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Ahmed Ali U, Kiran RP. Conversion of Failed J-Pouch to Kock Pouch: Indications, Contraindications, and Outcomes. Dis Colon Rectum 2024; 67:S46-S51. [PMID: 38276945 DOI: 10.1097/dcr.0000000000003182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
BACKGROUND The IPAA has been successful in restoring intestinal continuity and preserving continence in the majority of patients requiring a proctocolectomy. However, a subset of individuals experience significant complications that might result in pouch failure. The conversion of the J-pouch to a continent ileostomy pouch represents a significant surgical procedure. In this article, we discuss the indications and contraindications, present the technical principles applied for the conversion, and describe the outcomes of such conversion in the literature. OBJECTIVE The main objective during the conversion of the J-pouch to a continent ileostomy is the creation of a sufficiently sized reservoir with a high-quality valve mechanism while preserving as much small bowel as possible. CONCLUSIONS The conversion of the J-pouch to a continent ileostomy represents a significant surgical procedure. When performed in centers of expertise, it can be a good option for patients who otherwise will require an end ileostomy. Indications for conversion include most cases of J-pouch failure, with a few important exceptions. See video from symposium .
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Affiliation(s)
- Usama Ahmed Ali
- Division of Colorectal Surgery, Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, New York
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Alipouriani A, Hull T, Lipman J, Holubar SD, Gorgun E, Liska D, Valente M, Steele SR. Diagnosis and treatment of primary ileal pouch leaks: a 27-year experience at a referral center. J Gastrointest Surg 2024; 28:860-866. [PMID: 38553296 DOI: 10.1016/j.gassur.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 03/03/2024] [Accepted: 03/09/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Ileal pouch-anal anastomosis (IPAA) is considered the preferred restorative surgical procedure for patients with ulcerative colitis and familial adenomatous polyposis requiring proctocolectomy. Unfortunately, postoperative leaks remain a complication with potentially significant ramifications. This study aimed to provide a comprehensive description of the evaluation, management, and outcomes of leaks after primary IPAA procedures. METHODS Between 1995 and 2022, a total of 4058 primary IPAA procedures were performed at Cleveland Clinic. From a prospectively maintained pouch registry, we retrospectively reviewed the data of 237 patients who presented to the pouch center for management. Of these, 114 (3%) had undergone the index IPAA procedure at our clinic (de novo cases), whereas 123 patients had their index IPAA performed elsewhere. Data were missing for 43 patients, resulting in a final cohort of 194 patients. RESULTS Our cohort had an average age of 41 years (range, 16-76) at the time of leak diagnosis. Overall, 55.2% were males, average body mass index was 24.4 kg/m2, and pain was the most prevalent presenting symptom (61.8%), followed by fever (34%). Leaks were confirmed through diagnostic testing in 141 cases, whereas 27.3% were detected intraoperatively. The most common initial diagnoses were pelvic abscess (47.4%) and enteric fistulas (26.8%), including cutaneous (9.8%), vaginal (7.2%), and bladder fistulas (3.1%). By location, leaks occurred at the tip of the "J" (52.6%), at the pouch-anal anastomotic site (35%), and in the body of the pouch (12.4%). A nonoperative management approach was initially attempted in 49.5% of cases, including antibiotic therapy, drainage, endoclip, and endo-sponge, with a success rate of 18.5%. Surgery was eventually required in 81.4% of patients, including (1) sutured or stapled pouch repair (52.5%), with diversion performed in 87.9% of these cases either before or during the salvage surgery; (2) pouch excision with neo-IPAA (22.7%), including 9 patients from the first group; and (3) pouch disconnection, repair, and reanastomosis (9.3%). Pouch failure occurred in 8.4%, with either pouch excision (11.1%) or permanent diversion (4.5%). Ultimately, 12.4% of patients (24 of 194) required permanent diversion, with all necessitating pouch excision. In the 30-day follow-up after salvage surgery, short-term complications arose in 38.7% of patients. The most common complications observed were ileus, pelvic abscess/sepsis, and fever. CONCLUSION Leaks after primary IPAA procedures represent an infrequent, yet challenging, complication. Despite attempts at nonoperative management, the success rate is limited. Salvage surgery is associated with a high pouch retention rate, underscoring its importance in the management of post-IPAA leaks.
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Affiliation(s)
- Ali Alipouriani
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, United States
| | - Tracy Hull
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, United States
| | - Jeremy Lipman
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, United States
| | - Stefan D Holubar
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, United States
| | - Emre Gorgun
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, United States
| | - David Liska
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, United States
| | - Michael Valente
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, United States
| | - Scott R Steele
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio, United States.
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Yang ML, Brar MS, Kennedy E, de Buck van Overstraeten A. Three-stage versus modified two-stage surgery for ulcerative colitis: a patient-centred treatment trade-off study. Colorectal Dis 2024; 26:1184-1190. [PMID: 38609339 DOI: 10.1111/codi.16984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/08/2024] [Accepted: 03/13/2024] [Indexed: 04/14/2024]
Abstract
AIM There is ongoing debate about whether ileal pouch-anal anastomosis needs temporary diversion at the time of construction. Stomas may reduce risk for anastomotic leak (AL) but are also associated with complications, emergency department visits and readmissions. This treatment trade-off study aims to measure patients' preferences by assessing the absolute risk of AL and pouch failure (PF) they are willing to accept to avoid a diverting ileostomy. METHODS Fifty-two patients with ulcerative colitis, with or without previous pouch surgery, from Mount Sinai Hospital, Toronto, participated in this study. Standardized interviews were conducted using the treatment trade-off threshold technique. An online anonymous survey was used to collect patient demographics. We measured the absolute increased risk in AL and PF that patients would accept to undergo modified two-stage surgery as opposed to traditional three-stage surgery. RESULTS Thirty-two patients (mean age 38.7 ± 15.3) with previous surgery and 20 patients (mean age 39.5 ± 11.9) with no previous surgery participated. Patients were willing to accept an absolute increased leak rate of 5% (interquartile range 4.5%-15%) to avoid a diverting ileostomy. Similarly, patients were willing to accept an absolute increased PF rate of 5% (interquartile range 2.5%-10%). Younger patients, aged 21-29, had lower tolerance for PF, accepting an absolute increase of only 2% versus 5% for patients older than 30 (P = 0.01). CONCLUSION Patients were willing to accept a 5% increased AL rate or PF rate to avoid a temporary diverting ileostomy. This should be taken into consideration when deciding between modified two- and three-stage pouch procedures.
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Affiliation(s)
- Mei Lucy Yang
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mantaj S Brar
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Erin Kennedy
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Maspero M, Lavryk O, Holubar SD, Lipman JM, Steele SR, Hull T. Third Time's the Charm? Indications and Outcomes for Redo-Redo IPAA. Dis Colon Rectum 2024; 67:805-811. [PMID: 38363195 DOI: 10.1097/dcr.0000000000003165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
BACKGROUND Up to 20% to 40% cases of redo IPAA procedures will result in pouch failure. Whether to offer a second redo procedure to maintain intestinal continuity remains a controversial decision. OBJECTIVE To report our institutional experience of second redo IPAA procedures. DESIGN This was a retrospective review. Patient-reported outcomes were compared between patients undergoing second redo procedures and those undergoing first redo procedures using propensity score matching to balance the 2 cohorts. SETTINGS Tertiary referral center. PATIENTS Patients who underwent second redo IPAA procedures between 2004 and 2021 were included in this study. INTERVENTIONS Second redo IPAA. MAIN OUTCOME MEASURES Pouch survival and patient-reported outcomes were measured using the Cleveland Global Quality of Life survey. RESULTS Twenty-three patients were included (65% women), 20 (87%) with an index diagnosis of ulcerative colitis and 3 (13%) with indeterminate colitis. The final diagnosis was changed to Crohn's disease in 8 (35%) cases. The indication for pouch salvage was the same for the first and second redo procedures in 21 (91%) cases: 20 (87%) patients had both redo IPAAs for septic complications. After a median follow-up of 39 months (interquartile range, 18.5-95.5 months), pouch failure occurred in 8 (30%) cases (7 cases due to sepsis, of whom 3 never had their stoma closed, and 1 case due to poor function); all patients who experienced pouch failure underwent the second redo procedure due to septic complications. Overall pouch survival at 3 years was 76%: 62.5% in patients with a final diagnosis of Crohn's disease versus 82.5% in patients with ulcerative/indeterminate colitis ( p = 0.09). Overall quality-of-life score (0-1) was 0.6 (0.5-0.8). Quality of life and functional outcomes were comparable between first and second redo procedures, except incontinence, which was higher in second redo procedures. LIMITATIONS Single-center retrospective review. CONCLUSIONS A second pouch salvage procedure may be offered with acceptable outcomes to selected patients with high motivation to keep intestinal continuity. See Video Abstract . LA TERCERA ES LA VENCIDA INDICACIONES Y RESULTADOS DE LA RERECONFECCION DE LA ANASTOMOSIS ANAL CON BOLSA ILEAL ANTECEDENTES:Hasta un 20-40% de los casos de rehacer anastomosis anal con bolsa ileal (IPAA) resultarán en falla de la bolsa. La posibilidad de ofrecer un segundo procedimiento para mantener la continuidad intestinal sigue siendo una decisión controvertida.OBJETIVO:Reportar nuestra experiencia institucional de una segunda re-confección de la anastomosis anal con bolsa ileal.DISEÑO:Revisión retrospectiva; los resultados informados por los pacientes se compararon entre los pacientes que se sometieron a una segunda re-confeccion con los de los pacientes que se sometieron a una la primera re-confeccion utilizando el puntaje de propensión para equilibrar las dos cohortes.AJUSTES ENTORNO CLINICO:Centro de referencia terciario.PACIENTES:Pacientes que se sometieron a una segunda re-confeccion de de la anastomosis anal con bolsa ileal entre 2004 y 2021.INTERVENCIONES:Segunda re-confeccion de la anastomosis anal con bolsa ileal.PRINCIPALES MEDIDAS DE RESULTADO:Supervivencia de la bolsa, resultados informados por los pacientes medidos mediante la encuesta Cleveland Global Quality of Life.RESULTADOS:Se incluyeron veintitrés pacientes (65% mujeres), 20 (87%) con diagnóstico inicial de colitis ulcerosa y 3 (13%) con colitis indeterminada. El diagnóstico final se cambió a enfermedad de Crohn en ocho (35%) casos. La indicación para el rescate de la bolsa fue la misma para la primera y segunda re-confeccion en 21 (91%) casos: 20 (87%) pacientes tuvieron ambas re-confecciones de la anastomosis anal con bolsa ileal por complicaciones sépticas. Después de una mediana de seguimiento de 39 meses (RIC 18,5 - 95,5), se produjo falla de la bolsa en 8 (30%) casos (7 casos debido a sepsis, de los cuales 3 nunca cerraron el estoma y 1 caso debido a una mala función); todos los pacientes que experimentaron falla de la bolsa se sometieron a una segunda re-confeccion debido a complicaciones sépticas. La supervivencia global de la bolsa a los 3 años fue del 76%: 62,5% en pacientes con diagnóstico final de enfermedad de Crohn, versus 82,5% en colitis ulcerativa/indeterminada ( p = 0,09). La puntuación general de calidad de vida (0 -1) fue 0,6 (0,5 - 0,8). La calidad de vida y los resultados funcionales fueron comparables entre la primera y la segunda re-confeccion, excepto la incontinencia, que fue mayor en la segunda re-confeccion.LIMITACIONES:Revisión retrospectiva de un solo centro.CONCLUSIONES:Se puede ofrecer un segundo procedimiento de rescate de la bolsa con resultados aceptables a pacientes seleccionados con alta motivación para mantener la continuidad intestinal. (Traducción- Dr. Francisco M. Abarca-Rendon ).
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Affiliation(s)
- Marianna Maspero
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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Lelièvre O, Benoist S, Brouquet A. Indications, modalities, and outcomes of surgery for ulcerative colitis in 2024. J Visc Surg 2024; 161:182-193. [PMID: 38897710 DOI: 10.1016/j.jviscsurg.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Treatment of ulcerative colitis (UC) has been revolutionized by the arrival of biotherapies and technical progress in interventional endoscopy and surgery. (Sub)total emergency colectomy is required in the event of complicated severe acute colitis: colectasis, perforation, hemorrhage, organ failure. Corticosteroid therapy is the reference treatment for uncomplicated severe acute colitis, while infliximab and ciclosporin are 2nd-line treatments. At each step, before and after each line of treatment failure, surgery should be considered as an option. In cases refractory to medical treatment, the choice between surgery and change in medication must weigh the chronic symptoms associated with the disease against the risks of postoperative complications and functional sequelae inherent to surgery. Detection of dysplastic lesions necessitates chromoendoscopic imaging with multiple biopsies and anatomopathological verification. Endoscopic treatment of these lesions remains reserved for selected patients. These different indications call for multidisciplinary medical-surgical discussion. Total coloproctectomy with ileo-anal anastomosis (TCP-IAA) is the standard surgery, and it holds out hope for healing. Modalities depend on patient characteristics, previous emergency colectomy, and presence of dysplasia. It may be carried out in one, in two modified, or in three phases. The main complications are anastomotic fistula, short-term pouch-related fistula, ileo-anal pouch syndrome, pouchitis and long-term digestive and sexual disorders. For selected cases, an alternative can consist in total colectomy with ileo-rectal anastomosis or permanent terminal ileostomy. The objective of this update is to clarify the indications, modalities, and results of surgical treatment of ulcerative colitis in accordance with the most recent data in the literature.
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Affiliation(s)
- Océane Lelièvre
- Department of oncologic and digestive surgery, Bicêtre Hospital, Assistance publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France; Paris-Saclay University, Paris, France
| | - Stéphane Benoist
- Department of oncologic and digestive surgery, Bicêtre Hospital, Assistance publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France; Paris-Saclay University, Paris, France
| | - Antoine Brouquet
- Department of oncologic and digestive surgery, Bicêtre Hospital, Assistance publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France; Paris-Saclay University, Paris, France.
