Ulcerative colitis: female fecundity before diagnosis, during disease, and after surgery compared with a population sample

Does Surgery Before Pregnancy in Women With Inflammatory Bowel Disease Increase the Risk of Adverse Maternal and Fetal Outcomes? A Danish National Cohort Study

INTRODUCTION

Up to 15% of women with Crohn's disease (CD) or ulcerative colitis (UC) undergo bowel surgery before pregnancy, and there is little data on pregnancy outcomes in this population. We aimed to assess maternal/fetal outcomes in women with CD or UC who underwent surgeries before pregnancy.

METHODS

In this nationwide study, we included all pregnancies in women with CD or UC from 1997 to 2022 and examined 6 categories of CD and UC surgeries before pregnancy. We used multilevel logistic regression to compute crude and adjusted odds ratios (aOR) with 95% confidence intervals (95% CI) for the risk of pregnancy and offspring complications in women who did, vs did not, undergo surgery before pregnancy.

RESULTS

There were 833 UC and 3,150 CD pregnancies with prior surgery and 12,883 UC and CD 6,972 pregnancies without surgery. For UC, prior surgery was associated with Cesarian section (C-section) (ileoanal pouch: aOR: 20.03 [95% CI 10.33-38.83]; functional ileostomy: aOR:8.55 [6.10-11.98]; diverting ileostomy: aOR: 38.96 [17.05-89.01]) and preterm birth (aOR: 2.25 [1.48-3.75]; 3.25 [2.31-4.59]; and 2.17 [1.17-4.00]) respectively. For CD and prior intestinal surgery, the risks of C-section (aOR: 1.94 [1.66-2.27]), preterm birth (aOR: 1.30 [1.04-1.61]), and low 5-minute Apgar (aOR: 1.95 [95% CI 1.07-3.54]) increased and premature rupture of membranes (aOR: 0.68 [0.52-0.89]) decreased. For CD with only prior perianal surgery, the risk of C-section (aOR: 3.02 [2.31-3.95]) increased and risk of gestational hypertension/preeclampsia/eclampsia (aOR: 0.52 [0.30-0.89]) decreased.

DISCUSSION

Providers should be aware there is an increased likelihood of C-section and certain perinatal complications in patients with CD or UC surgery before pregnancy.

Comprehensive reproductive healthcare for women with immune-mediated inflammatory diseases: Addressing rheumatoid arthritis, spondyloarthritis and inflammatory bowel disease through life's stages

Immuno-mediated inflammatory diseases (IMIDs) such as rheumatoid arthritis, spondyloarthritis, and inflammatory bowel disease are characterised by pathophysiological mechanisms wherein the immune system erroneously targets the body's own tissues. This review explores the heightened vulnerability of women with IMIDs, influenced by hormonal modulators like estrogen and progesterone. The challenges this poses are multifaceted, encompassing the impact of active disease and medical treatments throughout life stages, including family planning, fertility, and menopause. From the perspectives of rheumatologists and gastroenterologists, we review current management strategies and underscore the need for a multidisciplinary and life-cycle approach to healthcare for women with IMIDs.

DECIDE: Delphi Expert Consensus Statement on Inflammatory Bowel Disease Dysplasia Shared Management Decision-Making

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.

IBD and Motherhood: A Journey through Conception, Pregnancy and Beyond

Inflammatory Bowel Disease (IBD) presents distinct challenges during pregnancy due to its influence on maternal health and pregnancy outcomes. This literature review aims to dissect the existing scientific evidence on pregnancy in women with IBD and provide evidence-based recommendations for clinical management. A comprehensive search was conducted across scientific databases, selecting clinical studies, systematic reviews, and other pertinent resources. Numerous studies have underscored an increased risk of complications during pregnancy for women with IBD, including preterm birth, low birth weight, neonates small for gestational age, and congenital malformations. Nevertheless, it's evident that proactive disease management before and throughout pregnancy can mitigate these risks. Continuation of IBD treatment during pregnancy and breastfeeding is deemed safe with agents like thiopurines, anti-TNF, vedolizumab, or ustekinumab. However, there's a call for caution when combining treatments due to the heightened risk of severe infections in the first year of life. For small molecules, their use is advised against in both scenarios. Effective disease management, minimizing disease activity, and interdisciplinary care are pivotal in attending to women with IBD. The emphasis is placed on the continual assessment of maternal and infant outcomes and an expressed need for further research to enhance the understanding of the ties between IBD and adverse pregnancy outcomes.

Does an Ileoanal Anastomosis Decrease the Rate of Successful Pregnancy Compared With an Ileorectal Anastomosis? A National Study of 1491 Patients

OBJECTIVE

Report the rate of successful pregnancy in a national cohort of women with either an ileal pouch anal (IPAA) or ileorectal (IRA) anastomosis constructed after colectomy for inflammatory bowel disease (IBD) or polyposis.

BACKGROUND

Fertility after IPAA is probably impaired. All available data are corroborated by only small sample size studies. It is not known whether construction of IPAA versus IRA influences the odds of subsequently achieving a successful pregnancy, especially with increased utilization of the laparoscopic approach.

METHODS

All women (age: 12-45 y) undergoing IRA or IPAA in France for polyposis or IBD, between 2010-2020, were included. A control population was defined as women aged from 12 to 45 years undergoing laparoscopic appendicectomy during the same period. The odds of successful pregnancy were studied using an adjusted survival analysis.

RESULTS

A total of 1491 women (IPAA=872, 58%; IRA=619, 42%) were included. A total of 220 deliveries (15%) occurred during the follow-up period of 71 months (39-100). After adjustment, the odds of successful pregnancy was not significantly associated with type of anastomosis (after IPAA: Hazard Ratio [HR]=0.79, 95% confidence interval=0.56-1.11, P =0.17). The laparoscopic approach increased the odds of achieving successful pregnancy (HR=1.79, 95% confidence interval=1.20-2.63, P =0.004). IRA and IPAA significantly impacted fertility when compared with the control population ( P <0.001).

CONCLUSIONS

In this large cohort study, total colectomy for polyposis or IBD was associated with reduced fertility compared with the general population. No difference in odds of achieving successful pregnancy was found between IRA and IPAA after adjustment. This analysis suggests laparoscopic surgery may be associated with greater likelihood of pregnancy.

Colectomy reconstruction for ulcerative colitis in Sweden and England: a multicenter prospective comparison between ileorectal anastomosis and ileal pouch-anal anastomosis after colectomy in patients with ulcerative colitis. (CRUISE-study)

BACKGROUND

There are no prospective trials comparing the two main reconstructive options after colectomy for Ulcerative colitis, ileal pouch anal anastomosis and ileorectal anastomosis. An attempt on a randomized controlled trial has been made but after receiving standardized information patients insisted on choosing operation themselves.

METHODS

Adult Ulcerative colitis patients subjected to colectomy eligible for both ileal pouch anastomosis and ileorectal anastomosis are asked to participate and after receiving standardized information the get to choose reconstructive method. Patients declining reconstruction or not considered eligible for both methods will be followed as controls. The CRUISE study is a prospective, non-randomized, multi-center, open-label, controlled trial on satisfaction, QoL, function, and complications between ileal pouch anal anastomosis and ileorectal anastomosis.

