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Giddings HL, Ng KS, Solomon MJ, Steffens D, Van Buskirk J, Young J. Unexpected variation in outcomes following total (procto)colectomies for ulcerative colitis in New South Wales, Australia: a population-based 19-year linked-data study. Colorectal Dis 2024. [PMID: 38937922 DOI: 10.1111/codi.17074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 02/02/2024] [Accepted: 01/06/2024] [Indexed: 06/29/2024]
Abstract
AIM Total (procto)colectomy for ulcerative colitis (UC) is associated with significant morbidity, which is increased in the emergency setting. This study aimed to evaluate the outcomes following total (procto)colectomies at a population level within New South Wales (NSW), Australia, and identify case mix and hospital factors associated with these outcomes. METHODS A retrospective data linkage study of patients undergoing total (procto)colectomy for UC in NSW over a 19-year period (2001-2020) was performed. The primary outcome was 90-day mortality. The influence of hospital level factors (including annual volume) and patient demographic variables on outcomes was assessed using logistic regression. Temporal trends in annual volume and evidence for centralization were assessed. RESULTS In all, 1418 patients (mean 47.0 years [SD 18.7], 58.7% male) underwent total (procto)colectomy during the study period. The overall 90-day mortality rate was 3.2% (emergency 8.6% and elective 0.8%). After adjusting for confounding, increasing age at total (procto)colectomy, higher comorbidity burden, public health insurance (Medicare) status, emergency operation and living outside a major city were significantly associated with increased mortality. Hospital volume was significantly associated with mortality at a univariate level, but this did not persist on multivariate modelling. CONCLUSIONS Outcomes of UC patients undergoing total (procto)colectomy in NSW Australia are comparable to international experience. Whilst higher mortality rates are observed in low volume and public hospitals, this appears attributable to case mix and acuity rather than surgical volume alone. However, as inflammatory bowel disease surgery is not centralized in Australia, only one NSW hospital performed >10 UC total (procto)colectomies annually. Variation in mortality according to insurance status and across regional/remote areas may indicate inequality in the availability of specialist inflammatory bowel disease treatment, which warrants further research.
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Affiliation(s)
- Hugh L Giddings
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SouRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kheng-Seong Ng
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SouRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SouRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SouRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Joe Van Buskirk
- Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- Public Health Research Analytics and Methods for Evidence, Sydney, New South Wales, Australia
| | - Jane Young
- Surgical Outcomes Research Centre (SouRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Giddings HL, Ng KS, Solomon MJ, Steffens D, Van Buskirk J, Young J. High but decreasing rates of reconstruction after total proctocolectomy for ulcerative colitis, and evidence of a direct volume outcome relationship. ANZ J Surg 2024. [PMID: 38525855 DOI: 10.1111/ans.18986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/19/2024] [Accepted: 03/12/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Total (procto)colectomy is indicated in 15%-20% of ulcerative colitis(UC) patients during their disease course. Reconstruction options to avoid a permanent ileostomy include an ileoanal pouch anastomosis (IPAA) or ileorectal anastomosis (IRA). This study aimed to investigate reconstruction rates using Australian-based population-level data, and factors influencing reconstruction. METHODS A retrospective data linkage study of the NSW population over a 19-year period was performed. Patients with UC who underwent total (procto)colectomy with a minimum of 1-year follow up were included. The main outcome was reconstruction with either IPAA or IRA. The influence of hospital and patient factors on reconstruction rates was assessed by Cox regression. RESULTS Overall, 1047 patients underwent a (procto)colectomy for UC (mean age 45.9 years [SD ± 18.3], 640 [61.1%] male). The 5-year reconstruction rate was 55% (IPAA 89%). Advanced age, emergent colectomy, higher comorbidity burden, and geographical remoteness were significantly associated with lower reconstruction rates. A lower reconstruction rate was also observed in the most recent time-period (2014-2019) (aHR 0.68[95% CI 0.54-0.86]), and where index (procto)colectomy was performed in low-volume (<1 pouch/year) pouch hospitals (aHR 0.60 [95% CI 0.43-0.82]). CONCLUSIONS NSW Australia has the highest reported rate of reconstruction following UC (procto)colectomy globally. However, rates reduced in the most recent time-period. There was variation in reconstruction rates across centres, with primary and overall reconstruction rates proportionate to hospital pouch volume. Reconstruction rates were also lower for patients living outside major cities. To ensure equitable opportunities for reconstruction, patients being considered for IBD pouch surgery should be centralized to a limited number of specialist pouch centres.
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Affiliation(s)
- Hugh L Giddings
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kheng-Seong Ng
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Joe Van Buskirk
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Public Health Research Analytics and Methods for Evidence, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Jane Young
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Hartikainen AK, Khan I, Karjalainen EK, Renkonen-Sinisalo L, Arkkila P, Jalanka J, Lepistö AH, Satokari R. Microbiota and mucosal gene expression of fecal microbiota transplantation or placebo treated patients with chronic pouchitis. Gut Microbes 2024; 16:2295445. [PMID: 38214604 DOI: 10.1080/19490976.2023.2295445] [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: 08/18/2023] [Accepted: 12/12/2023] [Indexed: 01/13/2024] Open
Abstract
Altered microbiota and impaired host immune function have been linked to the pathogenesis of pouchitis. We used 16S rRNA gene sequencing and RNA sequencing data from a previous randomized clinical trial (RCT) on fecal microbiota transplantation (FMT) therapy in 26 chronic pouchitis patients with one-year follow-up. We analyzed changes in both luminal and mucosal microbiota composition, as well as in host mucosal gene expression to gain insights into the host-microbiota interactions possibly underlying clinical outcomes of the patients. Antibiotic type and pattern of use were significant drivers of the luminal microbiota at baseline. Differential gene expression analysis indicated transition from ileal to colonic gene expression in the pouch, and upregulation in inflammation- and immune system-related pathways in the pouch. At 4 weeks, the non-relapsed FMT patients had a lower microbiota dissimilarity to the donor than the non-relapsed placebo patients (p = .02). While two FMT-treated patients showed a shift toward the donor's microbiota during the one-year follow-up, the overall FMT microbiota modulation effect was low. Patient's luminal and mucosal microbiota profiles were unstable in both FMT and placebo groups. Expression of the chemokine receptor CXCR4 was downregulated at 52 weeks compared to the baseline in the non-relapsed patients in both FMT and placebo groups. Microbiota modulation by FMT seems to be low in this patient group. The microbiota composition or alterations did not explain the relapse status of the patients. Some evidence for remission-related host gene expression pattern was found; specifically, CXCR4 expression may have a role in sustained remission.
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Affiliation(s)
- Anna K Hartikainen
- Human Microbiome Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Imran Khan
- Human Microbiome Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Essi K Karjalainen
- Department of Gastrointestinal Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Laura Renkonen-Sinisalo
- Department of Gastrointestinal Surgery, Helsinki University Hospital, Helsinki, Finland
- Genome-Scale Biology Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Perttu Arkkila
- Department of Gastroenterology, Helsinki University Hospital, Helsinki, Finland
- Department of Medicine, University of Helsinki, Helsinki, Finland
| | - Jonna Jalanka
- Human Microbiome Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Anna H Lepistö
- Department of Gastrointestinal Surgery, Helsinki University Hospital, Helsinki, Finland
- Genome-Scale Biology Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Reetta Satokari
- Human Microbiome Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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Giddings HL, Ng KS, Solomon MJ, Steffens D, Van Buskirk J, Young J. Reducing rate of total colectomies for ulcerative colitis but higher morbidity in the biologic era: an 18-year linked data study from New South Wales Australia. ANZ J Surg 2023; 93:2928-2938. [PMID: 37795917 DOI: 10.1111/ans.18713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/06/2023] [Accepted: 09/19/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND This study aims to investigate the trends in UC surgery in New South Wales (NSW) at a population level. METHODS A retrospective data linkage study of the NSW population was performed. Patients of any age with a diagnosis of UC who underwent a total abdominal colectomy (TAC) ± proctectomy between Jul-2001 and Jun-2019 were included. The age adjusted population rate was calculated using Australian Bureau of Statistics data. Multivariable linear regression modelled the trend of TAC rates, and assessed the effect of infliximab (listed on the Pharmaceutical Benefits Scheme for UC in Apr-2014). RESULTS A total of 1365 patients underwent a TAC ± proctectomy (mean age 47.0 years (±18.6), 59% Male). Controlling for differences between age groups, the annual rate of UC TACs decreased by 2.4% each year (95% CI 1.4%-3.4%) over the 18-year period from 1.30/100000 (2002) to 0.84/100000 (2019). An additional incremental decrease in the rate of TACs was observed after 2014 (OR 0.83, 95% CI 0.69-1.00). There was no change in the proportion of TACs performed emergently over the study period (OR 1.02, 95% CI 0.998-1.04). The odds of experiencing any perioperative surgical complication (aOR 1.54, 95% CI 1.01-2.33, P = 0.043), and requiring ICU admission (aOR 1.85, 95% CI 1.24-2.76, P = 0.003) significantly increased in 2014-2019 compared to 2002-2007. CONCLUSIONS The rate of TACs for UC has declined over the past two decades. This rate decrease may have been further influenced by the introduction of biologics. Higher rates of complications and ICU admissions in the biologic era may indicate poorer patient physiological status at the time of surgery.
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Affiliation(s)
- Hugh L Giddings
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kheng-Seong Ng
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Joe Van Buskirk
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Public Health Research Analytics and Methods for Evidence, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Jane Young
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Sobrado LF, Mori FNC, Facanali CBG, Camargo MGM, Nahas SC, Sobrado CW. RISK FACTORS FOR EARLY POSTOPERATIVE COMPLICATIONS IN ACUTE COLITIS IN THE ERA OF BIOLOGIC THERAPY. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2023; 36:e1770. [PMID: 37878974 PMCID: PMC10595074 DOI: 10.1590/0102-672020230052e1770] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 04/30/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Despite major advances in the clinical treatment of inflammatory bowel disease, some patients still present with acute colitis and require emergency surgery. AIMS To evaluate the risk factors for early postoperative complications in patients undergoing surgery for acute colitis in the era of biologic therapy. METHODS Patients with inflammatory bowel disease admitted for acute colitis who underwent total colectomy at a single tertiary hospital from 2012 to 2022 were evaluated. Postoperative complications were graded according to Clavien-Dindo classification (CDC). Patients with more severe complications (CDC≥2) were compared with those with less severe complications (CDC<2). RESULTS A total of 46 patients underwent surgery. The indications were: failure of clinical treatment (n=34), patients' or surgeon's preference (n=5), hemorrhage (n=3), toxic megacolon (n=2), and bowel perforation (n=2). There were eight reoperations, 60.9% of postoperative complications classified as CDC≥2, and three deaths. In univariate analyses, preoperative antibiotics use, ulcerative colitis diagnosis, lower albumin levels at admission, and preoperative hospital stay longer than seven days were associated with more severe postoperative complications. CONCLUSIONS Emergency surgery for acute colitis was associated with a high incidence of postoperative complications. Preoperative use of antibiotics, ulcerative colitis, lower albumin levels at admission, and delaying surgery for more than seven days were associated with more severe early postoperative complications. The use of biologics was not associated with worse outcomes.
