Male issues of the ileal pouch

Creation of an institutional preoperative checklist to support clinical risk assessment in patients with ulcerative colitis (UC) considering ileoanal pouch surgery

Background

Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the most established restorative operative approach for patients with ulcerative colitis. It has associated morbidity and the potential for major repercussions on quality of life. As such, patient selection is crucial to its success. The main aim of this paper is to present an institutional preoperative checklist to support clinical risk assessment and patient selection in those considering IPAA.

Methods

A literature review was performed to identify the risk factors associated with surgical complications, decreased functional outcomes/quality of life, and pouch failure after IPAA. Based on this, a preliminary checklist was devised and modified through an iterative process. This was then evaluated by a consensus group comprising the pouch multidisciplinary team (MDT) core members.

Results

The final preoperative checklist includes assessment for risk factors such as gender, advanced age, obesity, comorbidities, sphincteric impairment, Crohn's disease and pelvic radiation therapy. In addition, essential steps in the decision-making process, such as pouch nurse counselling and discussion regarding surgical alternatives, are also included. The last step of the checklist is discussion at a dedicated pouch-MDT.

Discussion

A preoperative checklist may support clinicians with the selection of patients that are suitable for pouch surgery. It also serves as a useful tool to inform the discussion of cases at the MDT meeting.

Ileal pouch-anal anastomosis provides good functional and quality of life outcomes following proctocolectomy: A 33-year single centre experience

BACKGROUND

Restorative proctocolectomy (RP) with ileal pouch-anal anastomosis (IPAA) remains the gold standard for the surgical management of patients with medically refractive mucosal ulcerative colitis. We aimed to identify functional and quality of life (QOL) outcomes in RP and IPAA surgery patients at our institution.

METHODS

A retrospective observational study was performed including all patients who had undergone RP and IPAA between August 1984 and November 2017 at Royal Prince Alfred Hospital (RPAH).

RESULTS

316 consecutive patients were identified, median age 39 (range 5 to 81) years. The median duration of disease was 60 (range 1 to 528) months. Ulcerative colitis was the main preoperative diagnosis with the main RP indication being failure of medical treatment. The median postoperative stay post-IPAA was 11 (range of 5 to 67) days. Pouchitis was the most common late complication (22.1%), bleeding pouch (3.5%) the earliest, with a 6.8% rate of symptomatic anastomotic leak. Visual analogue scale QOL measure (P-value <0.001), St Marks incontinence score (P-value = 0.001) and Cleveland clinic score (P-value = 0.002) all revealed significant improvement in functional outcomes and QOL.

CONCLUSION

QOL and functional outcomes following RP with IPAA in patients at our institution are excellent and comparable to institutions with larger patient numbers.

Linarin ameliorates dextran sulfate sodium-induced colitis in C57BL/6J mice via the improvement of intestinal barrier, suppression of inflammatory responses and modulation of gut microbiota

Linarin is a natural flavonoid compound found in Chrysanthemum indicum, Mentha species and other plants with various biological activities. The study aimed to investigate the protective effect of linarin supplementation on dextran sulfate sodium (DSS)-induced colitis in C57BL/6J mice and its potential mechanisms. The results showed that doses of linarin at 25 and 50 mg kg^-1 day^-1 alleviated the DSS-induced histopathological damage, and improved the mucosal layer and intestinal barrier function. Importantly, Linarin significantly suppressed the levels of myeloperoxidase activity and pro-inflammatory cytokines (IL-6, TNF-α, IFN-γ and IL-1β) in the colon, and enhanced the mRNA level of anti-inflammatory cytokine (IL-10). Moreover, 50 mg kg^-1 day^-1 linarin reversed the gut microbiota damaged by DSS, including Alistipes, Rikenella and Clostridia UCG-014_norank. Linarin also partly increased the relative abundance of short-chain fatty acids (SCFAs)-producing bacteria, including Lactobacillus, Roseburia, Parabacteroides and Blautia, and elevated the contents of SCFAs. Collectively, linarin attenuates DSS-induced colitis in mice, suggesting that linarin may be a promising nutritional strategy for reducing inflammatory bowel disease.

Diagnosis and classification of ileal pouch disorders: consensus guidelines from the International Ileal Pouch Consortium

Restorative proctocolectomy with ileal pouch-anal anastomosis is an option for most patients with ulcerative colitis or familial adenomatous polyposis who require colectomy. Although the construction of an ileal pouch substantially improves patients' health-related quality of life, the surgery is, directly or indirectly, associated with various structural, inflammatory, and functional adverse sequelae. Furthermore, the surgical procedure does not completely abolish the risk for neoplasia. Patients with ileal pouches often present with extraintestinal, systemic inflammatory conditions. The International Ileal Pouch Consortium was established to create this consensus document on the diagnosis and classification of ileal pouch disorders using available evidence and the panellists' expertise. In a given individual, the condition of the pouch can change over time. Therefore, close monitoring of the activity and progression of the disease is essential to make accurate modifications in the diagnosis and classification in a timely manner.

Endoscopic Treatment of Ileal Pouch Sinus

BACKGROUND AND AIMS

Pouch sinus is a serious complication in patients undergoing ileal pouch-anal anastomosis. The aim of this study was to verify the efficacy and safety of endoscopic needle knife sinusotomy (NKSi) in the management of pouch sinus.

METHODS

All consecutive patients with a pouch sinus treated with NKSi from 2008 to 2016 were identified. The primary outcomes were complete healing of the sinus and pouch survival.