DISCUSSION

Reconstruction after colectomy is a morbidity-associated as well as a resource-intensive activity with the sole purpose of enhancing function, QoL and patient satisfaction. The aim of this study is to provide the best possible information on the risks and benefits of each reconstructive treatment.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05628701.

Inflammatory bowel disease in pregnancy and breastfeeding

Inflammatory bowel disease (IBD) has a peak age of diagnosis before the age of 35 years. Concerns about infertility, adverse pregnancy outcomes, and heritability of IBD have influenced decision-making for patients of childbearing age and their care providers. The interplay between the complex physiology in pregnancy and IBD can affect placental development, microbiome composition and responses to therapy. Current evidence has shown that effective disease management, including pre-conception counselling, multidisciplinary care and therapeutic agents to minimize disease activity, can improve pregnancy outcomes. This Review outlines the management of IBD in pregnancy and the safety of IBD therapies, including novel agents, with regard to both maternal and fetal health. The vast majority of IBD therapies can be used with low risk during pregnancy and lactation without substantial effects on neonatal outcomes.

Inflammatory bowel disease can reduce ovarian reserve function in women: A systematic review and meta-analysis

PURPOSE

We conducted a systematic review and meta-analysis to examine the role of inflammatory bowel disease (IBD) in ovarian reserve functions.

METHODS

The PECO strategy was employed. Women of reproductive age (Population) and with IBD (Exposure) were compared with healthy women of reproductive age (Comparison) to evaluate the ovarian reserve function (Outcome). Two reviewers searched three databases as well as relevant gray literature. After following the PRISMA 2020 guidelines, RevMan 5.0 software and Newcastle-Ottawa Scale (NOS) scoring were used to analyze and summarize the data included in the studies. The protocol was registered on PROSPERO (CRD42021267804).

RESULTS

The search yielded 367 studies, out of which 13 were selected for full-text evaluation, and finally, seven studies were included in our research. An analysis of ovarian reserve function in IBD women of reproductive age and healthy women revealed that the ovarian reserve function was lower in IBD women of reproductive age than in healthy women (P < .01, I2 = 81%); the ovarian reserve function was significantly lower in women with IBD in remission than in healthy women (P < .01, I2 = 0%), and ovarian reserve function was lower in IBD women of reproductive age taking thalidomide than in healthy women (P < .01, I2 = 18%).

CONCLUSION

IBD could reduce ovarian reserve function in women of reproductive age, and patients should plan for conception as soon as possible under permissible conditions.

Ulcerative colitis (K51), adults

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Fertility and assisted reproductive technologies outcomes of women with non-surgically managed inflammatory bowel diseases: a systematic review

BACKGROUND AND AIM

In view of their frequent onset during childbearing years, the impact of inflammatory bowel diseases (IBD) on reproductive health is of important concern to young women and to the IBD physician. This study aims to assess the fertility and assisted reproductive technologies outcomes in non-surgically treated IBD female.

METHODS

A systematic review was conducted using MEDLINE, SCOPUS and EMBASE (until March 2022) to identify studies assessing fertility and assisted reproductive technologies outcomes in women with non-operated IBD, compared to non-IBD patients. Two reviewers independently selected studies, assessed risk of bias and extracted study data.

RESULTS

A total of 14 studies encompassing 18 012 patients with ulcerative colitis (UC) and 14 353 patients with Crohn's disease (CD) were included for analysis. The fertility rate in UC patients and in the general population was comparable, but UC patients tended to have fewer children, mainly by choice. On the contrary, the fertility of CD patients appeared to be reduced. Although a deliberate component cannot be not excluded, the disease itself could affect fertility. Disease activity was associated with reduced fertility in both UC and CD patients. In CD, the colonic involvement of the disease and perianal damage could be associated with subfertility, but data are less consistent. According to the only study reporting the assisted reproductive technologies outcomes, pregnancy rates after in vitro fertilization in subfertile non-operated UC patients and non-IBD patients were similar.

CONCLUSION

There is low-quality evidence from observational studies that patients with CD and relapsing UC may have impaired fertility. After assisted reproductive technologies, pregnancy rates of subfertile nonoperated UC patients were similar to those of the general population, although this observation requires further scrutiny in larger studies that should include UC and CD patients.

The impact of the ileoanal pouch on female fertility in ulcerative colitis: A systematic review and meta-analysis

AIM

Ileal pouch-anal anastomosis is a restorative option for patients with ulcerative colitis (UC) requiring surgery. The primary outcome of this study was the relative risk of infertility in women with UC undergoing restorative proctocolectomy (RPC) compared to the same patients before undergoing RPC. Infertility was defined as the inability to conceive after 1 year of regular sexual intercourse without contraception.

METHODS

A systematic review and meta-analysis were performed to include all relevant articles from 1946 from MEDLINE, Embase and Cochrane Central Register of Controlled Trials. Studies included reported on the fertility rate of a cohort with UC and also reported the rate after RPC in those within the cohort who underwent surgery. This study was registered on PROSPERO (CRD42021259745).

RESULTS

Thirteen studies met the inclusion criteria and accounted for 793 patients pre-pouch and 802 post-pouch. The mean and median age of the patients at analysis was 36.8 and 32.7 years respectively; and the median duration of follow-up following ileal pouch-anal anastomosis was 110.4 (68-139) months. Our results highlight that following RPC the relative risk of infertility is 4.17 (95% CI 1.99, 8.74) compared with patients before RPC who had UC.

CONCLUSIONS

The findings of this meta-analysis provide an update on a previous meta-analysis published over a decade ago and results remain congruent. This suggests that despite advancements in surgical techniques the risk to fertility remains similar to a decade ago. However, further high quality studies are needed to try and decipher independent risk factors associated with a decrease in infertility.

Outcomes during delivery hospitalisations with inflammatory bowel disease

OBJECTIVE

To characterise inflammatory bowel disease (IBD) trends and associated risk during delivery hospitalisations.

DESIGN

Cross-sectional.

SETTING

US delivery hospitalisations.

POPULATION

Delivery hospitalisations in the 2000-2018 National Inpatient Sample.

METHODS

This study analysed a nationally representative hospital discharge database based on the presence of IBD. Temporal trends in IBD were analysed using joinpoint regression to estimate the average annual percent change (AAPC). IBD severity was characterised by the presence of diagnoses such as penetrating and stricturing disease and history of bowel resection. Risks for adverse outcomes were analysed based on presence of IBD. Poisson regression models were performed with unadjusted and adjusted risk ratios (aRR) as measures of effect.

MAIN OUTCOME MEASURE

Prevalence of IBD and associated adverse outcomes.

RESULTS

Of 73 109 790 delivery hospitalisations, 89 965 had a diagnosis of IBD. IBD rose from 0.06% in 2000 to 0.21% in 2018 (AAPC 7.3%, 95% CI 6.7-7.9%). Among deliveries with IBD, IBD severity diagnoses increased from 4.1% to 8.1% from 2000 to 2018. In adjusted analysis, IBD was associated with increased risk for preterm delivery (aRR 1.50, 95% CI 1.47-1.53), severe maternal morbidity (aRR 1.93, 95% CI 1.83-2.04), venous thrombo-embolism (aRR 2.76, 95% CI 2.39-3.18) and surgical injury during caesarean delivery hospitalisation (aRR 5.03, 95% CI 4.76-5.31). In the presence of a severe IBD diagnosis, risk was further increased for all adverse outcomes.

