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Deng XM, Zhu TY, Wang GJ, Gao BL, Li RX, Wang JT. Laparoscopic total colectomy with ileorectal anastomosis and subtotal colectomy with antiperistaltic cecorectal anastomosis for slow transit constipation. Updates Surg 2023:10.1007/s13304-023-01458-y. [PMID: 36914915 DOI: 10.1007/s13304-023-01458-y] [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] [Received: 09/23/2022] [Accepted: 02/09/2023] [Indexed: 03/14/2023]
Abstract
To investigate the clinical efficacy of laparoscopic total colectomy with ileorectal anastomosis (TC-IRA) and laparoscopic subtotal colectomy with antiperistaltic cecorectal anastomosis (SC-ACRA) on adults with slow transit constipation (STC). One hundred and three patients with STC were assigned to the TC-IRA group (n = 53) and the SC-ACRA group (n = 50). The clinical data were analyzed. The surgery was successful in all patients (100%). Significantly (P = 0.03) more patients took anti-laxatives during hospitalization in the TC-IRA than the SC-ACRA group (39.62% vs. 20.00%). Abdominal pain and distension was present in 33.96% and 32.00% patients in the TC-IRA and SC-ACRA group, respectively, which decreased insignificantly (P > 0.05) to 18.87% and 18.00% 24 months after surgery, respectively. The postoperative Wexner and gastrointestinal quality of life (GIQLI) scores were not significantly different (P > 0.05) at all times after surgery in both groups. The defecation frequency decreased in both groups, and the average defecation frequency was significantly (P < 0.05) higher in the TC-IRA than the SC-ACRA group (3.91 ± 1.23 vs. 3.14 ± 1.15 times/day) at 3 months. Three months after surgery, significantly (P < 0.05) fewer patients were satisfied with defecation frequency in the TC-IRA than the SC-ACRA group (29 vs. 37 patients), whereas the number of patients who were willing to choose the same procedure again was not significantly (P > 0.05) different between the two groups. The WIS score of patients was significantly (P = 0.035) higher in the TC-IRA than the SC-ACRA group (6 vs. 5) 3 months later. TC-IRA and SC-ACRA are both safe and effective for adult slow transit constipation, and can significantly improve the quality of life of patients. Even though SC-ACRA has better early defecation frequency, postoperative antidiarrheal application and satisfaction, the long-term follow-up effects are similar.
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Affiliation(s)
- Xiu-Mei Deng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Tian-Yu Zhu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Guo-Jun Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China.
| | - Bu-Lang Gao
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Rui-Xin Li
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Jing-Tao Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
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Campos FG, Martinez CAR, Bustamante-Lopez LA, Mendonça RLDS, Kanno DT. Intra-abdominal desmoid tumors in familial adenomatous polyposis: How much do clinical and surgical variables interfere with their development? Clinics (Sao Paulo) 2023; 78:100144. [PMID: 36476966 PMCID: PMC9723922 DOI: 10.1016/j.clinsp.2022.100144] [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: 05/25/2022] [Revised: 11/03/2022] [Accepted: 11/07/2022] [Indexed: 12/07/2022] Open
Abstract
OBJECTIVE Familial Adenomatous Polyposis is a complex hereditary disease that exposes the carrier to a great risk of Colorectal Cancer (CRC). After prophylactic surgery, intra-abdominal desmoid tumors are known to be one the most important cause of death. Therefore, recognition of increased-risk patients and modification of operative strategy may be crucial. AIM The objective of this study was to estimate the desmoid tumor risk in relation to various surgical and clinical variables. METHODS Patients who had undergone polyposis since 1958 were included in the study. After exclusion criteria were met, those who had developed desmoid tumors were selected to undergo further evaluation. RESULTS The study revealed that the risk of developing desmoid tumors was associated with various factors such as sex ratio, colectomy, and reoperations. On the other hand, the type of surgery, family history, and surgical approach did not affect the risk of developing desmoid tumors. The data collected from 146 polyposis patients revealed that 16% had desmoid polyps. The sex ratio was 7:1, and the median age at colectomy was 28.6 years. Family history, multiple abdominal operations, and reoperations were some of the characteristics that were common in desmoid patients. CONCLUSION Recognition of clinical (female sex) and surgical (timing of surgery and previous reoperations) data as unfavorable variables associated with greater risk may be useful during the decision-making process.