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Jabi O, Lan N, Pokala A, Kiran RP, Shen B. Endoscopic therapy of stoma closure site strictures in ileal pouches is safe and effective. Gastroenterol Rep (Oxf) 2024; 12:goae038. [PMID: 38766493 PMCID: PMC11099542 DOI: 10.1093/gastro/goae038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 01/26/2024] [Accepted: 02/17/2024] [Indexed: 05/22/2024] Open
Abstract
Background Strictures are a common complication after ileal pouch surgery with the most common locations being at the anastomosis, pouch inlet, and stoma closure site. No previous literature has described endoscopic therapy of stoma site stricture. This study aimed to assess the safety and efficacy of endoscopic therapy in the treatment of stoma closure site strictures. Method Patients diagnosed with stoma closure site strictures following ileal pouch surgery who underwent endoscopic treatment at the Center for Colorectal Diseases, Inflammatory Bowel Disease (IBD), and Ileal Pouch between 2018 and 2022 were analysed. Primary outcomes (technical success and surgery-free survival) were compared between endoscopic balloon dilation (EBD) and stricturotomy and/or strictureplasty. Results A total of 30 consecutive eligible patients were analysed. Most patients were female (66.7%) and most patients were diagnosed with IBD (93.3%). Twenty patients (66.7%) had end-to-end anastomosis. A total of 52 procedures were performed, with EBD in 16 (30.8%) and stricturotomy and/or strictureplasty in 36 (69.2%). The mean stricture length was 1.7 ± 1.0 cm. Immediate technical success was achieved in 47 of 52 interventions (90.4%). During a mean follow-up of 12.7 ± 9.9 months, none of the patients underwent surgical intervention for the stricture. Fourteen (46.7%) required endoscopic re-intervention for their strictures with an interval between index and re-interventional pouchoscopy of 8.8 ± 6.3 months. Post-procedural complications were reported in 2 (6.7%) with bleeding and none with perforation. Upon follow-up, 20 (66.7%) patients reported improvement in their symptoms. Conclusion EBD and endoscopic stricturotomy and/or strictureplasty are safe and effective in treating stoma closure site strictures in patients with ileal pouches, providing symptomatic relief in most patients as well as avoiding surgery.
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Affiliation(s)
- Osama Jabi
- The Global Center for Integrated Colorectal Surgery and IBD Interventional Endoscopy, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, NY, USA
| | - Nan Lan
- The Global Center for Integrated Colorectal Surgery and IBD Interventional Endoscopy, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, NY, USA
| | - Akshay Pokala
- The Global Center for Integrated Colorectal Surgery and IBD Interventional Endoscopy, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, NY, USA
| | - Ravi P Kiran
- The Global Center for Integrated Colorectal Surgery and IBD Interventional Endoscopy, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, NY, USA
| | - Bo Shen
- The Global Center for Integrated Colorectal Surgery and IBD Interventional Endoscopy, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, NY, USA
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Stephens IJB, Byrnes KG, Burke JP. Transanal ileal pouch-anal anastomosis: A systematic review and meta-analysis of technical approaches and clinical outcomes. Langenbecks Arch Surg 2024; 409:153. [PMID: 38705912 PMCID: PMC11070401 DOI: 10.1007/s00423-024-03343-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 04/29/2024] [Indexed: 05/07/2024]
Abstract
PURPOSE Transanal minimally invasive surgery has theoretical advantages for ileal pouch-anal anastomosis surgery. We performed a systematic review assessing technical approaches to transanal IPAA (Ta-IPAA) and meta-analysis comparing outcomes to transabdominal (abd-IPAA) approaches. METHODS Three databases were searched for articles investigating Ta-IPAA outcomes. Primary outcome was anastomotic leak rate. Secondary outcomes included conversion rate, post operative morbidity, and length of stay (LoS). Staging, plane of dissection, anastomosis, extraction site, operative time, and functional outcomes were also assessed. RESULTS Searches identified 13 studies with 404 unique Ta-IPAA and 563 abd-IPAA patients. Anastomotic leak rates were 6.3% and 8.4% (RD 0, 95% CI -0.066 to 0.065, p = 0.989) and conversion rates 2.5% and 12.5% (RD -0.106, 95% CI -0.155 to -0.057, p = 0.104) for Ta-IPAA and abd-IPAA. Average LoS was one day shorter (MD -1, 95% CI -1.876 to 0.302, p = 0.007). A three-stage approach was most common (47.6%), operative time was 261(± 60) mins, and total mesorectal excision and close rectal dissection were equally used (49.5% vs 50.5%). Functional outcomes were similar. Lack of randomised control trials, case-matched series, and significant study heterogeneity limited analysis, resulting in low to very low certainty of evidence. CONCLUSIONS Analysis demonstrated the feasibility and safety of Ta-IPAA with reduced LoS, trend towards less conversions, and comparable anastomotic leak rates and post operative morbidity. Though results are encouraging, they need to be interpreted with heterogeneity and selection bias in mind. Robust randomised clinical trials are warranted to adequately compare ta-IPAA to transabdominal approaches.
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Affiliation(s)
- Ian J B Stephens
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland.
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons Ireland, 123 St. Stephens Green, Dublin, Ireland.
| | - Kevin G Byrnes
- Havering and Redbridge University Trust, Greater London, UK
| | - John P Burke
- Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland
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Giddings HL, Yang PF, Steffens D, Solomon MJ, Ng KS. Influence of hospital-level and surgeon factors on the outcomes after ileo-anal pouch surgery for inflammatory bowel disease: systematic review. Br J Surg 2024; 111:znae088. [PMID: 38740552 DOI: 10.1093/bjs/znae088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/19/2024] [Accepted: 03/05/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Ileal pouch-anal anastomosis ('pouch surgery') provides a chance to avoid permanent ileostomy after proctocolectomy, but can be associated with poor outcomes. The relationship between hospital-level/surgeon factors (including volume) and outcomes after pouch surgery is of increasing interest given arguments for increasing centralization of these complex procedures. The aim of this systematic review was to appraise the literature describing the influence of hospital-level and surgeon factors on outcomes after pouch surgery for inflammatory bowel disease. METHODS A systematic review was performed of studies reporting outcomes after pouch surgery for inflammatory bowel disease. The MEDLINE (Ovid), Embase (Ovid), and Cochrane CENTRAL databases were searched (1978-2022). Data on outcomes, including mortality, morbidity, readmission, operative approach, reconstruction, postoperative parameters, and pouch-specific outcomes (failure), were extracted. Associations between hospital-level/surgeon factors and these outcomes were summarized. This systematic review was prospectively registered in PROSPERO, the international prospective register of systematic reviews (CRD42022352851). RESULTS A total of 29 studies, describing 41 344 patients who underwent a pouch procedure, were included; 3 studies demonstrated higher rates of pouch failure in lower-volume centres, 4 studies demonstrated higher reconstruction rates in higher-volume centres, 2 studies reported an inverse association between annual hospital pouch volume and readmission rates, and 4 studies reported a significant association between complication rates and surgeon experience. CONCLUSION This review summarizes the growing body of evidence that supports centralization of pouch surgery to specialist high-volume inflammatory bowel disease units. Centralization of this technically demanding surgery that requires dedicated perioperative medical and nursing support should facilitate improved patient outcomes and help train the next generation of pouch surgeons.
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Affiliation(s)
- Hugh L Giddings
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Phillip F Yang
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Kheng-Seong Ng
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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Krasnick BA, Kalady MF. Management of Rectal Cancer in Lynch Syndrome: Balancing Risk Reduction and Quality of Life. Clin Colon Rectal Surg 2024; 37:180-184. [PMID: 38606049 PMCID: PMC11006439 DOI: 10.1055/s-0043-1770730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
Patients with Lynch syndrome are predisposed to developing colorectal cancer and a variety of extracolonic malignancies, at a young age. The management of rectal cancer in the setting of Lynch syndrome is a complex clinical scenario that requires the expertise of a multidisciplinary management team. In this review, we delve into the approach for rectal cancer in these patients, and specifically focus on several key aspects of treatment. Some unique aspects of rectal cancer in Lynch syndrome include the decision between proctectomy alone versus total proctocolectomy with or without an ileal pouch, the utility of chemotherapy and immunotherapy, nonoperative rectal cancer management, and the management of rectal polyps. Throughout, we highlight the delicate interplay between future cancer risk reduction and quality of life optimization.
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Affiliation(s)
- Bradley A. Krasnick
- Division of Colorectal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Matthew F. Kalady
- Division of Colorectal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Djalal A, Wong SY, Colombel JF, Ungaro R, Kayal M. Problem with Hookups: Perianal Fistula After Ileal Pouch-Anal Anastomosis. Dig Dis Sci 2024; 69:1102-1104. [PMID: 38446307 DOI: 10.1007/s10620-024-08344-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/06/2024] [Indexed: 03/07/2024]
Affiliation(s)
- Arafa Djalal
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Serre-Yu Wong
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jean-Frédéric Colombel
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ryan Ungaro
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maia Kayal
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Yamamoto-Furusho J, López-Gómez J, Bosques-Padilla F, Martínez-Vázquez M, De-León-Rendón J. Primer consenso mexicano de la enfermedad de Crohn. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2024; 89:280-311. [DOI: 10.1016/j.rgmx.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2024]
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Carter M, Lim IIP. Surgical management of pediatric Crohn's disease. Semin Pediatr Surg 2024; 33:151401. [PMID: 38615423 DOI: 10.1016/j.sempedsurg.2024.151401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Management of pediatric-onset Crohn's disease uniquely necessitates consideration of growth, pubertal development, psychosocial function and an increased risk for multiple future surgical interventions. Both medical and surgical management are rapidly advancing; therefore, it is increasingly important to define the role of surgery and the breadth of surgical options available for this complex patient population. Particularly, the introduction of biologics has altered the disease course; however, the ultimate need for surgical intervention has remained unchanged. This review defines and evaluates the surgical techniques available for management of the most common phenotypes of pediatric-onset Crohn's disease as well as identifies critical perioperative considerations for optimizing post-surgical outcomes.
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Affiliation(s)
- Michela Carter
- Department of Surgery, Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Irene Isabel P Lim
- Department of Pediatric Surgery, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, United States.
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63
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Yamamoto-Furusho JK, López-Gómez JG, Bosques-Padilla FJ, Martínez-Vázquez MA, De-León-Rendón JL. First Mexican Consensus on Crohn's disease. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2024; 89:280-311. [PMID: 38762431 DOI: 10.1016/j.rgmxen.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/19/2024] [Indexed: 05/20/2024]
Abstract
INTRODUCTION Crohn's disease (CD) is a subtype of chronic and incurable inflammatory bowel disease. It can affect the entire gastrointestinal tract and its etiology is unknown. OBJECTIVE The aim of this consensus was to establish the most relevant aspects related to definitions, diagnosis, follow-up, medical treatment, and surgical treatment of Crohn's disease in Mexico. MATERIAL AND METHODS Mexican specialists in the areas of gastroenterology and inflammatory bowel disease were summoned. The consensus was divided into five modules, with 69 statements. Applying the Delphi panel method, the pre-meeting questions were sent to the participants, to be edited and weighted. At the face-to-face meeting, all the selected articles were shown, underlining their level of clinical evidence; all the statements were discussed, and a final vote was carried out, determining the percentage of agreement for each statement. RESULTS The first Mexican consensus on Crohn's disease was produced, in which recommendations for definitions, classifications, diagnostic aspects, follow-up, medical treatment, and surgical treatment were established. CONCLUSIONS Updated recommendations are provided that focus on definitions, classifications, diagnostic criteria, follow-up, and guidelines for conventional medical treatment, biologic therapy, and small molecule treatment, as well as surgical management.
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Affiliation(s)
- J K Yamamoto-Furusho
- Clínica de Enfermedad Inflamatoria Intestinal, Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
| | - J G López-Gómez
- Clínica de Enfermedad Inflamatoria Intestinal, Servicio de Gastroenterología, Centro Médico Nacional 20 de Noviembre, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE), Mexico City, Mexico
| | - F J Bosques-Padilla
- Departamento de Gastroenterología, Hospital Universitario de la Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | | | - J L De-León-Rendón
- Clínica de Enfermedad Inflamatoria Intestinal, Servicio de Coloproctología, Hospital General de México, Mexico City, Mexico
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64
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Ochoa B, McMahon L. Surgery for ulcerative colitis. Semin Pediatr Surg 2024; 33:151404. [PMID: 38615424 DOI: 10.1016/j.sempedsurg.2024.151404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Ulcerative colitis (UC) has a more severe presentation and rapid progression in pediatric patients, resulting in a greater need for surgical intervention compared to adults. Though medical management of UC has advanced with new biologic therapies, surgery continues to play an important role when disease progresses in the form of worsened or persistent symptoms, hemodynamic instability, or sepsis. The goals of surgical management are to restore intestinal continuity with a functional pouch when possible. While the literature has been growing regarding studies of pediatric patients with UC, high level of evidence studies are limited and most recommendations are based on adult studies. Similar to adults, pediatric patients who have ileal pouches created require surveillance for recurrent disease and cancer surveillance. Unique issues for pediatric patients include monitoring of growth and appropriate transition to adult care after adolescence. This review includes indications for surgical management, overview of staged surgical approaches, and the technical details of the three-stage approach.
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Affiliation(s)
- Brielle Ochoa
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, Arizona, USA
| | - Lisa McMahon
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, Arizona, USA.
