida (con ajuste en la calidad de vida).El modelo resultó en menos años de vida (36.22 frente a 37.02) y años de vida de menor calidad (33.42 frente a 31.57) para los casos de anastomosis ileorrectales. Esto se confirmó después del análisis de sensibilidad probabilística. El modelo era sensible a la utilidad de la anastomosis ileorrectal, la anastomosis del reservorio íleo-anal y la ileostomía terminal. Una mayor proporción de pacientes con anastomosis ileorectales desarrollarán cáncer de recto (7,6% frente a 3,2%) y el 43,5% de todos los pacientes con anastomosis ileorrectales terminarán con una ileostomía en comparación con el 23,0% de todos los pacientes con un reservorio íleo-anal.El analisis estuvo limitado por las características inherentes a los estudios de modelado, incluidas las suposiciones necesarias para construir el modelo, la entrada de datos basada en la mejor evidencia disponible pero a menudo limitada y la extrapolación e interpolación inevitable de datos.Las anastomosis ileorrectales fueron la opción de tratamiento preferida cuando el resultado fue ajustado en años con calidad de vida, con años de vida más larga para la anastomosis de reservorios íleo-anales. Este modelo destaca que ambas estrategias quirúrgicas son útiles en pacientes con colitis ulcerosa con rectos relativamente sanos. Consulte Video Resumen en http://links.lww.com/DCR/B249.
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26
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Margalit-Yehuda R, Ben-Horin S. Bottom-up: Can Trans-anal Rectal Resection Improve Outcomes in Ulcerative Colitis Patients Undergoing Proctocolectomy and Ileo-anal Pouch Anastomosis? J Crohns Colitis 2020; 14:724-725. [PMID: 32645154 DOI: 10.1093/ecco-jcc/jjaa007] [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: 02/08/2023]
Affiliation(s)
- Reuma Margalit-Yehuda
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Israel
| | - Shomron Ben-Horin
- Department of Gastroenterology, Sheba Medical Center Tel Hashomer, Sackler School of Medicine, Tel-Aviv University, Israel
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27
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Abstract
Elective abdominal surgery for inflammatory bowel disease is common. Surgery for Crohn's disease is not curative, and treatment must be individualized to the disease process. Surgery for ulcerative colitis generally is curative but consideration of patient-specific factors is important for staging of the procedure and determining whether ileal pouch-anal anastomosis is appropriate.
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29
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Landerholm K, Wood C, Bloemendaal A, Buchs N, George B, Guy R. The rectal remnant after total colectomy for colitis - intra-operative,post-operative and longer-term considerations. Scand J Gastroenterol 2018; 53:1443-1452. [PMID: 30451043 DOI: 10.1080/00365521.2018.1529195] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Acute severe colitis requires surgery in around 30% of the cases. Total colectomy with ileostomy is the standard procedure with distinct advantages to a laparoscopic approach. Less agreement exists regarding the formation or configuration of the retained rectal stump and its short-term and long-term management. In this review, aspects of management of the rectal remnant, including perioperative considerations, potential complications, medical treatment, surveillance and implications for proctectomy and reconstructive surgery are explored. METHODS A thorough literature review exploring the PubMed and EMBASE databases was undertaken to clarify the evidence base surrounding areas of controversy in the surgical approach to acute severe colitis. In particular, focus was given to evidence surrounding management of the rectal remnant. RESULTS There is a paucity of high quality evidence for optimal management of the rectal stump following colectomy, and randomised trials are lacking. Establishment of laparoscopic colectomy has been associated with distinct advantages as well as the emergence of unique considerations, including those specific to rectal remnant management. CONCLUSIONS Early surgical involvement and a multidisciplinary approach to the management of acute severe colitis are advocated. Laparoscopic subtotal colectomy and ileostomy should be the operation of choice, with division of the rectum at the pelvic brim leaving a closed intraperitoneal remnant. If the rectum is severely inflamed, a mucus fistula may be useful, and an indwelling rectal catheter is probably advantageous to reduce the complications associated with stump dehiscence. Patients electing not to proceed to proctectomy should undergo surveillance for dysplasia of the rectum.