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Affiliation(s)
- Lucas Faraco Sobrado
- Universidade de São Paulo, Coloproctology Division, Gastroenterology Department, Faculty of Medicine – São Paulo (SP), Brazil
| | - Fernando Noboru Cabral Mori
- Universidade de São Paulo, Coloproctology Division, Gastroenterology Department, Faculty of Medicine – São Paulo (SP), Brazil
| | | | - Mariane Gouvea Monteiro Camargo
- Universidade de São Paulo, Coloproctology Division, Gastroenterology Department, Faculty of Medicine – São Paulo (SP), Brazil
| | - Sérgio Carlos Nahas
- Universidade de São Paulo, Coloproctology Division, Gastroenterology Department, Faculty of Medicine – São Paulo (SP), Brazil
| | - Carlos Walter Sobrado
- Universidade de São Paulo, Coloproctology Division, Gastroenterology Department, Faculty of Medicine – São Paulo (SP), Brazil
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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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Ali N, Abdulkareem R. Pharmacogenetic Effect of Thiopurine Methyl Transferase (TPMT) Gene Expression and Serum TNF on the Imuran Response in Ulcerative Colitis (UC) Iraqi Patients. Rep Biochem Mol Biol 2023; 12:438-447. [PMID: 38618257 PMCID: PMC11015922 DOI: 10.61186/rbmb.12.3.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 09/24/2023] [Indexed: 04/16/2024]
Abstract
Background Ulcerative colitis (UC), a chronic inflammatory bowel disease (IBD), exerts its impact on both rectal and colonic mucosa, with a growing incidence. This study aims to explore the pharmacogenetic influence of thiopurine methyl transferase (TPMT) gene expression and serum tumor necrosis factor (TNF) levels on the response to Imuran in Iraqi patients with UC. Methods Seventy individuals with chronic UC and 30 healthy controls were enrolled in this investigation. RNA extraction using the triazole method and enzyme-linked immunosorbent assay (ELISA) for TNF measurement were employed. Patients, aged 15-50 years, underwent Imuran treatment. Results Diverse responses to Imuran were observed among patients, with TPMT gene expression levels below 1 in 35 patients leading to side effects, while the remaining 35 patients exhibited positive responses with TPMT gene expression exceeding 1. Patients with varying degrees of severe, moderate, and mild UC associated with TNF showed a significant correlation with Imuran non-response. Conclusions A distinct correlation was identified between TPMT gene expression and Imuran therapy outcomes in UC patients. Further investigation is warranted to elucidate the underlying mechanism, positioning the TPMT gene as a potential therapeutic target for mitigating the impact of UC.
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Affiliation(s)
- Noor Ali
- Institute of Genetic Engineering and Biotechnology for Postgraduate Studies, University of Bagdad, Baghdad, Iraq.
- These authors contributed equally to this work.
| | - Rafid Abdulkareem
- Institute of Genetic Engineering and Biotechnology for Postgraduate Studies, University of Bagdad, Baghdad, Iraq.
- These authors contributed equally to this work.
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Hoshino N, Hida K, Yoshida S, Ueno K, Noguchi T, Ishihara S, Sugihara K, Ajioka Y, Obama K. Postoperative complications and prognosis based on type of surgery in ulcerative colitis patients with colorectal cancer: A multicenter observational study of data from the Japanese Society for Cancer of the Colon and Rectum. Ann Gastroenterol Surg 2023; 7:626-636. [PMID: 37416741 PMCID: PMC10319604 DOI: 10.1002/ags3.12659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/24/2022] [Accepted: 01/19/2023] [Indexed: 07/08/2023] Open
Abstract
Background Patients with ulcerative colitis are reported to be at increased risk of colorectal cancer and are also at high risk of postoperative complications. However, the incidence of postoperative complications in these patients and how the type of surgery performed affects prognosis are not well understood. Methods Data collected by the Japanese Society for Cancer of the Colon and Rectum on ulcerative colitis patients with colorectal cancer between January 1983 and December 2020 were analyzed according to whether total colorectal resection was performed with ileoanal anastomosis (IAA), ileoanal canal anastomosis (IACA), or permanent stoma creation. The incidence of postoperative complications and the prognosis for each surgical technique were investigated. Results The incidence of overall complications was not significantly different among the IAA, IACA, and stoma groups (32.7%, 32.3%, and 37.7%, respectively; p = 0.510). The incidence of infectious complications was significantly higher in the stoma group (21.2%) than in the IAA (12.9%) and IACA (14.6%) groups (p = 0.048); however, the noninfectious complication rate was lower in the stoma group (13.7%) than in the IAA (21.1%) and IACA (16.2%) groups (p = 0.088). Five-year relapse-free survival was higher in patients without complications than in those with complications in the IACA group (92.8% vs. 75.2%; p = 0.041) and the stoma group (78.1% vs. 71.2%, p = 0.333) but not in the IAA group (90.3% vs. 90.0%, p = 0.888). Conclusion The risks of infectious and noninfectious complications differed according to the type of surgical technique used. Postoperative complications worsened prognosis.
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Affiliation(s)
- Nobuaki Hoshino
- Department of SurgeryKyoto University Graduate School of MedicineKyotoJapan
| | - Koya Hida
- Department of SurgeryKyoto University Graduate School of MedicineKyotoJapan
| | - Shinya Yoshida
- Department of SurgeryKyoto University Graduate School of MedicineKyotoJapan
| | - Kohei Ueno
- Department of SurgeryKyoto University Graduate School of MedicineKyotoJapan
| | - Tatsuki Noguchi
- Department of Surgical OncologyThe University of TokyoTokyoJapan
| | | | - Kenichi Sugihara
- Department of Surgical OncologyTokyo Medical and Dental UniversityTokyoJapan
| | - Yoichi Ajioka
- Division of Molecular and Diagnostic Pathology, Graduate School of Medical and Dental SciencesNiigata UniversityNiigataJapan
| | - Kazutaka Obama
- Department of SurgeryKyoto University Graduate School of MedicineKyotoJapan
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Gorgun E, Ozcimen E, Yilmaz S, Jia X, Ozgur I. Single-incision laparoscopic clockwise continuous total abdominal colectomy with end ileostomy in ulcerative colitis; surgical technique and results of a 7-year experience. Surg Endosc 2023; 37:4065-4074. [PMID: 36952049 DOI: 10.1007/s00464-023-09976-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 02/21/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Total abdominal colectomy with end ileostomy is the first stage of the three-stage surgical treatment of medically refractory ulcerative colitis. Laparoscopic surgery is a safe approach offering several benefits. Single-incision laparoscopic surgery is an alternative minimally invasive approach providing excellent cosmetic results. Literature on single-incision laparoscopic clockwise continuous total abdominal colectomy in the treatment of ulcerative colitis is limited. Aim of the study is to describe our surgical technique and report the outcomes. METHODS Medically refractory ulcerative colitis patients who underwent single-incision laparoscopic clockwise continuous total abdominal colectomy with end ileostomy by a single surgeon between January 2013 and December 2020 at our tertiary care center are included. Patient charts were reviewed retrospectively. RESULTS 52 patients were included in the final analysis. 51.9% patients were male with the median age of 31.5 years and body mass index of 22.2 kg/m2. Median duration of operation was 100 min with estimated blood loss of 50 ml. There were no intraoperative complications, conversions to conventional laparoscopy or open surgery. Postoperative complications were reported in 13 (25%) patients with most common being ileus (17.3%). 3 patients had surgical site infections. 2 patients had postoperative bleeding requiring blood transfusion. 2 patients had reoperation within postoperative 30 days. Median length of hospital stay was 2 days. No mortalities were reported. CONCLUSION Single-incision laparoscopic clockwise continuous approach is safe and effective in ulcerative colitis patients undergoing total abdominal colectomy with end ileostomy. Further prospective randomized studies are warranted.
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Affiliation(s)
- Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Main Campus, Cleveland, OH, 44195, USA.
| | - Elif Ozcimen
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Main Campus, Cleveland, OH, 44195, USA
| | - Sumeyye Yilmaz
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Main Campus, Cleveland, OH, 44195, USA
| | - Xue Jia
- Department of Quantitative Health Sciences, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Ilker Ozgur
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Main Campus, Cleveland, OH, 44195, USA
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He Q, Wu J, Ke J, Zhang Q, Zeng W, Luo Z, Gong J, Chen Y, He Z, Lan P. Therapeutic role of ursodeoxycholic acid in colitis-associated cancer via gut microbiota modulation. Mol Ther 2023; 31:585-598. [PMID: 38556635 PMCID: PMC9931610 DOI: 10.1016/j.ymthe.2022.10.014] [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: 03/22/2022] [Revised: 09/21/2022] [Accepted: 10/25/2022] [Indexed: 11/09/2022] Open
Abstract
Inflammatory bowel disease (IBD) is a predisposing factor for colitis-associated cancer (CAC). The association between bile acids and the gut microbiota has been demonstrated in colon neoplasia; however, the effect of ursodeoxycholic acid (UDCA) on gut microbiota alteration in development of colitis and CAC is unknown. Our analysis of publicly available datasets demonstrated the association of UDCA treatment and accumulation of Akkermansia. UDCA-mediated alleviation of DSS-induced colitis was microbially dependent. UDCA treatment significantly upregulated Akkermansia colonization in a mouse model. Colonization of Akkermansia was associated with enhancement of the mucus layer upon UDCA treatment as well as activation of bile acid receptors in macrophages. UDCA played a role in CAC prevention and treatment in the AOM-DSS and ApcMin/+-DSS models through downregulation of inflammation and accumulation of Akkermansia. This study suggests that UDCA intervention could reshape intestinal gut homeostasis, facilitating colonization of Akkermansia and preventing and treating colitis and CAC.
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Affiliation(s)
- Qilang He
- The Sixth Affiliated Hospital, School of Medicine, Sun Yat-sen University, Guangzhou, 510655 Guangdong, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, Guangzhou, 510655 Guangdong, China
| | - Jinjie Wu
- The Sixth Affiliated Hospital, School of Medicine, Sun Yat-sen University, Guangzhou, 510655 Guangdong, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, Guangzhou, 510655 Guangdong, China
| | - Jia Ke
- The Sixth Affiliated Hospital, School of Medicine, Sun Yat-sen University, Guangzhou, 510655 Guangdong, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, Guangzhou, 510655 Guangdong, China
| | - Qiang Zhang
- The Sixth Affiliated Hospital, School of Medicine, Sun Yat-sen University, Guangzhou, 510655 Guangdong, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, Guangzhou, 510655 Guangdong, China
| | - Wanyi Zeng
- The Sixth Affiliated Hospital, School of Medicine, Sun Yat-sen University, Guangzhou, 510655 Guangdong, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, Guangzhou, 510655 Guangdong, China
| | - Zhanhao Luo
- The Sixth Affiliated Hospital, School of Medicine, Sun Yat-sen University, Guangzhou, 510655 Guangdong, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, Guangzhou, 510655 Guangdong, China
| | - Junli Gong
- The Sixth Affiliated Hospital, School of Medicine, Sun Yat-sen University, Guangzhou, 510655 Guangdong, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, Guangzhou, 510655 Guangdong, China
| | - Yuan Chen
- The Sixth Affiliated Hospital, School of Medicine, Sun Yat-sen University, Guangzhou, 510655 Guangdong, China
| | - Zhen He
- The Sixth Affiliated Hospital, School of Medicine, Sun Yat-sen University, Guangzhou, 510655 Guangdong, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, Guangzhou, 510655 Guangdong, China.
| | - Ping Lan
- The Sixth Affiliated Hospital, School of Medicine, Sun Yat-sen University, Guangzhou, 510655 Guangdong, China; Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Guangdong Institute of Gastroenterology, Guangzhou, 510655 Guangdong, China.