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Lightner AL, Pineiro AO, Reese J, Ream J, Nachand D, Adams AC, Dadgar N, Hull T. Treatment effect of ex vivo expanded allogeneic bone marrow-derived mesenchymal stem cells for the treatment of fistulizing Crohn's disease are durable at 12 months. Surgery 2024; 175:984-990. [PMID: 38097485 DOI: 10.1016/j.surg.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/02/2023] [Accepted: 11/07/2023] [Indexed: 03/17/2024]
Abstract
BACKGROUND Mesenchymal stem cells have been administered via direct injection to treat perianal Crohn's fistulizing disease. We herein sought to determine the safety and durability of treatment response to 12 months with 3 individual phase IB/IIA clinical trials of mesenchymal stem cells for refractory perianal, rectovaginal, and ileal pouch fistulas in the setting of Crohn disease. METHODS Three phase IB/IIA randomized placebo-controlled single-blinded clinical trials were performed for (1) perianal fistulas, (2) rectovaginal fistula, and (3) ileal pouch in situ with anovaginal and/or perianal fistulas. Bone marrow-derived mesenchymal stem cells (75 million in 7.5 mL) were injected at the time of exam under anesthesia on day 0 and month 3. Outcome measures were adverse events and combined clinical and pelvic magnetic resonance imaging healing at month 6 and month 12. RESULTS Across all 3 trials, 64 patients were enrolled; 49 were treatment and 15 were control. At 6 months, combined clinical and radiographic healing was achieved in 83.3%, 33.3%, and 30.8% of the perianal, rectovaginal, and pouch fistula treatment cohorts, respectively. At 12 months, the treatment response was durable, with 67.7% of perianal, 37.5% of rectovaginal, and 46.2% of peripouch fistulas maintaining complete clinical and radiographic healing. Two patients in the perianal fistula control cohort achieved combined clinical and radiographic healing at 12 months, whereas 0% of rectovaginal and pouch control patients healed. CONCLUSION Bone marrow-derived mesenchymal stem cells offer a safe and effective alternative treatment approach for severe perianal, rectovaginal, and peripouch fistulizing Crohn's disease. Treatment results are durable at 12 months.
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Affiliation(s)
- Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, OH.
| | - Ana Otero Pineiro
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, OH
| | - Jane Reese
- National Center for Regenerative Medicine, Cleveland, OH
| | - Justin Ream
- Department of Abdominal Radiology, Digestive Disease Surgical Institute, Cleveland Clinic, OH
| | - Douglas Nachand
- Department of Abdominal Radiology, Digestive Disease Surgical Institute, Cleveland Clinic, OH
| | - Ashley C Adams
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, OH
| | - Neda Dadgar
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, OH
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Disease Surgical Institute, Cleveland Clinic, OH
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66
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Anto VP, Ramos AE, Mollen KP. Ouch, my pouch! a clinician's guide to pouchitis. Semin Pediatr Surg 2024; 33:151406. [PMID: 38636151 DOI: 10.1016/j.sempedsurg.2024.151406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
Pouchitis is defined as inflammation of the ileal pouch created during a restorative proctocolectomy with ileal pouch-anal anastomosis. Although the incidence of this inflammatory condition is high, the exact etiology often remains unclear and the management challenging. In this review, we summarize the clinical presentation, pathogenesis, diagnosis, and management of this common complication.
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Affiliation(s)
- Vincent P Anto
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anna E Ramos
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kevin P Mollen
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Maspero M, Liska D, Kessler H, Lipman J, Steele SR, Hull T, Qazi T, Rieder F, Cohen B, Holubar SD. Redo IPAA for long rectal cuff syndrome after ileoanal pouch for inflammatory bowel disease. Tech Coloproctol 2024; 28:38. [PMID: 38451358 DOI: 10.1007/s10151-023-02909-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/24/2023] [Indexed: 03/08/2024]
Abstract
ABTRACT BACKGROUND: When constructing an ileal pouch-anal anastomosis (IPAA), the rectal cuff should ideally be 1-2 cm long to avoid subsequent complications. METHODS We identified patients from our IBD center who underwent redo IPAA for a long rectal cuff. Long rectal cuff syndrome (LRCS) was defined as a symptomatic rectal cuff ≥ 4 cm. RESULTS Forty patients met the inclusion criteria: 42.5% female, median age at redo surgery 42.5 years. The presentation was ulcerative proctitis in 77.5% of the cases and outlet obstruction in 22.5%. The index pouch was laparoscopically performed in 18 patients (45%). The median rectal cuff length was 6 cm. The pouch was repaired in 16 (40%) cases, whereas 24 (60%) required the creation of a neo-pouch. At the final pathology, the rectal cuff showed chronic active colitis in 38 (90%) cases. After a median follow-up of 34.5 (IQR 12-109) months, pouch failure occurred in 9 (22.5%) cases. The pouch survival rate was 78% at 3 years. Data on the quality of life were available for 11 (27.5%) patients at a median of 75 months after redo surgery. The median QoL score (0-1) was 0.7 (0.4-0.9). CONCLUSION LRCS, a potentially avoidable complication, presents uniformly with symptoms of ulcerative proctitis or stricture. Redo IPAA was restorative for the majority.
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Affiliation(s)
- Marianna Maspero
- Department of Colon & Rectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44106, USA
| | - David Liska
- Department of Colon & Rectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44106, USA
| | - Hermann Kessler
- Department of Colon & Rectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44106, USA
| | - Jeremy Lipman
- Department of Colon & Rectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44106, USA
| | - Scott R Steele
- Department of Colon & Rectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44106, USA
| | - Tracy Hull
- Department of Colon & Rectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44106, USA
| | - Taha Qazi
- Department of Gastroenterology, Cleveland Clinic, Cleveland, OH, USA
| | - Florian Rieder
- Department of Gastroenterology, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin Cohen
- Department of Gastroenterology, Cleveland Clinic, Cleveland, OH, USA
| | - Stefan D Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44106, USA.
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Mesonero F, Zabana Y, Fernández-Clotet A, Leo-Carnerero E, Caballol B, Núñez-Ortiz A, García MJ, Bertoletti F, Mínguez A, Suris G, Casis B, Ferreiro-Iglesias R, Calafat M, Jiménez I, Miranda-Bautista J, Lamuela LJ, Fajardo I, Torrealba L, Nájera R, Sáiz-Chumillas RM, González I, Vicuña M, García-Morales N, Gutiérrez A, López-García A, Benítez JM, Rubín de Célix C, Tejido C, Brunet E, Hernández-Camba A, Suárez C, Rodríguez-Lago I, Piqueras M, Castaño A, Ramos L, Sobrino A, Rodríguez-Grau MC, Elosua A, Montoro M, Baltar R, Huguet JM, Hermida B, Caballero-Mateos A, Sánchez-Guillén L, Bouhmidi A, Pajares R, Baston-Rey I, López-Sanromán A, Albillos A, Barreiro-de Acosta M. Effectiveness and safety of azathioprine for inflammatory pouch disorders: results from the RESERVO study of GETECCU. Therap Adv Gastroenterol 2024; 17:17562848241234476. [PMID: 38445247 PMCID: PMC10913517 DOI: 10.1177/17562848241234476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/02/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND The usefulness of thiopurines has been poorly explored in pouchitis and other pouch disorders. OBJECTIVE To evaluate the effectiveness and safety of azathioprine as maintenance therapy in inflammatory pouch disorders. DESIGN This was a retrospective and multicentre study. METHODS We included patients diagnosed with inflammatory pouch disorders treated with azathioprine in monotherapy. Effectiveness was evaluated at 1 year and in the long term based on normalization of stool frequency, absence of pain, faecal urgency or fistula discharge (clinical remission), or any improvement in these symptoms (clinical response). Endoscopic response was evaluated using the Pouchitis Disease Activity Index (PDAI). RESULTS In all, 63 patients were included [54% males; median age, 49 (28-77) years]. The therapy was used to treat pouchitis (n = 37) or Crohn's disease of the pouch (n = 26). The rate of clinical response, remission and non-response at 12 months were 52%, 30% and 18%, respectively. After a median follow-up of 23 months (interquartile range 11-55), 19 patients (30%) were in clinical remission, and 45 (66%) stopped therapy. Endoscopic changes were evaluated in 19 cases. PDAI score decreased from 3 (range 2-4) to 1 (range 0-3). In all, 21 patients (33%) presented adverse events and 16 (25%) needed to stop therapy. CONCLUSION Azathioprine may be effective in the long term for the treatment of inflammatory pouch disorders and could be included as a therapeutic option.
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Affiliation(s)
- Francisco Mesonero
- Inflammatory Bowel Disease Unit, Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Cra. Colmenar km 9.1, Madrid 28034, Spain
| | - Yamile Zabana
- Hospital Universitario Mútua Terrassa, Terrassa, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Agnès Fernández-Clotet
- Hospital Clínic Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | - Berta Caballol
- Hospital Clínic Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | - María José García
- Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | | | | | - Gerard Suris
- Hospital Universitario de Bellvitge, Barcelona, Spain
| | - Begoña Casis
- Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Margalida Calafat
- Hospital Universitario Germans Trias i Pujol, Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Itxaso Jiménez
- Hospital Universitario de Galdakao, Biocruces Bizkaia Health Research Institute, Galdakao, Spain
| | | | | | | | | | | | | | | | | | | | - Ana Gutiérrez
- Hospital General Universitario Alicante Doctor Balmis (Alicante), Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Alicia López-García
- Hospital del Mar i Institut Mar d’Investigacions Mediques (IMIM), Barcelona, Spain
| | | | - Cristina Rubín de Célix
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Coral Tejido
- Complejo Hospitalario Universitario Ourense, Ourense, Spain
| | - Eduard Brunet
- Hospital Universitari Parc Taulí, Sabadell, Spain Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | - Cristina Suárez
- Hospital Universitario La Paz, Instituto de Investigación Sanitaria del Hospital Universitario La Paz (IdiPAZ), Madrid, Spain
| | - Iago Rodríguez-Lago
- Hospital Universitario de Galdakao, Biocruces Bizkaia Health Research Institute, Galdakao, Spain
| | | | | | - Laura Ramos
- Hospital Universitario de Canarias, Santa Cruz, Spain
| | - Ana Sobrino
- Hospital General Universitario Ciudad Real, Ciudad Real, Spain
| | | | | | | | - Ruth Baltar
- Hospital Universitario Álava, Vitoria, Spain
| | | | | | | | | | | | - Ramón Pajares
- Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Spain
| | - Iria Baston-Rey
- Hospital Clínico Universitario Santiago, Santiago de Compostela, Spain
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He K, Yu Z, Wu Y. To investigate the changes in colonic pouch function and retention rate after ileal pouch-anal anastomosis in elderly patients with ulcerative colitis: a multicenter retrospective analysis. Minerva Gastroenterol (Torino) 2024; 70:139-142. [PMID: 37338265 DOI: 10.23736/s2724-5985.23.03454-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Affiliation(s)
- Kaiqiang He
- Department of Anorectal, the First People's Hospital of Zunyi City, Zunyi, China
| | - Zhuang Yu
- Department of Anorectal, the First People's Hospital of Zunyi City, Zunyi, China
| | - Yuan Wu
- Department of Anorectal, the First People's Hospital of Zunyi City, Zunyi, China -
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Kanakaratne S, Hong J, Solomon MJ, Young CJ. Ileal pouch-anal anastomosis provides good functional and quality of life outcomes following proctocolectomy: A 33-year single centre experience. ANZ J Surg 2024; 94:404-411. [PMID: 38105626 DOI: 10.1111/ans.18827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Restorative proctocolectomy (RP) with ileal pouch-anal anastomosis (IPAA) remains the gold standard for the surgical management of patients with medically refractive mucosal ulcerative colitis. We aimed to identify functional and quality of life (QOL) outcomes in RP and IPAA surgery patients at our institution. METHODS A retrospective observational study was performed including all patients who had undergone RP and IPAA between August 1984 and November 2017 at Royal Prince Alfred Hospital (RPAH). RESULTS 316 consecutive patients were identified, median age 39 (range 5 to 81) years. The median duration of disease was 60 (range 1 to 528) months. Ulcerative colitis was the main preoperative diagnosis with the main RP indication being failure of medical treatment. The median postoperative stay post-IPAA was 11 (range of 5 to 67) days. Pouchitis was the most common late complication (22.1%), bleeding pouch (3.5%) the earliest, with a 6.8% rate of symptomatic anastomotic leak. Visual analogue scale QOL measure (P-value <0.001), St Marks incontinence score (P-value = 0.001) and Cleveland clinic score (P-value = 0.002) all revealed significant improvement in functional outcomes and QOL. CONCLUSION QOL and functional outcomes following RP with IPAA in patients at our institution are excellent and comparable to institutions with larger patient numbers.
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Affiliation(s)
- Shaveen Kanakaratne
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- The University of Sydney, Faculty of Medicine and Health, Sydney Medical School, Sydney, New South Wales, Australia
| | - Jonathan Hong
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- The University of Sydney, Faculty of Medicine and Health, Sydney Medical School, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- The University of Sydney, Faculty of Medicine and Health, Sydney Medical School, Sydney, New South Wales, Australia
| | - Christopher J Young
- The University of Sydney, Faculty of Medicine and Health, Sydney Medical School, Sydney, New South Wales, Australia
- Department of Surgery, University of Kansas School of Medicine, Abilene, Kansas, USA
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Warsop ZI, Manzo CA, Yu N, Yusuf B, Kontovounisios C, Celentano V. Patient-reported Outcome Measures in Ileoanal Pouch Surgery: a Systematic Review. J Crohns Colitis 2024; 18:479-487. [PMID: 37758036 DOI: 10.1093/ecco-jcc/jjad163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/14/2023] [Accepted: 09/21/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE To summarise frequency, type, and heterogeneity of patient-reported outcomes measures [PROMs] in papers reporting on outcomes after ileal pouch anal anastomosis [IPAA]. BACKGROUND Prevalence of ulcerative colitis [UC] has risen in Western countries, and one in three patients requires surgery. IPAA is a frequently performed procedure for UC, and a lack of standardisation is manifest in reporting outcomes for inflammatory bowel disease [IBD] despite the clear need for inclusion of PROMs as primary outcomes in IBD trials. METHODS Scopus, Pubmed, and Web of Science databases were searched from January 2010 to January 2023 for studies investigating outcomes in IPAA surgery. The primary outcome was the proportion of studies reporting outcomes for IPAA surgery for UC, which included PROMs. RESULTS The search identified a total of 8028 studies which, after de-duplication and exclusion, were reduced to 79 articles assessing outcomes after IPAA surgery. In all 44 [55.7%] reported PROMs, with 23 including validated questionnaires and 21 papers using authors' questions, 22 different PROMs were identified, with bowel function as the most investigated item. The majority of studies [67/79, 85%] were retrospective, only 14/79 [18%] were prospective papers and only two were [2.5%] randomised, controlled trials. CONCLUSIONS Only half of the papers reviewed used PROMs. The main reported item is bowel function and urogenital, social, and psychological functions are the most neglected. There is lack of standardisation for use of PROMs in IPAA. Complexity of UC and of outcomes after IPAA demands a change in clinical practice and follow-up, given how crucial PROMs are, compared with their non-routine use.