CONCLUSION

IBD is increasing in the obstetric population and is associated with adverse outcomes. Risk is increased in the presence of a severe IBD diagnosis.

TWEETABLE ABSTRACT

Deliveries among women with inflammatory bowel disease are increasing. Disease severity is associated with adverse outcomes.

Chemically Modified Hyaluronic Acid for Prevention of Post-Surgical Adhesions: New Aspects of Gel Barriers Physical Profiles

This study was conducted to provide information regarding the chemistry—including structure, synthesis, formulation, and mechanical properties—of two types of chemically modified anti-adhesion gels made of hyaluronic acid. Gel A (Hyalobarrier®) and gels B and C (HyaRegen® and MetaRegen®) that are used in postsurgical adhesion prevention. To date, little information is available on their physicochemical attributes. This information is necessary in order to understand the differences in their in vivo behavior. Methods: Comparative analyses were conducted under laboratory-controlled conditions, including measuring the shear viscosity, storage modulus G’, peel strength, and extrusion forces. Results: All polymers exhibited viscoelastic behavior. Polymer A showed a shear viscosity approximately three times larger than both polymers B and C (114 Pa.s−1 vs. 36–38 Pa.s−1) over the shear-rate range measured, indicating a possible better ability to resist flows and potentially remain in place at the site of application in vivo. The results of storage modulus (G’) measurements showed 100 Pa for polymer A and 16 Pa and 20 Pa for polymers B and C, respectively. This translated into a weaker elastic behavior for gels B and C, and a lower ability to resist sudden deformation. The peel test results showed a rupture strength of 72 mN (0.016 lbf) for polymer A, 39.6 mN (0.0089 lbf) for polymer B, and 38.3 mN (0.0086 lbf) for polymers C, indicating possible higher adhesive properties for polymer A. Tests measuring the extrudability of the hyaluronic acid gels in their commercial syringes showed an average extrusion force of 20 N (4.5 lbf) for polymer A, 28 N (6.33 lbf) for polymer B, and 17 N (3.79 lbf) for polymer C. Conclusions: Modified anti-adhesion gels made of hyaluronic acid differed in mechanical properties and concentration. Further clinical studies are needed to confirm whether these differences make one polymer easier to apply during surgery and more likely to stay in place longer after in vivo application, and to determine which is potentially superior in terms of preventing adhesions.

Functional outcomes, quality of life, sexual function, and fertility of adult patients undergoing ileo-anal pouch anastomosis in childhood

BACKGROUND

We conducted a questionnaire-based study of pouch function, quality of life, sexual function, and fertility among patients who had undergone ileal pouch anal anastomosis (IPAA) in childhood and who are now more than 18 years old.

METHODS

A consecutive series of patients were asked to complete the following questionnaires: Pouch function score (PFS), short form 36 (SF-36), International index of erectile function (IIEF) (males), and Female sexual function index (FSFI) (females). Fertility in females was also assessed. Data are quoted as a median (SD).

RESULTS

Of 144 patients who had IPAA, 101 were eligible, and 70 responded. Mean age at surgery was 14 years, and mean current age is 26 years. Most patients had either ulcerative colitis or familial adenomatous polyposis. The questionnaire was completed by 38/70 (54%). Median PFS score was 6 (5). SF-36 were lower than previous reports. Median FSFI was 30 (7.6), 84% of possible maximum. Median IIEF was 69, 92% of possible maximum. Successful conception was reported in 5/7 women who had tried. However, there were several miscarriages and two surgical emergencies during pregnancies.

CONCLUSIONS

IPAA can be performed in childhood with similar pouch function to reported adult series. Quality of life appears poorer, but sexual function is maintained. There may be an association with adverse events in pregnancy.

LEVEL OF EVIDENCE

IV.

Female reproductive health and inflammatory bowel disease: A practice-based review

Inflammatory bowel diseases, namely ulcerative colitis and Crohn's disease, occur worldwide and affect people of all ages, with a high impact on their quality of life. Sex differences in incidence and prevalence have been reported, and there are also gender-specific issues that physicians should recognize. For women, there are multiple, important concerns regarding issues of body image and sexuality, menstruation, contraception, fertility, pregnancy, breastfeeding and menopause. This practice-based review focuses on the main themes that run through the life of women with inflammatory bowel diseases from puberty to menopause. Gastroenterologists who specialize in inflammatory bowel diseases and other physicians who see female patients with inflammatory bowel diseases should provide support for these problems and offer adequate therapy to ensure that their patients achieve the same overall well-being and health as do women without inflammatory bowel diseases.

The Efficacy of Assisted Reproduction in Women with a Wide Spectrum of Chronic Diseases - A Review

Assisted reproductive technology (ART) treatments in women with underlying chronic diseases have become increasingly frequent. The objective of this review is to provide an overview of the literature examining the chance of having a live born child after ART in women with chronic diseases, compared to other women receiving ART. We focused on some of the most prevalent chronic diseases in women during their reproductive years, ie ulcerative colitis, Crohn’s disease, rheumatoid arthritis, multiple sclerosis, epilepsy, hyperthyroidism, hypothyroidism, and diabetes mellitus. Secondly, we studied the chance of successful implantation. The literature search was performed in the database Pubmed.gov. including all studies published before October 2020. Title and abstracts of 58 papers were reviewed, 37 papers were excluded and other 8 studies were excluded after full-text evaluation. Only 13 papers were eligible for review. Results indicate that women with ulcerative colitis, Crohn’s disease, rheumatoid arthritis, hyperthyroidism, and diabetes mellitus type 2 might have problems with low implantation rate or early embryo development during ART. On the contrary, the few studies on women with hypothyroidism, diabetes mellitus type 1, and epilepsy suggest an equivalent chance of a live birth compared to other women undergoing ART. A possible explanation behind these differences could reside in the disease-specific dysregulation of the innate or adaptive immune system. To our knowledge, this is the first review on ART in women with chronic diseases, and it has disclosed that the evidence in this area is indeed sparse. We encourage others to examine live birth after ART in women with chronic diseases.

Optimal Management of Acute Severe Ulcerative Colitis (ASUC): Challenges and Solutions

Acute severe colitis is a severe complication of ulcerative colitis, affecting approximately 20% of patients. For physicians, it remains a challenging condition to treat. Current treatment algorithms have diminished the mortality associated with acute severe ulcerative colitis (ASUC), but colectomy rates remain high (approximately 30%) despite advances in therapy. Colectomy in ASUC is particularly associated with important postoperative complications and morbidity. In this review, reasons for the inability to improve care and avoid evolution to colectomy for ASUC are explored and solutions that might lead to a better management of the disease are investigated.