RESULTS

A total of 109 patients were included. During a median follow-up of 2.1 years (interquartile range: 0.7-4.4), 54 (49.5%) patients achieved complete healing and 20 (18.3%) patients had partial healing, Twenty-two (20.2%) patients developed sinus-related pouch failure. In multivariable analysis for the sinus healing, Crohn's disease of the pouch was a risk factor [odds ratio (OR): 0.3, 95% confidence interval (CI): 0.1-0.8), whereas a longer interval between NKSi (OR: 1.1, 95%CI: 1.0-1.1) and high body mass index (OR: 1.2, 95%CI: 1.0-1.3) were protective factors. In the multivariable analysis for surgery-free survival, previously documented acute anastomotic leak (OR:3.5, 95%CI: 1.2-10.4), toxic megacolon (OR: 7.4, 95%CI: 1.9-29.1), an increased length of sinus (OR: 1.4, 95%CI: 1.0-2.0), and increased duration from sinus diagnosis to NKSi (OR: 2.6, 95%CI: 1.1-6.2) were risk factors; and a longer interval between NKSis (OR: 0.9, 95%CI: 0.9-0.99), and concurrent use of dextrose 50% (OR: 0.2, 95%CI: 0.04-0.6) and doxycycline during the NKSi procedure (OR: 0.2, 95%CI: 0.04-0.7) were protective factors. NKSi-associated complications were reported in 6 (1.8% per procedure) cases.

CONCLUSIONS

NKSi is an effective and safe procedure for treating pouch sinus.

Impact of sex on 30-day complications and long-term functional outcomes following ileal pouch-anal anastomosis for chronic ulcerative colitis

PURPOSE

To determine the impact of patient sex on operative characteristics, short-term complications, and long-term functional outcomes following ileal pouch-anal anastomosis (IPAA) for chronic ulcerative colitis (CUC).

METHODS

A retrospective review was performed on all patients undergoing two- or three-stage IPAA for CUC at our institution between January 2002 and August 2013. Patient demographics, operative characteristics, 30-day postoperative complications, and long-term functional outcomes from annual survey data were analyzed comparing men and women patients.

RESULTS

During the study period, 911 IPAAs (542 men, 369 women) were performed. Men were older and were more often obese (both p < 0.01). Use of a three-stage approach and laparoscopic approach were similar between men and women, but operation length, intraoperative blood loss, and hospital length of stay were all higher in men (all p < 0.05). At 30 days, women had increased rates of superficial surgical site infections and urinary tract infections (both p < 0.05), while men had increased rates of urinary retention (p = 0.03). Five hundred forty-six patients (60%; 307 men, 239 women) responded to the annual post IPAA survey with a median follow-up of 5.1 and 5.0 years in men and women, respectively. Women reported increased frequency of daytime stools in the early follow-up period, but this difference resolved with time. Other functional outcomes were similar.

CONCLUSION

Patient sex impacts intraoperative complexity, postoperative length of stay, 30-day postoperative outcomes, and initial long-term function. These findings underscore the need to adjust preoperative counseling regarding IPAA outcomes based on sex.

Ulcerative colitis

Ulcerative colitis is a chronic inflammatory disease affecting the colon, and its incidence is rising worldwide. The pathogenesis is multifactorial, involving genetic predisposition, epithelial barrier defects, dysregulated immune responses, and environmental factors. Patients with ulcerative colitis have mucosal inflammation starting in the rectum that can extend continuously to proximal segments of the colon. Ulcerative colitis usually presents with bloody diarrhoea and is diagnosed by colonoscopy and histological findings. The aim of management is to induce and then maintain remission, defined as resolution of symptoms and endoscopic healing. Treatments for ulcerative colitis include 5-aminosalicylic acid drugs, steroids, and immunosuppressants. Some patients can require colectomy for medically refractory disease or to treat colonic neoplasia. The therapeutic armamentarium for ulcerative colitis is expanding, and the number of drugs with new targets will rapidly increase in coming years.

Multiparametric Prostate Magnetic Resonance Imaging and Cognitively Targeted Transperineal Biopsy in Patients With Previous Abdominoperineal Resection and Suspicion of Prostate Cancer

OBJECTIVE

To report our experience with a combination of prostate magnetic resonance imaging (MRI) and transperineal ultrasound biopsy for evaluating the prostate in patients with elevated prostate-specific antigen (PSA) who have previously undergone abdominoperineal resection (APR).

PATIENTS AND METHODS

We reviewed the records of 11 patients with a history of APR and clinical suspicion of prostate cancer due to elevated PSA levels over a 5-year period. All patients underwent multiparametric MRI at our institution prior to biopsy. MR diagnoses were validated either by transperineal ultrasound biopsy (Likert 3-5) guided by visual registration or clinical follow-up >6 months (Likert 1-2).

RESULTS

All 7 cases with highly suspicious lesions (Likert 4-5) on MRI demonstrated cancer-1 case of Gleason 3 + 3 and 6 cases of Gleason ≥3 + 4 disease. Two cases with Likert 3 MR lesions revealed benign tissue upon biopsy. Two patients with no suspicious lesions on MRI were followed-up clinically, with PSA levels remaining stable over a mean period of 17.5 months (range 7-28 months).

CONCLUSION

The use of prebiopsy multiparametric prostate MRI and subsequent cognitively targeted transperineal biopsy guided by visual registration can aid in the diagnostic pathway of patients with APR and a suspicion of prostate cancer.