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Karjalainen EK, Renkonen-Sinisalo L, Satokari R, Mustonen H, Ristimäki A, Arkkila P, Lepistö AH. Fecal Microbiota Transplantation in Chronic Pouchitis: A Randomized, Parallel, Double-Blinded Clinical Trial. Inflamm Bowel Dis 2021; 27:1766-1772. [PMID: 33501942 PMCID: PMC8528148 DOI: 10.1093/ibd/izab001] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND In ulcerative colitis, a pouchitis is the most common long-term adverse effect after proctocolectomy and ileal pouch-anal anastomosis. Approximately 5% of patients develop chronic antibiotic-dependent or antibiotic-refractory pouchitis without any effective treatment. The aim of this trial was to investigate the efficacy and safety of fecal microbiota transplantation in the treatment of chronic pouchitis. METHODS This was a single-center, double-blinded, parallel group trial comparing donor fecal microbiota transplantation with placebo (autologous transplant) in chronic pouchitis. Twenty-six patients were recruited at the Helsinki University Hospital between December 2017 and August 2018 and were randomly allocated a 1:1 ratio to either donor fecal microbiota transplantation or placebo. The protocol included 2 transplantations into the pouch on weeks 0 and 4, and patients were followed up for 52 weeks. RESULTS Nine patients in the intervention group and 8 patients in the placebo group relapsed during the 52-week follow-up, and the relapse-free survival did not differ between the groups (P = 0.183, log-rank; hazard ratio, 1.90 [95% confidence interval, 0.73-4.98; P = 0.190]). In the subgroup analysis of patients using continuous antibiotics before the study, the relapse-free survival was shorter in the intervention group (P = 0.004, log-rank; hazard ratio, 13.08 [95% confidence interval, 1.47-116.60; P = 0.021]). No major adverse effects were reported. CONCLUSIONS The fecal microbiota transplantation treatment regime used in our study was not effective in the treatment of chronic pouchitis. The safety profile of fecal microbiota transplantation was good. CLINICALTRIALS.GOV IDENTIFIER NCT03378921.
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Affiliation(s)
- Essi K Karjalainen
- Department of Gastrointestinal Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Laura Renkonen-Sinisalo
- Department of Gastrointestinal Surgery, Helsinki University Hospital, Helsinki, Finland
- Genome-Scale Biology Research Program, Research Programs Unit, University of Helsinki, Helsinki, Finland
| | - Reetta Satokari
- Human Microbiome Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Harri Mustonen
- Department of Gastrointestinal Surgery, Helsinki University Hospital, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
| | - Ari Ristimäki
- Department of Pathology, Medicum, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- HUS Diagnostic Center, HUSLAB, Pathology, Helsinki University Hospital, Helsinki, Finland
- Applied Tumor Genomics Research Program, Research Programs Unit, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Perttu Arkkila
- Department of Gastroenterology, Helsinki University Hospital, Helsinki, Finland
| | - Anna H Lepistö
- Department of Gastrointestinal Surgery, Helsinki University Hospital, Helsinki, Finland
- Genome-Scale Biology Research Program, Research Programs Unit, University of Helsinki, Helsinki, Finland
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12
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De Simone B, Davies J, Chouillard E, Di Saverio S, Hoentjen F, Tarasconi A, Sartelli M, Biffl WL, Ansaloni L, Coccolini F, Chiarugi M, De’Angelis N, Moore EE, Kluger Y, Abu-Zidan F, Sakakushev B, Coimbra R, Celentano V, Wani I, Pintar T, Sganga G, Di Carlo I, Tartaglia D, Pikoulis M, Cardi M, De Moya MA, Leppaniemi A, Kirkpatrick A, Agnoletti V, Poggioli G, Carcoforo P, Baiocchi GL, Catena F. WSES-AAST guidelines: management of inflammatory bowel disease in the emergency setting. World J Emerg Surg 2021; 16:23. [PMID: 33971899 PMCID: PMC8111988 DOI: 10.1186/s13017-021-00362-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/05/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Despite the current therapeutic options for the treatment of inflammatory bowel disease, surgery is still frequently required in the emergency setting, although the number of cases performed seems to have decreased in recent years. The World Society of Emergency Surgery decided to debate in a consensus conference of experts, the main pertinent issues around the management of inflammatory bowel disease in the emergent situation, with the need to provide focused guidelines for acute care and emergency surgeons. METHOD A group of experienced surgeons and gastroenterologists were nominated to develop the topics assigned and answer the questions addressed by the Steering Committee of the project. Each expert followed a precise analysis and grading of the studies selected for review. Statements and recommendations were discussed and voted at the Consensus Conference of the 6th World Society of Emergency Surgery held in Nijmegen (The Netherlands) in June 2019. CONCLUSIONS Complicated inflammatory bowel disease requires a multidisciplinary approach because of the complexity of this patient group and disease spectrum in the emergency setting, with the aim of obtaining safe surgery with good functional outcomes and a decreasing stoma rate where appropriate.
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Affiliation(s)
- Belinda De Simone
- Department of Metabolic, Digestive and Emergency Minimally Invasive Surgery, Centre Hospitalier Intercommunal de Poissy et Saint Germain en Laye, 10 rue du Champ Gaillard, 78303 Poissy, France
| | - Justin Davies
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Elie Chouillard
- Department of Metabolic, Digestive and Emergency Minimally Invasive Surgery, Centre Hospitalier Intercommunal de Poissy et Saint Germain en Laye, 10 rue du Champ Gaillard, 78303 Poissy, France
| | - Salomone Di Saverio
- Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Varese, Italy
| | - Frank Hoentjen
- RIMLS - Radboud Institute for Molecular Life Sciences, Radboud University-Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Antonio Tarasconi
- Department of Trauma and Emergency Surgery, Parma University Hospital, Parma, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Walter L. Biffl
- Scripps Memorial Hospital La Jolla, San Diego, California USA
| | - Luca Ansaloni
- Department of Surgery, University Hospital of Pavia, Pavia, Italy
| | - Federico Coccolini
- Department of Emergency and Trauma Surgery, University Hospital of Pisa, Pisa, Italy
| | - Massimo Chiarugi
- Department of Emergency and Trauma Surgery, University Hospital of Pisa, Pisa, Italy
| | - Nicola De’Angelis
- Minimally Invasive and Robotic Digestive Surgery Unit, Regional General Hospital F. Miulli, Acquaviva delle Fonti (Bari), Italy
| | - Ernest E. Moore
- Denver Health System - Denver Health Medical Center, Denver, USA
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Boris Sakakushev
- First Clinic of General Surgery, University Hospital St George, Plovdiv, Bulgaria
| | - Raul Coimbra
- UCSD Health System - Hillcrest Campus Department of Surgery Chief Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, San Diego, CA USA
| | - Valerio Celentano
- Department of Colorectal Surgery, Portsmouth Hospitals NHS Trust, Hampshire, UK
| | - Imtiaz Wani
- Government Gousia Hospital-Srinagar, Directorate of Health Services-Kashmir, Srinagar, Kashmir India
| | - Tadeja Pintar
- Department of Abdominal Surgery, Umc Ljubljana, Ljubljana, Slovenia
| | - Gabriele Sganga
- Department of Emergency Surgery, “A. Gemelli Hospital”, Catholic University of Rome, Rome, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, University of Catania, General Surgery, Cannizzaro Hospital, Catania, Italy
| | - Dario Tartaglia
- Emergency Surgery Unit & Trauma Center, New Santa Chiara Hospital, University of Pisa, Pisa, Italy
| | - Manos Pikoulis
- 3rd Department of Surgery, Attikon General Hospital, National & Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Maurizio Cardi
- Department of Oncological Surgery “P.Valdoni”, Sapienza University, Rome, Italy
| | - Marc A. De Moya
- Trauma/Acute Care Surgery Department, Medical College of Wisconsin/Froedtert Trauma Center, Wauwatosa, Wisconsin USA
| | - Ari Leppaniemi
- Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery Foothills Medical Centre, Calgary, Alberta Canada
| | | | - Gilberto Poggioli
- Department of Surgical Sciences, Policlinico Sant’Orsola Malpighi, Bologna, Italy
| | - Paolo Carcoforo
- Department of Surgery, University Hospital of Ferrara, Ferrara, Italy
| | | | - Fausto Catena
- Department of Trauma and Emergency Surgery, Parma University Hospital, Parma, Italy
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Tiu SPT, Hajirawala LN, Leonardi C, Davis KG, Orangio GR, Barton JS. Delayed Surgery Does Not Increase Risk in Urgent Colectomy for Ulcerative Colitis. Am Surg 2020; 87:880-884. [PMID: 33280393 DOI: 10.1177/0003134820971576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Medical management is the cornerstone of therapy for ulcerative colitis (UC). In the setting of fulminant disease, hospitalized patients may undergo medical rescue therapy (MRT) or urgent surgery. We hypothesized that delayed attempts at MRT result in increased morbidity and mortality following urgent surgery for UC. OBJECTIVE The aim is to assess the outcomes for patients requiring urgent, inpatient surgery for UC in a prompt or delayed fashion. DESIGN The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) general and colectomy-specific databases from 2013 to 2016 were queried. Urgent surgery was defined as nonelective, nonemergency surgery. Patients were divided into prompt and delayed groups based on time from admission to surgery of <48 hours or >48 hours. Baseline characteristics and 30-day outcomes were compared using univariate and multivariate analyses. SETTING The ACS NSQIP database from 2013 to 2016 was evaluated. PATIENTS Adult patients undergoing nonelective, nonemergency colectomy for UC. MAIN OUTCOME MEASURES 30-day morbidity and mortality. RESULTS 921 patients underwent urgent inpatient surgery for UC. In univariate analysis, there was no significant difference between prompt and delayed surgery for wound infection, sepsis, return to operating room, or readmission. LIMITATIONS Retrospective study of a quality improvement database. Patients who underwent successful MRT did not receive surgery, so are not included in the database. CONCLUSIONS Delaying surgery to further attempt MRT does not alter short-term outcomes and may allow conversion to elective future surgery. Contrarily, medical optimization does not improve short-term outcomes.
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Affiliation(s)
- Simon Peter T Tiu
- Department of Surgery, School of Medicine, Louisiana State University, New Orleans, LA, USA
| | - Luv N Hajirawala
- Department of Surgery, School of Medicine, Louisiana State University, New Orleans, LA, USA
| | - Claudia Leonardi
- Behavioral and Community Health Sciences, School of Public Health, School of Medicine, Louisiana State University, New Orleans, LA, USA
| | - Kurt G Davis
- Department of Surgery, Section of Colorectal Surgery, School of Medicine, Louisiana State University, New Orleans, LA, USA
| | - Guy R Orangio
- Department of Surgery, Section of Colorectal Surgery, School of Medicine, Louisiana State University, New Orleans, LA, USA
| | - Jeffrey S Barton
- Department of Surgery, Section of Colorectal Surgery, School of Medicine, Louisiana State University, New Orleans, LA, USA
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14
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Yang Y, Li L, Xu C, Wang Y, Wang Z, Chen M, Jiang Z, Pan J, Yang C, Li X, Song K, Yan J, Xie W, Wu X, Chen Z, Yuan Y, Zheng S, Yan J, Huang J, Qiu F. Cross-talk between the gut microbiota and monocyte-like macrophages mediates an inflammatory response to promote colitis-associated tumourigenesis. Gut 2020; 70:gutjnl-2020-320777. [PMID: 33122176 PMCID: PMC8292576 DOI: 10.1136/gutjnl-2020-320777] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 08/13/2020] [Accepted: 09/20/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Macrophages are among the most abundant cells in the colon tumour microenvironment, and there is a close relationship among monocytes, macrophages and the gut microbiota. Alterations in the gut microbiota are involved in tumour development, but the underlying mechanisms remain unclear. We aim to elucidate the temporal changes in macrophage subsets and functions, and how these dynamics are regulated by microbial cues in the initiation of colitis-associated cancer. DESIGN A mouse model of colitis-associated tumourigenesis was established to determine macrophage dynamics. The role of monocyte-like macrophage (MLM) was confirmed by targeting its chemotaxis. The effects of the gut microbiota were assessed by antibiotic treatment and faecal microbiota transplantation. RESULTS A selective increase in MLMs was observed in the initial stages of colitis-associated cancer, with an enhanced secretion of inflammatory cytokines. MLM accumulation was regulated by CCL2 expression of colonic epithelial cells, which was influenced by bacteria-derived lipopolysaccharide (LPS). LPS further stimulated interleukin 1β production from MLMs, inducing interleukin-17-producing T-helper cell activation to promote inflammation. These observations were also supported by altered microbial composition associated with human colitis and colorectal cancer, evolving transcriptional signature and immune response during human colitis-associated tumourigenesis. CONCLUSIONS The gut microbiota uses LPS as a trigger to regulate MLM accumulation in a chemokine-dependent manner and generate a precancerous inflammatory milieu to facilitate tumourigenesis.