Pregnancy and medications in inflammatory bowel disease

Inflammatory bowel disease (IBD) affects patients at a significant time in their lives, often coinciding with family planning or pregnancy. While advances in IBD therapies have afforded women greater opportunities for successful conception and pregnancy outcomes, there still remains considerable maternal fear surrounding continuation of treatment in pregnancy. With the exception of methotrexate, most IBD drugs are safe and well tolerated during pregnancy and are not associated with significant risk of adverse fetal or pregnancy outcomes. Furthermore, the current evidence overwhelmingly suggests that good control of disease activity and clinical remission at time of conception are the greatest prognostic factors for an uncomplicated pregnancy and maintenance of quiescent disease. Management of pregnant women with IBD should involve discussions with the mother and family about fears or concerns surrounding the impact of IBD on pregnancy. Mothers should be supported and counselled carefully on the safety and importance of adherence to therapy in maintaining remission. Optimal management of these women requires an inter-disciplinary team effort, involving the general practitioner, in close consultation with both gastroenterologists and obstetricians.

Women's Health and Ulcerative Colitis

Although ulcerative colitis affects males and females at similar rates, certain sex-specific differences influence the disease-related risks and experiences of females with ulcerative colitis. This article reviews topics that affect females with ulcerative colitis, including the impact of disease on the menstrual cycle, fertility, child bearing, sexual health, and recommendations for health care maintenance.

Inflammatory bowel disease and pregnancy: fertility, complications and treatment

Inflammatory bowel disease (IBD) is commonly diagnosed and treated in the young population. Therefore, it is common that women anticipating or undergoing pregnancy will have to cope with the additional burden of their IBD. Pregnancy in an IBD patient also presents challenges for the practitioner, in that the usual diagnostic and therapeutic armamentarium of potential tests and therapies is disrupted. This review covers the implications of IBD for fertility, pregnancy and offspring, and discusses the management of IBD in pregnancy.

Impaired Fertility in Women With Inflammatory Bowel Disease: A National Cohort Study From Sweden

BACKGROUND AND AIMS

Inflammatory bowel disease [IBD] has been associated with reduced female fertility. We analyse fertility in a national cohort of women with IBD.

METHODS

Fertility was assessed in women with IBD aged 15-44 years in 1964-2014, identified from the Swedish National Patient Register and a matched cohort [ratio 1:5]. Patients with indeterminate colitis or inconsistent IBD coding were classified as IBD-unclassified [IBD-U].

RESULTS

The cohorts included 27 331 women with IBD and 131 892 matched individuals. The fertility rate in IBD was 1.52 (standard deviation [SD] 1.22) births per 1000 person-years and 1.62 [SD 1.28] [p <0.001] in matched individuals. Fertility was impaired in all IBD subtypes compared with the matched cohort (hazard ratio Crohn's disease [CD] 0.88, 95% confidence interval [CI] 0.85-0.91; IBD-U 0.86, 95% CI 0.83-0.89; and ulcerative colitis [UC] 0.96, 95% CI 0.93-0.98). Fertility improved during the study period for the IBD cohort except for CD. Parity progression ratio, the proportion of IBD women progressing from one parity to the next compared with the matched cohort, was decreased at all parity levels for CD and IBD-U, but only for multiparous women in UC. Contraceptive usage was higher in IBD, both before and after the diagnosis. Disease severity, bowel resections, and perianal disease in CD affected fertility negatively.

CONCLUSIONS

Fertility was impaired mainly in women with CD and IBD-U, and less so in UC. During the study period, fertility improved in women with UC or IBD-U. Some results suggest a role of voluntarily reduced fertility.

Impact on Fertility After Failure of Restorative Proctocolectomy in Men and Women With Ulcerative Colitis: A 17-Year Cohort Study

BACKGROUND

Impact of restorative proctocolectomy failure on fertility has not been studied and is greatly relevant.

OBJECTIVE

The purpose of this study was to evaluate the impact of restorative proctocolectomy failure on birth rate in women and men, along with in vitro fertilization incidence and success.

DESIGN

This was a retrospective registry-based cohort study over 17 years.

SETTINGS

Records for parenting a child were cross-linked with patient records. In women, in vitro fertilization records were cross-linked. All data were prospectively registered.

PATIENTS

Patients of fertile age with ulcerative colitis between 1994 and 2010 were identified in Danish national databases. Patients with restorative proctocolectomy and restorative proctocolectomy failure were identified as subgroups.

MAIN OUTCOME MEASURES

Birth rate ratios and in vitro fertilization incidence and success were measured.

RESULTS

We included 11,939 women and 13,569 men with ulcerative colitis. A total of 711 women and 730 men had restorative proctocolectomy; 114 women and 90 men had failure. Birth rate in women with failure was significantly reduced compared with women without (birth rate ratio = 0.50 (95% CI, 0.29-0.82)). In men with failure, birth rate tended to be lower compared with men without (birth rate ratio = 0.74 (95% CI, 0.51-1.05)). In vitro fertilization incidence was similar with and without failure (HRs adjusted for age at start of follow-up = 0.98 (95% CI, 0.58-1.67]). In vitro fertilization success was significantly lower with failure compared with ulcerative colitis (OR adjusted for age at start of follow-up = 0.36 (95% CI, 0.4-0.92)).

LIMITATIONS

Information on patients leading up to restorative proctocolectomy failure is lacking. Failure patients may have had children during a period with pouch function. Therefore, the impact of failure may be underestimated.

CONCLUSIONS

Restorative proctocolectomy failure impairs birth rate, primarily in women. Although in vitro fertilization incidence is similar in women with and without failure, the likelihood of giving birth after in vitro fertilization is reduced. See Video Abstract at http://links.lww.com/DCR/B202. IMPACTO SOBRE LA FERTILIDAD DESPUéS DEL FRACASO DE LA PROCTOCOLECTOMíA RESTAURADORA EN HOMBRES Y MUJERES CON COLITIS ULCEROSA: UN ESTUDIO DE COHORTE DE 17 AñOS: No se ha estudiado el impacto de la falla de la proctocolectomía restauradora en la fertilidad y es muy relevante.Evaluar el impacto del fracaso de la proctocolectomía restauradora en la tasa de natalidad en mujeres y hombres, junto con la incidencia y el éxito de la fertilización in vitro.Estudio de cohorte retrospectivo basado en el registro de más de 17 años.Los registros de crianza de un niño se cruzaron con los registros de pacientes. En las mujeres, los registros de fertilización in vitro se cruzarón. Todos los datos se regitraron de forma prospectiva.Los pacientes de edad fértil con colitis ulcerosa entre 1994-2010 fueron identificados en las bases de datos nacionales danesas. Los pacientes con proctocolectomía restauradora y fracaso de la proctocolectomía restauradora se identificaron como subgrupos.Tasas de natalidad e incidencia y éxito de la fertilización in vitro.Se incluyeron 11939 mujeres y 13569 hombres con colitis ulcerosa. 711 mujeres y 730 hombres tuvieron proctocolectomía restauradora; 114 mujeres y 90 hombres tuvieron fracaso. La tasa de natalidad en las mujeres con fracaso se redujo significativamente en comparación con las mujeres sin fracaso (tasa de natalidad: 0,50; IC del 95% [0,29; 0,82]). En los hombres con fracaso, la tasa de natalidad tendió a ser más baja en comparación con los hombres sin fracaso (tasa de natalidad: 0,74; IC del 95% [0,51; 1,05]). La incidencia de fertilización in vitro fue similar con y sin falla (aHR: 0.98, IC 95% [0.58; 1.67]). El éxito de la fertilización in vitro fue significativamente menor con el fracaso en comparación con la colitis ulcerosa (aOR: 0.36 IC 95% [0.4; 0.92]).Falta información sobre los pacientes que conducen al fracaso de la proctocolectomía restauradora. Los pacientes con fracaso pueden haber tenido hijos durante un período con función de bolsa. Por lo tanto, el impacto del fracaso puede ser subestimado.El fracaso de la proctocolectomía restauradora afecta la tasa de natalidad, principalmente en mujeres. Aunque la incidencia de la fertilización in vitro es similar en las mujeres con y sin fracaso, la probabilidad de dar a luz después de la fertilización in vitro se reduce. Consulte Video Resumen en http://links.lww.com/DCR/B202. (Traducción-Dr Gonzalo Hagerman).

