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Wong MCY, Rotondi G, Roso M, Avanzini P, Gandullia P, Arrigo S, Mattioli G. Quality of life after colectomy and ileo-jpouch-anal anastomosis in paediatric patients with ulcerative colitis. Pediatr Surg Int 2024; 40:231. [PMID: 39154135 DOI: 10.1007/s00383-024-05824-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/13/2024] [Indexed: 08/19/2024]
Abstract
INTRODUCTION Ulcerative Colitis (UC) is an Inflammatory Bowel Disease (IBD). Surgery is required in cases of severe acute colitis, massive hemorrhage, toxic megacolon, and perforation; in such cases colectomy and JpouchIleoanal anastomosis (IPAA) are performed. The aim of this study was to evaluate functional outcome, and patient satisfaction and Quality of Life (QoL) after surgery. MATERIAL AND METHODS Questionnaires were administered to 24 patients with UC undergoing surgery from 2011 to 2022. RESULTS Mean age at IPAA was 10.8 years. Twenty patients underwent IPAA in 3 operations, 4 patients in 2. All patients underwent laparoscopic surgery. 6 months after surgery mean level of satisfaction was 8.7/10, perception of health status was 7.4. Twenty-three patients (95.8%) recommended IPAA. For 20 patients (83.3%) surgery did not cause delay in education, while 14 patients (58.3%) played sport. The lowest number of evacuations was 9.2 per day, the highest 13.3. Seventeen patients (70.8%) had no incontinence and 15 patients (62.5%) were not affected by pouchitis. After 12 months mean satisfaction level raised up to 9.2/10, perception of health status to 8.5. School absences decreased and no other patients showed any delay in education. Seventeen (70.8%) patients played sports. The number of evacuations decreased: the lowest number was 5.1 per day, the highest 7.5. Twenty patients (83.3%) were continent and 12 (50%) did not use antibiotics. CONCLUSION Most patients show a good functional outcome in defecation frequency and continence, which has improved through time, number of pouchitis episodes has increased. Patients appear satisfied after surgery.
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Affiliation(s)
- M C Y Wong
- Pediatric Surgery Department, IRCCS, Istituto Giannina Gaslini, Largo Gaslini 5, 16147, Genoa, Italy
| | - G Rotondi
- Pediatric Surgery Department, IRCCS, Istituto Giannina Gaslini, Largo Gaslini 5, 16147, Genoa, Italy.
- DINOGMI, University of Genoa, Genoa, Italy.
| | - M Roso
- Pediatric Surgery Department, IRCCS, Istituto Giannina Gaslini, Largo Gaslini 5, 16147, Genoa, Italy
| | - P Avanzini
- Pediatric Surgery Department, IRCCS, Istituto Giannina Gaslini, Largo Gaslini 5, 16147, Genoa, Italy
- DINOGMI, University of Genoa, Genoa, Italy
| | - P Gandullia
- Pediatric Gastroenterology and Endoscopy Department, IRCCS, Istituto Giannina Gaslini, 16147, Genoa, Italy
| | - S Arrigo
- Pediatric Gastroenterology and Endoscopy Department, IRCCS, Istituto Giannina Gaslini, 16147, Genoa, Italy
| | - G Mattioli
- Pediatric Surgery Department, IRCCS, Istituto Giannina Gaslini, Largo Gaslini 5, 16147, Genoa, Italy
- DINOGMI, University of Genoa, Genoa, Italy
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Barnes EL, Esckilsen S, Ashburn J, Barto A, Bloomfeld R, Cairns A, Mehta K, Patel P, Dziwis J, Dunn MS, Rahbar R, Sadiq TS, Hanson JS, Herfarth HH. Extensive Colitis and Smoking Are Associated With Postoperative Complications Within 30 Days of Ileal Pouch-Anal Anastomosis. Inflamm Bowel Dis 2024; 30:1326-1333. [PMID: 37607334 PMCID: PMC11291612 DOI: 10.1093/ibd/izad177] [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: 04/28/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Our understanding of outcomes after proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) is largely based on analyses of selected populations. We created a state-level registry to evaluate the epidemiology of IPAA surgery and pouch-related outcomes across the major healthcare systems performing these surgeries in our state. METHODS We created a retrospective cohort of all patients undergoing restorative proctocolectomy with IPAA for UC at 1 of 4 centers between January 1, 2018, and December 31, 2020. The primary outcomes of this study were the rate of complications and all-cause readmissions within the first 30 days of the final stage of IPAA surgery. RESULTS During the study period, 177 patients underwent IPAA surgery with 66 (37%) experiencing a complication within 30 days. After adjusting for the number of stages in IPAA surgery, patients with extensive UC (odds ratio, 3.61; 95% confidence interval, 1.39-9.33) and current or former smokers (odds ratio, 2.98; 95% confidence interval, 1.38-6.45) were more likely to experience a complication. Among all patients, 57 (32%) required readmission within 30 days. The most common reasons for readmission were ileus/small bowel obstruction (22%), peripouch abscess (19%), and dehydration (16%). CONCLUSION In this first state-level examination of the epidemiology of IPAA for UC, we demonstrated that the complication rate after IPAA for UC was 37%, with one-third of patients being readmitted within 30 days. Extensive disease at the time of colectomy appears to be an indicator of more severe disease and may portend a worse prognosis after IPAA.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, NC, USA
| | - Scott Esckilsen
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Jean Ashburn
- Division of Colon and Rectal Surgery, Atrium Health at Wake Forest Baptist, Winston-Salem, NC, USA
| | - Amy Barto
- Division of Gastroenterology and Hepatology, Duke University, Durham, NC, USA
| | - Richard Bloomfeld
- Section of Gastroenterology, Atrium Health at Wake Forest Baptist, Winston-Salem, NC, USA
| | - Ashley Cairns
- Division of Colon and Rectal Surgery, Atrium Health at Wake Forest Baptist, Winston-Salem, NC, USA
| | - Kurren Mehta
- Department of Medicine, Duke University, Durham, NC, USA
| | - Pooja Patel
- Department of Medicine, Duke University, Durham, NC, USA
| | - Jennifer Dziwis
- Section of Gastroenterology, Atrium Health at Wake Forest Baptist, Winston-Salem, NC, USA
- Department of Medicine, Duke University, Durham, NC, USA
| | - Michael S Dunn
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | | | - John S Hanson
- Division of Gastroenterology and Hepatology, Atrium Health, Charlotte, NC, USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, NC, USA
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Uchino T, Lincango EP, Lavryk O, Lipman J, Wood H, Angermeier K, Steele SR, Hull TL, Holubar SD. Long-term ileoanal pouch survival after pouch urinary tract fistulae. Tech Coloproctol 2024; 28:72. [PMID: 38918216 PMCID: PMC11199249 DOI: 10.1007/s10151-024-02948-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 05/25/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND Ileoanal pouch is a demanding procedure with many potential technical complications including bladder or ureteral injury, while inflammation or stricture of the anastomosis or anal transition zone may lead to the formation of strictures and fistulae, including to the adjacent urethra. Pouch urinary tract fistulae are rare. We aimed to describe the presentation, diagnostic workup, and management of patients with pouch urinary at our center. METHODS Our prospectively maintained pouch registry was queried using diagnostic codes and natural language processing free-text searches to identify ileoanal pouch patients diagnosed with any pouch-urinary tract fistula from 1997 to 2022. Descriptive statistics and pouch survival using Kaplan-Meier curves are presented. Numbers represent frequency (proportion) or median (range). RESULTS Over 25 years, urinary fistulae were observed 27 pouch patients; of these, 16 of the index pouches were performed at our institution [rate 0.3% (16/5236)]. Overall median age was 42 (27-62) years, and 92.3% of the patients were male. Fistula locations included pouch-urethra in 13 patients (48.1%), pouch-bladder in 12 patients (44.4%), and anal-urethra in 2 (7.4%). The median time from pouch to fistula was 7.0 (0.3-38) years. Pouch excision and end ileostomy were performed in 12 patients (bladder fistula, n = 3; urethral fistula, n = 9), while redo ileal pouch-anal anastomosis (IPAA) was performed in 5 patients (bladder fistula, n = 3; urethral fistula, n = 2). The 5-year overall pouch survival after fistula to the bladder was 58.3% vs. 33.3% with urethral fistulae (p = 0.25). CONCLUSION Pouch-urinary tract fistulae are a rare, morbid, and difficult to treat complication of ileoanal pouch that requires a multidisciplinary, often staged, surgical approach. In the long term, pouches with bladder fistulae were more likely to be salvaged than pouches with urethral fistulae.
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Affiliation(s)
- T Uchino
- Department of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic Main Campus, 9500 Euclid Ave, A30, Cleveland, OH, 44122, USA
| | - E P Lincango
- Department of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic Main Campus, 9500 Euclid Ave, A30, Cleveland, OH, 44122, USA
| | - O Lavryk
- Department of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic Main Campus, 9500 Euclid Ave, A30, Cleveland, OH, 44122, USA
| | - J Lipman
- Department of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic Main Campus, 9500 Euclid Ave, A30, Cleveland, OH, 44122, USA
| | - H Wood
- Department of Urology, Glickman Urology and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - K Angermeier
- Department of Urology, Glickman Urology and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - S R Steele
- Department of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic Main Campus, 9500 Euclid Ave, A30, Cleveland, OH, 44122, USA
| | - T L Hull
- Department of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic Main Campus, 9500 Euclid Ave, A30, Cleveland, OH, 44122, USA
| | - S D Holubar
- Department of Colorectal Surgery, Digestive Diseases Institute, Cleveland Clinic Main Campus, 9500 Euclid Ave, A30, Cleveland, OH, 44122, USA.
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Kotze PG, Avellaneda N, Moretti RDAM, Carvello M, Tomada EP, Campos FG, Spinelli A. Controversies in IPAA for Ulcerative Colitis: A Systematic Review of Different Anastomotic Techniques. Dis Colon Rectum 2024; 67:S26-S35. [PMID: 38710588 DOI: 10.1097/dcr.0000000000003292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
BACKGROUND Available techniques for IPAA in ulcerative colitis include handsewn, double-stapled, and single-stapled anastomoses. There are controversies, indications, and different outcomes regarding these techniques. OBJECTIVE To describe technical details, indications, and outcomes of 3 specific types of anastomoses in restorative proctocolectomy. DATA SOURCE Systematic literature review for articles in the PubMed database according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. STUDY SELECTION Studies describing outcomes of the 3 different types of anastomoses, during pouch surgery, in patients undergoing restorative proctocolectomy for ulcerative colitis. INTERVENTION IPAA technique. MAIN OUTCOME MEASURES Postoperative outcomes (anastomotic leaks, overall complication rates, and pouch function). RESULTS Twenty-one studies were initially included: 6 studies exclusively on single-stapled IPAA, 2 exclusively on double-stapled IPAA, 6 studies comparing single-stapled to double-stapled techniques, 6 comparing double-stapled to handsewn IPAA, and 1 comprising single-stapled to handsewn IPAA. Thirty-seven studies were added according to authors' discretion as complementary evidence. Between 1990 and 2015, most studies were related to double-stapled IPAA, either only analyzing the results of this technique or comparing it with the handsewn technique. Studies published after 2015 were mostly related to transanal approaches to proctectomy for IPAA, in which a single-stapled anastomosis was introduced instead of the double-stapled anastomosis, with some studies comparing both techniques. LIMITATIONS A low number of studies with handsewn IPAA technique and a large number of studies added at authors' discretion were the limitations of this strudy. CONCLUSIONS Handsewn IPAA should be considered if a mucosectomy is performed for dysplasia or cancer in the low rectum or, possibly, for re-do surgery. Double-stapled IPAA has been more widely adopted for its simplicity and for the advantage of preserving the anal transition zone, having lower complications, and having adequate pouch function. The single-stapled IPAA offers a more natural design, is feasible, and is associated with reasonable outcomes compared to double-stapled anastomosis. See video from symposium.
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Affiliation(s)
- Paulo Gustavo Kotze
- Colorectal Surgery Unit, Pontificia Universidade Católica do Paraná (PUCPR), Curitiba, Brazil
| | - Nicolas Avellaneda
- General and Colorectal Surgery Department, CEMIC University Hospital, Buenos Aires, Argentina
| | | | - Michele Carvello
- Division of Colon and Rectal Surgery, IRCCS-Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Elisa Paoluzzi Tomada
- Division of Colon and Rectal Surgery, IRCCS-Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | | | - Antonino Spinelli
- Division of Colon and Rectal Surgery, IRCCS-Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
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5
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Jabi O, Lan N, Pokala A, Kiran RP, Shen B. Endoscopic therapy of stoma closure site strictures in ileal pouches is safe and effective. Gastroenterol Rep (Oxf) 2024; 12:goae038. [PMID: 38766493 PMCID: PMC11099542 DOI: 10.1093/gastro/goae038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 01/26/2024] [Accepted: 02/17/2024] [Indexed: 05/22/2024] Open
Abstract
Background Strictures are a common complication after ileal pouch surgery with the most common locations being at the anastomosis, pouch inlet, and stoma closure site. No previous literature has described endoscopic therapy of stoma site stricture. This study aimed to assess the safety and efficacy of endoscopic therapy in the treatment of stoma closure site strictures. Method Patients diagnosed with stoma closure site strictures following ileal pouch surgery who underwent endoscopic treatment at the Center for Colorectal Diseases, Inflammatory Bowel Disease (IBD), and Ileal Pouch between 2018 and 2022 were analysed. Primary outcomes (technical success and surgery-free survival) were compared between endoscopic balloon dilation (EBD) and stricturotomy and/or strictureplasty. Results A total of 30 consecutive eligible patients were analysed. Most patients were female (66.7%) and most patients were diagnosed with IBD (93.3%). Twenty patients (66.7%) had end-to-end anastomosis. A total of 52 procedures were performed, with EBD in 16 (30.8%) and stricturotomy and/or strictureplasty in 36 (69.2%). The mean stricture length was 1.7 ± 1.0 cm. Immediate technical success was achieved in 47 of 52 interventions (90.4%). During a mean follow-up of 12.7 ± 9.9 months, none of the patients underwent surgical intervention for the stricture. Fourteen (46.7%) required endoscopic re-intervention for their strictures with an interval between index and re-interventional pouchoscopy of 8.8 ± 6.3 months. Post-procedural complications were reported in 2 (6.7%) with bleeding and none with perforation. Upon follow-up, 20 (66.7%) patients reported improvement in their symptoms. Conclusion EBD and endoscopic stricturotomy and/or strictureplasty are safe and effective in treating stoma closure site strictures in patients with ileal pouches, providing symptomatic relief in most patients as well as avoiding surgery.