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Affiliation(s)
- Kalle Landerholm
- a Department of Colorectal Surgery , Oxford University Hospital NHS Foundation Trust , Oxford , UK
| | - Christopher Wood
- a Department of Colorectal Surgery , Oxford University Hospital NHS Foundation Trust , Oxford , UK
| | - Alexander Bloemendaal
- a Department of Colorectal Surgery , Oxford University Hospital NHS Foundation Trust , Oxford , UK
| | - Nicolas Buchs
- a Department of Colorectal Surgery , Oxford University Hospital NHS Foundation Trust , Oxford , UK
| | - Bruce George
- a Department of Colorectal Surgery , Oxford University Hospital NHS Foundation Trust , Oxford , UK
| | - Richard Guy
- a Department of Colorectal Surgery , Oxford University Hospital NHS Foundation Trust , Oxford , UK
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30
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Worley G, Nordenvall C, Askari A, Pinkney T, Burns E, Akbar A, Olén O, Ekbom A, Bottai M, Myrelid P, Faiz O. Restorative surgery after colectomy for ulcerative colitis in England and Sweden: observations from a comparison of nationwide cohorts. Colorectal Dis 2018; 20:804-812. [PMID: 29603863 DOI: 10.1111/codi.14113] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 03/26/2018] [Indexed: 12/29/2022]
Abstract
AIM A longstanding disparity exists between the approaches to restorative surgery after colectomy for patients with ulcerative colitis (UC) in England and Sweden. This study aims to compare rates of colectomy and restorative surgery in comparable national cohorts. METHOD The English Hospital Episode Statistics (HES) and Swedish National Patient Register (NPR) were interrogated between 2002 and April 2012. Patients with two diagnostic episodes for UC (age ≥ 15 years) were included. Patients were excluded if they had an episode of inflammatory bowel disease or colectomy before 2002. The cumulative incidences of colectomy and restorative surgery were calculated using the Kaplan-Meier method. RESULTS A total of 98 691 patients were included in the study, 76 129 in England and 22 562 in Sweden. The 5-year cumulative incidence of all restorative surgery after colectomy in England was 33% vs 46% in Sweden (P-value < 0.001). Of the patients undergoing restorative surgery, 92.3% of English patients had a pouch vs 38.8% in Sweden and 7.7% vs 59.1% respectively had an ileorectal anastomosis (IRA). The 5-year cumulative incidence of colectomy in this study cohort was 13% in England and 6% in Sweden (P-value < 0.001). CONCLUSION Following colectomy for UC only one-third of English patients and half of Swedish patients underwent restorative surgery. In England nearly all these patients underwent pouches, in Sweden a less significant majority underwent IRAs. It is surprising to demonstrate this discrepancy in a comparable cohort of patients from similar healthcare systems. The causes and consequences of this international variation in management are not fully understood and require further investigation.
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Affiliation(s)
- G Worley
- Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - C Nordenvall
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Center for Digestive Disease, Division of Coloproctology, Karolinska University Hospital, Stockholm, Sweden
| | - A Askari
- Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - T Pinkney
- Academic Department of Surgery, University of Birmingham, Birmingham, UK
| | - E Burns
- Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - A Akbar
- Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - O Olén
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Sachs' Children and Youth Hospital, Stockholm, Sweden
| | - A Ekbom
- Clinical Epidemiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - M Bottai
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - P Myrelid
- Division of Surgery, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden.,Department of Surgery, County Council of Östergötland, Linköping, Sweden
| | - O Faiz
- Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital and Academic Institute, Harrow, Middlesex, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
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Short article: Recommendations on rectal surveillance for colorectal cancer after subtotal colectomy in patients with inflammatory bowel disease. Eur J Gastroenterol Hepatol 2018; 30:843-846. [PMID: 29781837 DOI: 10.1097/meg.0000000000001171] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Approximately 30% of patients with ulcerative colitis require a colectomy during their disease course. This substantially reduces colorectal cancer risk, although it is still possible to develop colorectal neoplasia in the remaining rectum. Although clear and well-accepted surveillance guidelines exist for patients with inflammatory bowel disease with an intact colon, specific surveillance recommendations following colectomy are less clear. Here, we aim to summarize the prevalence, incidence, and risk factors for developing colorectal cancer in patients with inflammatory bowel disease who underwent subtotal colectomy with a permanent end ileostomy and rectal stump, or with ileorectal anastomosis. Subsequently, gained insights are integrated into a proposed endoscopic surveillance strategy of the residual rectum.
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32
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Myrelid P, Abdalla M, Landerholm K. Reply. Clin Gastroenterol Hepatol 2018; 16:151-152. [PMID: 29249404 DOI: 10.1016/j.cgh.2017.09.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 09/15/2017] [Accepted: 09/18/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Pär Myrelid
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Department of Surgery, Linköping University Hospital, Linköping, Sweden
| | - Maie Abdalla
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Department of Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
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