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Affiliation(s)
- Fábio Guilherme Campos
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
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Salice M, Rizzello F, Sgambato D, Calabrese C, Manguso F, Laureti S, Rottoli M, Poggioli G, Gionchetti P. Long term remission after ileorectal anastomosis in Crohn's colitis. Dig Liver Dis 2021; 53:592-597. [PMID: 32616463 DOI: 10.1016/j.dld.2020.06.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 05/05/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Crohn's disease represents a heterogeneous entity, but its location tends to be relatively stable overtime. For extensive refractory Crohn's colitis, ileorectal anastomosis after colectomy is an engaging option, since the necessity of a permanent ileostomy is avoided. AIMS In our study, the long-term outcome of two groups of patients with Crohn's colitis who underwent colectomy and ileorectal anastomosis was compared. The first group had isolated colonic Crohn's disease without rectal involvement and perianal disease, while the second group included patients who had rectal and/or ileal involvement, with or without perianal disease. METHODS Between 1996 and 2016, in a single IBD tertiary center, 80 patients with a history of colectomy and ileorectal anastomosis for refractory Crohn's colitis were retrospectively identified. RESULTS Recurrence of disease was diagnosed in 57/64 of patients with Crohn's colitis with rectal and/or ileal and/or perianal involvement compared with 1/16 of patients with isolated Crohn's colitis without rectal and perianal disease in a median time of recurrence of 2 years (IQR 1-6 years, minimum to maximum, 1-18 years, p < 0.001). Only 6 patients (7,5%) underwent definitive end ileostomy without proctectomy (1 in the noIRP group and 5 in the IRP group). CONCLUSION Our data suggest that colectomy with ileorectal anastomosis may represent a curative option in patients with refractory isolated colitis without rectal and perianal involvement.
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Affiliation(s)
- Marco Salice
- IBD Unit, Department of Medical and Surgical Science, Sant'Orsola-Malpighi Hospital -University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Fernando Rizzello
- IBD Unit, Department of Medical and Surgical Science, Sant'Orsola-Malpighi Hospital -University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Dolores Sgambato
- Division of Hepato-Gastroenterology, Department of Clinical and Experimental Medicine, Second University of Naples, Via Pansini 5, 80131 Naples, Italy
| | - Carlo Calabrese
- IBD Unit, Department of Medical and Surgical Science, Sant'Orsola-Malpighi Hospital -University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Francesco Manguso
- Complex Operating Unit of Gastroenterology, AORN 'A. Cardarelli', Naples, Italy
| | - Silvio Laureti
- Surgical unit, Department of Medical and Surgical Science, Sant'Orsola-Malpighi Hospital -University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Matteo Rottoli
- Surgical unit, Department of Medical and Surgical Science, Sant'Orsola-Malpighi Hospital -University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Gilberto Poggioli
- Surgical unit, Department of Medical and Surgical Science, Sant'Orsola-Malpighi Hospital -University of Bologna, via Massarenti 9, 40138 Bologna, Italy
| | - Paolo Gionchetti
- IBD Unit, Department of Medical and Surgical Science, Sant'Orsola-Malpighi Hospital -University of Bologna, via Massarenti 9, 40138 Bologna, Italy.