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Affiliation(s)
- Osama Jabi
- The Global Center for Integrated Colorectal Surgery and IBD Interventional Endoscopy, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, NY, USA
| | - Nan Lan
- The Global Center for Integrated Colorectal Surgery and IBD Interventional Endoscopy, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, NY, USA
| | - Akshay Pokala
- The Global Center for Integrated Colorectal Surgery and IBD Interventional Endoscopy, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, NY, USA
| | - Ravi P Kiran
- The Global Center for Integrated Colorectal Surgery and IBD Interventional Endoscopy, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, NY, USA
| | - Bo Shen
- The Global Center for Integrated Colorectal Surgery and IBD Interventional Endoscopy, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, NY, USA
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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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TOMINAGA K, KOJIMA Y, KAWATA Y, TAKAHASHI K, SATO H, TSUCHIYA A, KAMIMURA K, TERAI S. An updated review on the treatment for diversion colitis and pouchitis, with a focus on the utility of autologous fecal microbiota transplantation and its relationship with the intestinal microbiota. BIOSCIENCE OF MICROBIOTA, FOOD AND HEALTH 2024; 43:162-169. [PMID: 38966047 PMCID: PMC11220330 DOI: 10.12938/bmfh.2024-014] [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: 02/09/2024] [Accepted: 04/09/2024] [Indexed: 07/06/2024]
Abstract
Diversion colitis (DC) is characterized by mucosal inflammation in the defunctioned segment of the colon following a colostomy or ileostomy. The major causes of DC are an increase in the number of aerobic bacteria, a lack of short-chain fatty acids (SCFAs), and immune disorders in the diverted colon. However, its exact pathogenesis remains unknown. Various treatment strategies for DC have been explored, although none have been definitively established. Treatment approaches such as SCFAs, 5-aminosalicylic acid enemas, steroid enemas, and irrigation with fibers have been attempted, yielding various degrees of efficacies in mitigating mucosal inflammation. However, only individual case reports demonstrating the limited effect of the following therapies have been published: leukocytapheresis, dextrose (hypertonic glucose) spray, infliximab, an elemental diet, and coconut oil. The usefulness of probiotics for treating DC has recently been reported. Furthermore, fecal microbiota transplantation (FMT) has emerged as a promising treatment for DC. This review provides an update on the treatment strategies of DC, with a particular focus on FMT and its relationship with the intestinal microbiota. FMT may become the first choice of treatment for some patients in the future because of its low medical costs, ease of use, and minimal side effects. Furthermore, FMT can also be used for postoperative DC prophylaxis.
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Affiliation(s)
- Kentaro TOMINAGA
- Division of Gastroenterology and Hepatology, Graduate School
of Medical and Dental Sciences, Niigata University, 1-757 Asahimachi-dori, Chuo-ku,
Niigata, Niigata 951-8510, Japan
| | - Yuichi KOJIMA
- Division of Gastroenterology and Hepatology, Graduate School
of Medical and Dental Sciences, Niigata University, 1-757 Asahimachi-dori, Chuo-ku,
Niigata, Niigata 951-8510, Japan
| | - Yuzo KAWATA
- Division of Gastroenterology and Hepatology, Graduate School
of Medical and Dental Sciences, Niigata University, 1-757 Asahimachi-dori, Chuo-ku,
Niigata, Niigata 951-8510, Japan
| | - Kazuya TAKAHASHI
- Division of Gastroenterology and Hepatology, Graduate School
of Medical and Dental Sciences, Niigata University, 1-757 Asahimachi-dori, Chuo-ku,
Niigata, Niigata 951-8510, Japan
| | - Hiroki SATO
- Division of Gastroenterology and Hepatology, Graduate School
of Medical and Dental Sciences, Niigata University, 1-757 Asahimachi-dori, Chuo-ku,
Niigata, Niigata 951-8510, Japan
| | - Atsunori TSUCHIYA
- Division of Gastroenterology and Hepatology, Graduate School
of Medical and Dental Sciences, Niigata University, 1-757 Asahimachi-dori, Chuo-ku,
Niigata, Niigata 951-8510, Japan
| | - Kenya KAMIMURA
- Division of Gastroenterology and Hepatology, Graduate School
of Medical and Dental Sciences, Niigata University, 1-757 Asahimachi-dori, Chuo-ku,
Niigata, Niigata 951-8510, Japan
| | - Shuji TERAI
- Division of Gastroenterology and Hepatology, Graduate School
of Medical and Dental Sciences, Niigata University, 1-757 Asahimachi-dori, Chuo-ku,
Niigata, Niigata 951-8510, Japan
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Lightner AL, Pineiro AO, Reese J, Ream J, Nachand D, Adams AC, Dadgar N, Hull T. Treatment effect of ex vivo expanded allogeneic bone marrow-derived mesenchymal stem cells for the treatment of fistulizing Crohn's disease are durable at 12 months. Surgery 2024; 175:984-990. [PMID: 38097485 DOI: 10.1016/j.surg.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/02/2023] [Accepted: 11/07/2023] [Indexed: 03/17/2024]
Abstract
BACKGROUND Mesenchymal stem cells have been administered via direct injection to treat perianal Crohn's fistulizing disease. We herein sought to determine the safety and durability of treatment response to 12 months with 3 individual phase IB/IIA clinical trials of mesenchymal stem cells for refractory perianal, rectovaginal, and ileal pouch fistulas in the setting of Crohn disease. METHODS Three phase IB/IIA randomized placebo-controlled single-blinded clinical trials were performed for (1) perianal fistulas, (2) rectovaginal fistula, and (3) ileal pouch in situ with anovaginal and/or perianal fistulas. Bone marrow-derived mesenchymal stem cells (75 million in 7.5 mL) were injected at the time of exam under anesthesia on day 0 and month 3. Outcome measures were adverse events and combined clinical and pelvic magnetic resonance imaging healing at month 6 and month 12. RESULTS Across all 3 trials, 64 patients were enrolled; 49 were treatment and 15 were control. At 6 months, combined clinical and radiographic healing was achieved in 83.3%, 33.3%, and 30.8% of the perianal, rectovaginal, and pouch fistula treatment cohorts, respectively. At 12 months, the treatment response was durable, with 67.7% of perianal, 37.5% of rectovaginal, and 46.2% of peripouch fistulas maintaining complete clinical and radiographic healing. Two patients in the perianal fistula control cohort achieved combined clinical and radiographic healing at 12 months, whereas 0% of rectovaginal and pouch control patients healed. CONCLUSION Bone marrow-derived mesenchymal stem cells offer a safe and effective alternative treatment approach for severe perianal, rectovaginal, and peripouch fistulizing Crohn's disease. Treatment results are durable at 12 months.
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Affiliation(s)
- Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, OH.
| | - Ana Otero Pineiro
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, OH
| | - Jane Reese
- National Center for Regenerative Medicine, Cleveland, OH
| | - Justin Ream
- Department of Abdominal Radiology, Digestive Disease Surgical Institute, Cleveland Clinic, OH
| | - Douglas Nachand
- Department of Abdominal Radiology, Digestive Disease Surgical Institute, Cleveland Clinic, OH
| | - Ashley C Adams
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, OH
| | - Neda Dadgar
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, OH
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, OH
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Liang JT, Liao YT, Chen TC, Huang J, Hung JS. Changing patterns and surgical outcomes of small bowel obstruction in the era of minimally invasive surgery for colorectal cancer. Int J Surg 2024; 110:1577-1585. [PMID: 38051917 PMCID: PMC10942203 DOI: 10.1097/js9.0000000000000980] [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: 08/11/2023] [Accepted: 11/21/2023] [Indexed: 12/07/2023]
Abstract
INTRODUCTION This study aimed to investigate whether the incidence, patterns, and surgical outcomes of small bowel obstruction (SBO) have changed in the era of minimally invasive surgery (MIS) for primary colorectal cancer (CRC). METHODS Consecutive patients who underwent laparotomy for SBO were divided into MIS and traditional open surgery (TOS) groups based on the previous colorectal cancer operation technique used. The MIS group was selected from 1544 consecutive patients who underwent MIS as a treatment for primary CRCs between 2014 and 2022, while the TOS group was selected from 1604 consecutive patients who underwent TOS as a treatment for primary CRCs between 2004 and 2013. The demographics, clinicopathological features, and surgical outcomes were compared between the two groups. RESULTS The SBO incidence in patients who underwent MIS for primary CRC was significantly lower than that in patients who underwent TOS (4.4%, n =68/1544 vs. 9.7%, n =156/1604, P <0.0001). Compared with the TOS group, the MIS group had significantly different ( P <0.0001) SBO patterns: adhesion (48.5 vs. 91.7%), internal herniation (23.5 vs. 2.6%), external herniation (11.8 vs. 1.9%), twisted bowel limbs (4.4 vs. 0.6%), ileal volvulus with pelvic floor adhesion (5.9 vs. 1.9%), and nonspecific external compression (5.9 vs. 1.3%). A subset analysis of patients with adhesive SBO (ASBO) showed that the MIS group tended to ( P <0.0001) have bands or simple adhesions (75.8%), whereas the TOS group predominantly had matted-type adhesions (59.4%). Furthermore, SBO in the MIS group had an acute (<3 months) or early (3-12 months) onset (64.7%), while that in the TOS group ( P <0.0001) had an intermediate or a late onset. When the surgical outcomes of SBO were evaluated, the TOS group had significantly more ( P <0.0001) blood loss and longer operation time; however, no significant difference was observed in the surgical morbidity/mortality (Clavien-Dindo classification ≧3, 11.8 vs. 14.1%, P =0.6367), hospitalization, and readmission rates between the two groups. Postoperative follow-up showed that the estimated 3-year (11.37 vs. 18.8%) and 6-year (25.54 vs. 67.4%) recurrence rates of SBO were significantly lower ( P =0.016) in the MIS group than in the TOS group. CONCLUSIONS The wide adoption of MIS to treat primary CRC has led to a lower incidence, altered patterns, and reduced recurrence rates of SBO. Awareness of this new trend will help develop surgical techniques to prevent incomplete restoration of anatomical defects and bowel malalignments specifically associated with MIS for CRC, as well as facilitate timely and appropriate management of SBO complications whenever they occur.
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Affiliation(s)
- Jin-Tung Liang
- Department of Surgery, Division of Colorectal Surgery, National Taiwan University Hospital and College of Medicine, Taipei
| | - Yu-Tso Liao
- Department of Surgery, Division of Colorectal Surgery, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu
| | - Tzu-Chun Chen
- Department of Surgical Oncology, National Taiwan University Cancer Center, Taipei, Taiwan, Republic of China
| | - John Huang
- Department of Surgery, Division of Colorectal Surgery, National Taiwan University Hospital and College of Medicine, Taipei
| | - Ji-Shiang Hung
- Department of Surgery, Division of Colorectal Surgery, National Taiwan University Hospital and College of Medicine, Taipei
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10
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Macleod A, Parks MA, Cook CN, Petras RE, Galandiuk S. Long-term behavior and functional outcomes of ileal-pouch anal anastomosis in inflammatory bowel disease with changing phenotype. Surgery 2024; 175:765-775. [PMID: 37802743 DOI: 10.1016/j.surg.2023.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/24/2023] [Accepted: 07/08/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Ileal-pouch-anal anastomosis is the operation of choice after proctocolectomy for ulcerative colitis; some patients will develop Crohn's disease. We aim to determine long-term behavior and outcomes of inflammatory bowel disease-ileal-pouch-anal anastomosis after colectomy, where a specialist gastrointestinal pathologist re-evaluated the initial colectomy specimen. METHODS Patients with inflammatory bowel disease-ileal-pouch-anal anastomosis were identified from a single-surgeon prospective database containing 1,165 patients accrued from 1991 to 2017 and invited to complete pouch-function and quality-of-life assessments. Medical records were used to obtain clinical outcomes and subjective functional assessments for those unable to be contacted. Data were compared between patients with and without histological assessment disagreement and subsequent inflammatory bowel disease behavior subgroups. RESULTS For 138 patients included in the analysis, the median follow-up was 22.5 (range: 5-39) years. A total of 39.1% of patients had histologic diagnostic change after gastrointestinal pathologist review, and 19% and 39% developed Crohn's disease-like disease behavior at 10- and 20-year follow-ups. Pouch function and quality-of-life scores were similar across diagnostic change subgroups. Pouch failure was higher in Crohn's-like disease (31.1 vs 13.0%, P < .05). Intestinal continuity was maintained in 68.9% of Crohn's disease-like patients, 57.9% required biologics. Gastrointestinal pathologist review did not alter the time to new diagnosis (P = .419) or time to pouch failure (P = .320), mean: 11.0 and 11.41 years, respectively. CONCLUSION We describe equivocal patient-reported outcomes in patients with ileal-pouch-anal anastomosis and changing histologic and clinical diagnosis. Although pouch excision and biologic use rates are higher, many Crohn's disease-like patients maintain their pouch. Diagnostic change and pouch failure often occur >10 years after ileal-pouch-anal anastomosis creation. This supports the consideration of ileal-pouch-anal anastomosis after colectomy in carefully selected patients with inflammatory bowel disease, even those with ambiguous histology and the need for close long-term follow-up.
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Affiliation(s)
- Anne Macleod
- Price Institute of Surgical Research, University of Louisville, KY
| | - Mary Alex Parks
- Price Institute of Surgical Research, University of Louisville, KY
| | - Cheyenne N Cook
- Price Institute of Surgical Research, University of Louisville, KY
| | | | - Susan Galandiuk
- Price Institute of Surgical Research, University of Louisville, KY; Division of Colon & Rectal Surgery, Hiram C Polk Jr MD Department of Surgery, University of Louisville, KY.