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Affiliation(s)
| | - Carlo Alberto Manzo
- Imperial College London School of Medicine, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Natalie Yu
- Imperial College London School of Medicine, London, UK
| | - Bilal Yusuf
- Imperial College London School of Medicine, London, UK
| | - Christos Kontovounisios
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Colorectal Surgery, Royal Marsden NHS Foundation Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Valerio Celentano
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
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Tsunoda J, Shigeta K, Seishima R, Okabayashi K, Kitagawa Y. Efficacy of transanal drainage tube placement in preventing anastomotic leakage after ileal pouch-anal anastomosis in patients with ulcerative colitis. Surg Endosc 2024; 38:837-845. [PMID: 38082005 DOI: 10.1007/s00464-023-10594-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 11/14/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND Transanal drainage tube (TDT) is used to prevent anastomotic leakage after surgery for rectal cancer. However, it remains unclear whether intraoperative TDT placement is also useful in preventing anastomotic leakage after ileal pouch-anal or ileal pouch-anal canal anastomosis (IPAA) in patients with ulcerative colitis (UC). This study aimed to evaluate the efficacy of intraoperative TDT placement in preventing anastomotic leakage after IPAA in patients with UC. METHODS Patients with UC who underwent proctectomy with IPAA in the study institution between January 2000 and December 2021 were enrolled in this retrospective cohort study. The relationship between TDT placement and anastomotic leakage was evaluated by logistic regression analysis. RESULTS The study population included 168 patients. TDT was placed intraoperatively in 103 of the 168 patients (61.3%). The rate of anastomotic leakage was significantly lower in the TDT group than in the non-TDT group (7.8% vs 18.5%, p = 0.037). Reoperation was not needed in any patient in the TDT group whereas two reoperations were necessary in the non-TDT group (3.1%). By logistic regression analysis, intraoperative TDT placement was an independent protective factor for anastomotic leakage. CONCLUSIONS TDT placement was significantly associated with anastomotic leakage of IPAA in patients with UC undergoing surgery. Although two-stage surgery with ileostomy is usually preferred in UC surgery, our findings suggest that TDT placement might contribute to the improvement of postoperative outcomes after UC surgery.
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Affiliation(s)
- Junya Tsunoda
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Kohei Shigeta
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan.
| | - Ryo Seishima
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Koji Okabayashi
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
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Darlington K, Wang A, Herfarth HH, Barnes EL. The Safety of Dilation of Ileoanal Strictures With Mechanical or Balloon Dilation Is Similar Among Patients After Ileal Pouch-Anal Anastomosis. Inflamm Bowel Dis 2024; 30:196-202. [PMID: 37043649 PMCID: PMC10834157 DOI: 10.1093/ibd/izad051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Indexed: 04/14/2023]
Abstract
BACKGROUND Anastomotic strictures occur in up to 38% of patients after ileal pouch-anal anastomosis (IPAA). We sought to compare the safety, effectiveness, and durability of mechanical dilation using a Hegar dilator to endoscopic through-the-scope balloon dilation (EBD) among IPAA patients with a rectal or ileoanal anastomotic stricture. METHODS We identified adult patients with an IPAA for ulcerative colitis (UC) who underwent a pouchoscopy between January 1, 2015, and December 31, 2019, at a single institution. We compared the effectiveness (median maximum diameter of dilation [MMD]), safety, and durability of mechanical and balloon dilation using standard statistical comparisons. RESULTS A total 74 patients had a stricture at the ileoanal anastomosis and underwent at least 1 mechanical or balloon dilation. The MMD with mechanical dilation was 19 (interquartile range [IQR], 18-20) mm for the first dilation and 20 (IQR, 18-20) mm for the second and third dilations. With balloon dilation, the MMD was 12 (IQR, 12-18) mm for the first dilation, 15 (IQR, 12-16.5) mm for the second dilation, and 18 (IQR, 15-18.5) mm for the third dilation. Patients undergoing mechanical dilation experienced a longer duration to second dilation (median 191 days vs 53 days: P < .001), with no difference in complications such as bleeding or perforation noted. CONCLUSIONS Among patients with ileoanal and rectal strictures, mechanical and balloon approaches to dilation demonstrated similar safety profiles and effectiveness. Mechanical dilation with Hegar dilators appears to be an effective and safe approach to the treatment of distal strictures after IPAA.
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Affiliation(s)
- Kimberly Darlington
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Annmarie Wang
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, NC, USA
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina, Chapel Hill, NC, USA
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, NC, USA
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina, Chapel Hill, NC, USA
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Godoy-Brewer G, Salem G, Limketkai B, Selaru FM, Grossen A, Policarpo T, Haq Z, Parian AM. Use of Biologics for the Treatment of Inflammatory Conditions of the Pouch: A Systematic Review. J Clin Gastroenterol 2024; 58:183-194. [PMID: 36753457 DOI: 10.1097/mcg.0000000000001828] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/07/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND Patients with medically-refractory ulcerative colitis or advanced neoplasia are often offered an ileal-pouch-anal anastomosis to restore bowel continuity. However, up to 50% of patients can suffer from inflammatory conditions of the pouch, some of which require biological therapy to treat. The aim of this study was to determine the efficacy of each biological agent for the treatment of inflammatory conditions of the pouch. MATERIALS AND METHODS A comprehensive literature search was performed in the major databases from inception through February 11, 2020, for studies assessing the efficacy of biologics in chronic antibiotic-refractory pouchitis (CARP) and Crohn's disease (CD) of the pouch. Both prospective and retrospective studies were included. The primary outcomes of interest were complete and partial responses were defined within each study. χ 2 test was used to compare variables. RESULTS Thirty-four studies were included in the systematic review and meta-analysis. Sixteen studies (N=247) evaluated the use of infliximab (IFX), showing complete response in 50.7% and partial response in 28.1% for CARP, and complete response in 66.7% and partial response in 20% for CD of the pouch. Seven studies (n=107) assessed the efficacy of adalimumab. For CARP, 33.3% of patients had a complete response, and 38.1% had a partial response, whereas for CD of the pouch, 47.7% experienced a complete response, and 24.6% had a partial response. Three studies (n=78) reported outcomes with the use of ustekinumab, showing 50% complete response and 3.8% partial response for CARP. For the CD of the pouch, 5.8% had a complete response and 78.8% had a partial response. Seven studies (n=151) reported the efficacy of vedolizumab, showing 28.4% complete response and 43.2% partial response in patients with CARP, whereas 63% of patients experienced partial response in CD of the pouch. IFX had higher rates of complete response in CARP compared with adalimumab ( P =0.04) and compared with vedolizumab ( P =0.005), but not compared with ustekinumab ( P =0.95). There were no new safety signals reported in any of the studies. CONCLUSIONS Biologics are safe and efficacious in the treatment of chronic, refractory inflammatory conditions of the pouch. IFX seems to be more efficacious than adalimumab and vedolizumab for CARP. Further prospective, head-to-head evaluations are needed to compare biological therapies in the treatment of CARP and CD of the pouch.
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Affiliation(s)
| | - George Salem
- Division of Digestive Diseases, University of Oklahoma Health Sciences Center, Oklahoma, OK
| | - Berkeley Limketkai
- Division of Digestive Diseases, University of California, Los Angeles, CA
| | - Florin M Selaru
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD
| | - Alyssa Grossen
- Division of Digestive Diseases, University of Oklahoma Health Sciences Center, Oklahoma, OK
| | - Tatiana Policarpo
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA
| | - Zadid Haq
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD
| | - Alyssa M Parian
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD
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Pooni A, Brar MS, Kennedy E, Cohen Z, MacRae H, de Buck van Overstraeten A. Routine diversion following delayed IPAA construction does not reduce the incidence of pouch-related sepsis or failure in patients with ulcerative colitis. Colorectal Dis 2024; 26:326-334. [PMID: 38169082 DOI: 10.1111/codi.16836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 03/11/2023] [Accepted: 10/01/2023] [Indexed: 01/05/2024]
Abstract
AIM The aim of this study was to compare modified 2-stage and 3-stage IPAA construction techniques to evaluate the effect of diverting loop ileostomy following completion proctectomy and IPAA for ulcerative colitis. In addition, our overall institutional experience was reviewed to describe long-term outcomes and changes in staging trends over time. METHODS Our institutional database was searched to identify all cases of IPAA for ulcerative colitis between 1981 and 2018. Patient, pouch and outcome characteristics were abstracted. Primary study outcomes were the incidence of primary pouch failure and pouch-related sepsis. Failure was evaluated by Kaplan-Meier estimates of survival over time. The adjusted effect of pouch stage was evaluated using multivariable Cox and logistic regression models. Exploratory analysis evaluated the effect of stage on failure in the pouch related sepsis subgroup. RESULTS A total of 2105 patients underwent primary IPAA over the study period. The 5, 10 and 20-year pouch survival probabilities were 95.2%, 92.7% and 86.6%. The incidence of pouch related sepsis was 12.3%. Adjusted analysis demonstrated no difference in pouch failure (HR = 0.64: 95% 0.39-1.07, p = 0.09) or post-operative sepsis (aOR = 0.79: 95% CI 0.53-1.17, p = 0.24) by stage of construction. Among patients experiencing pouch sepsis, there was no difference in Kaplan-Meier estimates of pouch survival by stage (p = 0.90). CONCLUSIONS Pouch related sepsis and IPAA failure did not differ between modified 2-stage and 3-stage construction techniques. Among the sub-group of patients experiencing pouch related sepsis, there was no difference in failure between groups. The results suggest diverting ileostomy may be safely avoided following delayed pouch reconstruction in appropriately selected patients.
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Affiliation(s)
- Amandeep Pooni
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Mantaj S Brar
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Erin Kennedy
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Zane Cohen
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Helen MacRae
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Anthony de Buck van Overstraeten
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada
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Xu W, Tang W, Ding W, Hua Z, Wang Y, Ge X, Cui L, Wu X, Zhou W, Ding Z, Du P, China UC Pouch Center Union. Surgical Options for Appropriate Length of J-Pouch Construction for Better Outcomes and Long-term Quality of Life in Patients with Ulcerative Colitis after Ileal Pouch-Anal Anastomosis. Gut Liver 2024; 18:85-96. [PMID: 36987383 PMCID: PMC10791498 DOI: 10.5009/gnl220471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/25/2022] [Accepted: 01/12/2023] [Indexed: 03/30/2023] Open
Abstract
Background/Aims Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is widely accepted as a radical surgery for refractory ulcerative colitis (UC). Definite results on the appropriate pouch length for an evaluation of the risk-to-benefit ratio regarding technical complications and long-term quality of life (QOL) are still scarce. Methods Data on UC patients who underwent IPAA from 2008 to 2022 in four well-established pouch centers affiliated to China UC Pouch Center Union were collected. Results A total of 208 patients with a median follow-up time of 6.0 years (interquartile range, 2.3 to 9.0 years) were enrolled. The median lengths of the patients' short and long pouches were 14.0 cm (interquartile range, 14.0 to 15.0 cm) and 22.0 cm (interquartile range, 20.0 to 24.0 cm), respectively. Patients with a short J pouch configuration were less likely to achieve significantly improved long-term QOL (p=0.015) and were prone to develop late postoperative complications (p=0.042), such as increased defecation frequency (p=0.003) and pouchitis (p=0.035). A short ileal pouch was an independent risk factor for the development of late postoperative complications (odds ratio, 3.100; 95% confidence interval, 1.519 to 6.329; p=0.002) and impaired longterm QOL improvement (odds ratio, 2.221; 95% confidence interval, 1.218 to 4.050, p=0.009). Conclusions The length of the J pouch was associated with the improvement in long-term QOL and the development of late post-IPAA complications. A long J pouch configuration could be a considerable surgical option for pouch construction.