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Xie M, Chen Y, Wei W, He X, Li X, Lian L, Lan P. Does ileoanal pouch surgery increase the risk of desmoid in patients with familial adenomatous polyposis? Int J Colorectal Dis 2020; 35:1599-1605. [PMID: 32435838 DOI: 10.1007/s00384-020-03578-y] [Citation(s) in RCA: 8] [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] [Accepted: 04/04/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Patients with familial adenomatous polyposis (FAP) may undergo either ileorectal anastomosis (IRA) or ileal pouch anal anastomosis (IPAA) depending on the degree of rectal involvement. Desmoid tumors (DTs) may arise postoperatively. Whether IPAA is associated with a higher risk of DTs as compared with IRA remains controversial. The purpose of this study was to determine whether IPAA increased the risk of DTs by analyzing the published data that compared IRA and IPAA as the primary treatment for FAP. METHODS A metaanalysis was performed to analyze the published data between 1989 and 2019. IRA and IPAA were compared with respect to the incidence of DTs. RESULTS Eight retrospective studies with a total of 1072 patients were identified: 491 underwent IPAA and 581 IRA. There was no significant difference in the incidence of DTs between IPAA and IRA (11.81% vs. 9.47%, OR 0.95, P = 0.85). Meanwhile, the overall complication (42.97% vs. 36.76%, OR 1.32, P = 0.11), incidence of cancer (4.88% vs. 8.37%, OR 0.28, P = 0.26), and overall mortality (0.33% vs. 5.20%, OR 0.49, P = 0.53) were comparable too. CONCLUSION Ileoanal pouch surgery is associated with similar risk of desmoid in patients with FAP after surgery.
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Affiliation(s)
- Minghao Xie
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, 26 Yuancun Er Heng Rd., Guangzhou, 510655, Guangdong, China.,Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yongle Chen
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, 26 Yuancun Er Heng Rd., Guangzhou, 510655, Guangdong, China
| | - Wancheng Wei
- Department of General Surgery, The People's Hospital of Gaozhou, Gaozhou, Guangdong, China
| | - Xiaowen He
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, 26 Yuancun Er Heng Rd., Guangzhou, 510655, Guangdong, China
| | - Xianzhe Li
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, 26 Yuancun Er Heng Rd., Guangzhou, 510655, Guangdong, China.,Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Lei Lian
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, 26 Yuancun Er Heng Rd., Guangzhou, 510655, Guangdong, China. .,Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
| | - Ping Lan
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, 26 Yuancun Er Heng Rd., Guangzhou, 510655, Guangdong, China. .,Guangdong Institute of Gastroenterology, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
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Abstract
Familial adenomatous polyposis (FAP) is an autosomal dominant genetic disease with a high tendency to develop colorectal cancer. The timing and choice of preventive surgical interventions should be based on the number, size and severity of adenomas, combined with a variety of considerations, in order to effectively prevent cancer and make patients easy to accept. Total proctocolectomy and ileal pouch-anal anastomosis (IPAA) procedure, which could minimize the residual rectal mucosa and reduce the risk of adenoma recurrence, has become the first choice for patients with FAP. Besides, laparoscopic IPAA has obvious advantages such as cosmetic appearance, quick recovery, little adhesion and high pregnancy rate. Patients with FAP should be managed by experienced surgeons working in specialized medical centers in order to get the most reasonable treatment at the best time and achieve long-term effective outcomes.
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Affiliation(s)
- Kai-Yu Li
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Gang Liu
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin 300052, China
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Segelman J, Mattsson I, Jung B, Nilsson PJ, Palmer G, Buchli C. Risk factors for anastomotic leakage following ileosigmoid or ileorectal anastomosis. Colorectal Dis 2018; 20:304-311. [PMID: 29059489 DOI: 10.1111/codi.13938] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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: 06/21/2017] [Accepted: 09/18/2017] [Indexed: 02/06/2023]
Abstract
AIM Reconstruction with an ileosigmoidal anastomosis (ISA) or ileorectal anastomosis (IRA) is a surgical option after a subtotal colectomy. Anastomotic leakage (AL) is a problematic complication and high rates have been reported, but there is limited understanding of the risk factors involved. The aim of this study was to assess the established and potential predictors of AL following ISA and IRA. METHOD This was a retrospective cohort study including all patients who had undergone ISA or IRA at three Swedish referral centres for colorectal surgery between January 2007 and March 2015. Data regarding clinical characteristics, treatment and outcome were collected from medical records. Univariate and multivariate logistic regression models were used to determine the association between patient and treatment related factors and the cumulative incidence of AL. RESULTS In total, 227 patients were included. Overall, AL was detected amongst 30 patients (13.2%). Amongst patients undergoing colectomy with synchronous ISA or IRA (one-stage procedure), AL occurred in 23 out of 120 (19.2%) compared with seven out of 107 (6.5%) after stoma reversal with ISA or IRA (two-stage procedure) (P = 0.004). In addition, the multivariate analyses revealed a statistically significantly lower odds ratio for AL following a two-stage procedure (OR 0.10, 95% CI 0.03-0.41, P = 0.001). CONCLUSIONS This study confirms high rates of AL following ISA and IRA. In particular, a synchronous procedure with colectomy and ISA/IRA carries a high risk of AL.
