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Maspero M, Otero A, Lavryk O, Gorgun E, Lipman J, Liska D, Valente M, Holubar S, Steele SR, Hull T. Outcome of incidental versus preoperatively diagnosed colorectal cancer during total proctocolectomy with ileal pouch-anal anastomosis for inflammatory bowel disease. Colorectal Dis 2024. [PMID: 38644666 DOI: 10.1111/codi.16996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 02/07/2024] [Accepted: 03/24/2024] [Indexed: 04/23/2024]
Abstract
AIM Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice for colorectal cancer (CRC) in inflammatory bowel disease. CRC may also be discovered incidentally at IPAA for other indications. We sought to determine whether incidentally found CRC at IPAA was associated with worse outcomes. METHODS Our institutional pouch registry (1983-2021) was retrospectively reviewed. Patients with CRC at pathology after IPAA were divided into two groups: a preoperative diagnosis (PreD) group and an incidental diagnosis (InD) group. Their long-term outcomes (overall survival, disease-free survival and pouch survival) were compared. RESULTS We included 164 patients: 53 (32%) InD and 111 (68%) PreD. There were no differences in cancer staging, differentiation and location. After a median follow-up of 11 (IQR 3-25) years for InD and 9 (IQR 3-20) years for the PreD group, deaths were 14 (26%) in the InD group and 18 (16%) in the PreD group. Pouch failures were five (9%) in the InD group and nine (8%) in the PreD group, of which two (5%) and four (4%) were cancer related. Ten-year overall survival was 94% for InD and 89% for PreD (P = 0.41), disease-free survival was 95% for InD and 90% for PreD (P = 0.685) and pouch survival was 89% for InD and 97% for PreD (P = 0.80). Pouch survival at 10 years was lower in rectal versus colon cancer (87% vs. 97%, P = 0.01). No difference was found in outcomes in handsewn versus stapled anastomoses. CONCLUSION Inflammatory bowel disease patients with incidentally found CRC during IPAA appear to have similarly excellent oncological and pouch outcomes to patients with a preoperative cancer diagnosis.
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Affiliation(s)
- Marianna Maspero
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Ana Otero
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Olga Lavryk
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Emre Gorgun
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jeremy Lipman
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - David Liska
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Michael Valente
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Stefan Holubar
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Scott R Steele
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Tracy Hull
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Ozgur I, Cheong JY, Liska D, Holubar S, Valante MA, Steele SR, Gorgun E. Endorobotic submucosal dissection of rectal lesions using the single port robot DaVinci-SP: initial experience of the first 10 cases. ANZ J Surg 2024; 94:691-696. [PMID: 38012087 DOI: 10.1111/ans.18796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/13/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Endoluminal surgery is increasingly recognized as a mode of treatment for colorectal neoplasms with the latest robotic single port platform Da Vinci-SP (Intuitive Surgical, Sunnyvale) facilitating submucosal dissection of benign rectal neoplasm. METHOD In this study, we present our initial experience with endorobotic submucosal dissection in the management of benign rectal neoplasms using the Da Vinci-SP (Intuitive Surgical, Sunnyvale) between 2020 and 2021. The primary endpoint was the successful completion of submucosal dissection. RESULTS During the study period, 10 patients underwent endorobotic submucosal dissection for benign rectal neoplasms. The median age of the patients was 68 (range: 59-78) years, and the mean BMI was 29.38 (range: 22.9-38.5). The mean size of the lesion was 42.3 mm (range: 20-65 mm) and was located 7.3 cm (mean) from the anal verge (range: 2-10 cm). The mean operative time was 91.3 minutes (range: 57-137 minutes). All 10 dissections were completed successfully en bloc. There were no intraoperative complications or mortality. All patients were discharged on the same day and commenced on a normal diet. Late bleeding was observed in one patient receiving anticoagulation, and one patient had urinary retention. Pathology revealed two adenocarcinomas, six tubulovillous adenomas, one tubular adenoma, and one sessile serrated adenoma. There was no recurrence in all other patients during the median follow-up of 6 months (range: 4-16 months). CONCLUSIONS Endorobotic submucosal dissection using a single-port robotic platform is safe and feasible for benign rectal mucosal neoplasms. The semiflexible platform offers an alternative to endoscopic submucosal dissection with favourable outcomes.
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Affiliation(s)
- Ilker Ozgur
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ju Yong Cheong
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - David Liska
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Stefan Holubar
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael A Valante
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Bolshinsky V, Sweet D, Vitello D, Jia X, Holubar S, Church J, Herts BR, Steele SR. Using Computed-Tomgraphy-Based Pelvimetry and Visceral Obesity Measurements to Predict Total Mesorectal Excision Quality for Patients Undergoing Rectal Cancer Surgery. Dis Colon Rectum 2024:00003453-990000000-00611. [PMID: 38517090 DOI: 10.1097/dcr.0000000000003147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
BACKGROUND A complete total mesorectal excision is the gold standard in curative rectal cancer surgery. Ensuring quality is challenging in a narrow pelvis, and obesity amplifies technical difficulties. Pelvimetry is the measurement of pelvic dimensions, but its role in gauging preoperatively difficulty of proctectomy is largely unexplored. OBJECTIVE To determine pelvic structural factors associated with incomplete total mesorectal excision following curative proctectomy and build a predictive model for total mesorectal excision quality. DESIGN Retrospective cohort study. SETTING A quaternary referral center database of patients diagnosed with rectal adenocarcinoma (2009-2017). PATIENTS Curative-intent proctectomy for rectal adenocarcinoma. INTERVENTIONS All radiological measurements were obtained from preoperative CT-images using validated imaging processing software tools. Completeness of total mesorectal excision was obtained from histology reports. MAIN OUTCOME MEASURES Ability of radiological pelvimetry and obesity measurements to predict total mesorectal excision quality. RESULTS Of the 410 cases meeting inclusion criteria, 362 had a complete total mesorectal excision (88%). A multivariable regression identified a deeper sacral curve (per 100 mm2 [OR: 1.14, 95% CI: 1.06-1.23, p < 0.001]), and greater transverse distance of pelvic outlet (per 10 mm [OR:1.41, 95% CI: 1.08-1.84, p = 0.012]) as independently associated with incomplete total mesorectal excision. An increased area of pelvic inlet (per 10 cm2); OR: 0.85, [95% CI: 0.75-0.97, p = 0.02] was associated with a higher rate of complete mesorectal excision. No difference in visceral obesity ratio and visceral obesity (ratio >0.4 vs.<0.4) between body mass index (<30 vs. ≥30) or sex was identified. A model was built to predict mesorectal quality using variables: depth of sacral curve, area of pelvic inlet and transverse distance of pelvic outlet. LIMITATIONS Retrospective analysis not controlled for choice of surgical approach. CONCLUSIONS Pelvimetry is predictive of total mesorectal excision quality in rectal cancer surgery and can alert surgeons preoperatively to cases of unusual difficulty. This predictive model may contribute to treatment strategy and aid in comparison of outcomes between traditional and novel techniques of total mesorectal excision. See Video Abstract.