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11
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Barnes EL, Dunn MS, Ashburn J, Barto A, Bloomfeld R, Cairns A, Mehta K, Patel P, Dziwis J, Esckilsen S, Rahbar R, Sadiq TS, Hanson JS, Herfarth HH. Extraintestinal Manifestations and Family History of Inflammatory Bowel Disease Increase the Risk of Pouchitis in a State-Level Epidemiology Study. Clin Transl Gastroenterol 2024; 15:e00670. [PMID: 38146854 PMCID: PMC10887435 DOI: 10.14309/ctg.0000000000000670] [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: 08/25/2023] [Accepted: 12/14/2023] [Indexed: 12/27/2023] Open
Abstract
INTRODUCTION Our understanding of the epidemiology of inflammatory conditions of the pouch and effectiveness of treatment is largely based on selected populations. We created a state-level registry to evaluate the incidence of pouchitis and the effectiveness of treatments used in an initial episode of pouchitis. METHODS In a state-level retrospective cohort of all patients undergoing proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis between January 1, 2018, and December 31, 2020, we evaluated the incidence of pouchitis and compared the proportion of patients developing recurrent pouchitis and chronic antibiotic-dependent pouchitis according to initial antibiotic therapy. RESULTS A total of 177 patients underwent surgery with 49 (28%) developing pouchitis within the 12 months after the final stage of IPAA. Patients with extraintestinal manifestations of inflammatory bowel disease (IBD) were significantly more likely to develop pouchitis within the first 12 months after IPAA (adjusted odds ratio 2.45, 95% confidence interval 1.03-5.81) after adjusting for family history of IBD (adjusted odds ratio 3.50, 95% 1.50-8.18). When comparing the proportion of patients who developed recurrent pouchitis or chronic antibiotic-dependent pouchitis with those who experienced an isolated episode of pouchitis, there were no significant differences among the initial antibiotic regimens used. DISCUSSION In a state-level examination of outcomes after IPAA for ulcerative colitis, patients with extraintestinal manifestations of IBD were more likely to develop pouchitis; however, the initial antibiotic regimen chosen did not seem to affect long-term outcomes.
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Affiliation(s)
- Edward L. Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Michael S. Dunn
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jean Ashburn
- Division of Colon and Rectal Surgery, Atrium Health at Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Amy Barto
- Division of Gastroenterology and Hepatology, Duke University, Durham, North Carolina, USA
| | - Richard Bloomfeld
- Section of Gastroenterology, Atrium Health at Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Ashley Cairns
- Division of Colon and Rectal Surgery, Atrium Health at Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Kurren Mehta
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Pooja Patel
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Jennifer Dziwis
- Section of Gastroenterology, Atrium Health at Wake Forest Baptist, Winston-Salem, North Carolina, USA
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Scott Esckilsen
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Reza Rahbar
- North Carolina Surgery, Raleigh, North Carolina, USA
| | | | - John S. Hanson
- Division of Gastroenterology and Hepatology, Atrium Health, Charlotte, North Carolina, USA
| | - Hans H. Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, North Carolina, USA
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12
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Dipasquale V, Catena MA, Paiano L, Trimarchi G, Romeo C, Navarra G, Mattioli G, Romano C. Colectomy and health-related Quality of Life in children with ulcerative colitis. Minerva Pediatr (Torino) 2024; 76:1-6. [PMID: 32418405 DOI: 10.23736/s2724-5276.20.05750-3] [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: 02/21/2024]
Abstract
BACKGROUND Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) is the recommended elective surgery for children with ulcerative colitis (UC). The aim of this study was to evaluate functional and long-term health-related Quality of Life (HRQoL) outcomes of surgery in pediatric patients with UC. METHODS We reviewed the hospital records of all pediatric patients who had undergone surgery for UC between January 2009 and December 2016 in the Units of Pediatric Gastroenterology and Surgery, of both the University Hospital of Messina, and the Gaslini Children's Hospital of Genoa. Surgical treatment was represented by restorative proctocolectomy and laparoscopic IPAA. Patients and parents were interviewed by telephone before and after surgery and responded to the modified IMPACT III questionnaire about health outcomes and HRQoL. The questionnaire was scored on a five-point scale with higher scores indicating a better HRQoL. The total score ranged from 35 (worst HRQoL) to 175 (best HRQoL). RESULTS Data were obtained in 30 patients (16 males), with a median age of 12 (range 3-16). The median amount of time elapsed after the operation was 3 years (range 1-4.5). Preoperative scores were very low in all 4 domains of the questionnaire. Postoperatively, HRQoL measures improved significantly (P<0.05) on symptoms, school attendance, social activities, and emotional aspects. Overall, nearly all were completely satisfied with the outcome of surgery. CONCLUSIONS Our data confirmed that surgical treatment improves the overall HRQoL in pediatric patients with UC.
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Affiliation(s)
- Valeria Dipasquale
- Unit of Pediatric Gastroenterology and Cystic Fibrosis, G. Barresi Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| | - Maria A Catena
- Unit of Pediatric Gastroenterology and Cystic Fibrosis, G. Barresi Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| | - Lucia Paiano
- Unit of Pediatric Surgery, G. Barresi Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| | | | - Carmelo Romeo
- Unit of Pediatric Surgery, G. Barresi Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| | - Giuseppe Navarra
- Unit of General Surgery, G. Barresi Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| | - Girolamo Mattioli
- Unit of Pediatric Surgery, Giannina Gaslini Research Institute and Children Hospital, Genoa, Italy
| | - Claudio Romano
- Unit of Pediatric Gastroenterology and Cystic Fibrosis, G. Barresi Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy -
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13
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Williams H, Steinhagen RM. Historical Perspectives: Malignancy in Crohn's Disease and Ulcerative Colitis. Clin Colon Rectal Surg 2024; 37:5-12. [PMID: 38188065 PMCID: PMC10769586 DOI: 10.1055/s-0043-1762557] [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: 01/09/2024]
Abstract
While both Crohn' disease (CD) and ulcerative colitis (UC) are known to predispose patients to certain intestinal malignancies, the exact mechanism of carcinogenesis remains unknown and optimal screening guidelines have not been established. This article will explore the history of our understanding of intestinal malignancy in inflammatory bowel disease (IBD). To contextualize the medical community's difficulty in linking each condition to cancer, the first section will review the discovery of CD and UC. Next, we discuss early attempts to define IBD's relationship with small bowel adenocarcinoma and colorectal cancer. The article concludes with a review of each disease's surgical history and the ways in which certain procedures produced poor oncologic outcomes.
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Affiliation(s)
- Hannah Williams
- Division of Colon and Rectal Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York
| | - Randolph M. Steinhagen
- Division of Colon and Rectal Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York
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14
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Santiago P, Barnes EL, Raffals LE. Classification and Management of Disorders of the J Pouch. Am J Gastroenterol 2023; 118:1931-1939. [PMID: 37252759 DOI: 10.14309/ajg.0000000000002348] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 05/25/2023] [Indexed: 05/31/2023]
Abstract
Total abdominal proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) is associated with substantial complications despite the benefits of managing refractory and/or neoplasia-associated disease. For the purpose of this review, we focused on the diagnosis of some of the most common inflammatory and structural pouch disorders and their respective management. Pouchitis is the most common complication, and it is typically responsive to antibiotics. However, chronic antibiotic refractory pouchitis (CARP) has been increasingly recognized, and biologic therapies have emerged as the mainstay of therapy. Crohn's-like disease of the pouch (CLDP) can affect up to 10% of patients with UC after IPAA. Medical options are similar to CARP therapies, including biologics with immunomodulators. Studies have shown higher efficacy rates of biologics for CLDP when compared with those for CARP. In addition, managing stricturing and fistulizing CLDP is challenging and often requires interventional endoscopy (balloon dilation and/or stricturotomy) and/or surgery. The implementation of standardized diagnostic criteria for inflammatory pouch disorders will help in advancing future therapeutic options. Structural pouch disorders are commonly related to surgical complications after IPAA. We focused on the diagnosis and management of anastomotic leaks, strictures, and floppy pouch complex. Anastomotic leaks and anastomotic strictures occur in approximately 15% and 11% of patients with UC after IPAA, respectively. Further complications from pouch leaks include the development of sinuses, fistulas, and pouch sepsis requiring excision. Novel endoscopic interventions and less invasive surgical procedures have emerged as options for the management of these disorders.
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Affiliation(s)
- Priscila Santiago
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Laura E Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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15
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Jillawar N, Bandla V, Galam P, Vajja R, Nirhale D. Study of late complications of restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis operated at a tertiary care center and factors affecting to that. Ann Afr Med 2023; 22:497-500. [PMID: 38358151 PMCID: PMC10775946 DOI: 10.4103/aam.aam_177_22] [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: 12/18/2022] [Revised: 05/01/2023] [Accepted: 05/03/2023] [Indexed: 02/16/2024] Open
Abstract
Background and Objective Restorative proctocolectomy with ileal pouch-anal anastomosis (RPC-IPAA) is usually preferred surgical treatment for ulcerative colitis (UC). Although treated primarily medically, some refractory and complicated cases of UC may require surgical intervention. It eliminates chronic UC and the risk of colonic cancer. This research aims to study the risk factors associated with the development of postoperative complications. Methodology For this cohort study, we included all the patients who underwent RPC-IPAA in the Department of Gastroenterology, Sheth Vadilal Sarabhai General Hospital, Ahmedabad, over 6 years. Data of the patients were obtained retrospectively from the medical records. We collected the data and analyzed using appropriate statistical tests to look for preoperative patient variables associated with late complications. Late complications were defined as those developed after 1 month. Results Out of 32 patients, 19 were male and 13 were female, with an average age of 32.3 years at the time of operation. Thirteen patients developed complications such as pouchitis (n = 6), incisional hernia (n = 3), bowel obstruction (n = 2), pouch leakage (n = 1), and erectile dysfunction (n = 1). We found serum albumin <3 mg/dl and pancolitis associated with more postoperative late complications with P = 0.007 and 0.04, respectively, which is statistically significant. Conclusion This study demonstrates that low preoperative albumin level and pancolitis are risk factors for late complications of IPAA. Preoperative nutritional support, especially albumin, could reduce late complications.
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Affiliation(s)
- Nikhil Jillawar
- Department of General Surgery, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
| | - Vijetha Bandla
- Department of General Surgery, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
| | - Pushkar Galam
- Department of General Surgery, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
| | - Ramya Vajja
- Department of General Surgery, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
| | - Dakshayani Nirhale
- Department of General Surgery, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
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16
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Maspero M, Hull TL. Clinical approach to patients with an ileal pouch. Abdom Radiol (NY) 2023; 48:2918-2929. [PMID: 37005915 DOI: 10.1007/s00261-023-03888-z] [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: 02/21/2023] [Revised: 03/13/2023] [Accepted: 03/13/2023] [Indexed: 04/04/2023]
Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis is the procedure of choice to maintain intestinal continuity when a total proctocolectomy is a required. It is a technically challenging operation that may be burdened by several nuanced complications both in the immediate postoperative period and in the long term. Most patients with a pouch and any kind of complication will undergo radiological studies, thus multidisciplinary collaboration between surgeons, gastroenterologists, and radiologists is paramount to their timely and accurate diagnosis. When treating pouch patients, radiologists should be familiar with regular pouch anatomy and its appearance in imaging studies, as well as with the most common complications that can occur in this population. In this review, we examine the clinical decision-making process at each step before and after pouch creation, as well as the most common complications associated with pouch surgery, their diagnosis, and their management.
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Affiliation(s)
- Marianna Maspero
- Department of Colorectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Tracy L Hull
- Department of Colorectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
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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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18
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Panteleimonitis S, Al-Dhaheri M, Harper M, Amer I, Ahmed AA, Nada MA, Parvaiz A. Short-term outcomes in robotic vs laparoscopic ileal pouch-anal anastomosis surgery: a propensity score match study. Langenbecks Arch Surg 2023; 408:175. [PMID: 37140753 PMCID: PMC10160174 DOI: 10.1007/s00423-023-02898-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 04/14/2023] [Indexed: 05/05/2023]
Abstract
PURPOSE Laparoscopic ileal pouch-anal anastomosis (IPAA) surgery offers improved short-term outcomes over open surgery but can be technically challenging. Robotic surgery has been increasingly used for IPAA surgery, but there is limited evidence supporting its use. This study aims to compare the short-term outcomes of laparoscopic and robotic IPAA procedures. METHODS All consecutive patients receiving laparoscopic and robotic IPAA surgery at 3 centres, from 3 countries, between 2008 and 2019 were identified from prospectively collated databases. Robotic surgery patients were propensity score matched with laparoscopic patients for gender, previous abdominal surgery, ASA grade (I, II vs III, IV) and procedure performed (proctocolectomy vs completion proctectomy). Their short-term outcomes were examined. RESULTS A total of 89 patients were identified (73 laparoscopic, 16 robotic). The 16 patients that received robotic surgery were matched with 15 laparoscopic patients. Baseline characteristics were similar between the two groups. There were no statistically significant differences in any of the investigated short-term outcomes. Length of stay trend was higher for laparoscopic surgery (9 vs 7 days, p = 0.072) CONCLUSION: Robotic IPAA surgery is safe and feasible and offers similar short-term outcomes to laparoscopic surgery. Length of stay may be lower for robotic IPAA surgery, but further larger scale studies are required in order to demonstrate this.