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Affiliation(s)
- J Segelman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Ersta Hospital, Stockholm, Sweden
| | - I Mattsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
| | - B Jung
- Department of Surgery and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - P J Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
| | - G Palmer
- Department of Molecular Medicine and Surgery, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
| | - C Buchli
- Department of Molecular Medicine and Surgery, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
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Takayama N, Tsujinaka S, Kakizawa N, Someya S, Takahashi J, Hasegawa F, Kikugawa R, Miyakura Y, Rikiyama T. Successful treatment of recurrent stoma prolapse after Hartmann's procedure through ileorectal anastomosis: A case report. Int J Surg Case Rep 2018; 41:489-492. [PMID: 29546023 PMCID: PMC5711666 DOI: 10.1016/j.ijscr.2017.11.041] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 11/20/2017] [Indexed: 11/25/2022] Open
Abstract
The patient with Parkinson’s disease had stoma prolapse after Hartmann’s procedure. Local procedure had failed, and stoma reversal was considered to be favorable. We assumed that stoma reversal alone led to worsening of concomitant constipation. We performed resection of the remnant colon with ileorectal anastomosis. It may be an optimal treatment for patients with concomitant colonic motility disorder.
Introduction Treatment strategy for recurrent stoma prolapse has not been well-established because of the rarity and complexity of the condition. We report a case of recurrent stoma prolapse that was successfully managed using unique surgical treatments. Presentation of case A 72-year-old man with a history of Parkinson's disease presented with transverse (T3N0M0) and sigmoid (T3N0M0) colon cancer. Considering the status of large bowel obstruction, Hartmann's procedure was indicated. Four months after surgery, stoma prolapse occurred, which became irreducible. Six months after surgery, local resection of the prolapsed bowel was performed. The patient continued to receive laxatives for bowel movement control and his abdomen remained distended. Ten months later, stoma prolapse recurred with evident bowel dilatation. Initially, we planned Hartmann’s reversal. However, as the patient had intractable constipation secondary to Parkinson’s disease, resection of the proximal colon and ileorectal anastomosis were considered as the treatment choices. Therefore, we performed right colectomy with ileorectal anastomosis. At 1.5 years after the last surgery, complications such as small bowel obstruction, difficulty in defecation, or fecal incontinence were not detected. Discussion The cause of stoma prolapse is generally ascribed to various anatomical factors such as redundant intestine, high intra-abdominal pressure, and intraperitoneal route. Stoma prolapse is also influenced by other factors, including old age, obesity, and the severity of illness that necessitated stoma creation. In this case, the decision regarding surgical management was complicated by colonic motility disorder with concomitant Parkinson’s disease. Conclusion We suggest that ileorectal anastomosis may be an optimal surgical treatment for patients with recurrent stoma prolapse and concomitant colonic motility disorder who have undergone Hartmann’s procedure.