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Affiliation(s)
| | - David Sweet
- Imaging Institute, Cleveland Clinic, Cleveland, Ohio
| | - Dominic Vitello
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Xue Jia
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Stefan Holubar
- Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - James Church
- Columbia University Medical Center, Herbert Irving Pavilion, New York, New York
| | - Brian R Herts
- Imaging Institute, Cleveland Clinic, Cleveland, Ohio
| | - Scott R Steele
- Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
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Lin S, Wang J, Mukherjee PK, Mao R, West G, Czarnecki D, Zhao S, Nguyen QT, Elias M, Massey WJ, Liu W, Wang Y, Prasad A, Banerjee S, Goren I, Chandra J, Le HT, Dejanovic D, Li J, Chen M, Holubar S, Olman M, Southern B, Hu S, Gordon IO, Atabai K, Fiocchi C, Rieder F. Milk fat globule-epidermal growth factor 8 (MFGE8) prevents intestinal fibrosis. Gut 2024:gutjnl-2022-328608. [PMID: 38378253 DOI: 10.1136/gutjnl-2022-328608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 01/18/2024] [Indexed: 02/22/2024]
Abstract
OBJECTIVE Intestinal fibrosis is considered an inevitable consequence of chronic IBD, leading to stricture formation and need for surgery. During the process of fibrogenesis, extracellular matrix (ECM) components critically regulate the function of mesenchymal cells. We characterised the composition and function of ECM in fibrostenosing Crohn's disease (CD) and control tissues. DESIGN Decellularised full-thickness intestinal tissue platforms were tested using three different protocols, and ECM composition in different tissue phenotypes was explored by proteomics and validated by quantitative PCR (qPCR) and immunohistochemistry. Primary human intestinal myofibroblasts (HIMFs) treated with milk fat globule-epidermal growth factor 8 (MFGE8) were evaluated regarding the mechanism of their antifibrotic response, and the action of MFGE8 was tested in two experimental intestinal fibrosis models. RESULTS We established and validated an optimal decellularisation protocol for intestinal IBD tissues. Matrisome analysis revealed elevated MFGE8 expression in CD strictured (CDs) tissue, which was confirmed at the mRNA and protein levels. Treatment with MFGE8 inhibited ECM production in normal control HIMF but not CDs HIMF. Next-generation sequencing uncovered functionally relevant integrin-mediated signalling pathways, and blockade of integrin αvβ5 and focal adhesion kinase rendered HIMF non-responsive to MFGE8. MFGE8 prevented and reversed experimental intestinal fibrosis in vitro and in vivo. CONCLUSION MFGE8 displays antifibrotic effects, and its administration may represent a future approach for prevention of IBD-induced intestinal strictures.
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Affiliation(s)
- Sinan Lin
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jie Wang
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Henan Key Laboratory of Immunology and Targeted Drug, Xinxiang Medical University, Xinxiang, Henan Province, China
| | - Pranab K Mukherjee
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ren Mao
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gail West
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Doug Czarnecki
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shuai Zhao
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Quang Tam Nguyen
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael Elias
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - William J Massey
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - WeiWei Liu
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Yan Wang
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ankita Prasad
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Suhanti Banerjee
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Idan Goren
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jyotsna Chandra
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Hongnga T Le
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Dina Dejanovic
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jiannan Li
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Minhu Chen
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Stefan Holubar
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mitchell Olman
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian Southern
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shaomin Hu
- Department of Pathology, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ilyssa O Gordon
- Department of Pathology, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kamran Atabai
- Cardiovascular Research Institute, Lung Biology Center, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Claudio Fiocchi
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Florian Rieder
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Program for Global Translational Inflammatory Bowel Diseases, Cleveland Clinic, Cleveland, Ohio, USA
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Syed H, Nadeem A, Gardinier D, Weekley K, Ribakow D, Lupe S, Bhat S, Holubar S, Cohen BL. Peri-Operative Optimization of Patients with Crohn's Disease. Curr Gastroenterol Rep 2024:10.1007/s11894-024-00925-9. [PMID: 38421577 DOI: 10.1007/s11894-024-00925-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 03/02/2024]
Abstract
PURPOSE OF REVIEW The management of patients with Crohn's disease (CD) undergoing surgery is complex and optimization of modifiable factors perioperatively can improve outcomes. This review focuses on the perioperative management of CD patients undergoing surgery, emphasizing the need for a multi-disciplinary approach. RECENT FINDINGS Research highlights the benefits of a comprehensive strategy, involving nutritional optimization, psychological assessment, and addressing septic complications before surgery. Despite many CD patients being on immune-suppressing medications, studies indicate that most of these medications are safe to use and should not delay surgery. However, a personalized approach for each case is needed. This review underscores the importance of multi-disciplinary team led peri-operative management of CD patients. We suggest that this can be done at a dedicated perioperative clinic for prehabilitation, with the potential to enhance outcomes for CD patients undergoing surgery.
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Affiliation(s)
- Hareem Syed
- Department of Internal Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Ahmed Nadeem
- Department of Internal Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - David Gardinier
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Kendra Weekley
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Dovid Ribakow
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Stephen Lupe
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Shubha Bhat
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Stefan Holubar
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Benjamin L Cohen
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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Powers JC, Cohen BL, Rieder F, Click BH, Lyu R, Westbrook K, Hull T, Holubar S, Regueiro MD, Qazi T. Preoperative Use of Multiple Advanced Therapies Is Not Associated With Endoscopic Inflammatory Pouch Diseases. Inflamm Bowel Dis 2024; 30:203-212. [PMID: 37061838 DOI: 10.1093/ibd/izad054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Indexed: 04/17/2023]
Abstract
BACKGROUND Patients with an ileal pouch-anal anastomosis (IPAA) can experience pouch inflammation postoperatively. The use of antitumor necrosis factor (anti-TNF) biologics may be associated with pouch inflammation, but limited data exist on the impact of multiple advanced therapies on development of subsequent pouch inflammation. The aim of this study was to assess for an association between preoperative use of multiple advanced therapies and risk of endoscopically detected inflammatory pouch diseases (EIPDs). METHODS We performed a retrospective analysis of ulcerative colitis (UC) and indeterminate colitis (IBDU) patients who underwent an IPAA at a quaternary care center from January 2015 to December 2019. Patients were grouped based on number and type of preoperative drug exposures. The primary outcome was EIPD within 5 years of IPAA. RESULTS Two hundred ninety-eight patients were included in this analysis. Most of these patients had UC (95.0%) and demonstrated pancolonic disease distribution (86.1%). The majority of patients were male (57.4%) and underwent surgery for medically refractory disease (79.2%). The overall median age at surgery was 38.6 years. Preoperatively, 68 patients were biologic/small molecule-naïve, 125 received anti-TNF agents only, and 105 received non-anti-TNF agents only or multiple classes. Ninety-one patients developed EIPD. There was no significant association between type (P = .38) or number (P = .58) of exposures and EIPD, but older individuals had a lower risk of EIPD (P = .001; hazard ratio, 0.972; 95% confidence interval, 0.956-0.989). CONCLUSION Development of EIPD was not associated with number or type of preoperative advanced therapies.
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Affiliation(s)
- Joseph Carter Powers
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Benjamin L Cohen
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Florian Rieder
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin H Click
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ruishen Lyu
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland, OH, USA
| | - Katherine Westbrook
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Tracy Hull
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Stefan Holubar
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Miguel D Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Taha Qazi
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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Otero-Piñerio AM, Aykun N, Maspero M, Holubar S, Hull T, Lipman J, Steele SR, Lightner AL. The mode of delivery does not influence the occurrence of post-partum perianal disease flares in patients with inflammatory bowel disease. BMC Gastroenterol 2024; 24:34. [PMID: 38229023 DOI: 10.1186/s12876-023-03018-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 10/28/2023] [Indexed: 01/18/2024] Open
Abstract
INTRODUCTION Perianal disease occurs in up to 34% of inflammatory bowel disease (IBD) patients. An estimated 25% of women will become pregnant after the initial diagnosis, thus introducing the dilemma of whether mode of delivery affects perianal disease. The aim of our study was to analyze whether a cesarean section (C-section) or vaginal delivery influence perianal involvement. We hypothesized the delivery route would not alter post-partum perianal manifestations in the setting of previously healed perianal disease. METHODS All consecutive eligible IBD female patients between 1997 and 2022 who delivered were included. Prior perianal involvement, perianal flare after delivery and delivery method were noted. RESULTS We identified 190 patients with IBD who had a total of 322 deliveries; 169 (52%) were vaginal and 153 (48%) were by C-section. Nineteen women (10%) experienced 21/322 (6%) post-partum perianal flares. Independent predictors were previous abdominal surgery for IBD (OR, 2.7; 95% CI, 1-7.2; p = 0.042), ileocolonic involvement (OR, 3.3; 95% CI, 1.1-9.4; p = 0.030), previous perianal disease (OR, 22; 95% CI, 7-69; p < 0.001), active perianal disease (OR, 96; 95% CI, 21-446; p < 0.001) and biologic (OR, 4.4; 95% CI,1.4-13.6; p < 0.011) or antibiotic (OR, 19.6; 95% CI, 7-54; p < 0.001) treatment. Negative association was found for vaginal delivery (OR, 0.19; 95% CI, 0.06-0.61; p < 0.005). Number of post-partum flares was higher in the C-section group [17 (11%) vs. 4 (2%), p = 0.002]. CONCLUSIONS Delivery by C-section section was not protective of ongoing perianal disease activity post-delivery, but should be recommended for women with active perianal involvement.