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Affiliation(s)
- Sofoklis Panteleimonitis
- University of Portsmouth, School of Health and Care Professions, St Andrews Court, St Michael's road, Portsmouth, PO1 2PR, UK
- Champalimaud Foundation, Av. Brasilia, 1400-038, Lisbon, Portugal
| | | | - Mick Harper
- University of Portsmouth, School of Health and Care Professions, St Andrews Court, St Michael's road, Portsmouth, PO1 2PR, UK
| | | | | | | | - Amjad Parvaiz
- University of Portsmouth, School of Health and Care Professions, St Andrews Court, St Michael's road, Portsmouth, PO1 2PR, UK
- Champalimaud Foundation, Av. Brasilia, 1400-038, Lisbon, Portugal
- Hamad Medical Corporation, Doha, Qatar
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19
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Transabdominal IPAA Revision: Does Indication Dictate Outcome? Dis Colon Rectum 2023; 66:559-566. [PMID: 35426379 DOI: 10.1097/dcr.0000000000002335] [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: 02/08/2023]
Abstract
BACKGROUND Following IPAA failure, select patients are eligible for IPAA revision. Presently, there is limited evidence describing long-term revision outcomes and predictors of revision failure. This represents an important knowledge gap when selecting and counseling patients. OBJECTIVE This study aimed to define long-term IPAA survival outcomes after transabdominal IPAA revision and identify preoperative clinical factors associated with revision failure. DESIGN This was a retrospective cohort study. SETTINGS This study was conducted at a tertiary referral center. PATIENTS This study included all patients who underwent revisional IPAA surgery between 1982 and 2017 for pouch failure. INTERVENTION Transabdominal IPAA revision was included. MAIN OUTCOME MEASURES The primary outcome was pouch failure, defined as pouch excision or permanent pouch diversion, after IPAA revision. RESULTS A total of 159 patients (64.2% women) were included with a median age of 36 years (interquartile range, 28.5-46.5) at revision. Eighty percent of patients had a primary diagnosis of ulcerative colitis. The most common indication for revision was leak/pelvic sepsis, representing 41% of the cohort, followed by pouch-vaginal fistula (22.2%), mechanical factors (20.4%), and poor pouch function (14.6%). During the study period, 56 patients (35.2%) experienced pouch failure. The 3-year pouch survival probability was 82.3% (95% CI, 75.5%-87.5%), 5-year pouch survival probability was 77.2% (95% CI, 69.8%-83.0%), and 10-year pouch survival probability was 70.6% (95% CI, 62.6%-77.2%). Compared to mechanical factors, pouch failure was significantly associated with pelvic sepsis (HR, 4.25; 95% CI, 1.50-12.0) and pouch-vaginal fistula (HR, 4.37; 95% CI, 1.47-12.99). No significant association was found between revision failure and previous revision, redo ileoanal anastomosis, or new pouch construction. LIMITATIONS This study is limited by its retrospective design. CONCLUSIONS Revisional IPAA can be undertaken with favorable long-term outcomes at high-volume centers. Consideration should be given to indication for revision when counseling patients regarding the risk of failure. Further research on risk stratifying patients before revision is required. See Video Abstract at http://links.lww.com/DCR/B966 . REVISIN DE LA ANASTOMOSIS ANAL DE LA BOLSA ILEAL TRANSABDOMINAL LA INDICACIN DICTA EL RESULTADO ANTECEDENTES:Después de la falla en la anastomosis del reservorio ileoanal, los pacientes seleccionados son elegibles para la revisión de la anastomosis del reservorio ileoanal. Actualmente, hay evidencias limitadas que describen los resultados de la revisión a largo plazo y los predictores del fracaso de la revisión. Esto representa un importante vacío de investigación a la hora de seleccionar y asesorar a los pacientes.OBJETIVO:Definir los resultados de supervivencia a largo plazo de la IPAA después de la revisión de la anastomosis del reservorio ileoanal transabdominal e identificar los factores clínicos preoperatorios asociados con el fracaso de la revisión.DISEÑO:Este fue un estudio de cohorte retrospectivo.ENTORNO CLINICO:Este estudio se realizó en un centro de referencia terciario.PARTICIPANTES:Todos los pacientes que se sometieron a una cirugía de revisión de la anastomosis ileoanal del reservorio entre 1982 y 2017, por falla del reservorio.INTERVENCIÓN:Revisión de la anastomosis de reservorio ileoanal transabdominal.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario es el fracaso del reservorio, definido como escisión del reservorio o derivación permanente del reservorio, después de la revisión de la anastomosis del reservorio ileoanal.RESULTADOS:Se incluyeron un total de 159 pacientes (64,2% mujeres) con una mediana de edad a la revisión de 36 años (RIC: 28,5-46,5). El ochenta por ciento tenía un diagnóstico primario de colitis ulcerosa. La indicación más común para la revisión fue la fuga/sepsis pélvica, que representó el 41 % de la cohorte, seguida de la fístula vaginal del reservorio (22,2 %), factores mecánicos (20,4 %) y mala función del reservorio 14,6 %. Durante el período de estudio, 56 pacientes (35,2 %) experimentaron fallas en la bolsa. Las probabilidades de supervivencia de la bolsa a los 3, 5 y 10 años fueron del 82,3% (IC del 95%: 75,5%-87,5%), del 77,2% (IC del 95%: 69,8%-83,0%) y del 70,6% (IC del 95%: 62,6%- 77,2%), respectivamente. En comparación con los factores mecánicos, la falla de la bolsa se asoció significativamente con sepsis pélvica (HR = 4,25, IC del 95 %: 1,50 a 12,0) y fístula vaginal de la bolsa (HR = 4,37, IC del 95 %: 1,47 a 12,99). No hubo una asociación significativa entre el fracaso de la revisión y la revisión previa, el rehacer la anastomosis ileoanal o la construcción de una nueva bolsa.LIMITACIONES:El estudio está limitado por su diseño retrospectivo.CONCLUSIONES:La revisión de la anastomosis del reservorio ileoanal se puede realizar con resultados favorables a largo plazo en centros de alto volumen. Se debe considerar la indicación de revisión al asesorar a los pacientes sobre el riesgo de fracaso. Se requiere investigación adicional sobre la estratificación del riesgo de los pacientes antes de la revisión. Consulte Video Resumen en http://links.lww.com/DCR/B966 . (Traducción - Dr. Fidel Ruiz Healy ).
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Shelygin YA, Ivashkin VT, Belousova EA, Reshetov IV, Maev IV, Achkasov SI, Abdulganieva DI, Alekseeva OA, Bakulin IG, Barysheva OY, Bolikhov KV, Vardanyan AV, Veselov AV, Veselov VV, Golovenko OV, Gubonina IV, Denisenko VL, Dolgushina AI, Kashnikov VN, Knyazev OV, Kostenko NV, Lakhin AV, Makarchuk PA, Moskalev AI, Nanaeva BA, Nikitin IG, Nikitina NV, Odintsova AK, Omelyanovskiy VV, Оshchepkov AV, Pavlenko VV, Poluektova EA, Sitkin SI, Sushkov OI, Tarasova LV, Tkachev AV, Тimerbulatov VM, Uspenskaya YB, Frolov SA, Khlynova OV, Chashkova EY, Chesnokova OV, Shapina MV, Sheptulin AA, Shifrin OS, Shkurko TV, Shchukina OB. Ulcerative colitis (K51), adults. KOLOPROKTOLOGIA 2023; 22:10-44. [DOI: 10.33878/2073-7556-2023-22-1-10-44] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Affiliation(s)
- Yu. A. Shelygin
- Ryzhikh National Medical Research Center of Coloproctology; Russian Medical Academy of Continous Professional Education
| | - V. T. Ivashkin
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | | | - I. V. Reshetov
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - I. V. Maev
- Moscow State University of Medicine and Dentistry named after A.I. Evdokimov
| | - S. I. Achkasov
- Ryzhikh National Medical Research Center of Coloproctology; Russian Medical Academy of Continous Professional Education
| | | | | | - I. G. Bakulin
- North-Western State Medical University named after I.I. Mechnikov
| | | | | | | | | | - V. V. Veselov
- Ryzhikh National Medical Research Center of Coloproctology; Russian Medical Academy of Continous Professional Education
| | - O. V. Golovenko
- Ryzhikh National Medical Research Center of Coloproctology; Russian Medical Academy of Continous Professional Education
| | | | - V. L. Denisenko
- Educational Establishment Vitebsk State Order of Peoples’ Friendship Medical University
| | - A. I. Dolgushina
- Federal State Budgetary Educational Institution of Higher Education «South-Ural State Medical University» of the Ministry of Healthcare of the Russian Federation
| | | | - O. V. Knyazev
- GBUZ Moscow Clinical Scientific Center named after Loginov MHD
| | - N. V. Kostenko
- Federal State Budgetary Educational Institution of Higher Education «Astrakhan State Medical University» of the Ministry of Health of the Russian Federation
| | | | | | - A. I. Moskalev
- Ryzhikh National Medical Research Center of Coloproctology
| | - B. A. Nanaeva
- Ryzhikh National Medical Research Center of Coloproctology
| | - I. G. Nikitin
- Pirogov Russian National Research Medical University
| | | | - A. Kh. Odintsova
- GAUZ «RCH» of the Ministry of Health of the Republic of Tatarstan
| | | | - A. V. Оshchepkov
- GBUZ SO «SOKB No. 1» of the Ministry of Health of the Sverdlovsk Region
| | | | - E. A. Poluektova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - S. I. Sitkin
- North-Western State Medical University named after I.I. Mechnikov
| | - O. I. Sushkov
- Ryzhikh National Medical Research Center of Coloproctology
| | - L. V. Tarasova
- Federal State Budgetary Educational Institution of Higher Education «Chuvash State University named after I.N. Ulyanov»
| | - A. V. Tkachev
- Federal State Budgetary Educational Institution of Higher Education «Rostov State Medical University» of the Ministry of Health of the Russian Federation
| | | | | | - S. A. Frolov
- Ryzhikh National Medical Research Center of Coloproctology
| | - O. V. Khlynova
- Perm State Medical University named after E.A. Wagner (PSMU) of the Ministry of Healthcare of the Russian Feaderation
| | - E. Yu. Chashkova
- Federal State Budgetary Scientific Institution «Irkutsk Scientific Center for Surgery and Traumatology»
| | | | - M. V. Shapina
- Ryzhikh National Medical Research Center of Coloproctology; Russian Medical Academy of Continous Professional Education
| | - A. A. Sheptulin
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - O. S. Shifrin
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - T. V. Shkurko
- Ryzhikh National Medical Research Center of Coloproctology
| | - O. B. Shchukina
- First St. Petersburg State Medical University named after Academician I.P. Pavlov of the Ministry of Health of Russia
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21
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Carpenter EL, Valdera FA, Chauviere MV, Krell RW. Outcomes of Partial Versus Total Colectomy in Ulcerative Colitis: A Propensity Score-Matched Analysis. J Surg Res 2023; 287:63-71. [PMID: 36868125 DOI: 10.1016/j.jss.2023.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 01/03/2023] [Accepted: 01/28/2023] [Indexed: 03/05/2023]
Abstract
INTRODUCTION Total abdominal colectomy (TAC) with ileostomy is the standard treatment for severe ulcerative colitis (UC). Partial colectomy (PC) with colostomy may present a less morbid treatment option. METHODS The 2012-19 ACS-NSQIP database was queried to assess 30-day outcomes among patients undergoing TAC versus PC for UC, utilizing propensity score matching (PSM) techniques to account for differences in disease severity, patient selection, and presentation acuity. RESULTS Before matching (n = 9888), patients undergoing PC were older, had more comorbidities, and experienced higher complication and 30-day mortality rates (P < 0.001). After matching (n = 1846), patients undergoing TAC experienced higher 30-day overall complications (41.9% versus 36.5%, P = 0.017) and serious complications (37.2% versus 31.5%, P = 0.011). Sensitivity analyses of older patients and those undergoing nonemergency surgery demonstrated higher overall rates of complications for patients receiving TAC. However, among patients undergoing emergency surgery only, no differences in complications were seen between the two surgical approaches. CONCLUSIONS PC with colostomy in the setting of ulcerative colitis has similar 30-day outcomes to TAC with ileostomy. PC may be an acceptable surgical alternative to TAC in select patients. Studies investigating longer-term outcomes are necessary to further investigate this option.
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Affiliation(s)
- Elizabeth L Carpenter
- Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, Texas.
| | - Franklin A Valdera
- Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Matthew V Chauviere
- Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Robert W Krell
- Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, Texas
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22
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Emrich Accioly JP, Maspero M, Zhao H, Khouri RK, Lavryk O, Angermeier KW, Hull T, Wood HM. Management and Outcomes of Ileal Pouch-Urethral Fistulas. Urology 2023; 172:213-219. [PMID: 36476982 DOI: 10.1016/j.urology.2022.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To describe a single-center experience with the management of ileal pouch-urethral fistulas (IPUF) following restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). METHODS We retrospectively identified patients with documented IPUF managed at our institution from a urethral fistula cohort and analyzed their cases. RESULTS Thirteen patients who underwent surgeries for IPUF management from 2005-2022 were identified. Median age at IPAA was 29 years (range 11-53). Indications for IPAA included familial adenomatous polyposis (n=3) and ulcerative colitis (n=10). Median time from IPAA to fistula diagnosis was 15 years (range 0.5-38.5). Eleven patients were initially diverted with either loop (n=8) or end ileostomy (n=3). Overall, two patients had resolution of IPUF symptoms with a loop ileostomy alone and eight eventually underwent pouch excision with end ileostomy, one of which subsequently underwent redo IPAA. Seven patients were managed with primary closure of the urethral defect at the time of pouch excision, five of which also underwent gracilis muscle interposition. With a median follow-up of 4 years (range 0.3-13 years), all patients had resolution of their fistulae without any recurrences. CONCLUSION IPUFs are a rare complication after IPAA. In this cohort, all patients had their urinary tract preserved, but most ultimately had permanent fecal diversion. These results can help guide management of this complex issue.