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Affiliation(s)
- Weimin Xu
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenbo Tang
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenjun Ding
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhebin Hua
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yaosheng Wang
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaolong Ge
- Department of General Surgery, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Guangzhou, China
| | - Long Cui
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaojian Wu
- Department of Gastrointestinal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wei Zhou
- Department of General Surgery, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Guangzhou, China
| | - Zhao Ding
- Department of Colorectal and Anal Surgery, Hubei Key Laboratory of Intestinal and Colorectal Diseases, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Peng Du
- Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Barnes EL, Agrawal M, Syal G, Ananthakrishnan AN, Cohen BL, Haydek JP, Al Kazzi ES, Eisenstein S, Hashash JG, Sultan SS, Raffals LE, Singh S. AGA Clinical Practice Guideline on the Management of Pouchitis and Inflammatory Pouch Disorders. Gastroenterology 2024; 166:59-85. [PMID: 38128971 PMCID: PMC11163976 DOI: 10.1053/j.gastro.2023.10.015] [Citation(s) in RCA: 43] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND & AIMS Pouchitis is the most common complication after restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. This American Gastroenterological Association (AGA) guideline is intended to support practitioners in the management of pouchitis and inflammatory pouch disorders. METHODS A multidisciplinary panel of content experts and guideline methodologists used the Grading of Recommendations Assessment, Development and Evaluation framework to prioritize clinical questions, identify patient-centered outcomes, conduct an evidence synthesis, and develop recommendations for the prevention and treatment of pouchitis, Crohn's-like disease of the pouch, and cuffitis. RESULTS The AGA guideline panel made 9 conditional recommendations. In patients with ulcerative colitis who have undergone ileal pouch-anal anastomosis and experience intermittent symptoms of pouchitis, the AGA suggests using antibiotics for the treatment of pouchitis. In patients who experience recurrent episodes of pouchitis that respond to antibiotics, the AGA suggests using probiotics for the prevention of recurrent pouchitis. In patients who experience recurrent pouchitis that responds to antibiotics but relapses shortly after stopping antibiotics (also known as "chronic antibiotic-dependent pouchitis"), the AGA suggests using chronic antibiotic therapy to prevent recurrent pouchitis; however, in patients who are intolerant to antibiotics or who are concerned about the risks of long-term antibiotic therapy, the AGA suggests using advanced immunosuppressive therapies (eg, biologics and/or oral small molecule drugs) approved for treatment of inflammatory bowel disease. In patients who experience recurrent pouchitis with inadequate response to antibiotics (also known as "chronic antibiotic-refractory pouchitis"), the AGA suggests using advanced immunosuppressive therapies; corticosteroids can also be considered in these patients. In patients who develop symptoms due to Crohn's-like disease of the pouch, the AGA suggests using corticosteroids and advanced immunosuppressive therapies. In patients who experience symptoms due to cuffitis, the AGA suggests using therapies that have been approved for the treatment of ulcerative colitis, starting with topical mesalamine or topical corticosteroids. The panel also proposed key implementation considerations for optimal management of pouchitis and Crohn's-like disease of the pouch and identified several knowledge gaps and areas for future research. CONCLUSIONS This guideline provides a comprehensive, patient-centered approach to the management of patients with pouchitis and other inflammatory conditions of the pouch.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Manasi Agrawal
- The Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York; Center for Molecular Prediction of Inflammatory Bowel Disease, Department of Clinical Medicine, Aalborg University, Copenhagen, Denmark
| | - Gaurav Syal
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Benjamin L Cohen
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases Institute, Cleveland Clinic, Cleveland, Ohio
| | - John P Haydek
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Elie S Al Kazzi
- Division of Gastroenterology, Case Western Reserve University, Cleveland, Ohio
| | - Samuel Eisenstein
- Division of Colorectal Surgery, Department of Surgery, University of California San Diego, La Jolla, California
| | - Jana G Hashash
- Inflammatory Bowel Disease Center, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Shahnaz S Sultan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota; Veterans Affairs Healthcare System, Minneapolis, Minnesota
| | - Laura E Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California
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Yang ML, Brar MS, Kennedy ED, de Buck van Overstraeten A. Laparoscopic Versus Transanal IPAA for Ulcerative Colitis: A Patient-Centered Treatment Trade-Off Study. Dis Colon Rectum 2024; 67:107-113. [PMID: 37682734 DOI: 10.1097/dcr.0000000000002902] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
BACKGROUND Transanal IPAA is a relatively new technique aiming to reduce surgical invasiveness while providing better access to the pelvis in patients with ulcerative colitis. Currently, patients' preference for a surgical approach has never been investigated. OBJECTIVE To observe patient preference between transanal and laparoscopic IPAA by measuring the potential risk, expressed in pouch function reduction, patients are willing to take to undergo transanal surgery. DESIGN We conducted standardized interviews of patients using the threshold technique. SETTINGS Patients from Mount Sinai Hospital in Toronto were included. PATIENTS Fifty-two patients with ulcerative colitis participated in this study. INTERVENTION Patients with ulcerative colitis, with or without previous pouch surgery, were submitted to standardized interviews using the threshold technique. MAIN OUTCOME MEASURES We measured the absolute increase in bowel frequency, bowel urgency, and fecal incontinence that patients would accept if undergoing transanal IPAA. RESULTS Thirty-two patients (mean age: 38.7 ± 15.3 years) with previous surgery and 20 patients (mean age: 39.5 ± 11.9 years) with no previous surgery participated in this study. Patients accepted an absolute increase of 2 bowel movements per day and 1 episode of fecal incontinence per month to undergo transanal IPAA. They also accepted 10 minutes of worsening bowel urgency (ie, decrease of 10 minutes in "holding time") for transanal surgery. Younger patients aged 21 to 29 years only accepted an absolute decrease of 5 minutes in "holding time" ( p = 0.02). LIMITATIONS Biases inherent to study design. CONCLUSIONS Patients were willing to accept a potential reduction in pouch function to receive the less invasive method of transanal IPAA. More studies evaluating long-term functional outcomes after transanal IPAA are required to help patients make educated surgical decisions. See Video Abstract. ANASTOMOSIS LAPAROSCPICA VERSUS TRANSANAL ILEALBOLSA ANAL PARA LA COLITIS ULCEROSA UN ESTUDIO DE COMPENSACIN DE TRATAMIENTO CENTRADO EN EL PACIENTE ANTECEDENTES:La anastomosis anal transanal con reservorio ileal es una técnica relativamente nueva que tiene como objetivo reducir la invasividad quirúrgica y al mismo tiempo proporcionar un mejor acceso a la pelvis en pacientes con colitis ulcerosa. Actualmente, nunca se ha investigado la preferencia de los pacientes sobre el abordaje quirúrgico.OBJETIVO:Observar la preferencia de los pacientes entre la anastomosis ileoanal con reservorio transanal y laparoscópica midiendo el riesgo potencial, expresado en la reducción de la función del reservorio, que los pacientes están dispuestos a someterse a una cirugía transanal.DISEÑO:Realizamos entrevistas estandarizadas de pacientes utilizando la técnica del umbral.AJUSTES:Se incluyeron pacientes del Hospital Mount Sinai en Toronto.PACIENTES:Cincuenta y dos pacientes con colitis ulcerosa participaron en este estudio.INTERVENCIÓN(ES):Los pacientes con colitis ulcerosa, con o sin cirugía previa de reservorio fueron sometidos a entrevistas estandarizadas utilizando la técnica del umbral.MEDIDAS DE RESULTADO PRINCIPALES:Medimos el aumento absoluto en la frecuencia intestinal, la urgencia intestinal y la incontinencia fecal que los pacientes aceptarían si se sometieran a una anastomosis transanal con bolsa ileal.RESULTADOS:Treinta y dos pacientes (edad media: 38,7 ± 15,3) con cirugía previa y 20 pacientes (edad media: 39,5 ± 11,9) sin cirugía previa participaron en este estudio. Los pacientes aceptaron un aumento absoluto de 2 deposiciones por día y un episodio de incontinencia fecal por mes para someterse a una anastomosis transanal ileoanal con reservorio. También aceptaron 10 minutos de empeoramiento de la urgencia intestinal (es decir, disminución de 10 minutos del "tiempo de espera") para la cirugía transanal. Los pacientes más jóvenes de 21 a 29 años solo aceptaron una disminución absoluta de 5 minutos en el "tiempo de espera" ( P = 0,02).LIMITACIONES:Sesgos inherentes al diseño del estudio.CONCLUSIONES:Los pacientes estaban dispuestos a aceptar una reducción potencial en la función del reservorio para recibir el método menos invasivo de anastomosis transanal ileoanal con reservorio. Se requieren más estudios que evalúen los resultados funcionales a largo plazo después de la anastomosis transanal ileoanal con reservorio para ayudar a los pacientes a tomar decisiones quirúrgicas informadas. (Traducción-Yesenia Rojas-Khalil ).
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Affiliation(s)
- Mei Lucy Yang
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Barchi A, Dal Buono A, D’Amico F, Furfaro F, Zilli A, Fiorino G, Parigi TL, Peyrin-Biroulet L, Danese S, Allocca M. Leaving behind the Mucosa: Advances and Future Directions of Intestinal Ultrasound in Ulcerative Colitis. J Clin Med 2023; 12:7569. [PMID: 38137644 PMCID: PMC10744120 DOI: 10.3390/jcm12247569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/27/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
Inflammatory Bowel Diseases (IBD), mainly Ulcerative Colitis (UC) and Crohn's Disease (CD), are disorders characterized by chronic inflammation with severe morbidity and long-term disabling quality of life outcomes. UC mainly affects the mucosal and sub-mucosal layers of the colon, without embracing the peri-intestinal structures. Considering the predominant mucosal location of UC inflammation, the implementation of transmural evaluation by cross-sectional imaging techniques, mainly Intestinal Ultrasound (IUS), has been left behind for ages, especially if compared to CD. Nevertheless, studies analyzing intestinal ultrasound parameters accuracy in disease activity detection reported a good-to-optimal correlation of IUS markers with colonic inflammation, suggesting comparable feasibility of IUS monitoring in UC as in CD. The easy-to-use, costless and point-of-care available status of IUS is therefore crucial in order to improve the diagnostic process and, according to the recent literature, to monitor the response to treatment leading to speeding up decision making and therapy adjustments. Recent studies have demonstrated the correlation between transmural healing in UC with favorable outcomes even in the long term. An evidence gap still exists in the assessment of the rectum, with trans-perineal ultrasound (TPUS) a potential answer to reach a more precise evaluation of rectal inflammation. Eventually, IUS is also increasingly showing promises in emergent or post-surgical UC settings, considering various efforts put in line to demonstrate its feasibility in predicting response to salvage therapy for surgery avoidance and in studying inflammation relapse after procto-colectomy with ileo-pouch-anal anastomosis (IPAA) creation.
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Affiliation(s)
- Alberto Barchi
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, 20132 Milan, Italy; (A.B.); (F.D.); (F.F.); (A.Z.); (G.F.); (S.D.)
| | - Arianna Dal Buono
- IBD Center, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy;
| | - Ferdinando D’Amico
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, 20132 Milan, Italy; (A.B.); (F.D.); (F.F.); (A.Z.); (G.F.); (S.D.)
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
| | - Federica Furfaro
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, 20132 Milan, Italy; (A.B.); (F.D.); (F.F.); (A.Z.); (G.F.); (S.D.)
| | - Alessandra Zilli
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, 20132 Milan, Italy; (A.B.); (F.D.); (F.F.); (A.Z.); (G.F.); (S.D.)
| | - Gionata Fiorino
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, 20132 Milan, Italy; (A.B.); (F.D.); (F.F.); (A.Z.); (G.F.); (S.D.)
| | - Tommaso Lorenzo Parigi
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, 20132 Milan, Italy; (A.B.); (F.D.); (F.F.); (A.Z.); (G.F.); (S.D.)
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, University of Lorraine, 54500 Vandoeuvre-lès-Nancy, France;
- Department of Gastroenterology, Nancy University Hospital, 54500 Vandœuvre-lès-Nancy, France
- INFINY Institute, Nancy University Hospital, 54500 Vandœuvre-lès-Nancy, France
- Federation Hospitalo-Univeristaire-CURE, Nancy University Hospital, 54500 Vandœuvre-lès-Nancy, France
- Groupe Hospitalier Privé Ambroise Paré-Hartmann, Paris IBD Center, 92200 Neuilly-sur-Seine, France
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC H4A 3J1, Canada
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, 20132 Milan, Italy; (A.B.); (F.D.); (F.F.); (A.Z.); (G.F.); (S.D.)
| | - Mariangela Allocca
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, 20132 Milan, Italy; (A.B.); (F.D.); (F.F.); (A.Z.); (G.F.); (S.D.)
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Barnes EL, Kayal M, Schwartzberg DM. The Rational Use of Advanced Therapies for Inflammatory Conditions of the Pouch. Inflamm Bowel Dis 2023; 29:2007-2009. [PMID: 37897227 PMCID: PMC10697410 DOI: 10.1093/ibd/izad264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Indexed: 10/29/2023]
Abstract
Lay Summary
We have seen an emergence of new literature supporting the use of advanced therapies in the treatment of chronic inflammatory conditions of the pouch. In this discussion, we review the use of advanced therapies for chronic pouchitis and Crohn’s-like disease of the pouch and suggest future directions for research and clinical care.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Maia Kayal
- Division of Gastroenterology, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David M Schwartzberg
- Division of Colon and Rectal Surgery, Inflammatory Bowel Disease Center, Columbia University Irving Medical Center, New York, NY, USA
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Abstract
Lay Summary
Identifying those patients at the greatest risk for pouchitis at the time of ileal pouch-anal anastomosis for ulcerative colitis remains a challenge. We discuss the importance of this topic by reviewing recent data regarding the impact of acute severe ulcerative colitis on risk of pouchitis and the implications for future clinical decisions and studies of risk stratification.
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Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
- Center for Gastrointestinal Biology and Disease, University of North Carolina, Chapel Hill, NC, USA
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina, Chapel Hill, NC, USA
| | - Shannon Chang
- Division of Gastroenterology and Hepatology, NYU Langone Health, New York, NY, USA
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82
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Maspero M, Holubar SD, Raj R, Yilmaz S, Prien C, Lavryk O, Pita A, Hashimoto K, Steele SR, Hull TL. Ileal Pouch-anal Anastomosis in Primary Sclerosing Cholangitis-inflammatory Bowel Disease (PSC-IBD): Long-term Pouch and Liver Transplant Outcomes. Ann Surg 2023; 278:961-968. [PMID: 37477000 DOI: 10.1097/sla.0000000000006041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
OBJECTIVE To compare the effect of liver transplantation (LT) on ileal pouch-anal anastomosis (IPAA) outcomes in patients with primary sclerosing cholangitis and inflammatory bowel disease (PSC-IBD). BACKGROUND Patients with PSC-IBD may require both IPAA for colitis and LT for PSC. METHODS Patients with PSC-IBD from out institutional pouch registry (1985-2022) were divided according to LT status and timing of LT (before and after IPAA) and their outcomes analyzed. RESULTS A total of 160 patients were included: 112 (70%) nontransplanted at last follow-up; 48 (30%) transplanted, of which 23 (14%) before IPAA and 25 (16%) after. Nontransplanted patients at IPAA had more laparoscopic procedures [37 (46%) vs 8 (18%), P =0.002] and less blood loss (median 250 vs 400 mL, P =0.006). Morbidity and mortality at 90 days were similar. Chronic pouchitis was higher in transplanted compared with nontransplanted patients [32 (67%) vs 51 (45.5%), P =0.03], but nontransplanted patients had a higher rate of chronic antibiotic refractory pouchitis. Overall survival was similar, but nontransplanted patients had more PSC-related deaths (12.5% vs 2%, P =0.002). Pouch survival at 10 years was 90% for nontransplanted patients and 100% for transplanted patients (log-rank P =0.052). Timing of LT had no impact on chronic pouchitis, pouch failure, or overall survival. PSC recurrence was 6% at 10 years. For transplanted patients, graft survival was similar regardless of IPAA timing. CONCLUSIONS In patients with PSC-IBD and IPAA, LT is linked to an increased pouchitis rate but does not affect overall and pouch survival. Timing of LT does not influence short-term and long-term pouch outcomes.