Surgery for Inflammatory Bowel Disease Has Unclear Impact on Female Fertility: A Cochrane Collaboration Systematic Review

Background and Aims

Surgical treatment of inflammatory bowel disease (IBD) may impair female fertility. We conducted a systematic review to determine the risk of infertility and pregnancy outcomes in women with IBD who underwent surgery.

Methods

We identified studies evaluating the impact of IBD surgery on infertility and pregnancy outcomes. Risk ratios (RR) and 95% confidence intervals (CIs) were pooled when data were presented using contingency tables. Odds ratios (OR) were pooled when raw numbers were not provided. GRADE was used to evaluate the certainty of evidence.

Results

Sixteen observational studies were included, comparing women with and without surgery, open and laparoscopic surgery and before and after surgery. All studies were of low quality. The effect of surgery on infertility at 12 months (RR 5.45, 95% CI 0.41 to 72.57) was uncertain. Similarly, the fertility effects of laparoscopic versus open surgery method were unclear (RR 0.70, 95% CI 0.38 to 1.27). The impact of IBD surgery on pregnancy outcomes should be interpreted with caution. Surgery was associated with miscarriage (OR 2.03, 95% CI 1.14 to 3.60), use of assisted reproductive technologies (RR 25.09, 95% CI 1.56 to 403.76) and caesarean section (RR 2.23, 95% CI 1.00 to 4.95), but not with stillbirth (RR 1.96, 95% CI 0.42 to 9.18), preterm birth (RR 1.91, 95% CI 0.67 to 5.48), low birth weight (RR 0.61, 95% CI 0.08 to 4.83) or small for gestational age (RR 2.54, 95% CI 0.80 to 8.01).

Conclusion

The effect of surgical therapy for IBD on rates of female infertility and pregnancy-related outcomes was uncertain due to poor quality of existing literature.

Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): ulcerative colitis

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of ulcerative colitis management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of ulcerative colitis. The committee was able to identify some points of major disagreement and suggested strategies to improve the quality of available data and acceptance of guidelines.

Fertility and Sexual Function in Women Following Pediatric Ileal Pouch-Anal Anastomosis

PURPOSE

Ileal Pouch-Anal Anastomosis (IPAA) is the standard of care for children requiring surgical treatment of severe colitis or polyposis syndromes. This study aims is to investigate the sexual function and fertility in women after undergoing childhood IPAA.

METHODS

A prospectively maintained colon and rectal database of consenting patients was queried from January 1980 to October 2015. We included all females that replied to at least 1 survey between the ages of 20 and 45 years that had undergone IPAA younger than 20 years of age.

RESULTS

Two hundred females met inclusion criteria, whereas 149 women replied to the sexual function questions. Ulcerative colitis was diagnosed in 122 (83%) patients, with the remainder having polyposis. Seven patients had a laparoscopic proctectomy. Only 2 patients had a pelvic infection, whereas 21 had intestinal obstruction postoperatively. A severely restricted sex life was reported in 6 (5%) patients. Of the 93 (62%) women who attempted pregnancy, 68 (73%) became pregnant. Median age of pregnancy and IPAA was 34 (range 22-45) and 17 years (range 9-20), respectively. Medical intervention to assist fertilization was required in 14/68. A total of 29 women reported problems during pregnancy with 58/68 (88%) giving birth to a live baby. Elective termination was reported in 2/68 surveys. Vaginal delivery occurred in 26/58 mothers with 27/58 planned and 9/58 unplanned cesarean sections. Age at IPAA, diagnosis, procedure type, pelvic infection, and obstruction were not associated with decreased fertility. All 7 patients operated laparoscopically have become pregnant. Change in pouch function after delivery was reported in 20/68 (32%, 5 missing) surveys.

CONCLUSIONS

73% of women who desired children become pregnant, and 88% had a successful delivery after pediatric IPAA. Only 5% reported severely restricted sexual function. Changes in pouch function occurred with pregnancy and persisted in 1/3 after delivery. Minimally invasive techniques may improve fertility rates but equire continued follow-up.

LEVEL OF EVIDENCE

Level IV.

TYPE OF STUDY

Observational study.

Recommendations of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) on pouchitis in ulcerative colitis. Part 1: Epidemiology, diagnosis and prognosis

Pouchitis is a common complication in ulcerative colitis patients after total proctocolectomy. This is an unspecific inflammation of the ileo-anal pouch, the aetiology of which is not fully known. This inflammation induces the onset of symptoms such as urgency, diarrhoea, rectal bleeding and abdominal pain. Many patients suffering from pouchitis have a lower quality of life. In addition to symptoms, an endoscopy with biopsies is mandatory in order to establish a definite diagnosis. The recommended index to assess its activity is the Pouchitis Disease Activity Index (PDAI), but its modified version (PDAIm) can be used in clinical practice. In accordance with the duration of symptoms, pouchitis can be classified as acute (<4 weeks) or chronic (>4 weeks), and, regarding its course, pouchitis can be infrequent (<4 episodes per year), recurrent (>4 episodes per year) or continuous.

Sexual health and fertility for individuals with inflammatory bowel disease

The impact of a chronic disease such as inflammatory bowel disease (IBD) on sexual functioning and body image can significantly impair the quality of life of patients. This review considers the sexual and fertility aspects of IBD patients and their daily management. Modern IBD healthcare management should include appropriate communication on sexuality and consider psychological, physiological, and biological issues. Patients with IBD have less children than the general population, and voluntary childlessness is frequent. The most influential factors reported by IBD patients who experience fertility alteration are psychological and surgery-related problems. Pregnancy is a major concern for patients, and any pregnancy for IBD patients should be closely followed-up to keep the chronic disease in a quiescent state. Preconceptional consultation is of great help.

Use and Success of In Vitro Fertilisation Following Restorative Proctocolectomy and Ileal Pouch-anal Anastomosis. A Nationwide 17-year Cohort Study

BACKGROUND AND AIMS

Fertility decreases in women following restorative proctocolectomy for ulcerative colitis. The use and success of in vitro fertilisation [IVF] after restorative proctocolectomy for ulcerative colitis is not systematically studied. We aimed to estimate the use and success of in vitro fertilisation treatment in female ulcerative colitis patients, with and without restorative proctocolectomy.