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Affiliation(s)
| | - Mariana Maspero
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland OH
| | - Hanson Zhao
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Roger K Khouri
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Olga Lavryk
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland OH
| | - Kenneth W Angermeier
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland OH
| | - Hadley M Wood
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
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23
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Otero-Piñerio AM, Lightner AL. Adult allogeneic bone-marrow-derived mesenchymal stem cells for the treatment of anovaginal and perianal fistulas in the setting of Crohn's like phenotype of the ileal pouch-anal anastomosis - a video vignette. Colorectal Dis 2023; 25:336-337. [PMID: 36004562 DOI: 10.1111/codi.16311] [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: 07/06/2022] [Revised: 08/11/2022] [Accepted: 08/14/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Ana M Otero-Piñerio
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio, USA.,National Center for Regenerative Medicine, Cleveland, Ohio, USA
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24
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Xu W, Yang Y, Hua Z, Wang Y, Ding W, Lian L, Cui L, Wu X, Ding Z, Du P, Ye H. Intraoperative crystalloid-colloid infusion ratio associated with the development of early surgical complications after ileal pouch-anal anastomosis in ulcerative colitis: a multicenter long-term follow-up study. Int J Colorectal Dis 2023; 38:15. [PMID: 36648457 DOI: 10.1007/s00384-023-04309-9] [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] [Accepted: 01/01/2023] [Indexed: 01/18/2023]
Abstract
BACKGROUND Intraoperative intravenous fluid administration proves to be associated with surgical patients' postoperative outcomes. Few studies reported the relationship between intraoperative crystalloid-colloid infusion ratio and early surgical complications after ileal pouch-anal anastomosis (IPAA) in ulcerative colitis (UC). METHODS Data on patients with underwent IPAA from January 2008 to March 2022 at our three inflammatory bowel disease (IBD) surgery centers were retrospectively collected. Intraoperative anesthetic data were recorded and later evaluated by our team anesthesiologist. RESULTS A total of 140 eligible patients with a median follow-up time of 6.0 years [interquartile range (IQR): 2.0-8.0] were enrolled. Among all enrolled patients, 34 (24.3%) developed early surgical complications after IPAA. Greater blood loss and lower crystalloid-colloid infusion ratio were observed in patients with early surgical complications. Crystalloid-colloid infusion ratio < 2 and blood loss ≥ 200 ml had the most significant area under the receiver-operating characteristic curve (AUC) of 0.664 and 0.674 in predicting early surgical complications. Crystalloid-colloid infusion ratio < 2 [odds ratio (OR), 2.571; 95% confidence intervals (CI), 1.067-6.195, p = 0.035] and blood loss ≥ 200 ml (OR, 3.165; 95% CI, 1.288-7.777, p = 0.012) were independent risk factors for the development of early post-IPAA complications. CONCLUSION Intraoperative crystalloid-colloid infusion ratio < 2 and blood loss volume over 200 ml during IPAA contribute to the occurrence of early surgical complications. Early attentions and necessary interventions are warranted to avoid these risk factors during the IPAA surgery in order to prevent the development of early surgical complications.
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Affiliation(s)
- Weimin Xu
- Department of Colorectal Surgery, School of Medicine, Xinhua Hospital, Shanghai Jiaotong University, 1665 Kongjiang Road, Shanghai, 200092, China
- China UC Pouch Center Union, Shanghai, China
| | - Yiqing Yang
- Department of Colorectal Surgery, School of Medicine, Xinhua Hospital, Shanghai Jiaotong University, 1665 Kongjiang Road, Shanghai, 200092, China
- China UC Pouch Center Union, Shanghai, China
| | - Zhebin Hua
- Department of Colorectal Surgery, School of Medicine, Xinhua Hospital, Shanghai Jiaotong University, 1665 Kongjiang Road, Shanghai, 200092, China
- China UC Pouch Center Union, Shanghai, China
| | - Yaosheng Wang
- Department of Colorectal Surgery, School of Medicine, Xinhua Hospital, Shanghai Jiaotong University, 1665 Kongjiang Road, Shanghai, 200092, China
- China UC Pouch Center Union, Shanghai, China
| | - Wenjun Ding
- Department of Colorectal Surgery, School of Medicine, Xinhua Hospital, Shanghai Jiaotong University, 1665 Kongjiang Road, Shanghai, 200092, China
- China UC Pouch Center Union, Shanghai, China
| | - Lei Lian
- Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, China
- China UC Pouch Center Union, Shanghai, China
| | - Long Cui
- Department of Colorectal Surgery, School of Medicine, Xinhua Hospital, Shanghai Jiaotong University, 1665 Kongjiang Road, Shanghai, 200092, China
- China UC Pouch Center Union, Shanghai, China
| | - Xiaojian Wu
- Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510655, China
- China UC Pouch Center Union, Shanghai, China
| | - Zhao Ding
- Department of Colorectal and Anal Surgery, Hubei Key Laboratory of Intestinal and Colorectal Diseases, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
- China UC Pouch Center Union, Shanghai, China
| | - Peng Du
- Department of Colorectal Surgery, School of Medicine, Xinhua Hospital, Shanghai Jiaotong University, 1665 Kongjiang Road, Shanghai, 200092, China.
- China UC Pouch Center Union, Shanghai, China.
| | - Hairong Ye
- Department of Anesthesia, Xinhua Hospital, Shanghai Jiaotong University, School of Medicine, 1665 Kongjiang Road, Shanghai, 200092, China.
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25
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Wu EH, Guo Z, Zhu WM. Postoperative diarrhea in Crohn’s disease: Pathogenesis, diagnosis, and therapy. World J Clin Cases 2023; 11:7-16. [PMID: 36687182 PMCID: PMC9846968 DOI: 10.12998/wjcc.v11.i1.7] [Citation(s) in RCA: 1] [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: 11/13/2022] [Revised: 12/08/2022] [Accepted: 12/23/2022] [Indexed: 01/04/2023] Open
Abstract
Diarrhea is a frequent symptom in postoperative patients with Crohn’s diseases (CD), and several different mechanisms likely account for postoperative diarrhea in CD. A targeted strategy based on a comprehensive understanding of postoperative diarrhea is helpful for better postoperative recovery.
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Affiliation(s)
- En-Hao Wu
- Department of General Surgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, Jiangsu Province, China
| | - Zhen Guo
- Department of General Surgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, Jiangsu Province, China
| | - Wei-Ming Zhu
- Department of General Surgery, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, Jiangsu Province, China
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26
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Xu W, Wang Y, Hua Z, Hu H, Chen W, Cai Z, Cui L, Wu X, Lian L, Ding Z, Du P. Risk Factors and Quality of Life in Patients with Diffuse Pouchitis After Ileal Pouch Anal Anastomosis According to the Chicago Classification for J Pouch: a Retrospective Multicenter Cohort Study in China. J Gastrointest Surg 2023; 27:766-776. [PMID: 36596961 DOI: 10.1007/s11605-022-05563-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/02/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Pouchitis is a common late complication in patients with ulcerative colitis (UC) who undergo ileal pouch-anal anastomosis (IPAA). The heterogeneous nature of the clinical and endoscopic presentations could affect the evaluation of therapeutic interventions for pouchitis. Thus, identifying the risk factors and clinical outcomes of pouch inflammation at different sites and severity is becoming increasingly important for colorectal surgeons. METHODS Data on patients who underwent IPAA January from 2008 to June 2022 in our three pouch centers affiliated with the China UC Pouch Center Union were retrospectively collected. Pouchitis was categorized as a different phenotype according to the Chicago Classification. J pouches were classified into short (14 ± 2 cm) and long pouches (22 ± 2 cm) according to the distribution of ileal pouch length in our institute. RESULTS Altogether, 143 patients with a median follow-up time of 5.0 years (interquartile range: 2.0-8.0) were enrolled. Among them, 41 patients (28.7%) developed pouchitis and 32 patients (78%) had diffuse inflammation of the pouch. Patients with diffuse pouchitis had a higher pouchitis disease activity index and more seriously impaired improvement of long-term quality of life than those with pouch phenotypes. A short J pouch, recurrent UC, and preoperative high white blood cell count were independent risk factors for diffuse pouchitis. Furthermore, a short J pouch could effectively predict the occurrence of diffuse pouchitis with an area under the receiver-operating characteristic curve of 0.614, a sensitivity of 62.5%, and a specificity of 60.4% (p = 0.049) and significantly decreased the overall diffuse pouchitis-free survival compared to a long J pouch (p = 0.0002). CONCLUSION Diffuse pouchitis is a common phenotype of pouchitis that seriously impairs long-term prognosis. For colorectal surgeons, decision-making regarding pouch construction with an appropriate length should be considered to prevent the development of diffuse pouchitis.
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Affiliation(s)
- Weimin Xu
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 200092, Shanghai, China.,China UC Pouch Center Union, Shanghai, China
| | - Yaosheng Wang
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 200092, Shanghai, China.,China UC Pouch Center Union, Shanghai, China
| | - Zhebin Hua
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 200092, Shanghai, China.,China UC Pouch Center Union, Shanghai, China
| | - Hang Hu
- Department of Colorectal and Anal Surgery, Hubei Key Laboratory of Intestinal and Colorectal Diseases, Zhongnan Hospital of Wuhan University, 430071, Wuhan, China.,China UC Pouch Center Union, Shanghai, China
| | - Wenhao Chen
- Department of Colorectal and Anal Surgery, Hubei Key Laboratory of Intestinal and Colorectal Diseases, Zhongnan Hospital of Wuhan University, 430071, Wuhan, China.,China UC Pouch Center Union, Shanghai, China
| | - Zerong Cai
- Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 510655, Guangzhou, China.,China UC Pouch Center Union, Shanghai, China
| | - Long Cui
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 200092, Shanghai, China.,China UC Pouch Center Union, Shanghai, China
| | - Xiaojian Wu
- Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 510655, Guangzhou, China.,China UC Pouch Center Union, Shanghai, China
| | - Lei Lian
- Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, 510655, Guangzhou, China.,China UC Pouch Center Union, Shanghai, China
| | - Zhao Ding
- Department of Colorectal and Anal Surgery, Hubei Key Laboratory of Intestinal and Colorectal Diseases, Zhongnan Hospital of Wuhan University, 430071, Wuhan, China. .,China UC Pouch Center Union, Shanghai, China.
| | - Peng Du
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, 200092, Shanghai, China. .,China UC Pouch Center Union, Shanghai, China.
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27
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Lan N, Smukalla STM, Chang S. Fecal Incontinence and Defecatory Disorders in Patients With Ileal Pouch-Anal Anastomosis. Gastroenterol Hepatol (N Y) 2023; 19:41-47. [PMID: 36865815 PMCID: PMC9972658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Functional anorectal disorders are common in patients with ileal pouch-anal anastomosis (IPAA) and often have a debilitating impact on quality of life. The diagnosis of functional anorectal disorders, including fecal incontinence (FI) and defecatory disorders, requires a combination of clinical symptoms and functional testing. Symptoms are generally underdiagnosed and underreported. Commonly utilized tests include anorectal manometry, balloon expulsion test, defecography, electromyography, and pouchoscopy. The treatment for FI begins with lifestyle modifications and medications. Sacral nerve stimulation and tibial nerve stimulation have been trialed on patients with IPAA and FI, resulting in improvement in symptoms. Biofeedback therapy has also been used in patients with FI but is more commonly utilized in defecatory disorders. Early diagnosis of functional anorectal disorders is important because a response to treatment may significantly improve a patient's quality of life. To date, there is limited literature describing the diagnosis and treatment of functional anorectal disorders in patients with IPAA. This article focuses on the clinical presentation, diagnosis, and treatment of FI and defecatory disorders in patients with IPAA.
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Affiliation(s)
- Nan Lan
- 1Department of Gastroenterology, Columbia University Irving Medical Center, New York, New York
| | - Scot t M. Smukalla
- 2Division of Gastroenterology, New York University Grossman School of Medicine, New York, New York
| | - Shannon Chang
- 2Division of Gastroenterology, New York University Grossman School of Medicine, New York, New York
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28
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Luberto A, Crippa J, Foppa C, Maroli A, Sacchi M, De Lucia F, Carvello M, Spinelli A. Routine placement of abdominal drainage in pouch surgery does not impact on surgical outcomes. Updates Surg 2022; 75:619-626. [PMID: 36479676 PMCID: PMC9734453 DOI: 10.1007/s13304-022-01411-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 10/22/2022] [Indexed: 12/12/2022]
Abstract
The evidence does not support the routine use of abdominal drainage (AD) in colorectal surgery. However, there is no data on the usefulness of AD, specifically, after ileal pouch-anal anastomosis (IPAA). The aim of this study is to assess post-operative outcomes of patients undergoing IPAA with or without AD at a high volume referral center. A retrospective analysis of prospectively collected data of consecutive patients undergoing IPAA with AD (AD group) or without AD (NAD group) was performed. Baseline characteristics, operative, and postoperative data were analyzed and compared between the two groups. A total of 97 patients were included in the analysis, 46 were in AD group and 51 in NAD group. AD group had a higher BMI (23.9 ± 3.9 kg/m2 vs 21.9 ± 3.0 kg/m2; p = 0.007) and more commonly underwent two-stage proctocolectomy with IPAA compared to the NAD group (50.0% vs 3.9%; p < 0.001). There was no difference in anastomotic leak rate (6.5% AD vs 5.9% NAD group; p = 1.000), major post-operative complication (8.6% vs 7.9%; p = 0.893); median length of stay [IQR] (5 [5-7] days vs 5 [4-7] days; p = 0.305) and readmission < 90 days (8.7% vs 3.9%; p = 0.418). The use of AD does not impact on surgical outcome after IPAA and question the actual benefit of its routine placement.
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Affiliation(s)
- Antonio Luberto
- IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Jacopo Crippa
- IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Caterina Foppa
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan Italy ,IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Annalisa Maroli
- IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Matteo Sacchi
- IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Francesca De Lucia
- IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Michele Carvello
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan Italy ,IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan Italy ,IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Rozzano, Milan Italy
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Robotic Surgery for the Ileal Pouch. Dis Colon Rectum 2022; 65:S37-S40. [PMID: 35867639 DOI: 10.1097/dcr.0000000000002549] [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: 01/04/2023]
Abstract
BACKGROUND A robotic approach to total colectomy/proctectomy and ileal pouch reconstruction would seem to be a sensible use of the platform's enhanced reach, visualization, and dexterity. OBJECTIVE The study aimed to discuss current published data for robotic ileal pouch surgery. STUDY SELECTION The study selection included a paucity of published data to date, representing early learning curves and case series with small numbers. CONCLUSIONS Current robotic platforms may offer advantages, particularly in the low pelvis beyond what is found with a laparoscopic approach.