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Affiliation(s)
- Marianna Maspero
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Stefan D Holubar
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Roma Raj
- Department of HPB Surgery and Liver Transplantation, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Sumeyye Yilmaz
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Christopher Prien
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Olga Lavryk
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Alejandro Pita
- Department of HPB Surgery and Liver Transplantation, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Koji Hashimoto
- Department of HPB Surgery and Liver Transplantation, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Scott R Steele
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Tracy L Hull
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
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83
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Clancy C, Connelly TM, Jia X, Lipman J, Lightner AL, Hull T, Steele SR, Holubar SD. Defining the safety of early ileostomy closure after ileal pouch anal anastomosis. Tech Coloproctol 2023; 27:1257-1263. [PMID: 37209279 DOI: 10.1007/s10151-023-02811-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 04/24/2023] [Indexed: 05/22/2023]
Abstract
PURPOSE The safety of early ileostomy reversal after ileal pouch anal anastomosis (IPAA) has not been established. Our hypothesis was that ileostomy reversal before 8 weeks is associated with negative outcomes. METHODS This was a retrospective cohort study from a prospectively maintained institutional database. Patients who underwent primary IPAA with ileostomy reversal between 2000 and 2021 from a Pouch Registry were stratified on the basis of timing of reversal. Those reversed before 8 weeks (early) and those reversed from 8 weeks to 116 days (routine) were compared. The primary outcome was overall complications according to timing and reason for closure. RESULTS Ileostomy reversal was performed early in 92 patients and routinely in 1908. Median time to closure was 49 days in the early group and 93 days in the routine group. Reasons for early reversal were stoma-related morbidity in 43.3% (n = 39) and scheduled closure in 56.7% (n = 51). The complication rate in the early group was 17.4% versus 11% in the routine group (p = 0.085). When early patients were stratified according to reason for reversal, those reversed early for stoma-related morbidity had an increased complication rate compared to the routine group (25.6% vs. 11%, p = 0.006). Patients undergoing scheduled reversal in the early group did not have increased complications (11.8% vs. 11%, p = 0.9). There was a higher likelihood of pouch anastomotic leak when reversal was performed early for stoma complications compared to routinely (OR 5.13, 95% CI 1.01-16.57, p = 0.049). CONCLUSIONS Early closure is safe but could be delayed in stoma morbidity as patients may experience increased complications.
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Affiliation(s)
- C Clancy
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - T M Connelly
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - X Jia
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - J Lipman
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - A L Lightner
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - T Hull
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - S R Steele
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - S D Holubar
- Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
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Kabir M, Thomas-Gibson S, Tozer PJ, Warusavitarne J, Faiz O, Hart A, Allison L, Acheson AG, Atici SD, Avery P, Brar M, Carvello M, Choy MC, Dart RJ, Davies J, Dhar A, Din S, Hayee B, Kandiah K, Katsanos KH, Lamb CA, Limdi JK, Lovegrove RE, Myrelid P, Noor N, Papaconstantinou I, Petrova D, Pavlidis P, Pinkney T, Proud D, Radford S, Rao R, Sebastian S, Segal JP, Selinger C, Spinelli A, Thomas K, Wolthuis A, Wilson A. DECIDE: Delphi Expert Consensus Statement on Inflammatory Bowel Disease Dysplasia Shared Management Decision-Making. J Crohns Colitis 2023; 17:1652-1671. [PMID: 37171140 DOI: 10.1093/ecco-jcc/jjad083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND AND AIMS Inflammatory bowel disease colitis-associated dysplasia is managed with either enhanced surveillance and endoscopic resection or prophylactic surgery. The rate of progression to cancer after a dysplasia diagnosis remains uncertain in many cases and patients have high thresholds for accepting proctocolectomy. Individualised discussion of management options is encouraged to take place between patients and their multidisciplinary teams for best outcomes. We aimed to develop a toolkit to support a structured, multidisciplinary and shared decision-making approach to discussions about dysplasia management options between clinicians and their patients. METHODS Evidence from systematic literature reviews, mixed-methods studies conducted with key stakeholders, and decision-making expert recommendations were consolidated to draft consensus statements by the DECIDE steering group. These were then subjected to an international, multidisciplinary modified electronic Delphi process until an a priori threshold of 80% agreement was achieved to establish consensus for each statement. RESULTS In all, 31 members [15 gastroenterologists, 14 colorectal surgeons and two nurse specialists] from nine countries formed the Delphi panel. We present the 18 consensus statements generated after two iterative rounds of anonymous voting. CONCLUSIONS By consolidating evidence for best practice using literature review and key stakeholder and decision-making expert consultation, we have developed international consensus recommendations to support health care professionals counselling patients on the management of high cancer risk colitis-associated dysplasia. The final toolkit includes clinician and patient decision aids to facilitate shared decision-making.
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Affiliation(s)
- Misha Kabir
- Division of GI Services, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
| | - Siwan Thomas-Gibson
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Phil J Tozer
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Janindra Warusavitarne
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Omar Faiz
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Ailsa Hart
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Lisa Allison
- Department of Gastroenterology, Royal Free Hospital, London, UK
| | - Austin G Acheson
- Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Semra Demirli Atici
- Department of Surgery, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey
| | - Pearl Avery
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Mantaj Brar
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Michele Carvello
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Surgery, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Matthew C Choy
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia
- Division of Medicine, Dentistry and Health Sciences, University of Melbourne, Austin Academic Centre, Melbourne, VIC, Australia
| | - Robin J Dart
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Justin Davies
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Anjan Dhar
- Department of Gastroenterology, Darlington Memorial Hospital, County Durham & Darlington NHS Foundation Trust, Darlington, UK
- Department of Gastroenterology, Teesside University, UK, Middlesbrough, UK
| | - Shahida Din
- Edinburgh IBD Unit, NHS Lothian, Western General Hospital, Edinburgh, UK
| | - Bu'Hussain Hayee
- Department of Gastroenterology, King's College Hospital, London, UK
| | - Kesavan Kandiah
- Department of Gastroenterology, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Konstantinos H Katsanos
- Division of Gastroenterology, Department of Internal Medicine, University of Ioannina School of Health Sciences, Ioannina, Greece
| | - Christopher Andrew Lamb
- Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Gastroenterology, Royal Victoria Infirmary, Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Jimmy K Limdi
- Department of Gastroenterology, Northern Care Alliance NHS Foundation Trust, Greater Manchester, UK
- Department of Gastroenterology, University of Manchester , Manchester, UK
| | - Richard E Lovegrove
- Department of Surgery, Worcestershire Acute Hospitals NHS Trust , Worcester, UK
| | - Pär Myrelid
- Department of Surgery, Linköping University Hospital, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Nurulamin Noor
- Department of Gastroenterology, Cambridge University Hospitals, Addenbrooke's Hospital, Cambridge, UK
| | - Ioannis Papaconstantinou
- Department of Surgery, Aretaieion Hospital, National and Kapodistrian University of Athens, A thens, Greece
| | - Dafina Petrova
- Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain
- Escuela Andaluza de Salud Pública [EASP], Granada, Spain
- CIBER of Epidemiology and Public Health [CIBERESP], Madrid, Spain
| | - Polychronis Pavlidis
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Thomas Pinkney
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - David Proud
- Department of Surgery, Austin Health, Heidelberg Victoria, VIC, Australia
| | - Shellie Radford
- Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Rohit Rao
- Department of Gastroenterology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Shaji Sebastian
- Department of Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Jonathan P Segal
- Department of Gastroenterology, Northern Hospital Epping, University of Melbourne, Melbourne, VIC, Australia
| | - Christian Selinger
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Antonino Spinelli
- Faculty of Life Sciences and Medicine, King's College London, London, UK
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Kathryn Thomas
- Department of Surgery, Nottingham University Hospitals, UK
| | - Albert Wolthuis
- Department of Surgery, University Hospital Leuven, The Netherlands
| | - Ana Wilson
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
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85
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Ardalan ZS, Livingstone KM, Polzella L, Avakian J, Rohani F, Sparrow MP, Gibson PR, Yao CK. Perceived dietary intolerances, habitual intake and diet quality of patients with an ileoanal pouch: Associations with pouch phenotype (and behaviour). Clin Nutr 2023; 42:2095-2108. [PMID: 37748240 DOI: 10.1016/j.clnu.2023.07.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 05/24/2023] [Accepted: 07/23/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND AND AIMS Ileoanal pouch patients frequently attribute pouch-related symptoms and pouchitis with diet. We aimed to assess perceived food intolerance and habitual dietary intake and their relationship with pouch indication, symptoms and current or history of pouchitis. METHODS In this cross-sectional study, patients with an ileoanal pouch completed a dietary intolerance and a food frequency questionnaire, that specifically quantifies habitual intake of FODMAPs. Perceived dietary intolerance rates, nutrient intake and diet quality, and their differences based on pouch indication, symptom, and current or history of pouchitis were assessed. Associations between intolerances and intake, and between dietary intake with pouchitis risk were analysed using univariable and multivariable regression analysis. RESULTS Of the 58 (10 FAP and 48 UC) patients with complete data, 81% of UC and 80% of FAP patients reported dietary intolerances. Overall diet quality was good. Differences in dietary intake were limited to a few food groups. Patients with a history of pouchitis had a lower intake of fruits (p = 0.03) and nuts (p = 0.004). Patients with current pouchitis had a lower intake of nuts (p = 0.02). On multivariable logistic regression, intake of dietary fibre was associated negatively [OR 0.68(95%CI:0.51-0.92)] and of non-digestible oligosaccharides positively with pouchitis history [OR 5.5(95% CI:1.04-29.1)]. CONCLUSIONS In patients with an ileoanal pouch, perceived dietary intolerances are common but had minimal impact on nutritional adequacy and diet quality. Negative associations of the intakes of fruits, nuts and dietary fibre and positive association with non-digestible oligosaccharides with a history of pouchitis require further study to inform dietary recommendations.
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Affiliation(s)
- Zaid S Ardalan
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Victoria, Australia.
| | - Katherine M Livingstone
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Burwood, Victoria, Australia
| | - Louise Polzella
- Department of Nutrition and Dietetics, Monash University, Victoria, Australia
| | - Julia Avakian
- Department of Nutrition and Dietetics, Monash University, Victoria, Australia
| | - Faran Rohani
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Victoria, Australia
| | - Miles P Sparrow
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Victoria, Australia
| | - Peter R Gibson
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Victoria, Australia
| | - Chu K Yao
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Victoria, Australia
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86
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Santiago P, Barnes EL, Raffals LE. Classification and Management of Disorders of the J Pouch. Am J Gastroenterol 2023; 118:1931-1939. [PMID: 37252759 DOI: 10.14309/ajg.0000000000002348] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 05/25/2023] [Indexed: 05/31/2023]
Abstract
Total abdominal proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) is associated with substantial complications despite the benefits of managing refractory and/or neoplasia-associated disease. For the purpose of this review, we focused on the diagnosis of some of the most common inflammatory and structural pouch disorders and their respective management. Pouchitis is the most common complication, and it is typically responsive to antibiotics. However, chronic antibiotic refractory pouchitis (CARP) has been increasingly recognized, and biologic therapies have emerged as the mainstay of therapy. Crohn's-like disease of the pouch (CLDP) can affect up to 10% of patients with UC after IPAA. Medical options are similar to CARP therapies, including biologics with immunomodulators. Studies have shown higher efficacy rates of biologics for CLDP when compared with those for CARP. In addition, managing stricturing and fistulizing CLDP is challenging and often requires interventional endoscopy (balloon dilation and/or stricturotomy) and/or surgery. The implementation of standardized diagnostic criteria for inflammatory pouch disorders will help in advancing future therapeutic options. Structural pouch disorders are commonly related to surgical complications after IPAA. We focused on the diagnosis and management of anastomotic leaks, strictures, and floppy pouch complex. Anastomotic leaks and anastomotic strictures occur in approximately 15% and 11% of patients with UC after IPAA, respectively. Further complications from pouch leaks include the development of sinuses, fistulas, and pouch sepsis requiring excision. Novel endoscopic interventions and less invasive surgical procedures have emerged as options for the management of these disorders.
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Affiliation(s)
- Priscila Santiago
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Laura E Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Emile SH, Horesh N, Freund MR, Garoufalia Z, Gefen R, Khan SM, Silva-Alvarenga E, Wexner SD. A Systematic Review and Meta-analysis of Randomized Clinical Trials on the Prevention and Treatment of Pouchitis after Ileoanal Pouch Anastomosis. J Gastrointest Surg 2023; 27:2650-2660. [PMID: 37815701 DOI: 10.1007/s11605-023-05841-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/26/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND This systematic review explored different medications and methods for prevention and treatment of pouchitis after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). METHODS PubMed, Scopus, and Web of Science were searched for randomized clinical trials that assessed prevention or treatment of pouchitis. The systematic review was reported in line with updated 2020 PRISMA guidelines. Risk of bias in the trials included was assessed using the ROB-2 tool and certainty of evidence was assessed using GRADE. The main outcomes were the incidence of new pouchitis episodes in the preventative studies and resolution or improvement of active pouchitis in the treatment studies. RESULTS Fifteen randomized trials were included. A meta-analysis of 7 trials on probiotics revealed significantly lower odds of pouchitis with the use of probiotics (RR: 0.26, 95% CI: 0.16-0.42, I2 = 20%, p < 0.001) and similar odds of adverse effects to placebo (RR: 2.43, 95% CI: 0.11-55.9, I2 = 0, p = 0.579). One trial investigated the prophylactic role of allopurinol in preventing pouchitis and found a comparable incidence of pouchitis in the two groups (31% vs 28%; p = 0.73). Seven trials assessed different treatments for active pouchitis. One recorded the resolution of pouchitis in all patients treated with ciprofloxacin versus 67% treated with metronidazole. Both budesonide enema and oral metronidazole were associated with similar significant improvement in pouchitis (58.3% vs 50%, p = 0.67). Rifaximin, adalimumab, fecal microbiota transplantation, and bismuth carbomer foam enema were not effective in treating pouchitis. CONCLUSIONS Probiotics are effective in preventing pouchitis after IPAA. Antibiotics, including ciprofloxacin and metronidazole, are likely effective in treating active pouchitis.