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Affiliation(s)
- Yunben Yang
- Department of Medical Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Key Laboratory of Tumor Microenvironment and Immune Therapy of Zhejiang Province, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Lili Li
- Department of Medical Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Key Laboratory of Tumor Microenvironment and Immune Therapy of Zhejiang Province, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Chunjing Xu
- Department of Breast Surgery, Zhejiang Hospital, Hangzhou, Zhejiang, China
| | - Yunke Wang
- Department of Medical Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Key Laboratory of Tumor Microenvironment and Immune Therapy of Zhejiang Province, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Zhen Wang
- Key Laboratory of Tumor Microenvironment and Immune Therapy of Zhejiang Province, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Mengyao Chen
- Department of Medical Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Key Laboratory of Tumor Microenvironment and Immune Therapy of Zhejiang Province, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Zhou Jiang
- Key Laboratory of Tumor Microenvironment and Immune Therapy of Zhejiang Province, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jun Pan
- Key Laboratory of Tumor Microenvironment and Immune Therapy of Zhejiang Province, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Chenghui Yang
- Key Laboratory of Tumor Microenvironment and Immune Therapy of Zhejiang Province, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiaoqian Li
- Key Laboratory of Tumor Microenvironment and Immune Therapy of Zhejiang Province, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Kai Song
- Department of Pathology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Junfeng Yan
- Key Laboratory of Tumor Microenvironment and Immune Therapy of Zhejiang Province, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Department of Surgical Oncology, Zhuji People's Hospital of Zhejiang Province, Zhuji, Zhejiang, China
| | - Wanglan Xie
- Department of Medical Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Key Laboratory of Tumor Microenvironment and Immune Therapy of Zhejiang Province, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xianguo Wu
- Department of Clinical Laboratory, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Zhigang Chen
- Key Laboratory of Tumor Microenvironment and Immune Therapy of Zhejiang Province, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Ying Yuan
- Department of Medical Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Shu Zheng
- Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jun Yan
- Department of Medicine and Department of Microbiology and Immunology, James Graham Brown Cancer Center, University of Louisville, Louisville, Kentucky, USA
| | - Jian Huang
- Key Laboratory of Tumor Microenvironment and Immune Therapy of Zhejiang Province, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Fuming Qiu
- Department of Medical Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Key Laboratory of Tumor Microenvironment and Immune Therapy of Zhejiang Province, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, Ministry of Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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15
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Mennillo E, Yang X, Paszek M, Auwerx J, Benner C, Chen S. NCoR1 Protects Mice From Dextran Sodium Sulfate-Induced Colitis by Guarding Colonic Crypt Cells From Luminal Insult. Cell Mol Gastroenterol Hepatol 2020; 10:133-147. [PMID: 32044398 PMCID: PMC7229481 DOI: 10.1016/j.jcmgh.2020.01.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Colonic stem cells are essential for producing the mucosal lining, which in turn protects stem cells from insult by luminal factors. Discovery of genetic and biochemical events that control stem cell proliferation and differentiation can be leveraged to decipher the causal factors of ulcerative colitis and aid the development of more effective therapy. METHODS We performed in vivo and in vitro studies from control (nuclear receptor corepressor 1 [NCoR1F/F]) and intestinal epithelial cell-specific NCoR1-deficient mice (NCoR1ΔIEC). Mice were challenged with dextran sodium sulfate to induce experimental ulcerative colitis, followed by colitis examination, barrier permeability analysis, cell proliferation immunostaining assays, and RNA sequencing analysis. By using crypt cultures, the organoid-forming efficiency, cell proliferation, apoptosis, and histone acetylation were analyzed after butyrate and/or tumor necrosis factor α treatments. RESULTS NCoR1ΔIEC mice showed a dramatic increase in disease severity in this colitis model, with suppression of proliferative cells at the crypt base as an early event and a concomitant increase in barrier permeability. Genome expression patterns showed an important role for NCoR1 in colonic stem cell proliferation and secretory cell differentiation. Colonic organoids cultured from NCoR1ΔIEC mice were more sensitive to butyrate-induced cell growth inhibition and apoptosis, which were exaggerated further by tumor necrosis factor α co-treatment, which was accompanied by increased histone acetylation. CONCLUSIONS NCoR1 regulates colonic stem cell proliferation and secretory cell differentiation. When NCoR1 is disrupted, barrier protection is weakened, allowing luminal products such as butyrate to penetrate and synergistically damage the colonic crypt cells. Transcript profiling: RNA sequencing data have been deposited in the GEO database, accession number: GSE136153.
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Affiliation(s)
- Elvira Mennillo
- Laboratory of Environmental Toxicology, Department of Pharmacology, University of California, San Diego, La Jolla, California
| | - Xiaojing Yang
- Laboratory of Environmental Toxicology, Department of Pharmacology, University of California, San Diego, La Jolla, California
| | - Miles Paszek
- Laboratory of Environmental Toxicology, Department of Pharmacology, University of California, San Diego, La Jolla, California
| | - Johan Auwerx
- Laboratory of Integrative and Systems Physiology, Institute of Bioengineering, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Christopher Benner
- Department of Medicine, School of Medicine, University of California, San Diego, La Jolla, California
| | - Shujuan Chen
- Laboratory of Environmental Toxicology, Department of Pharmacology, University of California, San Diego, La Jolla, California.
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16
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Yamada S, Kameyama H, Abe K, Tanaka K, Oyanagi H, Tajima Y, Nakano M, Shimada Y, Sakata J, Wakai T. Timing of Surgery to Treat Ulcerative Colitis: An Investigation Focused on Japanese Adults. Inflamm Intest Dis 2020; 5:20-26. [PMID: 32232051 DOI: 10.1159/000504885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 11/19/2019] [Indexed: 12/11/2022] Open
Abstract
Introduction There are no specific standards for the timing of surgery to treat ulcerative colitis, so reaching a decision on timing is often difficult. Objective The aim of this study was to evaluate the timing of surgery from the patients' perspective. Methods From among 203 patients who underwent restorative proctocolectomy with ileal pouch anal anastomosis to treat ulcerative colitis at our hospital from 1985 to 2013, we mailed a questionnaire to 101 of those who are currently attending periodic follow-up at our hospital. Results We analyzed 72 valid responses (71.2%). Overall, 65 patients (90.3%) responded that they were happy that they underwent surgery, 38 patients (52.8%) responded that the timing of surgery was appropriate, and 32 patients (44.4%) responded that they would have preferred to have had surgery earlier. The group of patients who would have preferred to have had surgery earlier included 23 patients (71.9%) who had undergone emergency surgery; the incidence of emergency surgery was significantly higher than in the group of 13 patients (34.2%) who had responded that the timing of surgery was appropriate (p = 0.002). Scores on the Medical Outcomes Study 36-Item Short-Form Health Survey (SF36), which reflect postoperative quality of life, were maintained at the same level as the Japanese standard values in our Japanese patients. Conclusion The degree of satisfaction of patients who underwent surgery for ulcerative colitis was favorable, although it is important to consider surgery at an earlier stage in patients who may need emergency surgery.
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Affiliation(s)
- Saki Yamada
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Hitoshi Kameyama
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Kaoru Abe
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Kana Tanaka
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Hidehito Oyanagi
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yosuke Tajima
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Masato Nakano
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yoshifumi Shimada
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Jun Sakata
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Toshifumi Wakai
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Karjalainen EK, Renkonen-Sinisalo L, Mustonen HK, Färkkilä M, Lepistö AH. Restorative Proctocolectomy in Ulcerative Colitis: Effect of Preoperative Immunomodulatory Therapy on Postoperative Complications and Pouch Failure. Scand J Surg 2020; 110:51-58. [PMID: 31960783 DOI: 10.1177/1457496919900409] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIMS Patients with ulcerative colitis are often treated with multiple immunomodulative agents to achieve remission. In refractory disease, the next option is frequently proctocolectomy with ileal pouch-anal anastomosis. No consensus exists as to whether immunomodulatory therapy at the time of ileal pouch surgery leads to any increase in postoperative complications. Our aim was to assess, in ulcerative colitis patients with restorative proctocolectomy, the effect of preoperative anti-tumor necrosis factor therapy and corticosteroids on postoperative complications and pouch failure. MATERIALS AND METHODS A retrospective medical record review of 445 patients with ulcerative colitis who underwent proctocolectomy with ileal pouch-anal anastomosis in Helsinki University Hospital between January 2005 and June 2016. RESULTS Anti-tumor necrosis factor agents were not associated with postoperative complications. Only high-dose corticosteroids (prednisolone ⩾20 mg or equivalent) were associated with higher incidence of anastomotic leak (12.6% vs 2.5%, P = 0.002) and wound dehiscence (4.2% vs 0%, P = 0.019), but pouch failure rate was no higher (2.1% vs 0%, P = 0.141) than in patients without corticosteroid treatment. A lower dosage of corticosteroids had no effect on early postoperative complications, but pouch failure rate was increased (4.4% vs 0%, P = 0.015). CONCLUSION Corticosteroids, but not anti-tumor necrosis factor therapy, were associated with postoperative complications. Preoperative use of corticosteroids may increase pouch failure rate, but the risk is still minor in high-volume centers performing ileal pouch surgery.
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Affiliation(s)
- E K Karjalainen
- Department of Gastrointestinal Surgery, Helsinki University Hospital, Helsinki, Finland
| | - L Renkonen-Sinisalo
- Department of Gastrointestinal Surgery, Helsinki University Hospital, Helsinki, Finland.,Genome-Scale Biology Research Program, Research Programs Unit, University of Helsinki, Helsinki, Finland
| | - H K Mustonen
- Department of Gastrointestinal Surgery, Helsinki University Hospital, Helsinki, Finland.,University of Helsinki, Helsinki, Finland
| | - M Färkkilä
- University of Helsinki, Helsinki, Finland.,Department of Gastroenterology, Helsinki University Hospital, Helsinki, Finland
| | - A H Lepistö
- Department of Gastrointestinal Surgery, Helsinki University Hospital, Helsinki, Finland.,Genome-Scale Biology Research Program, Research Programs Unit, University of Helsinki, Helsinki, Finland
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18
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Abstract
Since the introduction of the first anti-tumor necrosis factor antibodies in the late 1990s, biologic therapy has revolutionized the medical treatment of patients with inflammatory bowel disease (IBD). Nevertheless, surgery continues to play a significant role in treating IBD patients. Rates of intestinal resection in patients with Crohn's disease or colectomy in ulcerative colitis are reducing but not substantially over the long term. An increasing variety of biologic medications are now available to treat IBD patients in various clinical situations. Consequently, a number of questions persist about how biologic medications affect the need for surgery and overall course in IBD patients. Given the trend for earlier and more frequent use of biologic medications in IBD patients, a working knowledge of the effects of these medications on surgical decision-making and outcomes is essential for the practicing colorectal surgeon and gastroenterologist. This review seeks to summarize the relevant literature surrounding biologic use and IBD surgery with a focus on the effect of biologics on the frequency, type and complications of surgery in this 'age of biologics'.
