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Shen B, Bruining DH, YunMa H. Radiographic Evaluation of Ileal Pouch Disorders: A Systematic Review. Dis Colon Rectum 2024; 67:S70-S81. [PMID: 38441126 DOI: 10.1097/dcr.0000000000003181] [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: 05/08/2024]
Abstract
BACKGROUND Radiographic imaging of the abdomen and pelvis plays an important role in the diagnosis and management of ileal pouch disorders with modalities including CT, MRI, contrasted pouchography, and defecography. OBJECTIVES To perform a systematic review of the literature and describe applications of cross-sectional imaging, pouchography, defecography, and ultrasonography. DATA SOURCES PubMed, Google Scholar, and Cochrane database. STUDY SELECTION Relevant articles on endoscopy in ileal pouches published between January 2003 and June 2023 in English were included on the basis of Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. INTERVENTION Main abdominal and pelvic imaging modalities and their applications in the diagnosis of ileal pouch disorders were included. MAIN OUTCOME MEASURES Accuracy in characterization of ileal pouch disorders. RESULTS CT is the test of choice for the evaluation of acute anastomotic leaks, perforation, and abscess(es). MRI of the pelvis is suitable for the assessment of chronic anastomotic leaks and their associated fistulas and sinus tracts, as well as for the penetrating phenotype of Crohn's disease of the pouch. CT enterography and magnetic resonance enterography are useful in assessing intraluminal, intramural, and extraluminal disease processes of the pouch and prepouch ileum. Water-soluble contrast pouchography is particularly useful for evaluating acute or chronic anastomotic leaks and outlines the shape and configuration of the pouch. Defecography is the key modality to evaluate structural and functional pouch inlet and outlet obstructions. Ultrasonography can be performed to assess the pouch in experienced IBD centers. LIMITATIONS This is a qualitative, not quantitative, review of mainly case series and case reports. CONCLUSIONS Abdominopelvic imaging, along with clinical and endoscopic evaluation, is imperative for accurately assessing structural, inflammatory, functional, and neoplastic disorders. See video from symposium .
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Affiliation(s)
- Bo Shen
- The Global Center for Integrated Colorectal Surgery and IBD Interventional Endoscopy, Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Hong YunMa
- Department of Radiology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, New York
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Shen B. Endoscopic Evaluation of the Ileal Pouch. Dis Colon Rectum 2024; 67:S52-S69. [PMID: 38276962 DOI: 10.1097/dcr.0000000000003269] [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 Structural and inflammatory adverse sequelae are common after restorative proctocolectomy and IPAA. On rare occasions, neoplasia can occur in patients with ileal pouches. Pouchoscopy plays a key role in the diagnosis, differential diagnosis, disease monitoring, assessment of treatment response, surveillance, and delivery of therapy. OBJECTIVE A systematic review of the literature was performed, and principles and techniques of pouchoscopy were described. DATA SOURCES PubMed, Google Scholar, and Cochrane databases. STUDY SELECTION Relevant articles on endoscopy in ileal pouches published between January 2000 and May 2023 were included based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. INTERVENTION Diagnostic, surveillance, and therapeutic endoscopy in ileal pouch disorders were included. MAIN OUTCOME MEASURES Accurate characterization of the ileal pouch in healthy or diseased states. RESULTS The main anatomic structures of a J- or S-pouch are the stoma closure site, prepouch ileum, inlet, tip of the "J," pouch body, anastomosis, cuff, and anal transition zone. Each anatomic location can be prone to the development of structural, inflammatory, or neoplastic disorders. For example, ulcers and strictures are common at the stoma closure site, inlet, and anastomosis. Leaks are commonly detected at the tip of the "J" and anastomosis. Characterization of the anastomotic distribution of inflammation is critical for the differential diagnosis of subtypes of pouchitis and other inflammatory disorders of the pouch. Neoplastic lesions, albeit rare, mainly occur at the cuff, anal transition zone, or anastomosis. LIMITATIONS This is a qualitative, not quantitative, review of mainly case series. CONCLUSIONS Most structural, inflammatory, and neoplastic disorders can be reliably diagnosed with a careful pouchoscopy. The endoscopist and other clinicians taking care of pouch patients should be familiar with the anatomy of the ileal pouch and be able to recognize common abnormalities. See video from symposium.