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Affiliation(s)
- Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- General Surgery Department, Colorectal Surgery Unit, Mansoura University Hospitals, Mansoura, Egypt
| | - Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Department of Surgery and Transplantation, Sheba Medical Center, Ramat Gan, Israel
| | - Michael R Freund
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Department of General Surgery, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
- Department of General Surgery, Faculty of Medicine, Hadassah Medical Organization, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sualeh Muslim Khan
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | | | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA.
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Risto A, Andersson RE, Landerholm K, Bengtsson J, Block M, Myrelid P. Reoperations and Long-term Survival of Kock's Continent Ileostomy in Patients With IBD: A Population-Based National Cohort Study From Sweden. Dis Colon Rectum 2023; 66:1492-1499. [PMID: 36649179 DOI: 10.1097/dcr.0000000000002517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Kock's continent ileostomy is an option after proctocolectomy for patients not suitable for IPAA or ileorectal anastomosis. Ulcerative colitis is the most common indication for continent ileostomy. OBJECTIVE The aim of this study was to evaluate the long-term outcome of continent ileostomy. DESIGN Retrospective cohort register study. SETTINGS Data were obtained from the Swedish National Patient Registry. PATIENTS All patients with IBD and a continent ileostomy were identified. Data on demographics, diagnosis, reoperations, and excisions of the continent ileostomy were obtained. Patients with inconsistent diagnostic coding were classified as IBD-unclassified. MAIN OUTCOME MEASURES The main outcome measures were number of reoperations, time to reoperations, and time to excision of continent ileostomy. RESULTS We identified 727 patients, 428 (59%) with ulcerative colitis, 45 (6%) with Crohn's disease, and 254 (35%) with IBD-unclassified. After a median follow-up time of 27 (interquartile range, 21-31) years, 191 patients (26%) never had revision surgery. Some 1484 reoperations were performed on 536 patients (74%), and the median number of reoperations was 1 (interquartile range, 0-3) per patient. The continent ileostomy was excised in 77 patients (11%). Reoperation within the first year after reconstruction was associated with a higher rate of revisions (incidence rate ratio, 2.90; p < 0.001) and shorter time to excision (HR 2.38; p < 0.001). Constructing the continent ileostomy after year 2000 was associated with increased revision and excision rates (incidence rate ratio, 2.7; p < 0.001 and HR 2.74; p = 0.013). IBD-unclassified was associated with increased revisions (incidence rate ratio, 1.3; p < 0.001)' and the proportion of IBD-unclassified patients almost doubled from the 1980s (32%) to after 2000 (50%). LIMITATIONS Retrospective design, data from a register, and no data on quality of life were available were the limitations of this study. CONCLUSION Continent ileostomy is associated with substantial need for revision surgery, but most patients keep their reconstruction for a long time. See Video Abstract at http://links.lww.com/DCR/C122 . REOPERACIONES Y SUPERVIVENCIA A LARGO PLAZO DE LA ILEOSTOMA CONTINENTE DE KOCK EN PACIENTES CON ENFERMEDAD INFLAMATORIA INTESTINAL UN ESTUDIO DE COHORTE NACIONAL BASADO EN LA POBLACIN DE SUECIA ANTECEDENTES:La ileostomía continente de Kock es una opción después de la proctocolectomía para los pacientes que no son aptos para la anastomosis ileoanal con reservorio o la anastomosis ileorrectal. La colitis ulcerativa es la indicación más común para la ileostomía continente.OBJETIVO:El objetivo de este estudio fue evaluar el resultado a largo plazo de la ileostomía continente.DISEÑO:Estudio de registro de cohorte retrospectivo.AJUSTES:Los datos se obtuvieron del Registro Nacional de Pacientes de Suecia.PACIENTES:Se identificaron todos los pacientes con enfermedad inflamatoria intestinal e ileostomía continente. Se obtuvieron datos demograficos, diagnóstico, reoperaciones y extirpaciones de la ileostomía continente. Los pacientes con codificación diagnóstica inconsistente se clasificaron como no clasificados con EII.PRINCIPALES MEDIDAS DE RESULTADO:Las principales medidas de resultado fueron el número de reoperaciones, el tiempo hasta las reoperaciones y el tiempo hasta la escisión de la ileostomía continente.RESULTADOS:Identificamos 727 pacientes, 428 (59%) con colitis ulcerativa, 45 (6%) con enfermedad de Crohn y 254 (35%) con EII no clasificada. Después de una mediana de tiempo de seguimiento de 27 (IQR 21-31) años, 191 (26%) pacientes nunca se habían sometido a una cirugía de revisión. Se realizaron 1.484 reintervenciones en 536 (74%) pacientes, la mediana de reintervenciones fue de 1 (RIC 0-3) por paciente. La ileostomía continente se extirpó en 77 (11%) pacientes. La reoperación dentro del primer año después de la reconstrucción se asoció con una mayor tasa de revisiones (IRR 2,90 p < 0,001) y un tiempo más corto hasta la escisión (HR 2,38 p < 0,001). La construcción de la ileostomía continente después del año 2000 se asoció con mayores tasas de revisión y escisión (IRR 2,7 p < 0,001 y HR 2,74 p = 0,013). La EII no clasificada se asoció con un aumento de las revisiones (IRR 1,3 p < 0,001) y la proporción de pacientes con EII no clasificada casi se duplicó desde la década de 1980 (32%) hasta después de 2000 (50%).LIMITACIONES:Diseño retrospectivo, datos de registro. No hay datos disponibles sobre la calidad de vida.CONCLUSIÓN:La ileostomía continente se asocia con una necesidad sustancial de cirugía de revisión, pero la mayoría de los pacientes logran mantener su reconstrucción durante mucho tiempo. Consulte Video Resumen en http://links.lww.com/DCR/C122 . (Traducción-Dr. Yolanda Colorado ).
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Affiliation(s)
- Anton Risto
- Department of Surgery, Linköping University Hospital, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | - Roland E Andersson
- Department of Biomedical and Clinical Sciences, Faculty of Health Sciences, Linköping University, Linköping, Sweden
- Department of Surgery, County Hospital Ryhov, Jönköping, Sweden
| | - Kalle Landerholm
- Department of Biomedical and Clinical Sciences, Faculty of Health Sciences, Linköping University, Linköping, Sweden
- Department of Surgery, County Hospital Ryhov, Jönköping, Sweden
| | - Jonas Bengtsson
- Colorectal Unit, Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mattias Block
- Colorectal Unit, Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Pär Myrelid
- Department of Surgery, Linköping University Hospital, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Faculty of Health Sciences, Linköping University, Linköping, Sweden
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Giddings HL, Ng KS, Solomon MJ, Steffens D, Van Buskirk J, Young J. Population outcomes, trends and the future of pouch surgery for ulcerative colitis: a 19-year New South Wales data linkage study. ANZ J Surg 2023; 93:2686-2696. [PMID: 37449791 DOI: 10.1111/ans.18588] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/25/2023] [Accepted: 06/27/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Ileal pouch-anal anastomosis (IPAA) is considered the gold standard reconstructive option in ulcerative colitis (UC). Recent efforts to improve pouch outcomes have seen a push towards centralisation of surgery. This study aimed to document outcomes following pouch surgery at a population level within New South Wales (NSW), and identify factors associated with, and temporal trends of these outcomes. METHODS A retrospective data linkage study of the NSW population over a 19-year period was performed. The primary outcome was pouch failure in patients with UC who underwent IPAA. The influence of hospital level factors (including annual volume) and patient demographic variables on this outcome were assessed using Cox proportional hazards modelling. Temporal trends in annual volume and evidence for centralisation over the studied period were assessed using Poisson regression analysis. RESULTS The annual volume of UC pouches reduced over the study period. The pouch failure rates were 8.6% (95% CI 6.3-10.8%) and 10.6% (95% CI 8.0-13.1%) at 5- and 10-years, respectively. Increasing age and non-elective admission were associated with higher failure rates. One-third of UC pouches (31.6%) were performed in a single institution, which averaged 6.5 pouches/year throughout the study period. Three-quarters (19/25) of NSW public hospitals who performed pouches performed less than one UC pouch annually. CONCLUSIONS The outcomes following UC pouch surgery in NSW are comparable with global standards. Concentrating IBD pouch surgery with the aim of producing specialist surgical teams may be a reasonable way forward in NSW and would ensure equity of access and facilitate research and training collaboration.
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Affiliation(s)
- Hugh L Giddings
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kheng-Seong Ng
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
| | - Joe Van Buskirk
- Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, New South Wales, Australia
- Public Health Research Analytics and Methods for Evidence, Sydney Local Health District, New South Wales, Australia
| | - Jane Young
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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90
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Celentano V, Manzo CA. Assessment of the ileoanal pouch for the colorectal surgeon. Langenbecks Arch Surg 2023; 408:423. [PMID: 37910244 PMCID: PMC10620320 DOI: 10.1007/s00423-023-03151-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 10/11/2023] [Indexed: 11/03/2023]
Abstract
INTRODUCTION Many pouch complications following ileoanal pouch surgery have an inflammatory or mechanical nature, and specialist colorectal surgeons are required to assess the anatomy of the ileoanal pouch in multiple settings. In this study, we report our stepwise clinical and endoscopic assessment of the patient with an ileoanal pouch. METHODS The most common configuration of the ileoanal pouch is a J-pouch, and the stapled anastomosis is more frequently performed than a handsewn post-mucosectomy. A structured clinical and endoscopic assessment of the ileoanal pouch must provide information on 7 critical areas: anus and perineum, rectal cuff, pouch anal anastomosis, pouch body, blind end of the pouch, pouch inlet and pre-pouch ileum. RESULTS We have developed a structured pro forma for step-wise assessment of the ileoanal pouch, according to 7 essential areas to be evaluated, biopsied and reported. The structured assessment of the ileoanal pouch in 102 patients allowed reporting of abnormal findings in 63 (61.7%). Strictures were diagnosed in 27 patients (26.4%), 3 pouch inlet strictures, 21 pouch anal anastomosis strictures, and 3 pre-pouch ileum strictures. Chronic, recurrent pouchitis was diagnosed in 9 patients, whilst 1 patient had Crohn's disease of the pouch. CONCLUSIONS Detailed clinical history, assessment of symptoms and multidisciplinary input are all essential for the care of patients with an ileoanal pouch. We present a comprehensive reporting pro forma for initial clinical assessment of the patient with an ileoanal pouch, with the aim to guide further investigations and inform multidisciplinary decision-making.
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Affiliation(s)
- Valerio Celentano
- Inflammatory Bowel Disease and Ileoanal Pouch Surgery Centre, Chelsea and Westminster Hospital, NHS Foundation Trust, 369 Fulham Road, London, UK.
| | - Carlo Alberto Manzo
- Inflammatory Bowel Disease and Ileoanal Pouch Surgery Centre, Chelsea and Westminster Hospital, NHS Foundation Trust, 369 Fulham Road, London, UK
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91
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Ecker NKJ, Dinh C, Möslein G, Ecker KW. Comparing continent ileostomy (CI) conversion to repair/redo IPAA: favorable outcomes. Int J Colorectal Dis 2023; 38:261. [PMID: 37906299 PMCID: PMC10618396 DOI: 10.1007/s00384-023-04555-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 11/02/2023]
Abstract
PURPOSE This study aims to compare the outcomes of repair/redo ileal pouch-anal anastomosis (repair/redo-IPAA) with the conversion of IPAA to continent ileostomy (CI) in an effort to prevent the need for a permanent ileostomy (IS) following IPAA failure. METHODS This research involved a retrospective analysis of surgical records, employing descriptive statistics and Kaplan-Meier survival analysis. RESULTS Among 57 patients with an IPAA, up to three revisions were necessary due to complications or complete failure. Ultimately, repair/redo-IPAA preserved the IPAA in 14 patients (24.6%), conversion to CI salvaged the pouch in 21 patients (36.8%), and IS was unavoidable in 22 patients (38.6%). The cumulative probability of requiring conversion surgery was calculated to be 54.0% at 20 years, thereby reducing the cumulative risk of IS to 32.3%. The 20-year cumulative probability of pouch salvage by repair/redo IPAA was only 21.9%. However, this rate increased to 67.7% when conversion procedures were considered. Following repair/redo-IPAA, only 8.3% of patients reported evacuation frequencies of ≤ 4 during the day, and 16.7% were evacuation-free at night. In contrast, after conversion to CI, 98.0% of patients reported a maximum of four evacuations in a 24-h period. After undergoing repair/redo IPAA, between half and two-thirds of patients reported experiencing incontinence or soiling, while complete continence was achieved in all patients following conversion to CI. Notably, the majority of patients expressed overall satisfaction with their respective procedures. A positive correlation was identified between very high subjective satisfaction and positive objective surgical outcomes exclusively in patients who underwent conversion to CI. CONCLUSION When complications or failure of IPAA occur, conversion to CI emerges as a highly viable alternative to repair/redo IPAA. This conclusion is supported by the observation that patient satisfaction appears to be closely tied to stable surgical outcomes. To reinforce these findings, further prospective studies are warranted.
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Affiliation(s)
| | | | - Gabriela Möslein
- Center for Hereditary Tumors, Ev. Krankenhaus BETHESDA, University of Düsseldorf, Heerstraße 219, D-47053, Duisburg, Germany
| | - Karl-Wilhelm Ecker
- Dept. of General, Vascular, and Pediatric Surgery, University of Saarland, Homburg, Saar, Germany.
- Surgical Dept., MediClin Müritz-Klinikum, Weinbergstraße 19, D-17192, Waren, Germany.
- , Tannenweg 1, D-22889, Tangstedt, Germany.