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Affiliation(s)
- Daniel J Wong
- Department of Surgery, Division of Colon & Rectum Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Eve M Roth
- Department of Surgery, Division of Colon & Rectum Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph D Feuerstein
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Vitaliy Y Poylin
- Department of Surgery, Division of Colon & Rectum Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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19
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Wong DJ, Roth EM, Feuerstein JD, Poylin VY. Surgery in the age of biologics. Gastroenterol Rep (Oxf) 2019; 7:77-90. [PMID: 30976420 PMCID: PMC6454839 DOI: 10.1093/gastro/goz004] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 11/02/2018] [Indexed: 02/07/2023] Open
Abstract
Since the introduction of the first anti-tumor necrosis factor antibodies in the late 1990s, biologic therapy has revolutionized the medical treatment of patients with inflammatory bowel disease (IBD). Nevertheless, surgery continues to play a significant role in treating IBD patients. Rates of intestinal resection in patients with Crohn's disease or colectomy in ulcerative colitis are reducing but not substantially over the long term. An increasing variety of biologic medications are now available to treat IBD patients in various clinical situations. Consequently, a number of questions persist about how biologic medications affect the need for surgery and overall course in IBD patients. Given the trend for earlier and more frequent use of biologic medications in IBD patients, a working knowledge of the effects of these medications on surgical decision-making and outcomes is essential for the practicing colorectal surgeon and gastroenterologist. This review seeks to summarize the relevant literature surrounding biologic use and IBD surgery with a focus on the effect of biologics on the frequency, type and complications of surgery in this 'age of biologics'.
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Affiliation(s)
- Daniel J Wong
- Department of Surgery, Division of Colon & Rectum Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Eve M Roth
- Department of Surgery, Division of Colon & Rectum Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph D Feuerstein
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Vitaliy Y Poylin
- Department of Surgery, Division of Colon & Rectum Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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20
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The Effect of Biologics on Postoperative Complications in Children With Inflammatory Bowel Disease and Bowel Resection. J Pediatr Gastroenterol Nutr 2019; 68:334-338. [PMID: 30247424 DOI: 10.1097/mpg.0000000000002159] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES There has been limited investigation of pediatric patients with inflammatory bowel disease (IBD) who have been treated with biologic agents and undergo operative management. Postoperative complications in the adult setting have been mixed and in the pediatric population the data have been limited. This study compares children with IBD treated with biologic agents to patients treated with nonbiologic therapy before bowel resection. METHODS This is a single-center, retrospective chart review study of 62 children with IBD who underwent bowel resection between 2001 and 2017. Analysis included patient demographics, medications used before surgery, incidence of postoperative complications, indication for surgery, type of operation, and additional surgeries required. Postoperative complications were defined as superficial skin infection, leak at anastomotic site, intra-abdominal abscess, wound dehiscence, and so on. Complications were compared based on medical therapy. RESULTS Of the 62 children reviewed, 21 carried the diagnosis of ulcerative colitis, 40 had Crohn disease, and 1 had IBD-unspecified. Thirty-seven of the patients were treated with infliximab, adalimumab, or vedolizumab before their bowel resection. There were 4 complications documented within 30 days of the operation, with an overall complication rate of 6.45%. There were 2 complications in each of the cohorts, including intra-abdominal abscess (2), abdominal wall abscess (1), and pouchitis (1). CONCLUSION The number of complications was the same between those who did and did not receive a preoperative biologic agent. This study suggests that biologics may be safe to use in patients undergoing bowel resection.
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21
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Gröne J, Lorenz EM, Seifarth C, Seeliger H, Kreis ME, Mueller MH. Timing of surgery in ulcerative colitis in the biologic therapy era-the patient's perspective. Int J Colorectal Dis 2018; 33:1429-1435. [PMID: 30003360 DOI: 10.1007/s00384-018-3129-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND There is no general consensus regarding the ideal timing of surgery in patients with refractory ulcerative colitis (UC). Decision-making and timing of restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is influenced by treating physicians and patients themselves. The aim of this study was to determine whether or not patients would have preferred the operation to be performed earlier, at the same time, or at a later point of time and to determine the reasons for their preference. METHODS Clinical data of 193 patients with UC who have undergone IPAA were documented in a prospective database at our institution between 2004 and 2015. From this database, 190 patients were identified and a standardized custom-made questionnaire was mailed for follow-up survey. Patients who did not respond were called by telephone and encouraged to complete the questionnaire. RESULTS One hundred nine questionnaires were eligible for analysis (57.4%). Average time between diagnosis and surgery was 11.2 ± 10.8 years (mean ± SD). Indications for surgery were refractory disease (70.6%), colitis-associated colorectal cancer (11.0%), high-grade dysplasia or stenosis (11.9%), and septic complications of UC (6.4%); 39 of 77 patients (50.6%) with refractory UC reported to have preferred their operation to be carried out earlier as it was actually performed (16.8 ± 11.9 months). Refractory course of the disease was identified as a predictor for a retrospectively desired earlier surgical approach (p = 0.014). CONCLUSION A substantial proportion of patients felt that they should have undergone surgery earlier than actually performed. It appears that timing of the decision to undergo surgery is suboptimal. This situation may be improved by earlier surgical consultation in the course of the disease.
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Affiliation(s)
- Jörn Gröne
- Department of Surgery, Campus Benjamin Franklin, Charité University Medicine, Berlin, Germany.,Department of Surgery, Rotes Kreuz Krankenhaus, Bremen, Germany
| | - Eva-Maria Lorenz
- Department of Surgery, Campus Benjamin Franklin, Charité University Medicine, Berlin, Germany
| | - Claudia Seifarth
- Department of Surgery, Campus Benjamin Franklin, Charité University Medicine, Berlin, Germany
| | - Hendrik Seeliger
- Department of Surgery, Campus Benjamin Franklin, Charité University Medicine, Berlin, Germany
| | - Martin E Kreis
- Department of Surgery, Campus Benjamin Franklin, Charité University Medicine, Berlin, Germany
| | - Mario H Mueller
- Department of Surgery, Vivantes Hospital Neukölln, Rudower Straße 48, 12351, Berlin, Germany.
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22
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The Bisindole Alkaloid Caulerpin, from Seaweeds of the Genus Caulerpa, Attenuated Colon Damage in Murine Colitis Model. Mar Drugs 2018; 16:md16090318. [PMID: 30205459 PMCID: PMC6163434 DOI: 10.3390/md16090318] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 12/27/2022] Open
Abstract
Caulerpin (CLP), an alkaloid from algae of the genus Caulerpa, has shown anti-inflammatory activity. Therefore, this study aimed to analyze the effect of CLP in the murine model of peritonitis and ulcerative colitis. Firstly, the mice were submitted to peritonitis to evaluate which dose of CLP (40, 4, or 0.4 mg/kg) could decrease the inflammatory infiltration in the peritoneum. The most effective doses were 40 and 4 mg/kg. Then, C57BL/6 mice were submitted to colitis development with 3% dextran sulfate sodium (DSS) and treated with CLP at doses of 40 and 4 mg/kg. The disease development was analyzed through the disease activity index (DAI); furthermore, colonic tissue samples were submitted to histological analysis, NFκB determination, and in vitro culture for cytokines assay. Therefore, CLP at 4 mg/kg presented the best results, triggering improvement of DAI and attenuating the colon shortening and damage. This dose was able to reduce the TNF-α, IFN-γ, IL-6, IL-17, and NFκB p65 levels, and increased the levels of IL-10 in the colon tissue. Thus, CLP mice treatment at a dose of 4 mg/kg showed promising results in ameliorating the damage observed in the ulcerative colitis.
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23
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Fearnhead NS, Lee MJ, Acheson AG, Worley G, Faiz OD, Brown SR. Variation in practice of pouch surgery in England - using SWORD data to cut to the chase and justify centralization. Colorectal Dis 2018; 20:597-605. [PMID: 29383826 DOI: 10.1111/codi.14036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 01/20/2018] [Indexed: 12/14/2022]
Abstract
AIM Increasing scrutiny on both individual and unit outcomes after surgical procedures is now expected. In the field of inflammatory bowel disease, this is particularly pertinent for outcomes after ileoanal pouch surgery. METHOD The Surgical Workload and Outcomes Research Database (SWORD) relies on administrative data derived from Hospital Episode Statistics collected in England. The platform was interrogated for pouch procedures undertaken in England between April 2009 and December 2016 to assess national caseload and, between April 2012 and December 2016, to assess variation in caseload and outcomes after pouch surgery. RESULTS In England there is a suggestion that numbers of pouch procedures may be decreasing. Over 80% of Trusts offering pouch surgery do so at very low volume with less than five procedures per year. There is also a clear phenomenon of the occasional pouch surgeon with 126 surgeons undertaking just one pouch operation during the study period of almost 5 years. Laparoscopic practice varies but 60% of pouches overall were done via an open approach. Mean length of stay was 10.1 days and average 30-day readmission rates were 27.4%. Outside London there appears to be an increasing trend for higher volume units to do more adult pouch procedures and lower volume units to do fewer. CONCLUSION Low volume units and occasional pouch surgeons present a strong argument for centralization of pouch surgery. Data from England outside London suggest that this may already be happening.
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Affiliation(s)
- N S Fearnhead
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M J Lee
- Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - A G Acheson
- Nottingham Biomedical Research Centre, National Institute for Health Research (NIHR), Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - G Worley
- London North West Healthcare NHS Trust, St Mark's Hospital, Middlesex, UK
| | - O D Faiz
- London North West Healthcare NHS Trust, St Mark's Hospital, Middlesex, UK
| | - S R Brown
- Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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24
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Kulaylat AS, Kulaylat AN, Schaefer EW, Tinsley A, Williams E, Koltun W, Hollenbeak CS, Messaris E. Association of Preoperative Anti-Tumor Necrosis Factor Therapy With Adverse Postoperative Outcomes in Patients Undergoing Abdominal Surgery for Ulcerative Colitis. JAMA Surg 2017; 152:e171538. [PMID: 28614561 DOI: 10.1001/jamasurg.2017.1538] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Despite the increasing use of anti-tumor necrosis factor (TNF) therapy in ulcerative colitis, its effects on postoperative outcomes remain unclear, with many patients requiring surgical intervention despite optimal medical management. Objective To assess the association of preoperative use of anti-TNF agents with adverse postoperative outcomes. Design, Setting, and Participants This analysis used insurance claims data from a large national database to identify patients 18 years or older with ulcerative colitis. These insured patients had inpatient and/or outpatient claims between January 1, 2005, and December 31, 2013, with Current Procedural Terminology codes for a subtotal colectomy or total abdominal colectomy, a total proctocolectomy with end ileostomy, or a combined total proctocolectomy and ileal pouch-anal anastomosis. Only data regarding the first or index surgical admission within the time frame were abstracted. Use of anti-TNF agents, corticosteroids, and immunomodulators within 90 days of surgery was identified using Healthcare Common Procedure Coding System codes. Inclusion in the study required the patient to have an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code for ulcerative colitis. Exclusion occurred if the patient had a secondary ICD-9-CM diagnosis code for Crohn disease or if the patient was not continuously enrolled in an insurance plan for at least 180 days before and after the index surgery. Data were collected and analyzed from February 1, 2015, to June 2, 2016. Main Outcomes and Measures Outcomes included 90-day complications, emergency department visits, and readmissions. Multivariable logistic regression was used to model covariates, including anti-TNF agent use, on the occurrence of outcomes. Results Of the 2476 patients identified, 1379 (55.7%) were men, and the mean (SD) age was 42.1 (12.9) years. Among these, 950 (38.4%) underwent subtotal colectomy or total abdominal colectomy, 354 (14.3%) underwent total proctocolectomy with end ileostomy, and 1172 (47.3%) received ileal pouch-anal anastomoses. In univariate analyses, increased postoperative complications were observed among patients in the ileal pouch cohort who received anti-TNF agents preoperatively vs those who did not (137 [45.2%] vs 327 [37.6%]; P = .02) but not among those in the colectomy or proctocolectomy cohorts. An increase in complications was also observed on multivariable analyses among patients in the ileal pouch cohort (odds ratio, 1.38; 95% CI, 1.05-1.82). Conclusions and Relevance Unlike preoperative anti-TNF agent use among patients who underwent colectomy or total proctocolectomy and experienced no significant increase in postoperative complications, anti-TNF agent use within 90 days of surgery among patients who underwent ileal pouch-anal anastomosis was associated with higher 90-day postoperative complication rates.