METHODS

Women of fertile age [15-49 years] with restorative proctocolectomy for ulcerative colitis were compared with females with ulcerative colitis without restorative proctocolectomy. Data from the IVF registry from 1994-2010 were cross-linked with data from the National Danish Patient Registry and the Medical Birth Registry.

RESULTS

In vitro fertilisation is significantly more frequent in females with restorative proctocolectomy compared with females without restorative proctocolectomy, adjusted hazard ratio 3.2, 95% confidence interval [CI] [2.5;4.0]. The odds for having a live birth after in vitro fertilisation are no different in females with restorative proctocolectomy compared with females without restorative proctocolectomy, adjusted odds ratio 0.8, 95% CI [0.6;1.1]. The percentage of children born as a result of in vitro fertilisation is significantly higher in females with restorative proctocolectomy compared with females without restorative proctocolectomy (31.0%, 95% CI [24.1; 37.7] vs 5.0%, 95% CI [4.4; 5.6]).

CONCLUSIONS

Females with restorative proctocolectomy for ulcerative colitis have increased incidence of in vitro fertilisation by more than a factor three, the odds that a treatment results in a live birth are similar and six times more children are born as a result of in vitro fertilisation compared with females without restorative proctocolectomy.

The Impact of Inflammatory Bowel Disease on Pregnancy and the Fetus: A Literature Review

Inflammatory bowel disease (IBD) is a constellation of devastating chronic inflammatory changes in the bowel, either involving the large or small bowel or part of both. As it is widely diagnosed in the fertile age group, this disorder can present itself, very commonly, during pregnancy and thus a better understanding of the disease can be an important factor to influence the maternal and fetal well-being. Medications are what is considered the first line in the management of this disease to control the symptoms or keep the disease in remission. In addition to this, the drugs used to keep the disease in remission can also cause significant adverse effects on the patient and the new nurturing life preparing itself for the outside world. What the fetus gets from the mother will stay for life with the child. We conducted an electronic literature review search which highlights the significance and impact of sustained remission of IBD and the cautious use of various drugs during pregnancy for that purpose. In addition to the influences already mentioned, It is evident that nutritional deficiencies can also prevail with the advancing disease, something to manage as a side note as well. These deficiencies can have a definite effect on the fetus and may cause developmental malformations. In order to avoid this process, a systemic and joint approach should be curtailed. This can reduce the adverse outcomes associated with this ailment during pregnancy.

Ileal-anal pouches: A review of its history, indications, and complications

The ileal pouch anal anastomosis (IPAA) has revolutionised the surgical management of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Despite refinement in surgical technique(s) and patient selection, IPAA can be associated with significant morbidity. As the IPAA celebrated its 40^th anniversary in 2018, this review provides a timely outline of its history, indications, and complications. IPAA has undergone significant modification since 1978. For both UC and FAP, IPAA surgery aims to definitively cure disease and prevent malignant degeneration, while providing adequate continence and avoiding a permanent stoma. The majority of patients experience long-term success, but “early” and “late” complications are recognised. Pelvic sepsis is a common early complication with far-reaching consequences of long-term pouch dysfunction, but prompt intervention (either radiological or surgical) reduces the risk of pouch failure. Even in the absence of sepsis, pouch dysfunction is a long-term complication that may have a myriad of causes. Pouchitis is a common cause that remains incompletely understood and difficult to manage at times. 10% of patients succumb to the diagnosis of pouch failure, which is traditionally associated with the need for pouch excision. This review provides a timely outline of the history, indications, and complications associated with IPAA. Patient selection remains key, and contraindications exist for this surgery. A structured management plan is vital to the successful management of complications following pouch surgery.

Cost-effectiveness of the prevention of adhesions and adhesive small bowel obstruction after colorectal surgery with adhesion barriers: a modelling study

Background

Adhesion barriers have proven to reduce adhesion-related complications in colorectal surgery. However, barriers are seldom applied. The aim of this study was to determine the cost-effectiveness of adhesion barriers in colorectal surgery.

Methods

A decision-tree model was developed to compare cost-effectiveness of no adhesion barrier with the use of an adhesion barrier in open and laparoscopic surgery. Outcomes were incidence of clinical consequences of adhesions, direct healthcare costs, and incremental cost-effectiveness ratio per adhesion prevented. Deterministic and probabilistic sensitivity analyses were performed.

Results

Adhesion barriers reduce adhesion incidence and incidence of adhesive small bowel obstruction in open and laparoscopic surgery. Adhesion barriers in open surgery reduce costs compared to no adhesion barrier ($4376 versus $4482). Using an adhesion barrier in laparoscopic procedures increases costs by $162 ($4482 versus $4320). The ICER in the laparoscopic cohort was $123. Probabilistic sensitivity analysis showed 66% and 41% probabilities of an adhesion barrier reducing costs for open and laparoscopic colorectal surgery, respectively.

Conclusion

The use of adhesion barriers in open colorectal surgery is cost-effective in preventing adhesion-related problems. In laparoscopic colorectal surgery, an adhesion barrier is effective at low costs.

The impact of surgical therapies for inflammatory bowel disease on female fertility

BACKGROUND

Women with inflammatory bowel disease (IBD) may require surgery, which may result in higher risk of infertility. Restorative proctocolectomy with ileal anal pouch anastomosis (IPAA) may increase infertility, but the degree to which IPAA affects infertility remains unclear, and the impact of other surgical interventions on infertility is unknown.

OBJECTIVES

Primary objective• To determine the effects of surgical interventions for IBD on female infertility.Secondary objectives• To evaluate the impact of surgical interventions on the need for assisted reproductive technology (ART), time to pregnancy, miscarriage, stillbirth, prematurity, mode of delivery (spontaneous vaginal, instrumental vaginal, or Caesarean section), infant requirement for resuscitation and neonatal intensive care, low and very low birth weight, small for gestational age, antenatal and postpartum hemorrhage, retained placenta, postpartum depression, gestational diabetes, and gestational hypertension/preeclampsia.

SEARCH METHODS

We searched MEDLINE, Embase, CENTRAL, and the Cochrane IBD Group Specialized Register from inception to September 27, 2018, to identify relevant studies. We also searched references of relevant articles, conference abstracts, grey literature, and trials registers.

SELECTION CRITERIA

We included observational studies that compared women of reproductive age (≥ 12 years of age) who underwent surgery to women with IBD who had a different type of surgery or no surgery (i.e. treated medically). We also included studies comparing women before and after surgery. Any type of IBD-related surgery was permitted. Infertility was defined as an inability to become pregnant following 12 months of unprotected intercourse. Infertility at 6, 18, and 24 months was included as a secondary outcome. We excluded studies that included women without IBD and those comparing women with IBD to women without IBD..

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies and extracted data. We used the Newcastle-Ottawa Scale to assess bias and GRADE to assess the overall certainty of evidence. We calculated the pooled risk ratio (RR) and 95% confidence interval (CI) using random-effects models. When individual studies reported odds ratios (ORs) and did not provide raw numbers, we pooled ORs instead.