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92
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Jillawar N, Bandla V, Galam P, Vajja R, Nirhale D. Study of late complications of restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis operated at a tertiary care center and factors affecting to that. Ann Afr Med 2023; 22:497-500. [PMID: 38358151 PMCID: PMC10775946 DOI: 10.4103/aam.aam_177_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 05/01/2023] [Accepted: 05/03/2023] [Indexed: 02/16/2024] Open
Abstract
Background and Objective Restorative proctocolectomy with ileal pouch-anal anastomosis (RPC-IPAA) is usually preferred surgical treatment for ulcerative colitis (UC). Although treated primarily medically, some refractory and complicated cases of UC may require surgical intervention. It eliminates chronic UC and the risk of colonic cancer. This research aims to study the risk factors associated with the development of postoperative complications. Methodology For this cohort study, we included all the patients who underwent RPC-IPAA in the Department of Gastroenterology, Sheth Vadilal Sarabhai General Hospital, Ahmedabad, over 6 years. Data of the patients were obtained retrospectively from the medical records. We collected the data and analyzed using appropriate statistical tests to look for preoperative patient variables associated with late complications. Late complications were defined as those developed after 1 month. Results Out of 32 patients, 19 were male and 13 were female, with an average age of 32.3 years at the time of operation. Thirteen patients developed complications such as pouchitis (n = 6), incisional hernia (n = 3), bowel obstruction (n = 2), pouch leakage (n = 1), and erectile dysfunction (n = 1). We found serum albumin <3 mg/dl and pancolitis associated with more postoperative late complications with P = 0.007 and 0.04, respectively, which is statistically significant. Conclusion This study demonstrates that low preoperative albumin level and pancolitis are risk factors for late complications of IPAA. Preoperative nutritional support, especially albumin, could reduce late complications.
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Affiliation(s)
- Nikhil Jillawar
- Department of General Surgery, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
| | - Vijetha Bandla
- Department of General Surgery, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
| | - Pushkar Galam
- Department of General Surgery, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
| | - Ramya Vajja
- Department of General Surgery, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
| | - Dakshayani Nirhale
- Department of General Surgery, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
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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] [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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94
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Ream JM, Luk L, Sheedy S, Fletcher JG, Church JM, Baker ME. Dynamic ileal pouch emptying studies. Abdom Radiol (NY) 2023; 48:2956-2968. [PMID: 36732408 DOI: 10.1007/s00261-023-03811-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 01/06/2023] [Accepted: 01/10/2023] [Indexed: 02/04/2023]
Abstract
Although much radiologic literature has focused on the short-term post-operative complications associated with ileal pouches, as the number of patients with long-term pouches has grown, there is increasing realization of the functional deficits that may occur long after pouch creation. Dynamic pouch imaging using fluoroscopy and MRI can provide assessment of the underlying causes of symptomatic pouch dysfunction and can provide critical insight to the management of this complex patient population. In this paper, we provide an overview of the unique problems encountered in patients with long-term ileal pouches, and provide an overview of the techniques, interpretation, and reporting for fluoroscopic and MR pouch defecography.
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Affiliation(s)
- Justin M Ream
- Imaging Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Lyndon Luk
- Department of Radiology, Columbia University Medical Center, New York, NY, USA
| | - Shannon Sheedy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - J G Fletcher
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - James M Church
- Division of Colorectal Surgery, Columbia University Medical Center, New York, NY, USA
| | - Mark E Baker
- Imaging Institute, Digestive Diseases and Surgery Institute, and Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
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95
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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: 1.5] [Reference Citation Analysis] [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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96
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Huang C, Dane B, Santillan C, Ream J. MRI of the ileal pouch. Abdom Radiol (NY) 2023; 48:2944-2955. [PMID: 36740604 DOI: 10.1007/s00261-023-03803-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 02/07/2023]
Abstract
Ileal pouch surgery is the surgical gold standard treatment for patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). However, ileal pouch surgery is a technically challenging procedure and is associated with high morbidity. Clinical presentations of pouch complications are often nonspecific but imaging can identify many of these complications and is essential in clinical management. This paper will focus on magnetic resonance imaging (MRI) of the ileal pouch, including recommended MRI protocol and approach to imaging interpretation with an emphasis on those ileal pouch complications particularly well evaluated with MRI.
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Affiliation(s)
- Chenchan Huang
- NYU Langone Health, 660 First Avenue, New York, NY, 10016, USA.
| | - Bari Dane
- NYU Langone Health, 660 First Avenue, New York, NY, 10016, USA
| | | | - Justin Ream
- , 9500 Euclid Avenue, Cleveland, OH, 44195, USA
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97
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Le Berre C, Honap S, Peyrin-Biroulet L. Ulcerative colitis. Lancet 2023; 402:571-584. [PMID: 37573077 DOI: 10.1016/s0140-6736(23)00966-2] [Citation(s) in RCA: 519] [Impact Index Per Article: 259.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/03/2023] [Accepted: 05/08/2023] [Indexed: 08/14/2023]
Abstract
Ulcerative colitis is a lifelong inflammatory disease affecting the rectum and colon to a variable extent. In 2023, the prevalence of ulcerative colitis was estimated to be 5 million cases around the world, and the incidence is increasing worldwide. Ulcerative colitis is thought to occur in people with a genetic predisposition following environmental exposures; gut epithelial barrier defects, the microbiota, and a dysregulated immune response are strongly implicated. Patients usually present with bloody diarrhoea, and the diagnosis is based on a combination of clinical, biological, endoscopic, and histological findings. The aim of medical management is, first, to induce a rapid clinical response and normalise biomarkers and, second, to maintain clinical remission and reach endoscopic normalisation to prevent long-term disability. Treatments for inducing remission include 5-aminosalicylic acid drugs and corticosteroids. Maintenance treatments include 5-aminosalicylic acid drugs, thiopurines, biologics (eg, anti-cytokines and anti-integrins), and small molecules (Janus kinase inhibitors and sphingosine-1-phosphate receptor modulators). Although the therapeutic options are expanding, 10-20% of patients still require proctocolectomy for medically refractory disease. The keys to breaking through this therapeutic ceiling might be the combination of therapeutics with precision and personalised medicine.
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Affiliation(s)
- Catherine Le Berre
- Institut des Maladies de l'Appareil Digestif, Hépato-Gastro-Entérologie et Assistance Nutritionnelle, Inserm CIC 1413, Inserm UMR 1235, Nantes Université, CHU Nantes, Nantes, France
| | - Sailish Honap
- Department of Gastroenterology, St George's University Hospitals NHS Foundation Trust, London, UK; School of Immunology and Microbial Sciences, King's College London, London UK
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology, INFINY Institute, FHU-CURE, INSERM NGERE, Nancy University Hospital, Vandœuvre-lès-Nancy, France; Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, QC, Canada.
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Ricardo AP, Kayal M, Plietz MC, Khaitov S, Sylla P, Dubinsky MC, Greenstein A. Predictors of pouch failure: A tertiary care inflammatory bowel disease centre experience. Colorectal Dis 2023; 25:1469-1478. [PMID: 37128185 DOI: 10.1111/codi.16589] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 10/28/2022] [Accepted: 04/01/2023] [Indexed: 05/03/2023]
Abstract
AIM Rates of pouch failure after total proctocolectomy with ileal pouch-anal anastomosis (IPAA) range from 5% to 18%. There is little consistency across studies regarding the factors associated with failure, and most include patients who underwent IPAA in the pre-biologic era. Our aim was to analyse a cohort of patients who underwent IPAA in the biologic era at a large-volume inflammatory bowel disease institution to better determine preoperative, perioperative and postoperative factors associated with pouch failure. METHODS A retrospective cohort analysis was performed with data from an institutional review board approved prospective database with ulcerative colitis or unclassified inflammatory bowel disease patients who underwent total proctocolectomy with IPAA at Mount Sinai Hospital between 2008 and 2017. Preoperative, perioperative and postoperative data were collected and univariate and multivariate analyses were performed to identify factors associated with increased risk of pouch failure. RESULTS Out of 664 patients included in the study, pouch failure occurred in 41 (6.2%) patients, a median of 23.3 months after final surgical stage. Of these, 17 (41.4%) underwent pouch excision and 24 (58.5%) had diverting ileostomies. The most common indications for pouch failure were Crohn's disease like pouch inflammation (CDLPI) (n = 17, 41.5%), chronic pouchitis (n = 6, 14.6%), chronic cuffitis (n = 5, 12.2%) and anastomotic stricture (n = 4, 9.8%). On multivariate analysis, pre-colectomy biologic use (hazard ratio [HR] 2.25, 95% CI 1.09-4.67), CDLPI (HR 3.18, 95% CI 1.49-6.76) and pouch revision (HR 2.59, 95% CI 1.26-5.32) were significantly associated with pouch failure. CONCLUSIONS Pouch failure was significantly associated with CDLPI, preoperative biologic use and pouch revision; however, reassuringly it was not associated with postoperative complications.
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Affiliation(s)
- Alison P Ricardo
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Maia Kayal
- Department of Medicine, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Michael C Plietz
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sergey Khaitov
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Patricia Sylla
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Marla C Dubinsky
- Department of Medicine, Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexander Greenstein
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Freund MR, Horesh N, Meyer R, Garoufalia Z, Gefen R, Emile SH, Wexner SD. Can preoperative CT/MR enterography preclude the development of Crohn's disease-like pouch complications in ulcerative colitis patients undergoing J pouch surgery? Colorectal Dis 2023; 25:1460-1468. [PMID: 37128154 DOI: 10.1111/codi.16587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 01/07/2023] [Accepted: 03/13/2023] [Indexed: 05/03/2023]
Abstract
AIM We aimed to determine whether ulcerative colitis patients with preoperative negative computed tomography or magnetic resonance enterography (CTE/MRE) were less likely to develop Crohn's disease-like pouch complications (CDLPC) and establish risk factors and predictors for developing CDLPC. METHODS This was a single centre retrospective analysis of patients with ulcerative colitis (UC) and inflammatory bowel disease unclassified (IBDU) who underwent total proctocolectomy with ileal J-pouch between January 2010 and December 2020. The study group comprised patients with negative preoperative CTE/MRE and the control group included patients operated without preoperative CTE/MRE. RESULTS A total of 131 patients were divided into the negative CTE/MRE study group (76 [58%] patients) and control group (55 [42%] patients). There were no significant differences in incidence rates (21% vs. 23.6%, p = 0.83), time to developing CDLPC from ileostomy closure (22.3 vs. 23.8 months; p = 0.81), pouchitis rates (23.6% vs. 27.2%; p = 0.68), or pouch failure rates (5.2 vs. 7.2; p = 0.71). Multivariate Cox regression analysis showed backwash ileitis (HR 4.1; p = 0.03, CI: 1.1-15.1), severe pouchitis (HR 3.4; p = 0.039, CI: 1.0-10.9), and history of perianal disease (HR 3.4; p = 0.017, CI: 1.4-39.6) were independent predictors for CDLPC. CONCLUSIONS Negative findings on MRE/CTE prior to J-pouch surgery in ulcerative colitis should be interpreted with caution as it is does not reliably exclude or predict development of CDLPC. These patients should be preoperatively counselled concerning the possibility of developing CDLPC regardless of lack of positive findings on preoperative CTE/MRE. Patients with backwash ileitis with a previous history of perianal disease should be informed of the potentially increased risk of developing such complications.
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Affiliation(s)
- Michael R Freund
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
- Department of General Surgery, Shaare Zedek Medical Centre, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
- Department of Surgery and Transplantations, Sheba Medical Centre, Ramat Gan, Affiliated with the Faculty of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Ryan Meyer
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | - Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
- Department of General Surgery, Faculty of Medicine, Hadassah Medical Organization, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
- Colorectal Surgery Unit, Mansoura University Hospitals, Mansoura, Egypt
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
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Panganiban RP, Tuan A, Hart M, Pelton M, Mikhail D, Akhtar S, Bogale K, Deiling S, Zhou S, Coates MD, Yochum GS, Koltun W. Pyoderma Gangrenosum Is Associated With Increased Risk of Inflammatory Pouch-Related Complications: A Retrospective Cohort Study. CROHN'S & COLITIS 360 2023; 5:otad024. [PMID: 37663924 PMCID: PMC10474334 DOI: 10.1093/crocol/otad024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Indexed: 09/05/2023] Open
Abstract
Background Pyoderma gangrenosum (PG) is a rare, neutrophilic dermatosis that is a well-established extraintestinal manifestation (EIM) of inflammatory bowel disease. The clinical implications of developing PG in patients with ulcerative colitis (UC) who undergo total proctocolectomy colectomy and ileal pouch anal anastomosis (TPC-IPAA) surgery remain unknown. Methods Study participants were selected from patients enrolled in the Carlino Family Inflammatory Bowel and Colorectal Disease Biobank between 1998 and 2021 with a pre-colectomy diagnosis of UC and who underwent TPC-IPAA surgery. A retrospective study comparing patients with PG and those without PG was performed. The outcomes measured included the development of pouchitis, pouchitis classification, presence of pouch fistula, anal fistula, anal stenosis, and pouch failure. Results In this study, 357 IPAA patients were included, 10 of whom suffered PG. Patients with PG and without PG had similar demographics and clinical characteristics. Both groups had similar rates of pouchitis (80% in PG patients and 64% in patients without PG, P = .504). However, IPAA patients with PG had a higher risk of developing pouch fistula (50% vs 10%, P = .002), anal fistula (40% vs 12%, P = .031), and Crohn's-like disease of the pouch (70% vs 15%, P = .003) compared to patients without PG. Patients who developed PG prior to their first episode of pouchitis were more likely to eventually experience pouch failure (odds ratio: 20.7, 95% confidence interval: 3.9, 110.7, q = 0.003 after false discovery rate adjustment). Conclusions Among UC patients who undergo TPC-IPAA surgery, the development of PG portends poor pouch outcomes and is predictive of pouch failure.
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Affiliation(s)
- Ronaldo Paolo Panganiban
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
- Division of Colorectal Surgery, Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Alyssa Tuan
- College of Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Maxwell Hart
- Department of Medicine, The University of Arizona College of Medicine Tucson, Tucson, AZ, USA
| | - Mathew Pelton
- Department of Medicine, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Daniella Mikhail
- Department of Medicine, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Sarah Akhtar
- Department of Internal Medicine, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Kaleb Bogale
- Columbia University Irving Medical Center, New York, NY, USA
| | - Susan Deiling
- Division of Colorectal Surgery, Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Shouhao Zhou
- Division of Biostatistics and Bioinformatics, Department of Public Health Science, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Mathew D Coates
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Gregory S Yochum
- Division of Colorectal Surgery, Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, USA
- Department of Biochemistry and Molecular Biology, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Walter Koltun
- Division of Colorectal Surgery, Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, USA
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