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Affiliation(s)
- Audrey S Kulaylat
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey
| | - Afif N Kulaylat
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey
| | - Eric W Schaefer
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey
| | - Andrew Tinsley
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Pennsylvania State University, Hershey
| | - Emmanuelle Williams
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Pennsylvania State University, Hershey
| | - Walter Koltun
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey
| | - Christopher S Hollenbeak
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey.,Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey
| | - Evangelos Messaris
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey
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25
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Abstract
For patients with ulcerative colitis requiring surgery, surgical options include a total proctocolectomy with an end ileostomy and ileal pouch-anal anastomosis or a continent reservoir, or instead, a subtotal colectomy with an ileorectal anastomosis. The ileal pouch-anal anastomosis is currently considered the gold standard procedure that is employed in the majority of patients. Despite strong data supporting the feasibility, durability and the maintenance of long term functional outcomes and quality of life, certain controversies pertaining to its relative role, method of creation and effects on related pelvic structures remain a matter of debate.
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Affiliation(s)
- Steven Lee-Kong
- a Division of Colorectal Surgery , Columbia University Medical Center/New York Presbyterian Hospital , New York , NY , USA
| | - Ravi Pokala Kiran
- a Division of Colorectal Surgery , Columbia University Medical Center/New York Presbyterian Hospital , New York , NY , USA
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26
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Bhattacharya N, Yuan R, Prestwood TR, Penny HL, DiMaio MA, Reticker-Flynn NE, Krois CR, Kenkel JA, Pham TD, Carmi Y, Tolentino L, Choi O, Hulett R, Wang J, Winer DA, Napoli JL, Engleman EG. Normalizing Microbiota-Induced Retinoic Acid Deficiency Stimulates Protective CD8(+) T Cell-Mediated Immunity in Colorectal Cancer. Immunity 2016; 45:641-655. [PMID: 27590114 PMCID: PMC5132405 DOI: 10.1016/j.immuni.2016.08.008] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 04/07/2016] [Accepted: 06/06/2016] [Indexed: 12/11/2022]
Abstract
Although all-trans-retinoic acid (atRA) is a key regulator of intestinal immunity, its role in colorectal cancer (CRC) is unknown. We found that mice with colitis-associated CRC had a marked deficiency in colonic atRA due to alterations in atRA metabolism mediated by microbiota-induced intestinal inflammation. Human ulcerative colitis (UC), UC-associated CRC, and sporadic CRC specimens have similar alterations in atRA metabolic enzymes, consistent with reduced colonic atRA. Inhibition of atRA signaling promoted tumorigenesis, whereas atRA supplementation reduced tumor burden. The benefit of atRA treatment was mediated by cytotoxic CD8(+) T cells, which were activated due to MHCI upregulation on tumor cells. Consistent with these findings, increased colonic expression of the atRA-catabolizing enzyme, CYP26A1, correlated with reduced frequencies of tumoral cytotoxic CD8(+) T cells and with worse disease prognosis in human CRC. These results reveal a mechanism by which microbiota drive colon carcinogenesis and highlight atRA metabolism as a therapeutic target for CRC.
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Affiliation(s)
- Nupur Bhattacharya
- Department of Pathology, Stanford University School of Medicine (Blood Center), 3373 Hillview Avenue, Palo Alto, CA 94304, USA.
| | - Robert Yuan
- Department of Pathology, Stanford University School of Medicine (Blood Center), 3373 Hillview Avenue, Palo Alto, CA 94304, USA
| | - Tyler R Prestwood
- Department of Pathology, Stanford University School of Medicine (Blood Center), 3373 Hillview Avenue, Palo Alto, CA 94304, USA; Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, 265 Campus Drive, Stanford, CA 94305, USA
| | - Hweixian Leong Penny
- Department of Pathology, Stanford University School of Medicine (Blood Center), 3373 Hillview Avenue, Palo Alto, CA 94304, USA
| | - Michael A DiMaio
- Department of Pathology, Stanford University, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Nathan E Reticker-Flynn
- Department of Pathology, Stanford University School of Medicine (Blood Center), 3373 Hillview Avenue, Palo Alto, CA 94304, USA
| | - Charles R Krois
- Graduate Program in Metabolic Biology, Department of Nutritional Sciences and Toxicology, University of California, Berkeley, Berkeley, CA 94720, USA
| | - Justin A Kenkel
- Department of Pathology, Stanford University School of Medicine (Blood Center), 3373 Hillview Avenue, Palo Alto, CA 94304, USA
| | - Tho D Pham
- Department of Pathology, Stanford University School of Medicine (Blood Center), 3373 Hillview Avenue, Palo Alto, CA 94304, USA
| | - Yaron Carmi
- Department of Pathology, Stanford University School of Medicine (Blood Center), 3373 Hillview Avenue, Palo Alto, CA 94304, USA
| | - Lorna Tolentino
- Department of Pathology, Stanford University School of Medicine (Blood Center), 3373 Hillview Avenue, Palo Alto, CA 94304, USA
| | - Okmi Choi
- Department of Pathology, Stanford University School of Medicine (Blood Center), 3373 Hillview Avenue, Palo Alto, CA 94304, USA
| | - Reyna Hulett
- Department of Pathology, Stanford University School of Medicine (Blood Center), 3373 Hillview Avenue, Palo Alto, CA 94304, USA
| | - Jinshan Wang
- Graduate Program in Metabolic Biology, Department of Nutritional Sciences and Toxicology, University of California, Berkeley, Berkeley, CA 94720, USA
| | - Daniel A Winer
- Department of Pathology, University Health Network, and Departments of Laboratory Medicine and Pathobiology, and Immunology, University of Toronto, Toronto, ON M5G 2N2, Canada
| | - Joseph L Napoli
- Graduate Program in Metabolic Biology, Department of Nutritional Sciences and Toxicology, University of California, Berkeley, Berkeley, CA 94720, USA
| | - Edgar G Engleman
- Department of Pathology, Stanford University School of Medicine (Blood Center), 3373 Hillview Avenue, Palo Alto, CA 94304, USA.
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27
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Sofo L, Caprino P, Sacchetti F, Bossola M. Restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis: A narrative review. World J Gastrointest Surg 2016; 8:556-563. [PMID: 27648159 PMCID: PMC5003934 DOI: 10.4240/wjgs.v8.i8.556] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 04/09/2016] [Accepted: 05/27/2016] [Indexed: 02/07/2023] Open
Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis (RP-IPAA) is the gold standard surgical treatment for ulcerative colitis. However, despite the widespread use of RP-IPAA, many aspects of this treatment still remain controversial, such as the approach (open or laparoscopic), number of stages in the surgery, type of pouch, and construction type (hand-sewn or stapled ileal pouch-anal anastomosis). The present narrative review aims to discuss current evidence on the short-, mid-, and long-term results of each of these technical alternatives as well as their benefits and disadvantages. A review of the MEDLINE, EMBASE, and Ovid databases was performed to identify studies published through March 2016. Few large, randomized, controlled studies have been conducted, which limits the conclusions that can be drawn regarding controversial issues. The available data from retrospective studies suggest that laparoscopic surgery has no clear advantages compared with open surgery and that one-stage RP-IPAA may be indicated in selected cases. Regarding 2- and 3-stage RP-IPAA, patients who underwent these surgeries differed significantly with respect to clinical and laboratory variables, making any comparisons extremely difficult. The long-term results regarding the pouch type show that the W- and J-reservoirs do not differ significantly, although the J pouch is generally preferred by surgeons. Hand-sewn and stapled ileal pouch-anal anastomoses have their own advantages, and there is no clear benefit of one technique over the other.
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28
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Nickerson TP, Merchea A. Perioperative Considerations in Crohn Disease and Ulcerative Colitis. Clin Colon Rectal Surg 2016; 29:80-4. [PMID: 27247531 DOI: 10.1055/s-0036-1580633] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The management of inflammatory bowel disease (IBD) is medically and surgically complex. Numerous patient- and disease-oriented factors must be considered in treating patients with IBD, including nutritional replenishment/support, effect of immunosuppressive medications, extent of resection, and use of proximal diversion. Perioperative planning and optimization of the patient is imperative to ensuring favorable outcomes and limiting morbidity. These perioperative considerations in Crohn disease and ulcerative colitis are reviewed here.
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Affiliation(s)
| | - Amit Merchea
- Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, Florida
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29
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Edfors K, Ståhlberg D, Söderman C. Retrospective Single Center Study of Granulocyte Monocyte Adsorption Apheresis Treatment in Inflammatory Bowel Disease. Ther Apher Dial 2016; 20:79-85. [PMID: 26841133 DOI: 10.1111/1744-9987.12336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 05/03/2015] [Accepted: 06/08/2015] [Indexed: 01/17/2023]
Abstract
Patients with active inflammatory bowel disease (IBD) have elevated and activated myeloid leukocytes, which infiltrate the intestinal mucosa. A significant proportion of IBD patients do not respond adequately to conventional treatment regimes. Studies have suggested that treatment with granulocyte monocyte apheresis (GMA) could be a safe and efficacious alternative for these patients. We evaluated the efficacy and safety of granulocyte/monocyte apheresis in patients with IBD in a retrospective cohort study, conducted from a single center in Stockholm. Clinical details from consecutive apheresis treated patients were retrospectively reviewed from 2004 to 2012. A total of 37 patients were included, 23 patients with ulcerative colitis (UC) and 14 with Crohn's disease (CD). Clinical response was seen in 11 patients (30%) and complete remission in 11 patients (30%). The remission rate was higher in UC patients compared to CD patients, 39% (N = 9) and 14% (N = 2) respectively. A total of 9 patients experienced adverse events. Most frequently reported was headache (N = 4). GMA seems to be a valuable adjuvant treatment regime in the care of patients with refractory IBD.