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Affiliation(s)
- Ana M Otero-Piñerio
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - N Aykun
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - M Maspero
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Stefan Holubar
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Jeremy Lipman
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
- National Center for Regenerative Medicine, Cleveland, OH, USA.
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Otero-Piñeiro AM, Hull T, Holubar S, Pedersen KE, Aykun N, Obi M, Butler R, Steele SR, Lightner AL. Surgical Options for the Treatment of Perianal and Anovaginal Fistulas in the Setting of Ileoanal Pouch Crohn's Disease: Experience of a Tertiary Center. J Gastrointest Surg 2023; 27:2867-2875. [PMID: 37985619 DOI: 10.1007/s11605-023-05603-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/03/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND The leading cause of pouch failure following ileal pouch-anal anastomosis are peri-pouch fistulas and pelvic sepsis. OBJECTIVE Determine the overall efficacy of current surgical therapy for the treatment of perianal and anovaginal fistulizing disease related to Crohn's disease phenotype of the pouch. DESIGN Retrospective cohort study of a prospectively maintained, IRB-approved database. SETTINGS/PATIENTS Ninety-one (2.3%) patients of 3058 patients with an original diagnosis of ulcerative colitis who underwent proctocolectomy with ileal pouch-anal anastomosis between 2000 and 2021 at the Cleveland Clinic and underwent postoperative surgery for Crohn's-related perianal disease. INTERVENTIONS Two hundred thirty-one operations for perianal or anovaginal fistula(s). MAIN OUTCOME AND MEASURES Healing rate of surgical therapy for peri-pouch fistulizing disease, impact of recurrent interventions on outcomes, and predictors of surgical failure. RESULTS Overall mean age was 39.1 (± 11.6) years, with a BMI of 25.3 (± 6.3) kg/m2. More than half of the patients were female (n = 52, 57.1%). Sixty-three patients (69.2%) had a perianal fistula, 25 (27.5%) had an anovaginal fistula, and 3 (3.3%) patients had both. Overall success rate for healing was 59.3% (n = 54/91) at a mean follow-up of 6.4 (± 4.8) years. Seventeen (18.7%) patients underwent a concomitant diverting loop ileostomy. Among them, eight (47.0%) patients had the ileostomy closure after a mean time of 9.7 (± 2.8) months. In the multivariable logistic regression model, patients who had seton insertions in any operation were significantly less likely to heal (OR 0.11 95%, CI 0.03-0.43, p = 0.001). Overall pouch failure rate was 12.1%. LIMITATIONS Retrospective single-center study which lacks a control arm and consistent long-term follow-up specific to a population-based dataset. CONCLUSIONS Pouch patients who develop perianal disease are difficult to treat, sometimes requiring pouch excision. However, when medical treatment alone is not effective, a multidisciplinary approach including surgical intervention can result in complete fistula healing in more than half of the cases.
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Affiliation(s)
- Ana M Otero-Piñeiro
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Stefan Holubar
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Karina E Pedersen
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Nihal Aykun
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Megan Obi
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Robert Butler
- Department of General Surgery, Statistics, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
- Department of General Surgery, Statistics, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
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9
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Maspero M, Lavryk O, Lipman J, Valente M, Kessler H, Holubar S, Steele SR, Hull T. Redo ileal pouch-anal anastomosis for early versus late sepsis-related pouch failure. Surgery 2023; 174:801-807. [PMID: 37543468 DOI: 10.1016/j.surg.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/24/2023] [Accepted: 06/18/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Pouch failure after restorative proctocolectomy with ileal pouch-anal anastomosis occurs in 5% to 15% of cases, mostly due to septic complications. We aimed to determine if the timing of pouch failure impacted long-term outcomes for redo ileal pouch-anal anastomosis after sepsis-related complications. METHOD We retrospectively analyzed our prospectively collected institutional pouch database. Patients who underwent redo ileal pouch-anal anastomosis for septic complications between 1988 and 2020 were divided into an early (pouch failure within 6 months of stoma closure after index operation, or stoma never closed) and a late failure group (pouch failure after 6 months of stoma closure). The primary endpoint was pouch survival. RESULTS In total, 335 patients were included: 241 (72%) in the early and 94 (28%) in the late failure group. The most common indication for failure was an anastomotic leak in the early failure group (163, 68%) and fistula in the late failure group (59, 63%), P < .001. Pouch survival at 3, 5, and 10 years was 77%, 75%, and 72% for the early and 79%, 75%, and 68% for the late failure group (P = .94). The most common reason for redo pouch failure was fistula in both groups. Quality of life was similar in both groups. In multivariate analysis, the only factor associated with pouch failure was the final diagnosis of Crohn's disease. CONCLUSION Outcomes after redo ileal pouch-anal anastomosis were comparable between patients with early and late sepsis-related index pouch failure, with acceptable rates of long-term pouch survival and good quality of life.
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Affiliation(s)
- Marianna Maspero
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, OH. https://twitter.com/MariannaMaspero
| | - Olga Lavryk
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, OH. https://twitter.com/OlgaLavryk
| | - Jeremy Lipman
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, OH
| | - Michael Valente
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, OH
| | - Hermann Kessler
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, OH
| | - Stefan Holubar
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, OH. https://twitter.com/HolubarStefan
| | - Scott R Steele
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, OH. https://twitter.com/ScottRSteeleMD
| | - Tracy Hull
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, OH.
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10
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Maspero M, Lavryk O, Lipman J, DeRoss A, Kessler H, Holubar S, Steele SR, Hull T. Long-term Outcomes of Straight Ileoanal Anastomoses Converted to Ileal Pouch Anal Anastomoses. J Pediatr Surg 2023; 58:1898-1902. [PMID: 37005207 DOI: 10.1016/j.jpedsurg.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/22/2023] [Accepted: 03/04/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND While ileal pouch anal anastomosis (IPAA) is the recommended way to restore intestinal continuity after total proctocolectomy, straight ileoanal anastomoses (SIAA) are still selectively performed, especially in the pediatric population. In case of SIAA failure, conversion to IPAA is possible, but reports on its outcomes are scarce. METHODS We retrospectively analyzed our prospectively collected database on pelvic pouches, and identified patients with a SIAA that was converted to IPAA. Our aim was long-term functional outcomes. RESULTS Twenty-three patients were included (14 females, median age at SIAA 15 years, median age at conversion to IPAA 19 years). The indication for SIAA was ulcerative colitis in 17 (74%) cases, indeterminate colitis in 2 (9%) cases, and familial adenomatous polyposis in 4 (17%) cases. The indication for IPAA conversion was incontinence/poor quality of life in 12 (52%) cases, sepsis in 8 (35%) cases, anastomotic stricture in 2 (9%) cases, and prolapse in one (4%) case. The majority were diverted at IPAA conversion (22, 96%). Three (13%) patients never had stoma closure, due to patient wishes, failed healing of vaginal fistula, and pelvic sepsis, respectively. After a median follow up of 109 months (28-170), pouch failure occurred in 5 additional patients. Overall pouch survival was 71% at 5 years. Median quality of life was 8/10, of health 8/10, and of energy 7/10. Median satisfaction with surgery was 9.5/10. CONCLUSION Conversion of SIAA to IPAA leads to acceptable long-term outcomes and good quality of life, and can safely be offered to patients with problems related to SIAA. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Marianna Maspero
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Olga Lavryk
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jeremy Lipman
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Anthony DeRoss
- Department of Pediatric Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Hermann Kessler
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Stefan Holubar
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Scott R Steele
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Tracy Hull
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
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11
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Baker ME, Hull T, Holubar S, Lightner A, Qazi T. Clinical issues facing pouch patients: an introduction to a special issue on the ileal pouch. Abdom Radiol (NY) 2023; 48:2913-2917. [PMID: 36334124 DOI: 10.1007/s00261-022-03723-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022]
Abstract
For over 40 years, restorative proctocolectomy has been used in patients with ulcerative colitis or familial adenomatous polyposis undergoing proctocolectomy. Radiologists are now encountering an increasing number of patients with an ileal pouch and therefore need to understand the clinical issues and concerns in these patients. This review is the introduction of a special issue on the ileal pouch and was written with both surgeon and gastroenterology input. The intent is to assist the radiologist in understanding the clinical questions posed by both the patients and their physicians. Subsequent sessions will address specific imaging modalities and techniques, how the gastroenterologists and surgeons address issues with these patients, and a final session summarizing the sessions and speculating on future investigations and approaches.