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Affiliation(s)
- Bo Shen
- The Global Integrated Center for Colorectal Surgery and Interventional Endoscopy and Center for Inflammatory Bowel Diseases, Columbia University Irving Medical Center/NewYork Presbyterian Hospital, New York, New York
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Otero-Piñeiro AM, Maspero M, Holubar SD, Lightner AL, Steele SR, Hull T. Salvage Surgery: An Effective Therapy in the Management of Ileoanal Pouch Prolapse. Dis Colon Rectum 2024; 67:114-119. [PMID: 37000786 DOI: 10.1097/dcr.0000000000002669] [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: 04/01/2023]
Abstract
BACKGROUND Restorative proctocolectomy with IPAA is the surgical treatment of choice for patients requiring surgery for IBD and, less frequently, for other pathologies. Pouch prolapse is a rare complication that compromises pouch function and negatively affects patients' quality of life. OBJECTIVE This study aimed to describe our experience from a single high-volume center in this infrequent condition. DESIGN Restrospective cohort study of a prospectively maintained, Institutional Review Board-approved database. SETTINGS All consecutive eligible patients with IPAA and pouch prolapse were identified from 1990 to 2021. PATIENTS Patients with full-thickness prolapse treated by pouch pexy were included. INTERVENTIONS Pouch pexy (with/without mesh). MAIN OUTCOME MEASURES Success rate of pouch pexy, defined as no recurrence of prolapse. RESULTS A total of 4791 patients underwent IPAA; 7 (0.1%) were diagnosed with full-thickness prolapse. An additional 18 patients who underwent IPAA and had full-thickness prolapse were referred from outside institutions. Among 25 included patients, 16 (64.0%) were women, and the overall mean age was 35.6 ± 13.4 years. The time interval from initial pouch formation to prolapse was 4.2 (interquartile range, 1.1-8.5) years. Nine patients (36.0%) underwent previous treatment for prolapse. All patients presented with symptoms and physical examination compatible with full-thickness prolapse. Twenty patients (80.0%) underwent surgical pouch pexy without mesh and 5 (20.0%) had pouch pexy with mesh placement. A diverting ileostomy was performed in 1 patient (4.0%) before pouch pexy and in 8 patients (32.0%) at the time of surgical prolapse correction. After surgery, recurrent prolapse was noted in 3 patients (12.0%) at a median of 6.9 (interquartile range, 5.2-8.3) months. LIMITATIONS Retrospective study, small sample size thus prone to selection, and referral biases, which may limit the generalizability of our findings. CONCLUSION Pouch prolapse can be effectively treated with salvage surgery. Surgical intervention is safe and provides acceptable outcomes. See Video Abstract. CIRUGA DE RESCATE UNA TERAPIA EFICAZ EN EL MANEJO DEL PROLAPSO DE LA BOLSA ILEOANAL ANTECEDENTES:La proctocolectomía restauradora con anastomosis reservorio ileoanal es el tratamiento quirúrgico de elección para aquellos pacientes que requieren cirugía por enfermedad inflamatoria intestinal y, con menor frecuencia, por otras patologías. El prolapso de la bolsa es una complicación rara que compromete la función de la bolsa y afecta de manera negativa la calidad de vida de los pacientes.OBJETIVO:Describir nuestra experiencia de un solo centro de alto volumen en esta condición poco frecuente.DISEÑO:Estudio de cohorte retrospectivo de una base de datos mantenida prospectivamente aprobada por el IRB.AJUSTES/PACIENTES:Fueron identificados y elegibles de manera consecutiva todos los pacientes con anastomosis de bolsa ileoanal y prolapso de bolsa entre 1990 y 2021. Se incluyeron pacientes con prolapso de bolsa de espesor total tratados con pexia.INTERVENCIONES:Pexia de la bolsa (con/sin malla).PRINCIPALES MEDIDAS DE RESULTADO:Tasa de éxito de la pexia de la