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Affiliation(s)
- Noriya Takayama
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Japan
| | - Shingo Tsujinaka
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Japan.
| | - Nao Kakizawa
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Japan
| | - Soutoku Someya
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Japan
| | - Jun Takahashi
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Japan
| | - Fumi Hasegawa
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Japan
| | - Rina Kikugawa
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Japan
| | - Yasuyuki Miyakura
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Japan
| | - Toshiki Rikiyama
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Japan
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Khan M, Jayne D, Saunders R. Comparison of defecatory function after laparoscopic total colectomy and ileorectal anastomosis versus a traditional open approach. Ann R Coll Surg Engl 2018; 100:235-239. [PMID: 29364015 DOI: 10.1308/rcsann.2017.0219] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Introduction Total colectomy and ileorectal anastomosis can result in significant defecatory frequency and poor bowel function. The aim of this study was to assess whether a laparoscopic approach is associated with any improvement in this regard. Methods A single institution retrospective review was undertaken of patients undergoing elective total colectomy and ileorectal anastomosis between 2000 and 2011. Those undergoing emergency surgery and paediatric surgery were excluded. The primary outcome measure was satisfactory defecatory function after surgery. Results Forty-nine patients (24 male, 25 female) were included in the study. The median age was 48 years (range: 20-83 years). Laparoscopic total colectomy (LTC) was performed in 20 patients and open total colectomy (OTC) in 29 patients. Indications for surgery were slow colonic transit (n=17), colorectal cancer (CRC) (n=17), CRC with hereditary colorectal cancer syndrome (n=8), inflammatory bowel disease (n=4) and diverticular disease (n=3). In the LTC group, 85% had a satisfactory defecatory frequency of 1-6 motions per day compared with 45% in the OTC cohort (p=0.006). There was no statistically significant difference in bowel frequency related to primary pathology (benign vs cancer surgery, p=1.0). Postoperative complications for both groups included relaparotomy (n=3), anastomotic leak (n=2), small bowel obstruction (n=2), postoperative bleeding (n=1) and pneumonia (n=1). Conclusions This study indicates that long-term defecatory function is better following LTC than following OTC and ileorectal anastomosis. The mechanism for this improvement is unclear but it may relate to the underlying reason for surgery or possibly to reduced small bowel handling leading to fewer adhesions after laparoscopic surgery.
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Affiliation(s)
- Mas Khan
- Leeds Teaching Hospitals NHS Trust , UK
| | - D Jayne
- Leeds Teaching Hospitals NHS Trust , UK
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Schieffer KM, Poritz LS, Yochum GS, Koltun WA. Development of a total colectomy and ileorectal anastomosis rat model to evaluate colonic metaplasia. J Surg Res 2017; 218:217-225. [PMID: 28985852 DOI: 10.1016/j.jss.2017.05.120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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] [Received: 03/16/2017] [Revised: 05/16/2017] [Accepted: 05/25/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Ulcerative colitis is an idiopathic inflammatory condition of the colon that may require surgical intervention including proctocolectomy and either ileal pouch-anal anastomosis or in the pediatric population, low ileorectal anastomosis (IRA). Often, subsequent physiologic alteration (or colonic metaplasia) occurs in the anastomosed small bowel that includes changes in mucin content, villous blunting, and increased expression of WNT5A, a marker of colonic crypt regeneration. We developed a rat low IRA model to assess and study the development of colonic metaplasia. MATERIALS AND METHODS We subjected male Sprague-Dawley rats (n = 17) to total colectomy and low IRA surgery and evaluated healing periodically by endoscopic evaluation. The ileum upstream of the anastomosis was assessed by hematoxylin and eosin staining, and the mucin content was measured by high iron diamine-Alcian blue staining. Wnt5a transcripts were quantified by reverse transcription and quantitative polymerase chain reaction at the 8-wk study end point. RESULTS Although no gross endoscopic evidence of inflammation was seen throughout the course of the study, colonic metaplasia in the small bowel was detected in 7 out of 10 (70%) rats at the study end point. In rats with colonic metaplasia, enhanced expression of Wnt5a was evident at the study end point compared to levels in the terminal ileum at the time of surgery. CONCLUSIONS Within 4-8 wk, the majority of rats subjected to IRA developed colonic metaplasia defined by villous blunting, changes in mucin content, and increased expression of Wnt5a. This model provides a method to study small bowel colonic metaplasia.