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Affiliation(s)
- Mark E Baker
- Imaging Institute, 9500 Euclid Ave/L10, Cleveland, OH, 44195, USA.
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
- Crohn's Disease Focus Panel of the Society of Abdominal Radiology, East Dundee, USA.
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Stefan Holubar
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amy Lightner
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Taha Qazi
- Department of Gastroenterology and Hepatology, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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12
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Otero-Piñeiro AM, Jia X, Pedersen KE, Hull T, Lipman J, Holubar S, Steele SR, Lightner AL. Surgical Intervention is Effective for the Treatment of Crohn's related Rectovaginal Fistulas: Experience From A Tertiary Inflammatory Bowel Disease Practice. J Crohns Colitis 2022; 17:396-403. [PMID: 36219575 DOI: 10.1093/ecco-jcc/jjac151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Rectovaginal fistula occurs in up to 10-20% of women with Crohn's disease, significantly affecting their quality of life. We sought to determine outcomes of single and repeat operative interventions. METHODS A retrospective review of all adult patients with a Crohn's related rectovaginal fistula who underwent an operation between 1995 to 2021 was performed. Data collected included patient demographics, Crohn's related medical treatment, surgical intervention, postoperative outcomes, and fistula outcomes. RESULTS A total of 166 patients underwent 360 operations; mean age was 42.8 (+/-13.2) years. Thirty-four (20.7%) patients were current and 58 (35.4%) former smokers. The most commonly performed procedure was a local approach (n=160, 44.5%) using fibrin glue, fistulotomy/fistulectomy or seton placement, followed by a transvaginal/transanal approach (n=113, 31.4%) with an advancement flap repair (including Martius advancement flap) and episoproctotomy, a transabdominal approach (n=98, 27.2%) including proctectomy or redo anastomosis and finally gracilis muscle interposition (n=8, 2.2%). The median number of operative interventions per patient was 2 (1.0-3.0) procedures. The overall fistula healing rate per patient was 71.7% (n=119) at a median follow-up of 5.5 (1.2-9.8) years. Factors that impaired healing included former smoking (OR 0.52 95%, CI 0.31 - 0.87, p=0.014) and seton insertion (OR 0.42 95%, CI 0.21-0.83, p=0.012). CONCLUSION Over two-thirds of Crohn's related rectovaginal fistulas can achieve closure with multiple surgical interventions. Smoking and seton usage negatively impact healing rates and should be avoided.
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Affiliation(s)
- Ana M Otero-Piñeiro
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - Xue Jia
- Department of General Surgery, Statistics, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland OH
| | - Karina E Pedersen
- College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - Jeremy Lipman
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - Stefan Holubar
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, OH
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13
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Spinelli A, Bonovas S, Burisch J, Kucharzik T, Adamina M, Annese V, Bachmann O, Bettenworth D, Chaparro M, Czuber-Dochan W, Eder P, Ellul P, Fidalgo C, Fiorino G, Gionchetti P, Gisbert JP, Gordon H, Hedin C, Holubar S, Iacucci M, Karmiris K, Katsanos K, Kopylov U, Lakatos PL, Lytras T, Lyutakov I, Noor N, Pellino G, Piovani D, Savarino E, Selvaggi F, Verstockt B, Doherty G, Raine T, Panis Y. ECCO Guidelines on Therapeutics in Ulcerative Colitis: Surgical Treatment. J Crohns Colitis 2022; 16:179-189. [PMID: 34635910 DOI: 10.1093/ecco-jcc/jjab177] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This is the second of a series of two articles reporting the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of adult patients with ulcerative colitis [UC]. The first article is focused on medical management, and the present article addresses medical treatment of acute severe ulcerative colitis [ASUC] and surgical management of medically refractory UC patients, including preoperative optimisation, surgical strategies, and technical issues. The article provides advice for a variety of common clinical and surgical conditions. Together, the articles represent an update of the evidence-based recommendations of the ECCO for UC.
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Affiliation(s)
- Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, and Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Stefanos Bonovas
- Department of Biomedical Sciences, and IRCCS Humanitas Research Hospital, Milan, Italy
| | - Johan Burisch
- Gastrounit, Medical Division, and Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, University of Copenhagen, Denmark
| | - Torsten Kucharzik
- Department of Gastroenterology, Lüneburg Hospital, University of Hamburg, Lüneburg, Germany
| | - Michel Adamina
- Department of Surgery, Clinic of Visceral and Thoracic Surgery, Cantonal Hospital Winterthur, Zurich.,Department of Biomedical Engineering, Clinical Research and Artificial Intelligence in Surgery, Faculty of Medicine, University of Basel, Allschwil, Switzerland
| | - Vito Annese
- Department of Gastroenterology, Fakeeh University Hospital, Dubai, UAE
| | - Oliver Bachmann
- Department of Internal Medicine I, Siloah St. Trudpert Hospital, Pforzheim.,Hannover Medical School, Hannover, Germany
| | - Dominik Bettenworth
- University Hospital Munster, Department of Medicine B - Gastroenterology and Hepatology, Munster, Germany
| | - Maria Chaparro
- Gastroenterology Unit, IIS-IP, Universidad Autónoma de Madrid [UAM], CIBEREHD, Madrid, Spain
| | - Wladyslawa Czuber-Dochan
- King's College London, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, London, UK
| | - Piotr Eder
- Department of Gastroenterology, Dietetics and Internal Medicine, Poznań University of Medical Sciences, and Heliodor Święcicki University Hospital, Poznań, Poland
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | - Catarina Fidalgo
- Gastroenterology Division, Hospital Beatriz Ângelo, Loures, Portugal
| | - Gionata Fiorino
- Department of Biomedical Sciences, Humanitas University, and IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Paolo Gionchetti
- IBD Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna DIMEC, University of Bologna, Bologna, Italy
| | - Javier P Gisbert
- Gastroenterology Unit, IIS-IP, Universidad Autónoma de Madrid [UAM], CIBEREHD, Madrid, Spain
| | - Hannah Gordon
- Department of Gastroenterology, Barts Health NHS Trust, Royal London Hospital, London, UK
| | - Charlotte Hedin
- Karolinska Institutet, Department of Medicine Solna, and Karolinska University Hospital, Department of Gastroenterology, Dermatovenereology and Rheumatology, Stockholm, Sweden
| | - Stefan Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Marietta Iacucci
- Institute of Immunology and Immunotherapy, University of Birmingham, and Division of Gastroenterology, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | | | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, Division of Internal Medicine, University and Medical School of Ioannina, Ioannina, Greece
| | - Uri Kopylov
- Department of Gastroenterology, Tel-HaShomer Sheba Medical Center, Ramat Gan, and Sackler Medical School, Tel Aviv, Israel
| | - Peter L Lakatos
- Division of Gastroenterology, McGill University Health Centre, Montreal, QC, Canada.,1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Theodore Lytras
- School of Medicine, European University Cyprus, Nicosia, Cyprus
| | - Ivan Lyutakov
- Department of Gastroenterology, University Hospital 'Tsaritsa Yoanna - ISUL', Medical University Sofia, Sofia, Bulgaria
| | - Nurulamin Noor
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania "Luigi Vanvitelli", Naples, Italy, and Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, and IRCCS Humanitas Research Hospital, Milan, Italy
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Francesco Selvaggi
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, and Department of Chronic Diseases, Metabolism and Ageing, TARGID - IBD, KU Leuven, Leuven, Belgium
| | - Glen Doherty
- Department of Gastroenterology and Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Tim Raine
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Yves Panis
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Clichy and Université of Paris, France
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14
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Raine T, Bonovas S, Burisch J, Kucharzik T, Adamina M, Annese V, Bachmann O, Bettenworth D, Chaparro M, Czuber-Dochan W, Eder P, Ellul P, Fidalgo C, Fiorino G, Gionchetti P, Gisbert JP, Gordon H, Hedin C, Holubar S, Iacucci M, Karmiris K, Katsanos K, Kopylov U, Lakatos PL, Lytras T, Lyutakov I, Noor N, Pellino G, Piovani D, Savarino E, Selvaggi F, Verstockt B, Spinelli A, Panis Y, Doherty G. ECCO Guidelines on Therapeutics in Ulcerative Colitis: Medical Treatment. J Crohns Colitis 2022; 16:2-17. [PMID: 34635919 DOI: 10.1093/ecco-jcc/jjab178] [Citation(s) in RCA: 249] [Impact Index Per Article: 124.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Tim Raine
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University; IRCCS Humanitas Research Hospital, Milan, Italy
| | - Johan Burisch