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Affiliation(s)
- Kajsa Edfors
- Gastroenterology Unit, Department of Medicine, Capio St. Goran Hospital, Stockholm, Sweden
| | - Dagny Ståhlberg
- Gastroenterology Unit, Department of Medicine, Capio St. Goran Hospital, Stockholm, Sweden
| | - Charlotte Söderman
- Gastroenterology Unit, Department of Medicine, Capio St. Goran Hospital, Stockholm, Sweden
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30
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Colectomy in pediatric ulcerative colitis: A single center experience of indications, outcomes, and complications. J Pediatr Surg 2016; 51:277-81. [PMID: 26653944 DOI: 10.1016/j.jpedsurg.2015.10.077] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 10/30/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND/PURPOSE There is a paucity of data on outcomes and complications of colectomy for pediatric ulcerative colitis (UC). This study reports the experience of a regional center for 18years. METHODS Patients were identified from a prospective database and data obtained by note review. Median height/weight-SDS were calculated preoperatively and postoperatively. Data are expressed as median values (range). RESULTS 220 patients with UC (diagnosed <17years) were identified, and 19 (9%) had undergone colectomy. Age at diagnosis was 11.6years (1.3-16.5), and 42% of patients were male. Time from diagnosis to surgery was 2.2years (0.1-13.1). All patients had failed maximal medical therapy. Fifteen patients had urgent scheduled operation, and 4 had emergency procedures, with 2 for (11%) acute-severe colitis (1 Clostridium difficile colitis) and 2 for acute-severe colitis with toxic dilatation. All initial procedures were subtotal-colectomy with ileostomy. Nine patients (47%) had early complications (during initial admission), 7 (37%) requiring reoperation. Six (32%) had late complications, with 5 requiring laparotomy. No patients had both early and late complications. Height-SDS was -0.27 before surgery and -0.23 (maximal follow-up). Weight-SDS was 0.32 and 0.05 (maximal follow-up). CONCLUSION Approximately 1/11 children with UC required colectomy during childhood. Half of patients had acute complications, and 1/3 of patients required another operation during their first admission. 1/3 of patients developed late complications.
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Fornaro R, Caratto M, Barbruni G, Fornaro F, Salerno A, Giovinazzo D, Sticchi C, Caratto E. Surgical and medical treatment in patients with acute severe ulcerative colitis. J Dig Dis 2015; 16:558-67. [PMID: 26315728 DOI: 10.1111/1751-2980.12278] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 07/05/2015] [Accepted: 08/03/2015] [Indexed: 02/06/2023]
Abstract
Ulcerative colitis (UC) is a chronic inflammatory disease of the mucosa of the colorectum. The treatment of UC depends on the severity of symptoms and the extent of the disease. Acute severe colitis (ASC) occurs in 12-25% of patients with UC. Patients with ASC must be managed by a multidisciplinary team. Medically or surgically aggressive treatment is carried out with the final aim of reducing mortality. Intravenous administration of corticosteroids is the mainstay of the therapy. Medical rescue therapy based on cyclosporine or infliximab should be considered if there is no response to corticosteroids for 3 days. If there has been no response to medical rescue therapy after 4-7 days, the patient must undergo colectomy in emergency surgery. Prolonged observation is counterproductive, as over time it increases the risk of toxic megacolon and perforation, with a very high mortality rate. The best potential treatment is subtotal colectomy with ileostomy and preservation of the rectum. Emergency surgery in UC should not be seen as a last chance, but can be considered as a life-saving procedure. Colectomies in emergency setting are characterized by high morbidity rates but the mortality is low.
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Affiliation(s)
- Rosario Fornaro
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| | - Michela Caratto
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| | - Ginevra Barbruni
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| | - Francesco Fornaro
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| | - Alexander Salerno
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| | - Davide Giovinazzo
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
| | | | - Elisa Caratto
- University of Genoa, Department of Surgery, IRCCS Azienda Ospedaliera Universitaria San Martino, Istituto Nazionale per la Ricerca sul Cancro, Italy
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Tajti J, Simonka Z, Paszt A, Ábrahám S, Farkas K, Szepes Z, Molnár T, Nagy F, Lázár G. Role of laparoscopic surgery in the treatment of ulcerative colitis; short- and mid-term results. Scand J Gastroenterol 2015; 50:406-12. [PMID: 25615512 DOI: 10.3109/00365521.2014.985705] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Laparoscopy is used more widely for the surgery of ulcerative colitis. The objective of this study was a comparison of the surgical and 3-year follow-up results of patients treated with conventional and minimally invasive methods. MATERIALS AND METHODS A total of 45 patients received surgery for ulcerative colitis, 16 as emergency and 29 as elective cases. Laparoscopy was used in 23 and a conventional method in 22 cases. No difference was found between the two groups from the aspects of American Society of Anesthesiologists physical status (ASA) class, mean body mass index (BMI) and age. There were 4 emergency cases in the laparoscopy group, and 12 in the open group. Nineteen elective surgeries were performed in the laparoscopy group, and 10 in the open group. RESULTS There was no significant difference between the groups as concerns the length of hospital or intensive care unit (ICU) stay, the time to bowel function recovery, but the duration of open surgery was significantly shorter. There was no difference between the groups in the rate of early postoperative complications, whereas among potential late complications, the rates of intestinal obstruction (8.7% vs. 45%) and a septic condition (0% vs. 27%) were significantly lower in the laparoscopy group. There was a significant improvement in the quality of life after surgery in both groups, and better cosmetic results were observed in the laparoscopy group. CONCLUSION Laparoscopy can be used for ulcerative colitis both emergency and elective cases, it provides a good quality of life and the mid-term rate of complications is lower as compared with open surgery.
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Affiliation(s)
- János Tajti
- Department of Surgery, University of Szeged , Szeged , Hungary
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Abstract
PURPOSE Proctocolectomy has been a curative option for patients with severe ulcerative colitis. In recent years, there has been a growing use of medical salvage therapy in the management of patients with moderate to severe ulcerative colitis. We aimed at reviewing the role of surgical management in a time of intensified medical management on the basis of published trial data. The aim was to determine the efficacy of aggressive medical versus surgical management in achieving multifaceted treatment goals. METHODS A comprehensive search of Pubmed, Medline, the Cochrane database was performed. Abstracts were evaluated for relevance. Selected articles were then reviewed in detail, including references. Recommendations were then drafted based on evidence and conclusions in the selected articles. RESULTS The majority of patients with UC will not need surgery. However, steroid-refractoriness and steroid-dependence signal a subset of patients with more challenging disease. Biological therapy has been shown to achieve short-term improvement and temporarily reduce the need for a colectomy. However, there is a substantial financial and medical price to pay because a high fraction of these salvaged patients will still need a curative colectomy but may be exposed to the negative impact of prolonged immunosuppression, chronic illness, and a higher probability to require 3 rather than 2 operations. Proctocolectomy with ileo-anal pouch anastomosis-performed in 1, 2, or 3 steps depending on the patient's condition-remains the surgical procedure of choice. Even though it has its share of possible complications, it has been associated with excellent long-term outcomes and high levels of satisfaction, such that in the majority of patients they become indistinguishable from unaffected normal individuals. CONCLUSIONS The current data demonstrate that use of medical salvage therapy in the treatment of UC will likely continue to grow and evolve. Consensus is being developed to better define and predict failure of medical therapy and clarify the role of the different treatment modalities. For many patients, sacrificing the nonresponsive diseased colon is an underused or unnecessarily delayed chance to normalize their health and life. Biologicals in many instances may have to be considered the bridge to that end.
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Abstract
BACKGROUND The initial minimum operation for ulcerative colitis is a total abdominal colectomy. Healthy patients may undergo proctectomy at the same time; however, for ill patients, proctectomy is delayed. Since the introduction of biologic medications in 2005, ulcerative colitis medical management has changed dramatically. OBJECTIVE We examined how operative management for ulcerative colitis has changed from the prebiologic to biologic eras. DESIGN We conducted a retrospective review of data on patients with ulcerative colitis who were included in the Nationwide Inpatient Sample database. SETTINGS This study was conducted at a single university. PATIENTS A total of 1,547,852 patients with ulcerative colitis who were admitted to a US hospital from 1991 to 2011 were included in the study. MAIN OUTCOME MEASURES We examined patients whose initial operation consisted of total abdominal colectomy without proctectomy versus a total proctocolectomy with or without a pouch. We also examined which operation was done at the time of the construction of an ileoanal pouch. Patients who underwent colectomy and pouch construction in the same hospitalization were compared with those who received pouch formation at a subsequent hospitalization. RESULTS Ulcerative colitis-related admissions rose by 170% during the years examined, and the number of patients who required total abdominal colectomy increased by 44%. Total abdominal colectomy increased by 15%, as opposed to total proctocolectomy (p < 0.001). Pouch construction at a subsequent operation increased by 16% (p = 0.002). Since 2008, total abdominal colectomy has surpassed total proctocolectomy as the most common initial surgical intervention for ulcerative colitis. LIMITATIONS The Nationwide Inpatient Sample is a retrospective database, and we were limited to examining the variables within it. CONCLUSIONS Total abdominal colectomy is currently the most common initial operation for patients with ulcerative colitis, and an ileoanal pouch is more frequently constructed at a subsequent hospitalization. These trends coincide with the initiation of biologic treatments and may imply that patients are acutely ill at the time of initial operation. Alternately, there may be surgeon-perceived bias of increased surgical risk or a shift in care to specialized surgeons for pouch construction.
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Reich KM, Chang HJ, Rezaie A, Wang H, Goodman KJ, Kaplan GG, Svenson LW, Lees G, Fedorak RN, Kroeker KI. The incidence rate of colectomy for medically refractory ulcerative colitis has declined in parallel with increasing anti-TNF use: a time-trend study. Aliment Pharmacol Ther 2014; 40:629-38. [PMID: 25039715 DOI: 10.1111/apt.12873] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 03/10/2014] [Accepted: 06/21/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND Medical therapy is standard treatment for ulcerative colitis with colectomy reserved for medically refractory disease or malignancy. The introductions of ciclosporin in 1994 and anti-TNF therapy in 2005 have extended medical management options. AIM To determine whether the colectomy incidence rate for medically refractory ulcerative colitis has changed since the introduction of anti-TNF therapy. METHODS Adult patients with a diagnosis of ulcerative colitis and who subsequently underwent an urgent or elective colectomy for medically refractory disease in Edmonton, Canada between 1 January 1998 and 31 December 2011 were identified. Log-linear regression was used to estimate the annual percent change in the total colectomy incidence rate (urgent and elective combined) and the urgent and elective incidence rates individually, before and after 2005, the year infliximab was approved for use in ulcerative colitis. Temporal trends of drug utilisation in this study population were also described. RESULTS During 1998-2011, 481 patients with ulcerative colitis underwent a colectomy for medically refractory disease. There was negligible change in the total colectomy incidence rate from 1998 to 2005, with an annual percent change of 4.4% (95% confidence interval (CI): -1.12% to 10.16%). From 2005-2011, following the approval and increasing use of anti-TNF therapy, the total colectomy incidence rate decreased by 16.1% (95% CI: -21.32% to -10.54%) every year to 0.9 per 100 ulcerative colitis patients in 2011. CONCLUSION The total incidence rate of colectomy for medically refractory ulcerative colitis has declined substantially since 2005, paralleling the increased use of anti-TNF therapy in this patient population.