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Affiliation(s)
- Kathleen M Schieffer
- Division of Colon and Rectal Surgery, Department of Surgery, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Lisa S Poritz
- Division of Colon and Rectal Surgery, Department of Surgery, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Gregory S Yochum
- Division of Colon and Rectal Surgery, Department of Surgery, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania; Department of Biochemistry & Molecular Biology, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Walter A Koltun
- Division of Colon and Rectal Surgery, Department of Surgery, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania.
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Onder A, Benlice C, Church J, Kessler H, Gorgun E. Short-term outcomes of laparoscopic versus open total colectomy with ileorectal anastomosis: a case-matched analysis from a nationwide database. Tech Coloproctol 2016; 20:767-773. [PMID: 27783175 DOI: 10.1007/s10151-016-1539-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [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: 06/03/2016] [Accepted: 09/16/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND In the current study, we aimed to compare peri- and postoperative 30-day outcomes of patients undergoing laparoscopic versus open total colectomy with ileorectal anastomosis in a case-matched design using data procedure-targeted database. METHODS Patients who underwent elective total colectomy with ileorectal anastomosis in 2012 and 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Patients were divided into two groups according to the type of surgical approach (laparoscopic and open). Laparoscopic and open groups were matched (1:1) based on age, gender, diagnosis, body mass index, and American Society of Anesthesiologists classification. Comorbidities, perioperative, and short-term (30-day) postoperative outcomes were compared between the matched groups. RESULTS We identified 1442 patients-549 in the laparoscopic group and 893 patients in the open group. After case matching, there were 326 patients in each group. There were 48 (14.7%) patients who had conversion in the laparoscopic group. The open group had a higher proportion of patients with ascites [0 (0%) vs. 7 (2.1%) p = 0.015], preoperative weight loss [26 (8.0%) vs. 45 (13.8%) p = 0.018], and contaminated wound classifications [Clean/Contaminated 261 (80%) vs. 240 (74%), Contaminated 55 (16.9%) vs. 54 (16.6%), and Dirty/Infected 8 (2.5%) vs. 28 (8.6%), (p = 0.003)]. The laparoscopic group had a significantly longer operative time (242 ± 98 vs. 202 ± 116 min, p < 0.001), shorter hospital stay (9.4 ± 8.5 vs. 13.3 ± 10.7 days, p < 0.001), and lower ileus rate (23.9 vs. 31.0%, p = 0.045) than the open group. After adjusting for covariates, the differences in terms of operative time and hospital stay remained significant [odds ratio (OR): 0.79, confidence interval (CI) 0.74-0.85 and OR 1.36, CI 1.21-1.52, p < 0.001, respectively]. CONCLUSIONS Laparoscopic approach for total colectomy with ileorectal anastomosis is associated with a shorter hospital stay but longer operative time compared with an open approach.
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Affiliation(s)
- A Onder
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave. A-30, Cleveland, OH, 44195, USA
| | - C Benlice
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave. A-30, Cleveland, OH, 44195, USA
| | - J Church
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave. A-30, Cleveland, OH, 44195, USA
| | - H Kessler
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave. A-30, Cleveland, OH, 44195, USA
| | - E Gorgun
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave. A-30, Cleveland, OH, 44195, USA.