- Gastrounit, Medical Division, Hvidovre Hospital; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, University of Copenhagen, Denmark
| | - Torsten Kucharzik
- Department of Gastroenterology, Lüneburg Hospital, University of Hamburg, Lüneburg, Germany
| | - Michel Adamina
- Department of Surgery, Clinic of Visceral and Thoracic Surgery, Cantonal Hospital Winterthur, Zurich, Switzerland
- Department of Biomedical Engineering, Clinical Research and Artificial Intelligence in Surgery, Faculty of Medicine, University of Basel, Allschwil, Switzerland
| | - Vito Annese
- Department of Gastroenterology, Fakeeh University Hospital, Dubai, UAE
| | - Oliver Bachmann
- Department of Internal Medicine I, Siloah St. Trudpert Hospital, Pforzheim; Hannover Medical School, Hannover, Germany
| | - Dominik Bettenworth
- University Hospital Munster, Department of Medicine B - Gastroenterology and Hepatology, Munster, Germany
| | - Maria Chaparro
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Wladyslawa Czuber-Dochan
- King's College London, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, London, UK
| | - Piotr Eder
- Department of Gastroenterology, Dietetics and Internal Medicine - Poznań University of Medical Sciences; Heliodor Święcicki University Hospital, Poznań, Poland
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | - Catarina Fidalgo
- Gastroenterology Division, Hospital Beatriz Ângelo, Loures, Portugal
| | - Gionata Fiorino
- Department of Biomedical Sciences, Humanitas University; IBD Center, Humanitas Clinical and Research Center, Milan, Italy
| | - Paolo Gionchetti
- IBD Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna DIMEC, University of Bologna, Bologna, Italy
| | - Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Hannah Gordon
- Department of Gastroenterology, Barts Health NHS Trust, Royal London Hospital, London, UK
| | - Charlotte Hedin
- Karolinska Institutet, Department of Medicine Solna; Karolinska University Hospital, Department of Gastroenterology, Dermatovenereology and Rheumatology, Stockholm, Sweden
| | - Stefan Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Marietta Iacucci
- Institute of Immunology and Immunotherapy, NIHR Biomedical Research Centre, University of Birmingham; Division of Gastroenterology, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | | | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, Division of Internal Medicine, University and Medical School of Ioannina, Ioannina, Greece
| | - Uri Kopylov
- Department of Gastroenterology, Tel-HaShomer Sheba Medical Center, Ramat Gan, and Sackler Medical School, Tel Aviv, Israel
| | - Peter L Lakatos
- Division of Gastroenterology, McGill University Health Centre, Montreal, QC, Canada
- 1st Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Theodore Lytras
- School of Medicine, European University Cyprus, Nicosia, Cyprus
| | - Ivan Lyutakov
- Department of Gastroenterology, University Hospital 'Tsaritsa Yoanna - ISUL', Medical University Sofia, Sofia, Bulgaria
| | - Nurulamin Noor
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy
- Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University; IRCCS Humanitas Research Hospital, Milan, Italy
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Francesco Selvaggi
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy
| | - Bram Verstockt
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven; Department of Chronic Diseases, Metabolism and Ageing, TARGID - IBD, Leuven, Belgium
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University; IRCCS Humanitas Research Hospital, Milan, Italy
| | - Yves Panis
- Department of Colorectal Surgery, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, Clichy and Université of Paris, France
| | - Glen Doherty
- Department of Gastroenterology and Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
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15
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Hung L, Darabnia J, Judeeba S, Lightner AL, Holubar S, Steele SR, Valente MA. Timing and outcome of right- vs left-sided colonic anastomotic leaks: Is there a difference? Am J Surg 2021; 223:493-495. [PMID: 34969507 DOI: 10.1016/j.amjsurg.2021.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 12/15/2021] [Accepted: 12/17/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Anastomotic leaks (AL) contribute to postoperative mortality, prolonged hospitalization, and increased health care costs. While left-sided AL (LAL) are well described in the literature, there is a paucity of studies on outcomes and management of right-sided AL (RAL). This study aimed to compare the timing of RAL versus LAL, and the variable diagnosis, management and outcomes of RAL versus LAL. We hypothesized that the timing of RAL may be later compared to LAL and may result in worse overall outcomes. METHODS Patients who underwent curative intent surgery for neoplastic disease from January 1995 to December 2015 were included. Patients that underwent an anastomosis below the peritoneal reflection, neoadjuvant treatment, fecal diversion, previous colectomy/anastomosis, multiple anastomoses, and patients with inflammatory bowel disease or hereditary colorectal cancer syndromes were excluded. Patient demographics, neoplastic data, operative data, time to AL, methods utilized for diagnosis of AL, and management of AL were collected. The primary endpoint was timing of AL, and secondary endpoints were management and outcome based on RAL versus LAL. RAL and LAL were analyzed and compared using Chi-squared and categorical variables were expressed as number (percentage) and continuous variables expressed as median (interquartile range). RESULTS A total of 2223 patients underwent oncologic resection for colonic neoplasia (1457 right sided and 766 left sided anastomoses). 67% of patients were male and median age was 69 years (range, 34-91). There were 48 total AL events (2.16%): 26 RAL (1.78%) and 22 LAL (2.87%). There was no statistical difference in leak rates between RAL and LAL and no difference in time to diagnosis or management (Table 1). RAL had significantly decreased operative time (p = 0.016), decreased intraoperative blood loss (p = 0.002), and increased diagnosis by CT/plain radiograph (p = 0.04). All patients that underwent surgery for leak had some form of fecal diversion performed. Morbidity and mortality were comparable between groups (p = 0.70; p = 1.0). CONCLUSIONS This study found overall very low AL rates with comparable timing of RAL and LAL, and no difference in management or outcome of RAL vs. LAL. These findings are informative for patient and surgeon expectations before and after surgery and when AL is suspected.
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Affiliation(s)
- Laurie Hung
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jamshid Darabnia
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sami Judeeba
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Stefan Holubar
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Michael A Valente
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
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Lightner AL, Vaidya P, Holubar S, Warusavitarne J, Sahnan K, Carrano FM, Spinelli A, Zaghiyan K, Fleshner PR. Perioperative safety of tofacitinib in surgical ulcerative colitis patients. Colorectal Dis 2021; 23:2085-2090. [PMID: 33942470 DOI: 10.1111/codi.15702] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 02/03/2021] [Accepted: 03/11/2021] [Indexed: 01/19/2023]
Abstract
AIM The literature regarding monoclonal antibodies and increased postoperative complications in inflammatory bowel disease remains controversial. There have been no studies investigating tofacitinib. The aim of this work was to determine preoperative exposure to the small-molecule inhibitor tofacitinib and postoperative outcomes. METHOD We conducted a retrospective review of all adult patients exposed to tofacitinib within 4 weeks of total abdominal colectomy for medically refractory ulcerative colitis between 1 January 2018 and 1 September 2020 at four inflammatory bowel disease referral centres. Data collected included patient demographics and 90-day postoperative morbidity, readmission and reoperation rates. RESULTS Fifty-three patients (32 men, 60%) with ulcerative colitis underwent a total abdominal colectomy (n = 50 laparoscopic, 94%) for medically refractory disease. Previous exposure to monoclonal antibodies included infliximab (n = 34), adalimumab (n = 35), certolizumab pegol (n = 5), vedolizumab (n = 33) and ustekinumab (n = 10). Twenty-seven (51%) patients were on concurrent prednisone at a median daily dose of 30 mg by mouth (range 5-60 mg). There were no postoperative deaths. Ninety-day postoperative complications included ileus (n = 7, 13.2%), superficial surgical site infection (n = 4, 7.5%), intra-abdominal abscess (n = 2, 3.8%) and venous thromboembolism (VTE) (n = 7, 13.2%). Locations of VTE included portomesenteric venous thrombus (n = 4), internal iliac vein (n = 2) and pulmonary embolism (n = 1). Nine (17%) patients were readmitted to hospital and five (9%) patients had a reoperation. CONCLUSION Mirroring the recently issued US Food and Drug Administration black box warning of an increased risk of VTE in medically treated ulcerative colitis patients taking tofacitinib, preoperative tofacitinib exposure may present an increased risk of postoperative VTE events. Consideration should be given for prolonged VTE prophylaxis on hospital discharge.