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The Surgical Management of Ileal Pouch Strictures. Dis Colon Rectum 2022; 65:S105-S112. [PMID: 36399770 DOI: 10.1097/dcr.0000000000002546] [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: 11/19/2022]
Abstract
BACKGROUND Total proctocolectomy with IPAA reconstruction is the surgical approach of choice in ulcerative colitis, indeterminate colitis, familial adenomatous polyposis, and selected patients with Crohn's disease. Pouch stricture is a common complication after IPAA. OBJECTIVE This study aims to identify surgical management options for pouch stricture and offer a treatment algorithm. DATA SOURCES A computer-assisted search of the online bibliographic databases MEDLINE and Embase from 1990 to 2021 was performed. STUDY SELECTION Randomized controlled trials, cohort studies, observational studies, and case reports were considered. INTERVENTIONS Mechanical dilation, strictureplasty, stapler resection, pouch advancement, bypass, and repeat IPAA were included. MAIN OUTCOMES Twenty-three articles were considered eligible. Overall incidence of strictures varied from 5% to 38%. Strictures were categorized into 3 areas: pouch inlet (with a reported incidence of 9% to 56%), mid-pouch (with a reported incidence of 2%), and pouch-anal anastomosis (with a reported incidence of 43% to 87%). Pouch-anal strictures were initially managed using bougie or Hegar dilation, with various surgical procedures advocated when initial dilation failed. Mid-pouch strictures are relatively unstudied with scant data. Pouch inlet strictures can be surgically managed by various transabdominal techniques' including resection and reconnection, strictureplasty, or bypass. RESULTS Pouch-anal strictures should be managed in a step-up strategy as conservative procedures are associated with acceptable success rates. Initial mechanical dilation using bougie or Hegar dilation has a success rate of >80%, although it is likely to require repeat dilations. When these measures fail, transanal surgical approaches using strictureplasty, stapler resection' or pouch advancement should be offered. Transabdominal pouch revision should be offered to patients refractory to a transanal approach. In mid-pouch strictures, the treatment of choice is pouch revision and reanastomosis. Pouch inlet strictures can be managed by resection, strictureplasty, or bypass depending on the location and length of the stricture and surgeon experience. LIMITATIONS Studies were often small and retrospectively analyzed. There were no randomized controlled trials or comparison between different treatment options.
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Shibata K, Ebinuma S, Sakamoto S, Suzuki A, Terasaki Y, Taketomi A. Two-time perforation of the ileal J-pouch 6 and 18 years after restorative proctocolectomy and ileal pouch–anal anastomosis for familial adenomatous polyposis: a case report. Surg Case Rep 2022; 8:2. [PMID: 34982288 PMCID: PMC8727658 DOI: 10.1186/s40792-021-01355-9] [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: 11/01/2021] [Accepted: 12/19/2021] [Indexed: 11/10/2022] Open
Abstract
Background Perforation of the ileal J-pouch after restorative proctocolectomy and ileal pouch–anal anastomosis are extremely rare. There has been no report of perforation of the ileal J-pouch occurring twice over several years. We report the first case of perforation at 6 and 18 years following restorative proctocolectomy. Case presentation The patient was a 52-year-old man who underwent a two-stage restorative proctocolectomy with a hand-sewn ileal J-pouch anal anastomosis due to familial adenomatous polyposis and sigmoid colon cancer at 34 years of age. At the age of 40, he underwent ileal pouch resection at its blind end, abdominal drainage, and anastomotic dilatation. The patient had a perforation of the blind end of the ileal J-pouch from increased intraluminal pressure, with anastomotic stricture and pervasive peritonitis. The patient had no symptoms for a few years; however, 18 years after the initial surgery and 12 years after the first perforation, the patient presented with severe abdominal pain. Computed tomography demonstrated pneumoperitoneum; accordingly, laparotomy was performed. Upon opening the abdominal cavity, contaminated ascites and inflammatory changes were documented involving the ileum. A 2-mm perforation involving the blind end of the ileal J-pouch was also observed and repaired, followed by temporary loop ileostomy creation. Postoperative endoscopy revealed an ulcer in the ileal J-pouch and a stricture located directly at the anastomosis. Conclusions The blind end of the J-pouch repeatedly perforated over the years due to recurrent anastomotic stricture. Regular surveillance is, therefore, considered necessary for the release of stricture, maintenance of anastomotic patency, and prevention of ileal J-pouch perforation.
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Abstract
BACKGROUND Pelvic pouch surgery evolved under the late Dr. Victor Fazio's influence. OBJECTIVE This article aimed to describe construction of J- and S-pouches according to Fazio's teachings. TECHNICAL POINTS There are several key points to consider for pelvic pouch construction, starting with the decision of performing a 2- or 3-stage procedure and handling of the rectal stump. At time of pouch construction, ileal reach must be assessed early in the operative course, and mesenteric lengthening maneuvers are deployed as warranted. If these maneuvers still do not allow sufficient length, alternatives include an S-pouch, longer rectal stump/anal transitional zone, or returning to the operating room at a later date. The rectum is then mobilized sufficiently to allow a straight stapler firing to avoid outlet obstruction from impinged nearby tissues. The 15- to 20-cm pouch is constructed, ensuring that its staple lines are straight, staple line bleeding is addressed, the tip of the J is closed to be as short as possible, and a leak test is performed. At the time of the anastomosis, it is crucial to keep the mesentery and pouch straight, ensure no bowel is trapped below the mesentery, confirm that anterior structures are not being incorporated into the anastomosis, and perform a leak test, adding transanal sutures as needed to repair any defects. An ileostomy is then created. CONCLUSION Pouch construction is challenging. At each stage, consider the patient, who carries the ultimate risk. The end goal is a functional, long-lasting pouch.
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Abstract
BACKGROUND Patients with ulcerative colitis refractory to medication or familial adenomatous polyposis may require ileal pouch-anal anastomosis after a colectomy. IPAA is generally well tolerated. However, patients can experience posttreatment complications, including pouch strictures and leaks. Medical therapy has a limited role in mechanical fibrotic strictures, whereas surgery is invasive and costly. In the past few decades, endoscopic therapies have provided a less invasive and less costly intervention for pouch strictures and leaks. OBJECTIVE This systematic literature review aimed to describe the status of advancements in endoscopic therapy for pouch leaks and strictures. DATA SOURCES The sources used were PubMed and Cochrane databases. STUDY SELECTION Studies between January 1990 and January 2022, in any language, were included. Articles regarding surgical management or pouches other than adult ileal pouch-anal anastomosis were excluded. INTERVENTIONS Endoscopic management of acute and chronic leaks and strictures ileal pouch-anal anastomosis was included. MAIN OUTCOME MEASURES Successful management (including persistent leak or stricture, pouch failure, subsequent endoscopy, or surgery) was measured. RESULTS Sixty-one studies were included in this review, including 4 meta-analyses or systematic reviews, 11 reviews, 17 cohort studies, and 18 case series. LIMITATIONS The limitations include qualitative review of all study types, with no randomized controlled studies available. CONCLUSION Ileal pouch-anal anastomosis leaks are various in configuration, and endoscopic therapies have included clipping leaks at the tip of the "J" as well as endoscopic sinusotomy. Endoscopic therapies for pouch strictures have included endoscopic balloon dilation, endoscopic stricturotomy, and endoscopic stricturoplasty, which are now considered first-line therapies for pouch strictures. Endoscopic balloon dilation has shown safety and efficacy in single, short, and straight strictures and endoscopic stricturotomy for refractory long, fibrotic, anastomotic strictures. Endoscopic therapies can delay or prevent invasive surgeries. Key tenets of successful endoscopic therapy include patient and lesion candidacy, an experienced endoscopist, and adequate rescue surgery plans.
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Abstract
BACKGROUND Pouchitis is the most common inflammatory complication in ulcerative colitis patients undergoing postoperative construction of an IPAA. Pouchitis refers to a spectrum of diseases, and as such, it lacks a universally accepted definition as well as validated instruments to measure disease activity and treatment response. Assessing pouchitis activity is challenging, and methods for diagnosis and classification of severity of pouchitis are not universally agreed upon. CLINICAL FEATURES Pouchitis is characterized by a constellation of clinical symptoms, including increased stool frequency, urgency, incontinence, bleeding, and rarely constitutional symptoms such as malaise and low-grade fever. However, these symptoms are subjective, and similar symptoms can be caused by noninflammatory conditions including anal sphincter dysfunction, anastomotic strictures, occult leaks, pouch inlet obstruction, and cuffitis. Objective scores that include endoscopic and histologic criteria have been developed for subjects with an IPAA. However, these instruments are not validated for measuring pouchitis disease activity and are associated with a number of challenges. In addition, the clinical components of the scores correlate poorly with endoscopic and histologic findings. CONCLUSION AND FUTURE DIRECTIONS There is a need for prospective studies to facilitate the development and validation of novel instruments that are valid, reliable, and responsive to change that would facilitate the development of therapeutic agents for the treatment of pouchitis.
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Role of robotic approach in ileal pouch–anal anastomosis (IPAA): A systematic review of the literature. J Robot Surg 2022; 17:941-947. [DOI: 10.1007/s11701-022-01490-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 11/06/2022] [Indexed: 11/17/2022]
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36
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Lightner AL, Reese J, Ream J, Nachand D, Jia X, Pineiro AO, Dadgar N, Steele S, Hull T. A Phase IB/IIA study of allogeneic bone marrow derived mesenchymal stem cells for the treatment of refractory ileal anal anastomosis and peripouch fistulas in the setting of Crohn's disease of the pouch. J Crohns Colitis 2022; 17:480-488. [PMID: 36322714 DOI: 10.1093/ecco-jcc/jjac172] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND AIMS Mesenchymal stem cells (MSCs) have been used for the treatment of perianal Crohn's fistulizing disease by direction injection. No studies to date have included patients with an ileal pouch anal anastomosis (IPAA) in situ. METHODS A phase IB/IIA randomized control trial of bone marrow derived allogeneic MSCs via direct injection to treat adult patients with a peripouch fistula(s) was conducted. 75 million MSCs were administered with a 22G needle; repeat injection at 3 months was given if complete clinical and radiographic healing were not achieved. Adverse and serious adverse events at post procedure day 1, week 2, week 6, month 3, month 6 and month 12 were assessed. Clinical healing, radiographic healing per pelvic MRI, and patient reported outcomes were assessed at the same time points. RESULTS A total of 22 patients were enrolled and treated; 16 were treatment and 6 were control. There were no adverse or serious adverse events related to MSC therapy. At six months, 31% of the treatment group and 20% of the control had complete clinical and radiographic healing. When stratifying the treatment group into perianal (n=7) and anovaginal (n=8) fistulas, 6 month healing in the treatment groups was 57% and 0%, respectively. The perianal Crohn's disease activity index (PCDAI), Wexner incontinence score, and VanAssche score all significantly decreased in treatment patients at six months; only the PCDAI decreased in the control group. CONCLUSION Bone marrow derived allogeneic MSCs offer a safe and effective alternative treatment approach for peripouch fistulas in the setting of a Crohn's like phenotype of the pouch.
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Affiliation(s)
- Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland OH
| | - Jane Reese
- National Center for Regenerative Medicine, Cleveland, OH
| | - Justin Ream
- Department of Abdominal Radiology, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland OH
| | - Douglas Nachand
- Department of Abdominal Radiology, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland OH
| | - Xue Jia
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland OH
| | - Ana Otero Pineiro
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland OH
| | - Neda Dadgar
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland OH
| | - Scott Steele
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland OH
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland OH
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37
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Lynn PB, Brandstetter S, Schwartzberg DM. Pelvic Pouch Failure: Treatment Options. Clin Colon Rectal Surg 2022; 35:487-494. [PMID: 36591403 PMCID: PMC9797280 DOI: 10.1055/s-0042-1758140] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Up to 30% of patients with ulcerative colitis (UC) will require surgical management of their disease during their lifetime. An ileal pouch-anal anastomosis (IPAA) is the gold standard of care, giving patients the ability to be free from UC's bowel disease and avoid a permanent ostomy. Despite surgical advancements, a minority of patients will still experience pouch failure which can be debilitating and often require further surgical interventions. Signs and symptoms of pouch failure should be addressed with the appropriate workup and treatment plans formulated according with the patient's wishes. This article will discuss the identification, workup, and treatment options for pouch failure after IPAA.
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Affiliation(s)
- Patricio B. Lynn
- Division of Colorectal Surgery, New York–Presbyterian/Weill-Cornell Medical Center, New York, New York
| | | | - David M. Schwartzberg
- Division of Colorectal Surgery & Inflammatory Bowel Disease, Department of Surgery, New York–Presbyterian/Columbia University Medical Center, New York, New York
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38
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Malick A, Shen B. Endoscopic Treatment of Postoperative Bleeding, Bezoars, and Foreign Bodies. Gastrointest Endosc Clin N Am 2022; 32:829-843. [PMID: 36202519 DOI: 10.1016/j.giec.2022.05.008] [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: 02/04/2023]
Abstract
Altered gastrointestinal anatomy is common in patients with inflammatory bowel disease, particularly in those who underwent bowel surgery. Commonly performed surgeries are bowel resection and anastomosis and strictureplasty for Crohn's disease; and restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. The area of anastomosis and suture line is at the greatest risk for the development of postoperative bleeding. Altered bowel anatomy, especially the presence of strictures, strictureplasty, or structural or functional pouch outlet obstruction, puts these patients at risk for bezoar formation and foreign body retention, including video endoscopy capsule. This article will focus on postoperative bleeding, bezoar formation, and video capsule retention in patients with inflammatory bowel disease. Endoscopic management of these conditions is useful and is becoming an increasingly popular alternative to surgery.
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Affiliation(s)
- Alyyah Malick
- Department of Medicine, Columbia University Irving Medical Center-New York Presbyterian Hospital, 622 W 168th St, New York, NY 10032, USA.
| | - Bo Shen
- Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center-NewYork Presbyterian Hospital, 161 Fort Washington Avenue, 8th Floor, New York, NY 10032, USA
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39
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Shore BM, Kochar B, Herfarth HH, Barnes EL. Current Perspectives on Indications for Ileal Pouch-Anal Anastomosis in Older Patients. Clin Exp Gastroenterol 2022; 15:163-170. [PMID: 36176671 PMCID: PMC9514131 DOI: 10.2147/ceg.s340338] [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: 06/28/2022] [Accepted: 09/12/2022] [Indexed: 11/30/2022] Open
Abstract
The population of older patients with inflammatory bowel disease (IBD) is expected to continue to increase in the coming decades, which necessitates and improved understanding of the critical issues faced by patients in this population. Although restorative proctocolectomy with IPAA remains the surgical procedure of choice for the majority of patients with medically refractory ulcerative colitis (UC) and UC-related dysplasia, the evidence surrounding surgery for older patients UC remains sparse. In particular, comparisons of outcomes among older and younger patients undergoing IPAA and comparisons between older patients undergoing IPAA and those undergoing proctocolectomy with end ileostomy remain an understudied and important issue, as evidence in this area will be used to guide patient-centered surgical choices among older patients who require colectomy for UC. In this narrative review, we review the available literature regarding IPAA for older patients, as well as the pre-, peri-, and postoperative factors that may influence outcomes in this population.