bolsa, definida como ausencia de recurrencia del prolapso.RESULTADOS:Un total de 4.791 pacientes fueron sometidos a anastomosis de bolsa ileoanal; siete (0,1%) fueron diagnosticados con prolapso de espesor total. Otros 18 pacientes con anastomosis de reservorio ileoanal fueron derivados de instituciones externas. De entre los 25 pacientes incluidos, 16 (64,0 %) eran mujeres y la edad media promedio fue de 35,6+/-13,4 años. El intervalo de tiempo desde la creación inicial de la bolsa hasta el prolapso fue de 4,2 (IQR 1,1-8,5) años. Nueve (36,0 %) pacientes fueron sometidos a tratamiento previo para el prolapso (fisioterapia n = 4, pexia de la bolsa n = 2, pexia de la bolsa con malla n = 2, resección de la mucosa n = 1). Todos los pacientes presentaron síntomas y exploración física compatibles con prolapso de espesor total. Veinte (80,0%) pacientes se sometieron a pexia de bolsa quirúrgica sin malla y cinco (20,0%) se sometieron a pexia de bolsa con colocación de malla. Se realizó una ileostomía de derivación en un (4,0%) paciente antes de la pexia de la bolsa y en ocho (32,0%) pacientes en el momento de la corrección quirúrgica del prolapso. Posterior a la cirugía, se observó prolapso recurrente en tres pacientes (12,0 %) con una mediana de 6,9 (IQR 5,2-8,3) meses.LIMITACIONES:Estudio retrospectivo, pequeño tamaño de muestra, por lo tanto, propenso a sesgos de selección y referencia que pueden limitar la generalización de nuestros hallazgos.CONCLUSIÓN:El prolapso de la bolsa ileoanal puede tratarse de manera efectiva mediante la cirugía de rescate. La intervención quirúrgica es segura y proporciona resultados aceptables. (Traducción-Dr. Mauricio Santamaria ).
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Affiliation(s)
- Ana M Otero-Piñeiro
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
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Shen B, Kochhar GS, Kariv R, Liu X, Navaneethan U, Rubin DT, Cross RK, Sugita A, D'Hoore A, Schairer J, Farraye FA, Kiran RP, Fleshner P, Rosh J, Shah SA, Chang S, Scherl E, Pardi DS, Schwartz DA, Kotze PG, Bruining DH, Kane SV, Philpott J, Abraham B, Segal J, Sedano R, Kayal M, Bentley-Hibbert S, Tarabar D, El-Hachem S, Sehgal P, McCormick JT, Picoraro JA, Silverberg MS, Bernstein CN, Sandborn WJ, Vermeire S. Diagnosis and classification of ileal pouch disorders: consensus guidelines from the International Ileal Pouch Consortium. Lancet Gastroenterol Hepatol 2021; 6:826-849. [PMID: 34416186 DOI: 10.1016/s2468-1253(21)00101-1] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/12/2021] [Accepted: 03/15/2021] [Indexed: 12/12/2022]
Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis is an option for most patients with ulcerative colitis or familial adenomatous polyposis who require colectomy. Although the construction of an ileal pouch substantially improves patients' health-related quality of life, the surgery is, directly or indirectly, associated with various structural, inflammatory, and functional adverse sequelae. Furthermore, the surgical procedure does not completely abolish the risk for neoplasia. Patients with ileal pouches often present with extraintestinal, systemic inflammatory conditions. The International Ileal Pouch Consortium was established to create this consensus document on the diagnosis and classification of ileal pouch disorders using available evidence and the panellists' expertise. In a given individual, the condition of the pouch can change over time. Therefore, close monitoring of the activity and progression of the disease is essential to make accurate modifications in the diagnosis and classification in a timely manner.
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Affiliation(s)
- Bo Shen
- Center for Interventional Inflammatory Bowel Disease, Columbia University Irving Medical Center-New-York Presbyterian Hospital, NY, USA.