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Konishi T, Ishida H, Ueno H, Kobayashi H, Hinoi T, Inoue Y, Ishida F, Kanemitsu Y, Yamaguchi T, Tomita N, Matsubara N, Watanabe T, Sugihara K. Feasibility of laparoscopic total proctocolectomy with ileal pouch-anal anastomosis and total colectomy with ileorectal anastomosis for familial adenomatous polyposis: results of a nationwide multicenter study. Int J Clin Oncol 2016; 21:953-61. [PMID: 27095110 DOI: 10.1007/s10147-016-0977-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 03/26/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Data supporting the safety and feasibility of laparoscopic total proctocolectomy with ileal pouch-anal anastomosis (TPC-IPAA) and total colectomy with ileorectal anastomosis (TC-IRA) for patients with familial adenomatous polyposis (FAP) are limited. The aim of this study was to clarify the feasibility and morbidity of laparoscopic TPC-IPAA and TC-IRA for patients with FAP, using a large Japanese multicenter dataset. METHODS Data on 256 patients with FAP who underwent TPC-IPAA (n = 171) or TC-IRA (n = 85) at 23 institutions between the years 2000 and 2012 were collected. Short- and long-term clinical outcomes were compared between laparoscopic and open approaches for each procedure. RESULTS Among the 256 patients with FAP, a total of 126 patients underwent laparoscopic surgery, consisting of 74 laparoscopic TPC-IPAAs and 52 laparoscopic TC-IRAs. The proportion of the FAP patients who underwent laparoscopic surgery increased during the study period, reaching 79 % of all TPC-IPAAs and 82 % of all TC-IRAs in the final two years covered by the data. In both TPC-IPAA and TC-IRA, the laparoscopic approach was associated with a longer operative duration but a similarly low postoperative morbidity and comparably adequate anal function compared with the open approach. The overall survival and the incidence of desmoid tumor were also comparable between the laparoscopic and open approaches in both procedures. CONCLUSIONS Laparoscopic TPC-IPAA and TC-IRA are both feasible options-with low rates of morbidity, good functional outcomes, and excellent overall survival rates-in patients with FAP. Since the data indicate that laparoscopic TPC-IPAA and TC-IRA are feasible, they also support the recent increase in laparoscopic surgery for patients with FAP in Japan.
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Campos FG. Surgical treatment of familial adenomatous polyposis: Dilemmas and current recommendations. World J Gastroenterol 2014; 20:16620-16629. [PMID: 25469031 PMCID: PMC4248206 DOI: 10.3748/wjg.v20.i44.16620] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 07/14/2014] [Accepted: 08/28/2014] [Indexed: 02/06/2023] Open
Abstract
Familial adenomatous polyposis (FAP) is an autosomal dominant inherited syndrome characterized by multiple adenomatous polyps (predisposing to colorectal cancer development) and numerous extracolonic manifestations. The underlying genetic burden generates variable clinical features that may influence operative management. As a precancerous hereditary condition, the rationale of performing a prophylactic surgery is a mainstay of FAP management. The purpose of the present paper is to bring up many controversial aspects regarding surgical treatment for FAP, and to discuss the results and perspectives of the operative choices and approaches. Preferably, the decision-making process should not be limited to the conventional confrontation of pros and cons of ileorectal anastomosis or restorative proctocolectomy. A wide discussion with the patient may evaluate issues such as age, genotype, family history, sphincter function, the presence or risk of desmoid disease, potential complications of each procedure and chances of postoperative surveillance. Therefore, the definition of the best moment and the choice of appropriate procedure constitute an individual decision that must take into consideration patient’s preferences and full information about the complex nature of the disease. All these facts reinforce the idea that FAP patients should be managed by experienced surgeons working in specialized centers to achieve the best immediate and long-term results.
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Scoglio D, Ahmed Ali U, Fichera A. Surgical treatment of ulcerative colitis: Ileorectal vs ileal pouch-anal anastomosis. World J Gastroenterol 2014; 20:13211-13218. [PMID: 25309058 PMCID: PMC4188879 DOI: 10.3748/wjg.v20.i37.13211] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 04/19/2014] [Accepted: 05/26/2014] [Indexed: 02/06/2023] Open
Abstract
Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the current gold standard in the surgical treatment of ulcerative colitis (UC) refractory to medical management. A procedure of significant magnitude carries its own risks including anastomotic failure, pelvic sepsis and a low rate of neoplastic degeneration overtime. Recent studies have shown that total colectomy with ileorectal anastomosis (IRA) has been associated with good long-term functional results in a selected group of UC patients amenable to undergo a strict surveillance for the relatively high risk of cancer in the rectum. This manuscript will review and compare the most recent literature on IRA and IPAA as it pertains to postoperative morbidity and mortality, failure rates, functional outcomes and cancer risk.