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Affiliation(s)
- Brandon M Shore
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Bharati Kochar
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA.,The Mongan Institute, Boston, MA, USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Center for Gastrointestinal Biology and Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Center for Gastrointestinal Biology and Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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40
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Levy AN. Diagnosis and Classification of Inflammatory Bowel Disease Strictures. Gastrointest Endosc Clin N Am 2022; 32:615-629. [PMID: 36202506 DOI: 10.1016/j.giec.2022.04.001] [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: 02/04/2023]
Abstract
Intestinal strictures are a common complication in inflammatory bowel disease (IBD). Symptoms due to intestinal strictures range from mild bloating and/or abdominal discomfort to complete bowel obstruction. Careful selection of available medical, endoscopic, or surgical therapies is critical for optimizing patient outcomes and is dependent on the effective characterization of the stricture. This article will focus on the diagnosis and classification of IBD strictures.
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Affiliation(s)
- Alexander N Levy
- Division of Gastroenterology & Hepatology, Tufts Medical Center, 800 Washington Street, Box 233, Boston, MA 02111, USA.
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Bianchi G, Gavriilidis P, Martínez-Pérez A, de’Angelis GL, Uzzan M, Sobhani I, Coccolini F, Schena CA, Carra MC, Spinoglio G, de’Angelis N. Robotic multiquadrant colorectal procedures: A single-center experience and a systematic review of the literature. Front Surg 2022; 9:991704. [PMID: 36061042 PMCID: PMC9428340 DOI: 10.3389/fsurg.2022.991704] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 08/03/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose Robotic surgery has been progressively implemented for colorectal procedures but is still limited for multiquadrant abdominal resections. The present study aims to describe our experience in robotic multiquadrant colorectal surgeries and provide a systematic review and meta-analysis of the literature investigating the outcomes of robotic total proctocolectomy (TPC), total colectomy (TC), subtotal colectomy (STC), or completion proctectomy (CP) compared to laparoscopy. Methods At our institution 16 consecutive patients underwent a 2- or 3-stage totally robotic total proctocolectomy (TPC) with ileal pouch-anal anastomosis. A systematic review of the literature was performed to select studies on robotic and laparoscopic multiquadrant colorectal procedures. Meta-analyses were used to compare the two approaches. Results In our case series, 14/16 patients underwent a 2-stage robotic TPC for ulcerative colitis with a mean operative time of 271.42 (SD:37.95) minutes. No conversion occurred. Two patients developed postoperative complications. The mean hospital stay was 8.28 (SD:1.47) days with no readmissions. Mortality was nil. All patients underwent loop-ileostomy closure, and functional outcomes were satisfactory. The literature appraisal was based on 23 retrospective studies, including 736 robotic and 9,904 laparoscopic multiquadrant surgeries. In the robotic group, 36 patients underwent STC, 371 TC, 166 TPC, and 163 CP. Pooled data analysis showed that robotic TC and STC had a lower conversion rate (OR = 0.17;95% CI, 0.04–0.82; p = 0.03) than laparoscopic TC and STC. The robotic approach was associated with longer operative time for TC and STC (MD = 104.64;95% CI, 18.42–190.87; p = 0.02) and TPC and CP (MD = 38.8;95% CI, 18.7–59.06; p = 0.0002), with no differences for postoperative complications and hospital stay. Reports on urological outcomes, sexual dysfunction, and quality of life were missing. Conclusions Our experience and the literature suggest that robotic multiquadrant colorectal surgery is safe and effective, with low morbidity and mortality rates. Nevertheless, the overall level of evidence is low, and functional outcomes of robotic approach remain largely unknown.
Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier: CRD42022303016.
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Affiliation(s)
- Giorgio Bianchi
- Unit of general surgery, CARE Department, Henri Mondor University Hospital, Créteil, France
- Department of medicine and surgery, University of Parma, Parma, Italy
- Gastroenterology and Endoscopy Unit, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Paschalis Gavriilidis
- Department of surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Aleix Martínez-Pérez
- Faculty of Health Sciences, Valencian International University, Valencia, Spain
- Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Gian Luigi de’Angelis
- Gastroenterology and Endoscopy Unit, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
- Correspondence: Gian Luigi de'Angelis
| | - Mathieu Uzzan
- Department of Gastroenterology, APHP-Henri Mondor University Hospital, Creteil, France
| | - Iradj Sobhani
- Department of Gastroenterology, APHP-Henri Mondor University Hospital, Creteil, France
- EC2M-EA7375 Research Team, Henri Modor Campus, Paris East University, Creteil, France
| | - Federico Coccolini
- General, Emergency and Trauma Department, Pisa University Hospital, Pisa, Italy
| | - Carlo Alberto Schena
- Unit of general surgery, CARE Department, Henri Mondor University Hospital, Créteil, France
| | | | - Giuseppe Spinoglio
- IRCAD Faculty Member Robotic and Colorectal Surgery-IRCAD, Strasbourg, France
| | - Nicola de’Angelis
- Unit of general surgery, CARE Department, Henri Mondor University Hospital, Créteil, France
- EC2M-EA7375 Research Team, Henri Modor Campus, Paris East University, Creteil, France
- University Paris-Est, UPEC, Créteil, France
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Angriman I, Colangelo A, Mescoli C, Fassan M, D’Incà R, Savarino E, Pucciarelli S, Bardini R, Ruffolo C, Scarpa M. Validation of the Padova Prognostic Score for Colitis in Predicting Long-Term Outcome After Restorative Proctocolectomy. Front Surg 2022; 9:911044. [PMID: 35959125 PMCID: PMC9357893 DOI: 10.3389/fsurg.2022.911044] [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: 04/01/2022] [Accepted: 06/13/2022] [Indexed: 11/30/2022] Open
Abstract
Background In 10%–20% of cases it is impossible to make a differential diagnosis between ulcerative colitis and Crohn's colitis. A 50% failure rate of J pouch ilea-anal anastomosis is observed in Crohn's colitis. In 2009, we created the Padua Prognostic Score for Colitis (PPSC) to predict the long-term clinical and functional outcome and quality of life of patients undergoing restorative proctocolectomy with J pouch. The aim of the present study is to establish and validate the accuracy of a prognostic score for chronic inflammatory bowel diseases (IBD). Patient population and methods The PPSC was created in 2009 by integrating clinical and histological information of patients undergoing RPC. It included preoperative perianal abscess or fistula, rectal sparing, terminal ileum involvement, skip lesions and histological diagnosis of indeterminate colitis or Crohn's colitis on the operative specimen. The validity of this score was tested in predicting postoperative abscess or fistula, anal canal disease, pouchitis, pouch failure and new diagnosis of Crohn's disease. Correlation analysis, ROC curve analysis and survival analysis were used to validate the PPSC in a different cohort from the previous one. Results We retrospectively enrolled in this study 138 consecutive patients undergoing CPR for ulcerative colitis (n = 127) or indeterminate colitis (n = 11) in our institution since 2005 to 2020. In this period, we observed 11 patients with postoperative abscess or fistula, 3 with anal canal disease, 40 with pouchitis, 6 with pouch failure and 6 with new diagnosis of Crohn's disease. In the new validation cohort, the PPSC confirmed to have a good accuracy in predicting the onset of postoperative CD (AUC = 74.5%, p = 0.018). Kaplan Meier curves demonstrate how a PPSC over 1 can reliably predicts the long-term onset of, pouchitis (p = 0.002) and anal abscess or fistulae (p = 0.04). Conclusions In this validation study we confirmed the accuracy of the PPSC in predicting postoperative fistulas or abscesses and pouchitis. Therefore, we believe that in clinical practice patients with a PPSC score greater than 1 should be warned of this risk of possible Crohn’s disease diagnosis and pouch failure.
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Affiliation(s)
- Imerio Angriman
- Clinica Chirurgica I, University Hospital of Padova, Padova, Italy
- Correspondence: Imerio Angriman,
| | | | - Claudia Mescoli
- Department of Medicine, (Pathology Section), University Hospital of Padova, Padova, Italy
| | - Matteo Fassan
- Department of Medicine, (Pathology Section), University Hospital of Padova, Padova, Italy
| | - Renata D’Incà
- Department of Surgical & Gastroenterological Sciences, (Gastroenterology Section),University Hospital of Padova, Padova, Italy
| | - Edoardo Savarino
- Department of Surgical & Gastroenterological Sciences, (Gastroenterology Section),University Hospital of Padova, Padova, Italy
| | | | - Romeo Bardini
- Department of Surgical & Gastroenterological Sciences, (Gastroenterology Section),University Hospital of Padova, Padova, Italy
| | - Cesare Ruffolo
- Clinica Chirurgica I, University Hospital of Padova, Padova, Italy
| | - Marco Scarpa
- Clinica Chirurgica I, University Hospital of Padova, Padova, Italy
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Bar N, Avraham Y, Dubinsky V, Cohen NA, Weiss GA, Banon L, Tulchinsky H, Maharshak N, Gophna U, Dotan I. Long-term Antibiotic Treatment in Pouchitis-Patterns of Use and Safety. Inflamm Bowel Dis 2022; 28:1027-1033. [PMID: 34536075 DOI: 10.1093/ibd/izab209] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Pouchitis, often developing after colectomy and ileal pouch-anal anastomosis for ulcerative colitis, is highly responsive to antibiotics. Ciprofloxacin and/or metronidazole are commonly used, often for prolonged periods. We report patterns of antibiotic use, adverse events, and resistant infections in patients with pouchitis with long-term antibiotic treatment. METHODS In a cohort of patients following pouch surgery, a retrospective nested case-control analysis was performed between 2010 and 2017. Ultra-long-term use, defined as the top 10% of users, was compared with the remaining users. Patterns of antibiotic use, adverse events, and resistant infections were analyzed. RESULTS The cohort included 205 patients with UC, of whom 167 (81.5%) used antibiotics for pouchitis, predominantly ciprofloxacin. The long-term antibiotic use rate was 18% and 42% at 5 and 20 years postsurgery, respectively. Mean antibiotic use of at least 1, 3, and 6 months/year was noted in 54 (26.3%), 31 (15.1%), and 14 (6.8%) patients, respectively. Twenty-two (13.2%) and 4 (2.4%) patients reported mild and severe (transient) adverse events, respectively, without mortalities, tendinopathies or arrhythmias. Adverse event rates for ciprofloxacin and metronidazole were 1per 10,000 and 6 per 10,000 use-days, respectively. Longer, but not ultra-long antibiotic use, was associated with mild adverse events. There was no association between antibiotic use and resistant infections. Thirteen (6.3%) patients required ileostomy procedures-more commonly in the ultra-long-term antibiotic users. CONCLUSIONS Patients with pouchitis may require prolonged antibiotic treatment, reflecting clinical benefit and favorable safety profile. Few adverse events and resistant infections were observed with long-term antibiotics use. However, resistant microbial strains selection, which are potentially transmittable, warrants consideration of different therapeutic alternatives.
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Affiliation(s)
- Nir Bar
- Department of Gastroenterology and Hepatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoav Avraham
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Vadim Dubinsky
- School of Molecular Cell Biology and Biotechnology, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Nathaniel A Cohen
- Department of Gastroenterology and Hepatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Guy A Weiss
- Celiac Disease Program, Vatche and Tamar Manoukian Division of Digestive Diseases, University of California Los Angeles, Los Angeles, California, USA
| | - Lian Banon
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Internal Medicine H, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Hagit Tulchinsky
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Colorectal Unit, Department of Surgery, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Nitsan Maharshak
- Department of Gastroenterology and Hepatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Gophna
- School of Molecular Cell Biology and Biotechnology, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Iris Dotan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel
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Quinn KP, Busciglio IA, Burton DD, Inoue A, Lee YS, Heiken JP, Sheedy SP, Fletcher JG, Raffals LE. Defining normal pouch function in patients with ileal pouch-anal anastomosis: a pilot study. Aliment Pharmacol Ther 2022; 55:1560-1568. [PMID: 35274320 DOI: 10.1111/apt.16859] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 10/27/2022] [Accepted: 02/20/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Most patients experience good functional outcomes following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis. AIM We aimed to determine if asymptomatic patients with an IPAA had findings consistent with normal defecation on standard objective anorectal tests. METHODS Patients 18-65 years old with IPAA and self-reported healthy pouch function were recruited. Patients with chronic pouchitis, Crohn's disease, anastomotic stricture, or indication for IPAA other than ulcerative or indeterminate colitis were excluded. Patients underwent an interview with an abbreviated Rome Questionnaire followed by high-resolution ano-pouch manometry, balloon expulsion test, pouch barostat, and magnetic resonance (MR) defecography. RESULTS Twenty patients completed all testing. Six patients were excluded from the final analysis due to symptoms suggestive of pouch evacuation disorder on the abbreviated Rome Questionnaire (n = 2), structural abnormality on MR imaging (n = 3), or both (n = 1). Of the remaining 14 patients, mean anal resting pressure during high-resolution manometry was 72 ± 16 mmHg, mean anal squeeze pressure was 247 ± 69 mmHg, and mean pouch-anal gradient during the simulated evacuation was -27 ± 37 mmHg. The meantime to balloon expulsion was 54 seconds. During dynamic MR defecography, the mean descent of ano-pouch junction was 2.6 cm, and mean pouch evacuation was 44.5% and 74.2% pre- and posttoilet phase, respectively. CONCLUSIONS A substantial proportion of patients with IPAA and self-reported healthy pouch function have anatomic and/or functional abnormalities of the pouch. In asymptomatic IPAA patients with an anatomically normal pouch, we have proposed normal parameters for high-resolution ano-pouch manometry, time to balloon expulsion, pouch barostat, and MR defecography.