MAIN RESULTS

We identified 16 observational studies for inclusion. Ten studies were included in meta-analyses, of which nine compared women with and without a previous IBD-related surgery and the other compared women with open and laparoscopic IPAA. Of the ten studies included in meta-analyses, four evaluated infertility, one evaluated ART, and seven reported on pregnancy-related outcomes. Seven studies in which women were compared before and after colectomy and/or IPAA were summarized qualitatively, of which five included a comparison of infertility, three included the use of ART, and three included other pregnancy-related outcomes. One study included a comparison of women with and without IPAA, as well as before and after IPAA, and was therefore included in both the meta-analysis and the qualitative summary. All studies were at high risk of bias for at least two domains.We are very uncertain of the effect of IBD surgery on infertility at 12 months (RR 5.45, 95% CI 0.41 to 72.57; 114 participants; 2 studies) and at 24 months (RR 3.59, 95% CI 1.32 to 9.73; 190 participants; 1 study). Infertility was lower in women who received laparoscopic surgery compared to open restorative proctocolectomy at 12 months (RR 0.70, 95% CI 0.38 to 1.27; 37 participants; 1 study).We are very uncertain of the effect of IBD surgery on pregnancy-related outcomes, including miscarriage (OR 2.03, 95% CI 1.14 to 3.60; 776 pregnancies; 5 studies), use of ART (RR 25.09, 95% CI 1.56 to 403.76; 106 participants; 1 study), delivery via Caesarean section (RR 2.23, 95% CI 1.00 to 4.95; 20 pregnancies; 1 study), stillbirth (RR 1.96, 95% CI 0.42 to 9.18; 246 pregnancies; 3 studies), preterm birth (RR 1.91, 95% CI 0.67 to 5.48; 194 pregnancies; 3 studies), low birth weight (RR 0.61, 95% CI 0.08 to 4.83), and small for gestational age (RR 2.54, 95% CI 0.80 to 8.01; 65 pregnancies; 1 study).Studies comparing infertility before and after IBD-related surgery reported numerically higher rates of infertility at six months (before: 1/5, 20.0%; after: 9/15, 60.0%; 1 study), at 12 months (before: 68/327, 20.8%; after: 239/377, 63.4%; 5 studies), and at 24 months (before: 14/89, 15.7%; after: 115/164, 70.1%; 2 studies); use of ART (before: 5.3% to 42.2%; after: 30.3% to 34.3%; proportions varied across studies due to differences in which women were identified as at risk of using ART); and delivery via Caesarean section (before: 8/73, 11.0%; after: 36/75, 48.0%; 2 studies). In addition, women had a longer time to conception after surgery (two to five months; 2 studies) than before surgery (5 to 16 months; 2 studies). The proportions of women experiencing miscarriage (before: 19/123, 15.4%; after: 21/134, 15.7%; 3 studies) and stillbirth (before: 2/38, 5.3%; after: 3/80: 3.8%; 2 studies) were similar before and after surgery. Fewer women experienced gestational diabetes after surgery (before: 3/37, 8.1%; after: 0/37; 1 study), and the risk of preeclampsia was similar before and after surgery (before: 2/37, 5.4%; after: 0/37; 1 study). We are very uncertain of the effects of IBD-related surgery on these outcomes due to poor quality evidence, including confounding bias due to increased age of women after surgery.We rated evidence for all outcomes and comparisons as very low quality due to the observational nature of the data, inclusion of small studies with imprecise estimates, and high risk of bias among included studies.

AUTHORS' CONCLUSIONS

The effect of surgical therapy for IBD on female infertility is uncertain. It is also uncertain if there are any differences in infertility among those undergoing open versus laparoscopic procedures. Previous surgery was associated with higher risk of miscarriage, use of ART, Caesarean section delivery, and giving birth to a low birth weight infant, but was not associated with risk of stillbirth, preterm delivery, or delivery of a small for gestational age infant. These findings are based on very low-quality evidence. As a result, definitive conclusions cannot be made, and future well-designed studies are needed to fully understand the impact of surgery on infertility and pregnancy outcomes.

Overlooked Long-Term Complications of Colorectal Surgery

While colorectal surgery has been documented to have some of the highest complication rates in the surgical field, some of the more common, functional complications are often overlooked in the literature and in discussion with patients. Urinary, sexual, and defecatory dysfunction are common after colorectal surgery, especially after pelvic dissections, and may severely impact the postoperative quality of life for patients. These complications include urinary retention, erectile dysfunction, retrograde ejaculation, dyspareunia, infertility, and low anterior resection syndrome. The majority is rooted in autonomic nerve damage, both sympathetic and parasympathetic, that occurs during mobilization and resection of the sigmoid colon and rectum. While not all of these postoperative complications are preventable, treatment strategies have been developed to ameliorate the impact on quality of life. Given the high incidence and direct effect on patients, clinicians should be familiar with the etiology, prevention, and treatment strategies of these complications to provide the highest quality of care.

The rectal remnant after total colectomy for colitis - intra-operative,post-operative and longer-term considerations

OBJECTIVES

Acute severe colitis requires surgery in around 30% of the cases. Total colectomy with ileostomy is the standard procedure with distinct advantages to a laparoscopic approach. Less agreement exists regarding the formation or configuration of the retained rectal stump and its short-term and long-term management. In this review, aspects of management of the rectal remnant, including perioperative considerations, potential complications, medical treatment, surveillance and implications for proctectomy and reconstructive surgery are explored.

METHODS

A thorough literature review exploring the PubMed and EMBASE databases was undertaken to clarify the evidence base surrounding areas of controversy in the surgical approach to acute severe colitis. In particular, focus was given to evidence surrounding management of the rectal remnant.

RESULTS

There is a paucity of high quality evidence for optimal management of the rectal stump following colectomy, and randomised trials are lacking. Establishment of laparoscopic colectomy has been associated with distinct advantages as well as the emergence of unique considerations, including those specific to rectal remnant management.

CONCLUSIONS

Early surgical involvement and a multidisciplinary approach to the management of acute severe colitis are advocated. Laparoscopic subtotal colectomy and ileostomy should be the operation of choice, with division of the rectum at the pelvic brim leaving a closed intraperitoneal remnant. If the rectum is severely inflamed, a mucus fistula may be useful, and an indwelling rectal catheter is probably advantageous to reduce the complications associated with stump dehiscence. Patients electing not to proceed to proctectomy should undergo surveillance for dysplasia of the rectum.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

AIM

There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology.

METHODS

Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines.

RESULTS

All aspects of surgical care for IBD have been included along with 157 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Salvage therapy for acute severe ulcerative colitis during pregnancy

Ulcerative colitis (UC) is a chronic inflammatory bowel disease with an age of onset that affects young people during the peak of their reproductive years. Management of flares of disease during pregnancy can be complex and there are few case reports of pregnant women with acute severe ulcerative colitis (ASUC). We present the case of a 31-year-old pregnant woman who at 16 weeks gestation developed ASUC in the context of primary non-response to infliximab therapy. She subsequently underwent an emergency laparoscopic colectomy after failing to respond to hydrocortisone and cyclosporine salvage therapy. Her pregnancy was further complicated by HELLP (Haemolysis, Elevated liver enzymes and Low Platelets) syndrome resulting in premature delivery at 27 weeks gestation. This case highlights the management issues involved in ASUC during pregnancy and the assessment of disease activity, use of salvage therapies, and provides a framework to approach this complex medical emergency.