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - Revital Kariv
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Xiuli Liu
- Department of Pathology and Immunology, Washington University, MO, USA
| | - Udayakumar Navaneethan
- IBD Center and IBD Interventional Unit, Center for Interventional Endoscopy, Orlando Health, Orlando, FL, USA
| | - David T Rubin
- Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, IL, USA
| | - Raymond K Cross
- Inflammatory Bowel Disease Program, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Akira Sugita
- Department of Clinical Research and Department of Inflammatory Bowel Disease, Yokohama Municipal Citizens Hospital Yokohama, Japan
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospital Leuven, Belgium
| | - Jason Schairer
- Department of Gastroenterology, Henry Ford Health System, Detroit, MI, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Ravi P Kiran
- Division of Colorectal Surgery, Columbia University Irving Medical Center-New-York Presbyterian Hospital, NY, USA
| | - Philip Fleshner
- Division of Colorectal Surgery, University of California-Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Joel Rosh
- Department of Pediatric Gastroenterology, Goryeb Children's Hospital-Atlantic Health, Morristown, NJ, USA
| | - Samir A Shah
- Alpert Medical School of Brown University and Miriam Hospital, Gastroenterology Associates, Providence, RI, USA
| | - Shannon Chang
- Division of Gastroenterology, New York University Langone Health, New York, NY, USA
| | - Ellen Scherl
- New York Presbyterian Hospital, Jill Roberts Center for IBD, Weill Cornell Medicine, Gastroenterology and Hepatology, New York, NY, USA
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - David A Schwartz
- Department of Gastroenterology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Paulo G Kotze
- IBD Outpatients Clinic, Catholic University of Paraná, Curitiba, Brazil
| | - David H Bruining
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jessica Philpott
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Bincy Abraham
- Houston Methodist and Weill Cornell Medical College, Houston, TX, USA
| | - Jonathan Segal
- Department of Gastroenterology and Hepatology, Hillingdon Hospital, Uxbridge, UK
| | - Rocio Sedano
- Department of Medicine, Division of Gastroenterology, Western University, London, ON, Canada
| | - Maia Kayal
- Department of Gastroenterology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Stuart Bentley-Hibbert
- Department of Radiology, Columbia University Irving Medical Center-New-York Presbyterian Hospital, NY, USA
| | - Dino Tarabar
- IBD Clinical Center, University Hospital Center Dr Dragiša Mišović, Belgrade, Serbia
| | - Sandra El-Hachem
- Division of Gastroenterology, Hepatology, and Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
| | - Priya Sehgal
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center-New-York Presbyterian Hospital, NY, USA
| | - James T McCormick
- Division of Colon and Rectal Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Joseph A Picoraro
- Department of Pediatrics, Columbia University Irving Medical Center-Morgan Stanley Children's Hospital, New York, NY, USA
| | - Mark S Silverberg
- Mount Sinai Hospital Inflammatory Bowel Disease Centre, Toronto, ON, Canada
| | - Charles N Bernstein
- Inflammatory Bowel Disease Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada
| | - William J Sandborn
- Department of Gastroenterology, University of California San Diego, San Diego, CA, USA
| | - Séverine Vermeire
- Department of Gastroenterology, University hospitals Leuven, Leuven, Belgium
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da Silva Rodrigues MR, de Souza MA. Acute abdomen due to J-pouch outlet obstruction: A case report and review of literature. Int J Surg Case Rep 2021; 84:106075. [PMID: 34147935 PMCID: PMC8225982 DOI: 10.1016/j.ijscr.2021.106075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/28/2021] [Accepted: 06/02/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Ileal pouch–anal anastomosis is the procedure of choice for re-establishing intestinal continuity for patients undergoing total proctocolectomy. Despite growing experience with this procedure, it is still associated with considerable morbidity rates. Presentation of case Herein, we report the case of a 14-year-old boy with familial adenomatous polyposis who underwent total proctocolectomy, ileal pouch–anal anastomosis, and diverting ileostomy. The patient developed early postoperative complications; on postoperative day 1, he developed bleeding from the pouch staple line, which was managed endoscopically. On postoperative day 15, he developed intestinal obstruction due to