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Affiliation(s)
- Kevin P Quinn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Irene A Busciglio
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Mayo Clinic, Rochester, Minnesota, USA
| | - Duane D Burton
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Mayo Clinic, Rochester, Minnesota, USA
| | - Akitoshi Inoue
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yong S Lee
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jay P Heiken
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Joel G Fletcher
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Laura E Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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A Single-Center Comparative Study of Open Transabdominal and Laparoscopic Transanal Ileal Pouch-Anal Anastomosis with Total Mesorectal Excision. Has the Bar Been Raised? J Gastrointest Surg 2022; 26:1070-1076. [PMID: 34993896 DOI: 10.1007/s11605-021-05236-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 12/19/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Most ulcerative colitis (UC) patients requiring surgery undergo transabdominal ileal pouch-anal anastomosis (IPAA) performed minimally invasively or open. Although one multicenter study demonstrated acceptably low morbidity after transanal pouch, our initial single-center experience with transanal IPAA (ta-IPAA) was associated with an unacceptably high rate of anastomotic leak. The aim of this study was to compare the short-term outcomes of ta-IPAA and transabdominal IPAA with growing experience of transanal proctectomy and determine whether one approach offered any advantage or benefit over the other. METHODS Single-center series of consecutive ulcerative colitis patients underwent 3-stage IPAA, either ta-IPAA or transabdominal IPAA at a tertiary referral center. The primary outcome measure was overall complications until immediately prior to stoma closure. Secondary outcomes included postoperative clinical measures. RESULTS The study group consisted of 113 patients, which included 37 (33%) patients undergoing transabdominal or open IPAA and 76 (67%) patients undergoing ta-IPAA. The overall complication rate was numerically higher in the ta-IPAA group (56%) compared to the transabdominal group (38%) (p = 0.07) as was the incidence of anastomotic leak in the ta-IPAA group (12 vs. 5%) (p = 0.17). Mean length of hospital stay was significantly higher in the transanal IPAA group (p = 0.04). Operating time, opioid use and pain scores were similar between groups. CONCLUSION Transanal IPAA has a higher incidence of overall complications and anastomotic leak compared to transabdominal IPAA. Postoperative length of stay is significantly higher in patients undergoing ta-IPAA. Operating room time, opiate use and pain scores are comparable between the two surgical approaches. Transanal IPAA appears to offer little advantage over transabdominal IPAA.
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Opoku D, Hart A, Thompson DT, Tran C, Suraju MF, Chang J, Boatman S, Troester A, Goffredo P, Hassan I. Equivalency of short-term perioperative outcomes after open, laparoscopic and robotic ileal anal pouch anastomosis. Does procedure complexity override operative approach? Surg Open Sci 2022; 9:86-90. [PMID: 35719413 PMCID: PMC9201005 DOI: 10.1016/j.sopen.2022.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/02/2022] [Accepted: 05/14/2022] [Indexed: 02/07/2023] Open
Abstract
Background Ileal pouch anal anastomosis is the treatment of choice for patients with chronic ulcerative colitis and familial adenomatous polyposis undergoing a proctocolectomy and desiring bowel continuity. It is a technically complex operation associated with significant morbidity and may be performed by an open, laparoscopic, or robotic approach. However, there is a paucity of data regarding the comparative perioperative outcomes between these 3 techniques outside of institutional studies. Methods The NSQIP targeted proctectomy data set was used to identify patients who underwent open, laparoscopic, and robotic ileal pouch anal anastomosis between 2016 and 2019. Thirty-day outcomes between different surgical approaches were compared using univariate and multivariable analysis. Results During the study period, 1,067 open, 971 laparoscopic, and 341 robotic ileal pouch anal anastomosis were performed. The most frequent indications were inflammatory bowel disease (64%), malignancy (18%), and familial adenomatous polyposis (7%). Mean age of the cohort was 43 ± 15 years with 43% female and 76% with body mass index ≤ 30 kg/m2. Overall morbidity was 26.8% for the entire cohort with 4% anastomotic leak, 6% reoperation, 21% ileus, and 21% readmission rate. After adjusting for available confounders, operative approach was not associated with better short-term outcomes, including length of stay, overall morbidity, anastomotic leak, reoperation, incidence of ileus, and 30-day readmissions. Conclusion Ileal pouch anal anastomosis continues to be associated with significant postoperative morbidity regardless of operative approach. Patient-related advantages in terms of perioperative outcomes for laparoscopic and robotic platforms compared to open surgery are less pronounced in complex operations such as ileal pouch anal anastomosis. Ileal anal pouch anastomosis is a technically complex operation associated with significant postoperative 30-day morbidity. Postoperative morbidity is similar between open, laparoscopic, and robotic approaches. In complex operations such as ileal anal pouch anastomosis, the short-term perioperative advantages of minimally invasive approaches may not be clinically evident.
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Harsløf S, Pachler FR, Thaysen HV, Drejer M, Brandsborg S, Nørager CB, Tøttrup A. Functional outcome and quality of life after transanal minimal invasive pouch surgery. Int J Colorectal Dis 2022; 37:1141-1150. [PMID: 35467122 DOI: 10.1007/s00384-022-04158-y] [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] [Accepted: 04/17/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE To investigate functional outcomes and quality of life (QoL) after restorative proctocolectomy (RPC) using transanal minimal invasive surgery (TAMIS). METHOD The study consists of two sub-studies. A cohort study comprised 98 consecutive patients, who underwent TAMIS RPC. These patients were the first at our department to undergo TAMIS RPC. We collected information about surgery, complications, postoperative morbidity and mortality ≤ 30 days, and pouch problems. Patients were also invited to participate in a case-control study in which the patients would respond to three different questionnaires, the Inflammatory Bowel Disease Questionnaire (IBDQ), the Short Form-36 General Health Questionnaire (SF-36), and questions from the Pouch Dysfunction Score. We compared the responding TAMIS RPC patients to a Danish national cohort (0-10 years from RPC, n = 514) of patients having RPC between 1980 and 2010. We compared functional outcomes and QoL. RESULTS Four (4%) of the TAMIS patients had an anastomotic leak; none of these required re-operation with removal of the pouch. Anastomotic leak was treated with antibiotics and drain. Out of the four leaks, only one ended up with a permanent stoma; all others had their stoma reversed successfully. The TAMIS patients had the same number of bowel movements as the patients in the Danish national cohort study. The same was seen with regard to incontinence. We had no conversions in our series of TAMIS procedures. CONCLUSION The TAMIS technique shows acceptable outcomes, both in regard to postoperative complications and also functional outcome and QoL.
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Affiliation(s)
- Sanne Harsløf
- Surgical Department, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Frederik Rønne Pachler
- Surgical Department, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Henriette Vind Thaysen
- Surgical Department, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Marie Drejer
- Surgical Department, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Søren Brandsborg
- Surgical Department, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Charlotte Buchard Nørager
- Surgical Department, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Anders Tøttrup
- Surgical Department, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
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48
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Quinn KP, Urquhart SA, Janssens LP, Lennon RJ, Chedid VG, Raffals LE. Primary Sclerosing Cholangitis-Associated Pouchitis: A Distinct Clinical Phenotype. Clin Gastroenterol Hepatol 2022; 20:e964-e973. [PMID: 33549866 DOI: 10.1016/j.cgh.2021.02.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 01/20/2021] [Accepted: 02/02/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with primary sclerosing cholangitis (PSC) commonly undergo ileal pouch-anal anastomosis (IPAA) for medically-refractory ulcerative colitis (UC) or colorectal dysplasia. Pouchitis develops more frequently in patients with PSC, potentially leading to increased morbidity. We aimed to assess clinical characteristics and treatment outcomes for pouchitis in patients with PSC compared to a matched, non-PSC cohort. METHODS All patients with PSC who underwent IPAA and were diagnosed with pouchitis (PSC-pouchitis) were identified. A matched cohort composed of non-PSC patients who underwent IPAA for UC and subsequently developed pouchitis (UC-pouchitis) was developed. Relevant demographic, clinical, endoscopic, histologic, and treatment data were collected and compared between groups. RESULTS Of those with PSC-pouchitis (n=182), 53.9% and 46.1% underwent IPAA for medically-refractory disease and dysplasia, respectively, compared to 88.7% and 11.3% in the UC-pouchitis group (P < .001). Patients with PSC-pouchitis were more likely to develop chronic pouchitis (68.1% vs 34.1%; P < .001), have moderate-to-severe pouch inflammation (54.9% vs 32.4%; P < .001), and prepouch ileitis (34.1% vs 11.5%; P < .001) compared to UC-pouchitis. Of those with PSC-pouchitis, 50.6% and 17.6% developed chronic antibiotic-dependent or antibiotic-refractory pouchitis, respectively, compared to 25.8% and 7.7% with UC-pouchitis. There was no difference in treatment response between the two groups with use of thiopurines, anti-tumor necrosis factor agents, and newer biologics. CONCLUSIONS PSC-associated pouchitis presents with a unique clinical phenotype, characterized by increased risk of chronic pouchitis, moderate-to-severe pouch inflammation, prepouch ileitis, and less response to conventional antimicrobial therapy.
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Affiliation(s)
- Kevin P Quinn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Siri A Urquhart
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Ryan J Lennon
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Victor G Chedid
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Laura E Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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Duraes LC, Liang J, Steele SR, Cengiz B, Delaney CP, Holubar SD, Gorgun E. Restorative proctocolectomy with ileal pouch-anal anastomosis in elderly patients - is advanced age a contraindication? ANZ J Surg 2022; 92:2180-2184. [PMID: 35434821 PMCID: PMC9542127 DOI: 10.1111/ans.17728] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/23/2022] [Accepted: 03/30/2022] [Indexed: 12/17/2022]
Abstract
Aim We aimed to determine pouch function and retention rate for restorative proctocolectomy with ileal pouch‐anal anastomosis (IPAA) for ulcerative colitis (UC) in elderly patients. Methods We identified patients over 50 years old subjected to IPAA for confirmed pathological UC from 1980 until 2016. Patients were grouped according to age: 50–59, 60–69 and 70+ years. Short and long‐term outcomes and quality of life (QOL) were compared among the groups. Results Six hundred and one patients were identified (399 (66.4%) between 50–59 181 (30.1%) between 60–69, and 21 (3.5%) over 70 years of age). More males were in the 70+ arm, and more two‐stage procedures were performed in this group. Wound infection increased with age (P = 0.023). There was a trend of more fistula and pouchitis in the 70+ patients (P = 0.052 and P = 0.055, respectively). Pouch failure rate increased with age, and it was statistically significant in the 70+ cohort (P = 0.015). Multivariate stepwise logistic regression showed that pelvic sepsis (HR 4.8 (95% CI 1.5–15.4), P = 0.009), fistula (HR 6.0 (95% CI 1.7–21.5), and mucosectomy with handsewn anastomosis (HR 4.5 (95% CI 1.4–14.7)), were independently associated with pouch failure. No difference was observed in the QOL among the groups, but pouch function was better for patients younger than 60 years. Conclusion In elderly patients with UC, IPAA may be offered with reasonable functional outcomes, and ileal pouch retention rates, as an alternative to the permanent stoma. Stapled anastomosis increases the chance of pouch retention and should be recommended as long as the distal rectum does not carry dysplasia.
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Affiliation(s)
- Leonardo C Duraes
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jennifer Liang
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Bora Cengiz
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Conor P Delaney
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Stefan D Holubar
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Emre Gorgun
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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50
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Syed A, Seoud T, Carleton NM, Thakkar S, Kiran RP, Shen B. Association Between Portal Vein Thrombosis and Pouchitis in Patients with Ulcerative Colitis. Dig Dis Sci 2022; 67:1303-1310. [PMID: 33948758 DOI: 10.1007/s10620-021-06969-5] [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: 11/15/2020] [Accepted: 03/23/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pouchitis is the most common long-term complication in patients requiring colectomy ileal pouch-anal anastomosis with medically refractory ulcerative colitis or colitis-associated neoplasia. A previous small case series suggests associated between portal vein thrombosis (PVT) and ischemic pouchitis. AIM To evaluate the association between PVT and other demographic and clinical factors and pouchitis. METHODS We used Explorys Inc., a population-based database, to search medical records between 1999 and 2020 with SNOMED-CT code criteria for "construction of pouch" and "ileal pouchitis." Patients with pouchitis were compared to those with previous pouch construction without pouchitis. Factors associated with pouchitis identified with univariable analysis were introduced into a multivariable model. A post hoc analysis further stratified demographical findings of the association between PVT and pouchitis. RESULTS We identified 7900 patients with ileal pouchitis (7.5%) and 97,510 with pouch construction without pouchitis. In multivariate binary logistic regression, adjusted odds ratio (aOR) for the risk of pouchitis in patients with PVT was 10.78 (95% confidence interval [CI] 7.04-16.49, P < 0.001). Other significant factors associated with pouchitis included male gender (aOR 1.11, 95% CI 1.02-1.21, P = 0.018), deep vein thrombosis (aOR 1.46, 95% CI 1.23-1.72, P < 0.001), and the use of non-steroidal anti-inflammatory drugs (aOR 1.37, 95% CI 1.28-1.45, P < 0.001). Smoking was a protective factor (aOR 0.30, 95% CI 0.33-0.36, P < 0.001). Further sub-analysis showed a higher prevalence of younger patients with PVT and pouchitis. CONCLUSIONS We report PVT as an independent risk factor associated with pouchitis. Our findings support that PVT is a potentially manageable perioperative complication, and intervention may reduce the risk of pouchitis.
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Affiliation(s)
- Aslam Syed
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, PA, USA.,Department of Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Talal Seoud
- Division of Gastroenterology and Hepatology, Stony Brook University Hospital, Long Island, NY, USA
| | - Neil M Carleton
- Medical Scientist Training Program, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Shyam Thakkar
- Adjunct Faculty, Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Ravi P Kiran
- Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center/New York Presbyterian Hospital, Herbert Irving Pavilion-Rm 843, 161 Fort Washington Ave, New York, NY, 10032, USA
| | - Bo Shen
- Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center/New York Presbyterian Hospital, Herbert Irving Pavilion-Rm 843, 161 Fort Washington Ave, New York, NY, 10032, USA.
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