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Affiliation(s)
- K M Reich
- Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
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Vaizey CJ, Gibson PR, Black CM, Nicholls RJ, Weston AR, Gaya DR, Sebastian S, Shaw I, Lewis S, Bloom S, Gordon JN, Beale A, Arnott I, Campbell S, Fan T. Disease status, patient quality of life and healthcare resource use for ulcerative colitis in the UK: an observational study. Frontline Gastroenterol 2014; 5:183-189. [PMID: 28839768 PMCID: PMC5369729 DOI: 10.1136/flgastro-2013-100409] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 11/27/2013] [Accepted: 11/28/2013] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Ulcerative colitis is a lifelong, chronic, relapsing-remitting disease. OBJECTIVE To assess the relationship between ulcerative colitis disease status and patient quality of life, and to determine the impact of ulcerative colitis on healthcare costs and work productivity, in the UK. METHODS Clinicians assessed 173 adult patients' current disease status at a single study visit using the partial Mayo (pMayo) instrument. Patients completed the Euro Quality of Life 5-dimension, 5-level (EQ-5D-5L) questionnaire, the Work Productivity and Activity Impairment (WPAI) questionnaire. Healthcare resource use was determined from questionnaires and from patients' medical charts. RESULTS Patients in remission had a significantly higher EQ-5D-5L scores (mean (SD) 0.86 (0.15)) than patients with active disease (0.71 (0.20); p<0.001). Patients with mild disease had significantly higher mean (SD) EQ-5D-5L scores than patients with moderate/severe disease: 0.77 (0.11) and 0.66 (0.24), respectively (p<0.001). The mean percent productivity impairment was greater for patients with active disease than for patients in remission on all items of the WPAI questionnaire: 24.6% vs 1.8% for work time missed, 34.1% vs 12.9% for impairment while working, 40.8% vs 14.4% for overall work impairment and 42.7% vs 13.0% for activity impairment (p<0.001 for all comparisons). The mean (SD) total cost of healthcare for ulcerative colitis in the prior 3 months was £1211 (1588). CONCLUSIONS When compared with patients in remission, patients with active ulcerative colitis have significantly worse quality of life and significantly more work impairment. The healthcare costs of ulcerative colitis are considerable.
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Affiliation(s)
| | - Peter R Gibson
- Alfred Hospital, Melbourne, and Monash University, Victoria, Australia
| | - Christopher M Black
- St. John's University, Queens, New York, USA,Merck & Co., Inc., Global Health Outcomes, Whitehouse Station, New Jersey, USA
| | | | | | - Daniel R Gaya
- Gastroenterology Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - Shaji Sebastian
- Department of Gastroenterology, Hull Royal Infirmary, Hull, UK
| | - Ian Shaw
- Department of Gastroenterology, Gloucester Royal Hospital, Gloucester, UK
| | - Stephen Lewis
- Department of Gastroenterology, Derriford Hospital, Plymouth, UK
| | - Stuart Bloom
- Department of Gastroenterology, University College London Hospital, London, UK
| | - John N Gordon
- Department of Gastroenterology, Royal Hampshire Hospital, Winchester, UK
| | | | | | | | - Tao Fan
- Merck & Co., Inc., Global Health Outcomes, Whitehouse Station, New Jersey, USA
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Mosli M, Al Beshir M, Al-Judaibi B, Al-Ameel T, Saleem A, Bessissow T, Ghosh S, Almadi M. Advances in the diagnosis and management of inflammatory bowel disease: challenges and uncertainties. Saudi J Gastroenterol 2014; 20:81-101. [PMID: 24705146 PMCID: PMC3987157 DOI: 10.4103/1319-3767.129473] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 12/30/2013] [Indexed: 12/14/2022] Open
Abstract
Over the past two decades, several advances have been made in the management of patients with inflammatory bowel disease (IBD) from both evaluative and therapeutic perspectives. This review discusses the medical advancements that have recently been made as the standard of care for managing patients with ulcerative colitis (UC) and Crohn's Disease (CD) and to identify the challenges associated with implementing their use in clinical practice. A comprehensive literature search of the major databases (PubMed and Embase) was conducted for all recent scientific papers (1990-2013) giving the recent updates on the management of IBD and the data were extracted. The reported advancements in managing IBD range from diagnostic and evaluative tools, such as genetic tests, biochemical surrogate markers of activity, endoscopic techniques, and radiological modalities, to therapeutic advances, which encompass medical, endoscopic, and surgical interventions. There are limited studies addressing the cost-effectiveness and the impact that these advances have had on medical practice. The majority of the advances developed for managing IBD, while considered instrumental by some IBD experts in improving patient care, have questionable applications due to constraints of cost, lack of availability, and most importantly, insufficient evidence that supports their role in improving important long-term health-related outcomes.
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Affiliation(s)
- Mahmoud Mosli
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- Department of Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
| | - Mohammad Al Beshir
- Department of Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
- Department of Medicine, King Fahd Specialist Hospital, Dammam, Saudi Arabia
| | - Bandar Al-Judaibi
- Department of Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
- Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Turki Al-Ameel
- Department of Medicine, King Fahd Specialist Hospital, Dammam, Saudi Arabia
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Abdulaziz Saleem
- Department of Surgery, McGill University and McGill University Health Centre, Montreal, Canada
- Department of Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Talat Bessissow
- Department of Medicine, McGill University and McGill University Health Centre, Montreal, Canada
| | - Subrata Ghosh
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Majid Almadi
- Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
- Department of Medicine, McGill University and McGill University Health Centre, Montreal, Canada
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Does intramesorectal proctectomy with rectal eversion affect postoperative complications compared to standard total mesorectal excision in patients with ulcerative colitis? J Gastrointest Surg 2014; 18:385-90. [PMID: 24146339 DOI: 10.1007/s11605-013-2359-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 09/12/2013] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Proctectomy for ulcerative colitis (UC) can be performed via intramesorectal proctectomy with concomitant rectal eversion (IMP/RE) or total mesorectal excision (TME). No data exists comparing the outcomes of the two techniques. METHODS All UC patients undergoing J-pouch surgery at a single institution over 10.5 years were included. Postoperative complications with IMP/RE vs. TME were analyzed using univariable and multivariable statistics. RESULTS One hundred nineteen of 201 (59 %) patients underwent IMP/RE. Demographic and disease characteristics were similar between groups. On univariable analysis, IMP/RE had fewer total perioperative complications than TME (p = 0.02), but no differences in postoperative length of stay or readmissions. Multivariable regression accounting for patient age, comorbidities, disease severity, preoperative medications, operative technique, and follow-up time (mean 5.5 ± 0.2 years) suggested that both anastomotic leak rate (OR 0.32; p = 0.04) and overall postoperative complications (2.10 ± 0.17 vs. 2.60 ± 0.20; p = 0.05) were lower in the IMP/RE group. CONCLUSIONS IMP/RE may be associated with fewer overall postoperative complications compared to TME. However, further studies on functional and long-term outcomes are needed.
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Ceriati E, De Peppo F, Rivosecchi M. Role of surgery in pediatric ulcerative colitis. Pediatr Surg Int 2013; 29:1231-41. [PMID: 24173816 DOI: 10.1007/s00383-013-3425-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2013] [Indexed: 12/13/2022]
Abstract
Pediatric ulcerative colitis (UC) has a more extensive and progressive clinical course than adult UC. Therefore, more aggressive initial therapies and more frequent surgical treatments are needed. The therapeutic goal is to gain clinical and laboratory control of the disease with minimal adverse effects while permitting the patient to function as normally as possible. Approximately 5-10 % of patients with UC require acute surgical intervention because of fulminant colitis refractory to medical therapy. Mucosal proctocolectomy with ileal J-pouch anal anastomosis is currently recommended as a standard curative surgical procedure for UC in both children and adults worldwide. This review will focus on the current issues regarding the surgical indications for pediatric UC, the technical details of procedures and results of most recent published series to take the most appropriate next step to improve the surgical outcomes and patients' quality of life.
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Affiliation(s)
- Emanuela Ceriati
- Division of Pediatric Surgery, Department of Surgery, Bambino Gesù Children's Hospital IRCCS, Palidoro, Rome, Italy,
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Bordeianou L, Maguire L. State-of-the-art surgical approaches to the treatment of medically refractory ulcerative colitis. J Gastrointest Surg 2013; 17:2013-9. [PMID: 24002758 DOI: 10.1007/s11605-013-2312-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 07/31/2013] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Management of medically refractory ulcerative collitis (UC) is a significant challenge to the surgeon. Operative morbidity is high and the potential for mortality remains. DISCUSSION Medical therapies have the potential to meaningfully improve the patient, or may dangerously delay and complicate surgery. Operative planning must appropriately address the patient's acuity without losing sight of the patient's long-term need for definitive surgical care and adequate functional outcome. State-of-the-art treatment hinges on prompt recognition of patients with acute severe UC, multidisciplinary coordination of medical therapy, and mature surgical judgment. Biologic therapies and minimally invasive surgical technologies represent the vanguard in UC. However, state-of-the-art treatment of acute severe UC is not employment of the newest drug or technology, but early performance of standard of care surgery, ileal pouch anal anastomosis, for every eligible patient. As the range of therapies available for UC continues to expand, the challenge for the surgeon is incorporating these new drugs and devices without losing sight of the standard of care.
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Affiliation(s)
- Liliana Bordeianou
- The Crohn's and Colitis Center and the Department of Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman Street, ACC 460, Boston, MA, 02114, USA,
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Patel SS, Patel MS, Goldfarb M, Ortega A, Ault GT, Kaiser AM, Senagore AJ. Elective versus emergency surgery for ulcerative colitis: a National Surgical Quality Improvement Program analysis. Am J Surg 2013; 205:333-7; discussion 337-8. [DOI: 10.1016/j.amjsurg.2012.10.014] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 09/17/2012] [Accepted: 10/13/2012] [Indexed: 12/22/2022]
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Zhang YJ, Han Y, Lin MB, He YG, Zhang HB, Yin L, Huang L. Ileal pouch anal anastomosis with modified double-stapled mucosectomy-the experience in China. World J Gastroenterol 2013; 19:1299-1305. [PMID: 23483639 PMCID: PMC3587488 DOI: 10.3748/wjg.v19.i8.1299] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 09/11/2012] [Accepted: 12/17/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the feasibility and long-term functional outcome of ileal pouch-anal anastomosis with modified double-stapled mucosectomy.
METHODS: From January 2002 to March 2011, fourty-five patients underwent ileal pouch anal anastomosis with modified double-stapled mucosectomy technique and the clinical data obtained for these patients were reviewed.
RESULTS: Patients with ulcerative colitis (n = 29) and familial adenomatous polyposis (n = 16) underwent ileal pouch-anal anastomosis with modified double-stapled mucosectomy. Twenty-eight patients underwent one-stage restorative proctocolectomy, ileal pouch anal anastomosis, protective ileostomy and the ileostomy was closed 4-12 mo postoperatively. Two-stage procedures were performed in seventeen urgent patients, proctectomy and ileal pouch anal anastomosis were completed after previous colectomy with ileostomy. Morbidity within the first 30 d of surgery occurred in 10 (22.2%) patients, all of them could be treated conservatively. During the median follow-up of 65 mo, mild to moderate anastomotic narrowing was occurred in 4 patients, one patient developed persistent anastomotic stricture and need surgical intervention. Thirty-five percent of patients developed at least 1 episode of pouchitis. There was no incontinence in our patients, the median functional Oresland score was 6, 3 and 2 after 1 year, 2.5 years and 5 years respectively. Nearly half patients (44.4%) reported “moderate functioning”, 37.7% reported “good functioning”, whereas in 17.7% of patients “poor functioning” was observed after 1 year. Five years later, 79.2% of patients with good function, 16.7% with moderate function, only 4.2% of patients with poor function.
CONCLUSION: The results of ileal pouch anal anastomosis with modified double-stapled mucosectomy technique are promising, with a low complication rate and good long-term functional results.
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