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Block M, Jørgensen KK, Oresland T, Lindholm E, Grzyb K, Cvancarova M, Vatn MH, Boberg KM, Börjesson L. Colectomy for patients with ulcerative colitis and primary sclerosing cholangitis - what next? J Crohns Colitis 2014; 8:421-30. [PMID: 24239402 DOI: 10.1016/j.crohns.2013.10.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 09/24/2013] [Accepted: 10/24/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Primary sclerosing cholangitis (PSC) occurs in 2%-8% of patients who suffer from ulcerative colitis (UC). For patients who require colectomy, ileal pouch-anal anastomosis (IPAA) or ileorectal anastomosis (IRA) is employed to preserve continence.We evaluated the outcomes after IPAA and IRA for patients with UC-PSC, using patients with UC but without PSC as controls (UC-only group). PATIENTS In a case-control study conducted at Sahlgrenska University Hospital, Sweden, patients with UC-PSC (N=48; 31 IPAA and 17 IRA) were compared to patients with UC only (N=113; 62 IPAA and 51 IRA). Functional outcomes (Öresland score), pouchitis, surgical complications, and failure were evaluated. RESULTS For patients with IPAA, the median Öresland scores were similar for the two groups: 5 (range, 0-13) for the UC-PSC group and 5 for the UC-only group (range, 0-12; p>0.05). However, the IRA scores were significantly different at 7 (range, 2-11) and 3 (range, 0-11) for the respective groups (p=0.005). Pouchitis was more frequent in patients with UC-PSC. Complication rates did not differ. For patients with IPAA, the failure rate was 16% for those in the UC-PSC group versus 6% for those in the UC-only group (p>0.05); the corresponding results for IRA were 53% versus 22% (p=0.03). CONCLUSIONS For cases of IPAA, pouchitis seems to be more common in patients with UC-PSC. However, the functional outcomes and failure rates are unaffected by concurrent PSC. For patients with UC-PSC, functional outcome is poor and the failure rate is high after IRA.
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Smith JC, Schäffer MW, Ballard BR, Smoot DT, Herline AJ, Adunyah SE, M'Koma AE. Adenocarcinomas After Prophylactic Surgery For Familial Adenomatous Polyposis. ACTA ACUST UNITED AC 2013; 4:260-270. [PMID: 23875116 DOI: 10.4236/jct.2013.41033] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The incidence of familial adenomatous polyposis (FAP) is one in 7,000 to 12,000 live births. Virtually, all surgically untreated patients with FAP inevitably develop colorectal-cancer in their lifetime because they carry the adenomatous polyposis coli gene. Thus prophylactic proctocolectomy is indicated. Surgical treatment of FAP is still controversial. There are however, four surgical options: ileorectal anastomosis, restorative proctocolectomy with ileal pouch-anal anastomosis, proctocolectomy with ileostomy, and proctocolectomy with continent-ileostomy. Conventional proctocolectomy options largely lie between colectomy with ileorectal anastomosis or ileal pouch-anal anastomosis. Detractors of ileal pouch-anal anastomosis prefer ileorectal anastomosis because of better functional results and quality of life. The functional outcome of total colectomy with ileorectal anastomosis is undoubtedly far superior to that of the ileoanal pouch; however, the risk for rectal cancer is increased by 30%. Even after mucosectomy, inadvertent small mucosal residual islands remain. These residual islands carry the potential for the development of subsequent malignancy. We reviewed the literature (1975-2012) on the incidence, nature, and possible etiology of subsequent ileal-pouch and anal transit zone adenocarcinoma after prophylactic surgery procedure for FAP. To date there are 24 studies reporting 92 pouch-related cancers; 15 case reports, 4 prospective and 5 retrospective studies. Twenty three of 92 cancers (25%) developed in the pouch mucosa and 69 (75%) in anal transit zone (ATZ). Current recommendation for pouch surveillance and treatment are presented. Data suggest lifetime surveillance of these patients.
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Affiliation(s)
- Joan C Smith
- Laboratory of Inflammatory Bowel Disease Research, Division of Biomedical Sciences, Department of Biochemistry and Cancer Biology, Meharry Medical College School of Medicine, Nashville, Tennessee
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