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Affiliation(s)
- Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Prashansha Vaidya
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Stefan Holubar
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | | | - Kapil Sahnan
- Division of Colon and Rectal Surgery, St Marks Hospital, London, UK
| | - Francesco Maria Carrano
- Division of Colon and Rectal Surgery, Humanitas Clinical and Research Center, Colon and Rectal Surgery Unit, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy
| | - Karen Zaghiyan
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Phillip R Fleshner
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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17
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Syal G, Serrano M, Jain A, Cohen BL, Rieder F, Stone C, Abraham B, Hudesman D, Malter L, McCabe R, Holubar S, Afzali A, Cheifetz AS, Gaidos JKJ, Moss AC. Health Maintenance Consensus for Adults With Inflammatory Bowel Disease. Inflamm Bowel Dis 2021; 27:1552-1563. [PMID: 34279600 PMCID: PMC8861367 DOI: 10.1093/ibd/izab155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND With the management of inflammatory bowel disease (IBD) becoming increasingly complex, incorporating preventive care health maintenance measures can be challenging. The aim of developing these updated recommendations is to provide more specific details to facilitate their use into a busy clinical practice setting. METHOD Fifteen statements were formulated with recommendations regarding the target, timing, and frequency of the health maintenance interventions in patients with IBD. We used a modified Delphi method and a literature review to establish a consensus among the panel of experts. The appropriateness of each health maintenance statement was rated on a scale of 1 to 5 (1-2 as inappropriate, and 4-5 as appropriate) by each panelist. Interventions were considered appropriate, and statements were accepted if ≥80% of the panelists agreed with a score ≥4. RESULTS The panel approved 15 health maintenance recommendations for adults with IBD based on the current literature and expert opinion. These recommendations include explicit details regarding specific screening tools, timing of screening, and vaccinations for adults with IBD. CONCLUSIONS Patients with IBD are at an increased risk for infections, malignancies, and other comorbidities. Given the complexity of caring for patients with IBD, this focused list of recommendations can be easily incorporated in to clinical care to help eliminate the gap in preventative care for patients with IBD.
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Affiliation(s)
- Gaurav Syal
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | - Animesh Jain
- University of North Carolina, Chapel Hill, North Carolina, USA
| | | | | | - Christian Stone
- Comprehensive Digestive Institute of Nevada, Las Vegas, Nevada, USA
| | | | - David Hudesman
- New York University Langone Medical Center, New York, New York, USA
| | - Lisa Malter
- NYU Grossman School of Medicine, Bellevue Hospital Center, New York, New York, USA
| | | | | | - Anita Afzali
- Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Adam S Cheifetz
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Alan C Moss
- Boston University School of Medicine, Boston, Massachusetts, USA,Address correspondence to: Alan C. Moss, MD, MBBCh, BAO, Professor, Boston University School of Medicine, 830 Harrison Avenue, 2nd floor, Boston, MA, 02118, USA. E-mail:
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18
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Cavallaro PM, Fearnhead NS, Bissett IP, Brar MS, Cataldo TE, Clarke R, Denoya P, Elder AL, Gecse KB, Hendren S, Holubar S, Jeganathan N, Myrelid P, Norton BA, Wexner SD, Wilson L, Zaghiyan K, Bordeianou L. Patients Undergoing Ileoanal Pouch Surgery Experience a Constellation of Symptoms and Consequences Representing a Unique Syndrome: A Report From the Patient-Reported Outcomes After Pouch Surgery (PROPS) Delphi Consensus Study. Ann Surg 2021; 274:138-145. [PMID: 33914449 PMCID: PMC8968673 DOI: 10.1097/sla.0000000000004829] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The primary aim was to create a patient-centered definition of core symptoms that should be included in future studies of pouch function. BACKGROUND Functional outcomes after ileoanal pouch creation have been studied; however, there is great variability in how relevant outcomes are defined and reported. More importantly, the perspective of patients has not been represented in deciding which outcomes should be the focus of research. METHODS Expert stakeholders were chosen to correlate with the clinical scenario of the multidisciplinary team that cares for pouch patients: patients, colorectal surgeons, gastroenterologists/other clinicians. Three rounds of surveys were employed to select high-priority items. Survey voting was followed by a series of online patient consultation meetings used to clarify voting trends. A final online consensus meeting with representation from all 3 expert panels was held to finalize a consensus statement. RESULTS One hundred ninety-five patients, 62 colorectal surgeons, and 48 gastroenterologists/nurse specialists completed all 3 Delphi rounds. Fifty-three patients participated in online focus groups. One hundred sixty-one stakeholders participated in the final consensus meeting. On conclusion of the consensus meeting, 7 bowel symptoms and 7 consequences of undergoing ileoanal pouch surgery were included in the final consensus statement. CONCLUSIONS This study is the first to identify key functional outcomes after pouch surgery with direct input from a large panel of ileoanal pouch patients. The inclusion of patients in all stages of the consensus process allowed for a true patient-centered approach in defining the core domains that should be focused on in future studies of pouch function.
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Affiliation(s)
- Paul M. Cavallaro
- Department of General Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Nicola S. Fearnhead
- Department of Colorectal Surgery, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - Ian P. Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Mantaj S. Brar
- Division of General Surgery, Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Thomas E. Cataldo
- Division of Colon and Rectum Surgery, Beth Israel-Deaconess Health Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - Paula Denoya
- Division of Colon and Rectal Surgery, Department of Surgery, Stony Brook University Hospital. Stony Brook, New York
| | | | - Krisztina B. Gecse
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Samantha Hendren
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Stefan Holubar
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Nimalan Jeganathan
- Department of Surgery, Division of Colon and Rectal Surgery, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Pär Myrelid
- Department of Surgery, County Council of Östergötland, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Beth-Anne Norton
- Crohn’s and Colitis Center, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Steven D. Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Lauren Wilson
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Karen Zaghiyan
- Division of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Liliana Bordeianou
- Massachusetts General Hospital Colorectal Surgery and Crohn’s Colitis Centers, Department of Gastrointestinal Surgery and Surgical Oncology, Boston, Massachusetts
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19
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Sedano R, Ma C, Pai RK, D' Haens G, Guizzetti L, Shackelton LM, Remillard J, Gionchetti P, Gordon IO, Holubar S, Kayal M, Lauwers GY, Pai RK, Pardi DS, Samaan MA, Schaeffer DF, Shen B, Silverberg MS, Feagan BG, Sandborn WJ, Jairath V. An expert consensus to standardise clinical, endoscopic and histologic items and inclusion and outcome criteria for evaluation of pouchitis disease activity in clinical trials. Aliment Pharmacol Ther 2021; 53:1108-1117. [PMID: 33735522 DOI: 10.1111/apt.16328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 01/29/2021] [Accepted: 02/26/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Pouchitis is a condition with large unmet medical needs and no approved therapies. Lack of validated instruments to measure disease activity and treatment response is a major barrier to drug development. AIM To conduct a modified RAND/University of California Los Angeles appropriateness process to produce a standardised assessment of pouchitis disease activity in clinical trials. METHODS A list of 164 items generated upon a systematic review and expert opinion were rated based on a 9-point scale (appropriate, uncertain and inappropriate), by a panel including 16 gastroenterologists, surgeons and histopathologists. RESULTS Items rated as appropriate to evaluate in pouchitis clinical trials were: (a) clinical: stool frequency and faecal urgency; (b) endoscopic: primary assessment in the pouch body according to the percentage of affected area (<50%, 50%-75% and >75%), evaluation of the presence of ulcers/erosions according to size (erosions <5 mm, ulcers ≥5 mm to 2 cm and large ulcers >2 cm) and ulcerated area (<10%, 10%-30% and >30%); (c) histologic: two biopsies from each segment, from the ulcer's edge when present, or endoscopically normal areas, assessment of lamina propria chronic inflammation, epithelial and lamina propria neutrophils, epithelial damage, erosions and ulcers; and (d) clinical trial inclusion/outcome criteria: minimum histologic disease activity for inclusion, a primary endpoint based on stool frequency and assessment of clinical, endoscopic and histologic response and remission. The overall majority of items surveyed (100/164) were rated 'uncertain'. CONCLUSION We conducted a RAND/UCLA appropriateness process to help inform measurement of pouchitis disease activity within clinical trials and foster the development of novel therapies.