Gastro-intestinal surgery and fertility

In France, 10 to 15% of couples in the overall population have a fertility problem. Preservation of sexual and reproductive function should be a major concern for all patients capable of procreation who undergo treatment for gastro-intestinal disease. The gastro-intestinal diseases most often responsible for fertility disorders include chronic inflammatory diseases, intestinal cancer and hereditary diseases, such as the Lynch syndrome and familial adenomatous polyposis. Obesity is responsible for a 20% loss of fertility but the effects of bariatric surgery on fertility are controversial. Nonetheless, in the light of progress in surgical techniques and better knowledge of gastro-intestinal disease the negative impact of surgery on fertility warrants attention. Effectively, fertility can be preserved after certain major gastro-intestinal operations such as cytoreductive surgery with intraperitoneal chemotherapy, total coloprotectomy with ileo-anal anastomosis and rectosigmoid resection, as long as the patient's age permits and resection of the reproductive organs is not necessary.

Family planning in inflammatory bowel disease: childlessness and disease-related concerns among female patients

OBJECTIVE

Inflammatory bowel disease (IBD) frequently affects women when family planning and pregnancy (FPP) are important issues. This survey aimed to identify patients with an increased need for medical counselling.

PATIENTS AND METHODS

An internet-based questionnaire was offered to women with IBD. Characteristics in terms of FPP were analysed with respect to sociodemographic and disease-related factors.

RESULTS

Childlessness was frequently reported (64.8% of 443 participants). In women older than 35 years with IBD, childlessness was significantly more prevalent than that in the general population (36.7 vs. 22.9%, odds ratio=1.9, P<0.001). Overall, 44.2% of the women were satisfied with counselling in general, and only 27.3% with the specific advice on FPP. Women younger than 25 years were rarely satisfied with the advice in terms of FPP (18.2%) and demanded an intensified counselling (44.6%). Frequent concerns were the heritability of IBD (all women, 59.2%; mothers, 51.5%; childless, 62.5%, P<0.01), medication during FPP (44.7, 26.1, 52.4%, P<0.01) and miscarriage (38.9, 16.8, 48.7%, P<0.01).

CONCLUSION

The prevalence of childlessness in women with IBD compared with the general population increases with age. FPP-related worries, especially in terms of heredity, medication and miscarriage, are associated with an increased risk for childlessness. The results underline the importance of qualified counselling as early as possible during the course of the disase.

Acute severe ulcerative colitis: latest evidence and therapeutic implications

Ulcerative colitis (UC) is a chronic inflammatory bowel disease of the colorectum which results from a complex interplay between environmental, genetic and microbial factors. One-fifth of patients with UC will experience an acute flare requiring hospitalization. This is a medical emergency and requires prompt recognition and multidisciplinary management. In patients who fail first-line therapy after approximately 3-5 days of intravenous steroids, medical rescue therapy is indicated with either infliximab (IFX) or cyclosporine (CsA). Optimal dosing strategies for IFX are uncertain, with several retrospective studies suggesting an association between an intensified or accelerated IFX induction regimen and lower colectomy rates, although prospective studies are warranted. In patients not responding to medical rescue therapy, or in those with fulminant colitis, urgent colectomy is indicated. Longer prognosis is suboptimal, with half of patients requiring colectomy within 5 years of presentation with acute severe UC (ASUC).

Sexuality, Fertility, and Pregnancy in Crohn's Disease

Many factors influence the sexual health of people with Crohn's disease, but active disease and depression play key roles. The fertility rate in nonoperated patients with inflammatory bowel disease with quiescent disease is similar to that in the general population. Crohn's disease can increase the risk for adverse pregnancy outcomes, but being in remission on a stable, steroid-free medication regimen for at least 3 months before conception and adhering to the treatment throughout pregnancy can improve outcomes. Infants with intrauterine exposure to anti-tumor necrosis factor medications should avoid live vaccines for the first 9 months or until drug concentrations are undetectable.

Risk of Rectal Cancer After Colectomy for Patients With Ulcerative Colitis: A National Cohort Study

BACKGROUND & AIMS

Patients with ulcerative colitis (UC) have an increased risk of rectal cancer, therefore reconstruction with an ileal pouch-anal anastomosis (IPAA) generally is preferred to an ileorectal anastomosis (IRA) after subtotal colectomy. Similarly, completion proctectomy is recommended for patients with ileostomy and a diverted rectum, although this approach has been questioned because anti-inflammatory agents might reduce cancer risk. We performed a national cohort study in Sweden to assess the risk of rectal cancer in patients with UC who have an IRA, IPAA, or diverted rectum after subtotal colectomy.

METHODS

We collected data from the Swedish National Patient Register for a cohort of 5886 patients with UC who underwent subtotal colectomy with an IRA, IPAA, or diverted rectum from 1964 through 2010. Patients who developed rectal cancer were identified from the Swedish National Cancer Register. The risk of rectal cancer was compared between this cohort and the general population by standardized incidence ratio analysis.

RESULTS

Rectal cancer occurred in 20 of 1112 patients (1.8%) who received IRA, 1 of 1796 patients (0.06%) who received an IPAA, and 25 of 4358 patients (0.6%) with a diverted rectum. Standardized incidence ratios for rectal cancer were 8.7 in patients with an IRA, 0.4 in patients with an IPAA, and 3.8 in patients with a diverted rectum. Risk factors for rectal cancer were primary sclerosing cholangitis in patients with an IRA (hazard ratio, 6.12), and colonic severe dysplasia or cancer before subtotal colectomy in patients with a diverted rectum (hazard ratio, 3.67).

CONCLUSIONS

In an analysis of the Swedish National Patient Register, we found that the risk for rectal cancer after colectomy in patients with UC is low, in relative and absolute terms, after reconstruction with an IPAA. An IRA and diverted rectum are associated with an increased risk of rectal cancer, compared with the general population, but the absolute risk is low. Patients and their health care providers should consider these findings in making decisions to leave the rectum intact, perform completion proctectomy, or reconstruct the colon with an IRA or IPAA.

Management of ulcerative colitis in Taiwan: consensus guideline of the Taiwan Society of Inflammatory Bowel Disease

Ulcerative colitis (UC) is an inflammatory bowel disease characterized by chronic mucosal inflammation of the colon, and the prevalence and incidence of UC have been steadily increasing in Taiwan. A steering committee was established by the Taiwan Society of Inflammatory Bowel Disease to formulate statements on the diagnosis and management of UC taking into account currently available evidence and the expert opinion of the committee. Accurate diagnosis of UC requires thorough clinical, endoscopic, and histological assessment and careful exclusion of differential diagnoses, particularly infectious colitis. The goals of UC therapy are to induce and maintain remission, reduce the risk of complications, and improve quality of life. As outlined in the recommended treatment algorithm, choice of treatment is dictated by severity, extent, and course of disease. Patients should be evaluated for hepatitis B virus and tuberculosis infection prior to immunosuppressive treatment, especially with steroids and biologic agents, and should be regularly monitored for reactivation of latent infection. These consensus statements are also based on current local evidence with consideration of factors, and could be serve as concise and practical guidelines for supporting clinicians in the management of UC in Taiwan.