adhesions. One year after proctocolectomy, ileostomy closure was performed uneventfully. From postoperative day 3, the patient presented with obstructive signs such as abdominal distention, bloating, abdominal pain, and fever. Computed tomography identified diffuse intense intestinal distension with pouch dilatation. Digital rectal examination identified the pouch filled with liquid stool and no signs of anal canal anastomosis stenosis. The patient was considered to have pouch outlet obstruction and was successfully managed using bedside evacuation anoscopy. After 3 days, oral nutrition was re-established, and appropriate stool evacuation and fecal continence were achieved. Discussion Proctocolectomy with ileal pouch–anal anastomosis still carries a considerable complication rate. Proper identification of causative factors is mandatory for appropriate treatment. Pouch outlet obstruction can present as acute abdomen after diverting ileostomy closure. In this case, outlet obstruction was identified and treated by pouch evacuation, avoiding morbidity of a new surgical procedure. Conclusion We presented an unusual case of acute intestinal obstruction due to pouch outlet obstruction that was managed nonoperatively with bedside pouch evacuation. Proctocolectomy with ileal pouch-anal anastomosis is the main treatment for APC The procedure is technically demanding and carries considerable complications rate Intestinal obstruction is frequent early complication, mostly due to intestinal adhesions Pouch outlet obstruction can promote acute abdomen and can be managed conservatively
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Gao XH, Yu GY, Khan F, Li JQ, Stocchi L, Hull TL, Shen B. Greater Peripouch Fat Area on CT Image Is Associated with Chronic Pouchitis and Pouch Failure in Inflammatory Bowel Diseases Patients. Dig Dis Sci 2020; 65:3660-3671. [PMID: 32500285 DOI: 10.1007/s10620-020-06363-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 05/21/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND The causes of chronic antibiotic refractory pouchitis (CARP) and pouch failure in inflammatory bowel disease (IBD) patients remain unknown. Our previous small study showed peripouch fat area measured by MRI was associated with pouchitis. AIMS To explore the relationship between peripouch fat area on CT imaging and pouch outcomes. METHODS This is a historical cohort study. Demographic, clinical, and radiographic data of IBD patients with abdominal CT scans after pouch surgery between 2002 and 2017 were collected. Peripouch fat areas and mesenteric peripouch fat areas were measured on CT images at the middle pouch level. RESULTS A total of 435 IBD patients were included. Patients with higher peripouch fat areas had a higher prevalence of CARP. Univariate analyses demonstrated that long duration of the pouch, high weight or body mass index, the presence of primary sclerosing cholangitis or other autoimmune disorders, and greater peripouch fat area or mesenteric peripouch fat area were risk factors for CARP. Multivariable analyses demonstrated that the presence of primary sclerosing cholangitis or autoimmuned disorders, and greater peripouch fat area (odds ratio [OR] 1.031; 95% confidence interval [CI] 1.016-1.047, P < 0.001) or mesenteric peripouch fat area were independent risk factors for CARP. Of the 435 patients, 139 (32.0%) had two or more CT scans. Multivariable Cox proportional hazard analyses showed that "peripouch fat area increase ≥ 15%" (OR 3.808, 95%CI 1.703-8.517, P = 0.001) was an independent predictor of pouch failure. CONCLUSIONS A great peripouch fat area measured on CT image is associated with a higher prevalence of CARP, and the accumulation of peripouch fat is a risk factor for pouch failure. The assessment of peripouch fat may be used to monitor the disease course of the ileal pouch.
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Affiliation(s)
- Xian-Hua Gao
- Department of Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Guan-Yu Yu
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Freeha Khan
- Department of Gastroenterology/Hepatology, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jin-Qiao Li
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Luca Stocchi
- Department of Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Tracy L Hull
- Department of Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Bo Shen
- Department of Gastroenterology/Hepatology, The Cleveland Clinic Foundation, Cleveland, OH, USA.
- The Inflammatory Bowel Disease Center at Columbia, Columbia University Irving Medical Center, 161 Fort Washington Ave Suite 843, New York, NY, 10032, USA.
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