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20
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Capona R, Hassab T, Sapci I, Aiello A, Liska D, Holubar S, Lightner AL, Steele SR, Valente MA. Surgical intervention for mechanical large bowel obstruction at a tertiary hospital: Which patients receive a stoma and how often are they reversed? Am J Surg 2020; 221:594-597. [PMID: 33288223 DOI: 10.1016/j.amjsurg.2020.11.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 11/05/2020] [Accepted: 11/12/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The surgical management of large bowel obstruction (LBO) is heterogeneous and influenced by multiple variables. The aim of this study was to analyze and compare the surgical interventions and outcomes of patients necessitating surgery for LBO. METHODS Patients with LBO between 2000 and 2017 were included. Main outcomes measures are intraoperative findings, operative management, post-operative outcomes and stoma closure rates. RESULTS 133 patients were included with predominately left-sided obstruction (82%). The most common etiology was colorectal cancer (44%) followed by extrinsic malignant compression (29%). The most common operation performed was fecal diversion without resection (46%). This group had significantly more stage 4 carcinoma, carcinomatosis and had the lowest stoma closure rate (16%). Eighty-six percent of the operated patients underwent fecal diversion, of these, 27% had stoma reversal at 6 months. Patients that had a resection and anastomosis with diverting loop ileostomy were most likely to undergo stoma reversal (p = 0.005) and had the lowest number of patients with stage-IV carcinoma. CONCLUSIONS In this single institution analysis, the management of LBO entails high operative and stoma rates, with less than 30% of patient undergoing stoma closure. Resection, anastomosis and DLI had the highest chance of stoma reversal.
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Affiliation(s)
- Rodrigo Capona
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tarek Hassab
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ipek Sapci
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Alexandra Aiello
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - David Liska
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Stefan Holubar
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Michael A Valente
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
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21
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Lightner AL, Kearney D, Giugliano D, Hull T, Holubar S, Shawki S, Steele SR. Excisional haemorrhoidectomy: is it safe in patients with an ileal pouch-anal anastomosis? Colorectal Dis 2020; 22:1154-1158. [PMID: 32003920 DOI: 10.1111/codi.14996] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 12/15/2019] [Indexed: 02/08/2023]
Abstract
AIM Excisional haemorrhoidectomy in patients with ulcerative colitis (UC), especially those undergoing an ileal pouch-anal anastomosis (IPAA), remains controversial. The aim of our study was to determine the safety of excisional haemorrhoidectomy in UC patients with and without an IPAA. METHOD A retrospective review of all adult UC patients undergoing excisional haemorrhoidectomy between 1 January 1995 and 1 January 2019 at a tertiary inflammatory bowel disease referral centre was performed. Data collected included patient demographics, clinical characteristics of UC, prior surgical intervention for UC (colectomy, IPAA) and complications after haemorrhoidectomy. RESULTS Forty-one adult patients [50% male; median age 52 (range 25-79) years] with UC underwent excisional haemorrhoidectomy between 1 January 1995 and 1 January 2019. The majority (n = 23) had not previously undergone surgery for UC. However, eight had already undergone construction of an IPAA at the time of haemorrhoidectomy, seven had IPAA at the time of haemorrhoidectomy and three had an IPAA constructed subsequent to haemorrhoidectomy. Two (4.9%) patients need to go back to theatre for postoperative bleeding. There were no further 30-day complications or long-term nonhealing of the surgical site. There were no pouch complications in those who had haemorrhoidectomy at the time of IPAA construction or in the presence of an IPAA. CONCLUSION Our data suggest that excisional haemorrhoidectomy may be performed safely in carefully selected UC patients with symptomatic haemorrhoids with or without IPAA and even at the time of IPAA construction.
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Affiliation(s)
- A L Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - D Kearney
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - D Giugliano
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - T Hull
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - S Holubar
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - S Shawki
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - S R Steele
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, Cleveland, Ohio, USA
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22
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Soop M, Holubar S. Introduction. Seminars in Colon and Rectal Surgery 2020. [DOI: 10.1016/j.scrs.2020.100739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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23
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Yoon YS, Stocchi L, Holubar S, Aiello A, Shawki S, Gorgun E, Steele SR, Delaney CP, Hull T. When should we add a diverting loop ileostomy to laparoscopic ileocolic resection for primary Crohn’s disease? Surg Endosc 2020; 35:2543-2557. [DOI: 10.1007/s00464-020-07670-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 05/21/2020] [Indexed: 12/14/2022]
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Abstract
The use of biologic agents including anti-tumor necrosis factor monoclonal antibodies followed by anti-integrins and anti-interleukins has drastically changed the treatment paradigm of Crohn’s disease (CD) by improving clinical symptoms and mucosal healing. However, up to 70% of CD patients still eventually undergo surgery mainly due to fibrostenotic strictures. There are no specific anti-fibrotic drugs yet. This review comprehensively addresses the mechanism, prediction, diagnosis and treatment of the fibrostenotic strictures in CD. We also introduce promising anti-fibrotic agents which may be available in the near future and summarize challenges in developing novel therapies to treat fibrostenotic strictures in CD.
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Affiliation(s)
- Jun Hwan Yoo
- Digestive Disease Center, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Stefan Holubar
- Department of Colorectal Surgery, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Florian Rieder
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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25
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Ritter KA, Burke JP, Stocchi L, Aiello A, Holubar S, Ashburn JH, Lipman JM, Shawki S, Hull T. Postoperative Steroid Taper Is Associated With Pelvic Sepsis After Ileal Pouch-anal Anastomosis. Inflamm Bowel Dis 2019; 25:1383-1389. [PMID: 30597024 DOI: 10.1093/ibd/izy388] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVE We hypothesized that postoperative oral steroid taper after ileal pouch-anal anastomosis for inflammatory bowel disease would not be associated with pelvic septic complications. BACKGROUND Recent data has emphasized the possible association between biologic medication use and pelvic sepsis following ileal pouch-anal anastomosis. Limited contemporary data exist examining the effects of steroid use on these complications. METHODS Consecutive patients undergoing ileal pouch-anal anastomosis for inflammatory bowel disease at a single institution from January 2009 to December 2013 were included. Factors associated with anastomotic leak and pelvic sepsis were assessed using univariate and multivariate analysis. RESULTS A total of 686 patients were included (mean age 39.5 years, 59% males). Postoperative oral steroid taper was associated with both anastomotic leak and pelvic sepsis on univariate analysis. Stress dose intravenous steroid use was not associated with complications. Multivariate analysis indicated total proctocolectomy (odds ratio [OR] 2.2; confidence interval [CI] 1.01-4.7, P = 0.047), and postoperative oral steroid taper (OR 2.3; CI 1.06-5.1; P = 0.035) as independent factors significantly associated with pelvic sepsis. CONCLUSIONS Prolonged postoperative oral steroid taper after ileal pouch-anal anastomosis should be avoided. If preoperative steroid weaning is not possible before a planned total proctocolectomy and ileal pouch-anal anastomosis, patients should undergo an initial total abdominal colectomy.
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Affiliation(s)
- Kaitlin A Ritter
- Cleveland Clinic, Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland, Ohio, USA
| | - John P Burke
- Beaumont Hospital, Department of Colorectal Surgery, Dublin, Ireland
| | - Luca Stocchi
- Cleveland Clinic, Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland, Ohio, USA
| | - Alexandra Aiello
- Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, Ohio, USA
| | - Stefan Holubar
- Cleveland Clinic, Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland, Ohio, USA
| | - Jean H Ashburn
- Department of Surgery, Wake Forest University, Winston Salem, North Carolina, USA
| | - Jeremy M Lipman
- Cleveland Clinic, Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland, Ohio, USA
| | - Sherief Shawki
- Cleveland Clinic, Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland, Ohio, USA
| | - Tracy Hull
- Cleveland Clinic, Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland, Ohio, USA
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26
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Holubar S. Surgical serious video games. Bull Am Coll Surg 2010; 95:67-68. [PMID: 21462426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Abstract
Handheld computers, or personal digital assistants (PDAs), have been used to assist clinicians in medical nutrition since the early 1980s. The term PDA was originally applied to programmable calculators; over time, the capabilities of these devices were expanded to allow for the use of more complicated programs such as databases, spreadsheets, and electronic books. Slowly, the device evolved into what is more commonly thought of as a PDA, that is, a device such as a PalmOS (PalmSource, Inc, Tokyo, Japan) or PocketPC (Microsoft, Redmond, WA) unit. We present a review of the literature about the use of PDAs in medical nutrition, followed by a discussion of the different types of PDAs and mobile technologies that are commercially available. This is followed by a discussion of software applications that are currently available for use by nutrition clinicians, focusing on freeware applications. Finally, future technologies and applications are discussed.
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Affiliation(s)
- Stefan Holubar
- Department of Surgery, North Shore University Hospital, Manhasset, New York, USA.
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28
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Abstract
Splenic injury is a known, albeit rare, complication of diagnostic and therapeutic colonoscopy. Within a 6-month period, we observed two colonoscopic splenic injuries. We report these two cases of splenic injury who presented differently after colonoscopy: one presented as frank hemorrhagic shock, and the other as a subacute splenic hemorrhage with symptomatic anemia. The first patient presented with hemorrhagic shock several hours after a diagnostic colonoscopy and required an emergency splenectomy. The second patient presented with symptomatic anemia several days after a diagnostic colonoscopy and was treated by angiographic embolization. Clinical presentation and discussion of the mechanisms of injury, available treatment options, and strategies for preventing colonoscopic splenic injuries are presented. Awareness of this complication is paramount in early recognition and management of this potentially life-threatening injury.
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Affiliation(s)
- Stefan Holubar
- Department of General Surgery, North Shore University-Long Island Jewish Hospital, Manhasset, New York
| | - Amit Dwivedi
- Department of General Surgery, North Shore University-Long Island Jewish Hospital, Manhasset, New York
| | - J. Eisendorfer
- Department of General Surgery, North Shore University-Long Island Jewish Hospital, Manhasset, New York
| | - R. Levine
- Department of General Surgery, North Shore University-Long Island Jewish Hospital, Manhasset, New York
| | - R. Strauss
- Department of General Surgery, North Shore University-Long Island Jewish Hospital, Manhasset, New York
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Holubar S, Dwivedi A, Eisdorfer J, Eisendorfer J, Levine R, Strauss R. Splenic rupture: an unusual complication of colonoscopy. Am Surg 2007; 73:393-6. [PMID: 17439036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Splenic injury is a known, albeit rare, complication of diagnostic and therapeutic colonoscopy. Within a 6-month period, we observed two colonoscopic splenic injuries. We report these two cases of splenic injury who presented differently after colonoscopy: one presented as frank hemorrhagic shock, and the other as a subacute splenic hemorrhage with symptomatic anemia. The first patient presented with hemorrhagic shock several hours after a diagnostic colonoscopy and required an emergency splenectomy. The second patient presented with symptomatic anemia several days after a diagnostic colonoscopy and was treated by angiographic embolization. Clinical presentation and discussion of the mechanisms of injury, available treatment options, and strategies for preventing colonoscopic splenic injuries are presented. Awareness of this complication is paramount in early recognition and management of this potentially life-threatening injury.
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Affiliation(s)
- Stefan Holubar
- Department of General Surgery, North Shore University-Long Island Jewish Hospital, Manhasset, New York, USA
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30
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Holubar S, Dwivedi AJ, O'Connor J. Giant mesenteric fibromatosis presenting as small bowel obstruction. Am Surg 2006; 72:427-9. [PMID: 16719198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Mesenteric fibromatosis is a proliferative fibroblastic neoplasia of the small intestine mesentery that may occur as a unique or multiple formation. Mesenteric fibromatosis is a rare, locally aggressive neoplasm and may present with abdominal discomfort, abdominal pain, weight loss, or symptoms of ureteral obstruction, mesenteric ischemia, or intestinal obstruction. It is of the utmost importance to distinguish mesenteric fibromatosis from gastrointestinal stromal tumors. Histopathology accurately differentiates between these two distinct entities. The preferred treatment is local surgical excision with a margin of uninvolved tissue. The involvement of important structures like the superior mesenteric artery and the superior mesenteric vein may pose a challenge during resection, but these tumors can be excised and the vessels repaired primarily.
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Affiliation(s)
- Stefan Holubar
- Department of Surgery, North Shore University/Long Island Jewish Medical Center, Manhasset, New York, USA
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Abstract
Mesenteric fibromatosis is a proliferative fibroblastic neoplasia of the small intestine mesentery that may occur as a unique or multiple formation. Mesenteric fibromatosis is a rare, locally aggressive neoplasm and may present with abdominal discomfort, abdominal pain, weight loss, or symptoms of ureteral obstruction, mesenteric ischemia, or intestinal obstruction. It is of the utmost importance to distinguish mesenteric fibromatosis from gastrointestinal stromal tumors. Histopathology accurately differentiates between these two distinct entities. The preferred treatment is local surgical excision with a margin of uninvolved tissue. The involvement of important structures like the superior mesenteric artery and the superior mesenteric vein may pose a challenge during resection, but these tumors can be excised and the vessels repaired primarily.
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Affiliation(s)
- Stefan Holubar
- From the Department of Surgery, North Shore University/Long Island Jewish Medical Center, Manhasset, New York
| | - Amit J. Dwivedi
- From the Department of Surgery, North Shore University/Long Island Jewish Medical Center, Manhasset, New York
| | - James O'Connor
- From the Department of Surgery, North Shore University/Long Island Jewish Medical Center, Manhasset, New York
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32
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Abstract
PURPOSE This study was conducted to compare continence after double-stapled ileal pouch-anal anastomosis and laparoscopic cholecystectomy using the Fecal Incontinence Severity Index and to assess the impact on quality of life using the Fecal Incontinence Quality of Life Scale. METHODS Fifty-five patients randomly selected from a prospective pelvic pouch database were matched with regard to age and gender with patients who had undergone laparoscopic cholecystectomy during the same time interval by the same surgeon. Patients were mailed the two questionnaires, which were reviewed by an independent observer. Demographics, duration since surgery, and functional results were recorded. The Fecal Incontinence Severity Index and Fecal Incontinence Quality of Life scores were compared by the analysis of variance method. RESULTS Fifty-one pelvic pouch and 50 laparoscopic cholecystectomy patients were able to be contacted and completed both of the measuring tools. For the pouch patients, the median number of bowel movements per day was six (range, 2-15), with two patients reporting more than occasional nighttime incontinence. Mean incontinence scores were higher for the pelvic pouch patients than for the laparoscopic cholecystectomy patients (17.8 vs. 10.7; P = 0.03). However, the quality-of-life scores were very similar: lifestyle (3.8 vs. 3.83; P = 0.88), depression/self-perception (3.81 vs. 3.83; P = 0.94), embarrassment (3.76 vs. 3.8; P = 0.84), and behavior/coping (3.57 vs. 3.71; P = 0.5). CONCLUSION Although continence is clearly altered after pelvic pouch surgery, quality of life is extremely well preserved.
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Affiliation(s)
- Stefan Holubar
- Department of Surgery, University of Vermont College of Medicine, Burlington, Vermont, USA
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