1
|
Martinelli M, Miele E, Staiano A. Surgical Complications Need to Be Carefully Excluded Before Ruling Out a Diagnosis of De Novo Crohn's Disease. Inflamm Bowel Dis 2024; 30:690. [PMID: 38401568 DOI: 10.1093/ibd/izae026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2024]
Affiliation(s)
- Massimo Martinelli
- Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II" Naples, Italy
| | - Erasmo Miele
- Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II" Naples, Italy
| | - Annamaria Staiano
- Department of Translational Medical Science, Section of Pediatrics, University of Naples "Federico II" Naples, Italy
| |
Collapse
|
2
|
Suttichaimongkol T, Loftus EV. Characteristics, Clinical Outcomes, and Prognosis of Anal and Pouch-related Carcinoma in Patients With Crohn's Disease. Inflamm Bowel Dis 2024; 30:547-553. [PMID: 37279944 DOI: 10.1093/ibd/izad104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND This study described the clinical characteristics, outcomes, and prognosis of Crohn's disease (CD) patients with anal cancer in a tertiary referral center. METHODS The electronic medical records of 35 adult CD patients, including CD of the pouch, with anal carcinoma evaluated at Mayo Clinic Rochester, Florida, or Arizona between January 1989 and August 2022 were retrospectively reviewed. RESULTS Before cancer diagnosis, patients with pouch-related carcinoma had a shorter median duration of inflammatory bowel disease than those with anal carcinoma (10 vs 26 years). Twenty-six patients (74%) had perianal diseases or rectovaginal fistula, and 35% had a history of human papillomavirus infection. Twenty-one patients (60%) were diagnosed with cancer by anal examination under anesthesia (EUA). More than half of adenocarcinomas were mucinous. Sixteen patients (47%) were American Joint Committee on Cancer (AJCC) Tumor Nodes Metastasis (TNM) stage 3, and 83% were treated by surgery. At last follow-up, 57% of patients were alive without cancer. The 1-, 3- and 5-year overall survival rates were 93.8% (95% confidence interval [CI], 85.7%-100%), 71.5% (95% CI, 56.4%-90.7%), and 67.7% (95% CI, 51.2%-87.7%), respectively. Advanced AJCC TNM stage (hazard ratio, 3.20 per stage; 95% CI, 1.05-9.72; P = .040) was significantly associated with increased risk of death, whereas the period of cancer diagnosis in 2011-2022 (HR, relative to 1989-2000, 0.16; 95% CI, 0.04-0.72; P = .017) was significantly related to decreased risk of death. CONCLUSIONS Anal and pouch-related carcinomas were rare complications of CD, and long-standing perianal diseases were an important risk factor. Anal EUA improved the diagnostic yield. Newer cancer treatment strategies and surgery were associated with excellent survival outcome.
Collapse
Affiliation(s)
- Tanita Suttichaimongkol
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
- Division of Gastroenterology and Hepatology, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| |
Collapse
|
3
|
Djalal A, Wong SY, Colombel JF, Ungaro R, Kayal M. Problem with Hookups: Perianal Fistula After Ileal Pouch-Anal Anastomosis. Dig Dis Sci 2024; 69:1102-1104. [PMID: 38446307 DOI: 10.1007/s10620-024-08344-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/06/2024] [Indexed: 03/07/2024]
Affiliation(s)
- Arafa Djalal
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Serre-Yu Wong
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jean-Frédéric Colombel
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ryan Ungaro
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maia Kayal
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
4
|
Ochoa B, McMahon L. Surgery for ulcerative colitis. Semin Pediatr Surg 2024; 33:151404. [PMID: 38615424 DOI: 10.1016/j.sempedsurg.2024.151404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Ulcerative colitis (UC) has a more severe presentation and rapid progression in pediatric patients, resulting in a greater need for surgical intervention compared to adults. Though medical management of UC has advanced with new biologic therapies, surgery continues to play an important role when disease progresses in the form of worsened or persistent symptoms, hemodynamic instability, or sepsis. The goals of surgical management are to restore intestinal continuity with a functional pouch when possible. While the literature has been growing regarding studies of pediatric patients with UC, high level of evidence studies are limited and most recommendations are based on adult studies. Similar to adults, pediatric patients who have ileal pouches created require surveillance for recurrent disease and cancer surveillance. Unique issues for pediatric patients include monitoring of growth and appropriate transition to adult care after adolescence. This review includes indications for surgical management, overview of staged surgical approaches, and the technical details of the three-stage approach.
Collapse
Affiliation(s)
- Brielle Ochoa
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, Arizona, USA
| | - Lisa McMahon
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's, Phoenix, Arizona, USA.
| |
Collapse
|
5
|
Mesonero F, Zabana Y, Fernández-Clotet A, Leo-Carnerero E, Caballol B, Núñez-Ortiz A, García MJ, Bertoletti F, Mínguez A, Suris G, Casis B, Ferreiro-Iglesias R, Calafat M, Jiménez I, Miranda-Bautista J, Lamuela LJ, Fajardo I, Torrealba L, Nájera R, Sáiz-Chumillas RM, González I, Vicuña M, García-Morales N, Gutiérrez A, López-García A, Benítez JM, Rubín de Célix C, Tejido C, Brunet E, Hernández-Camba A, Suárez C, Rodríguez-Lago I, Piqueras M, Castaño A, Ramos L, Sobrino A, Rodríguez-Grau MC, Elosua A, Montoro M, Baltar R, Huguet JM, Hermida B, Caballero-Mateos A, Sánchez-Guillén L, Bouhmidi A, Pajares R, Baston-Rey I, López-Sanromán A, Albillos A, Barreiro-de Acosta M. Effectiveness and safety of azathioprine for inflammatory pouch disorders: results from the RESERVO study of GETECCU. Therap Adv Gastroenterol 2024; 17:17562848241234476. [PMID: 38445247 PMCID: PMC10913517 DOI: 10.1177/17562848241234476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/02/2024] [Indexed: 03/07/2024] Open
Abstract
Background The usefulness of thiopurines has been poorly explored in pouchitis and other pouch disorders. Objective To evaluate the effectiveness and safety of azathioprine as maintenance therapy in inflammatory pouch disorders. Design This was a retrospective and multicentre study. Methods We included patients diagnosed with inflammatory pouch disorders treated with azathioprine in monotherapy. Effectiveness was evaluated at 1 year and in the long term based on normalization of stool frequency, absence of pain, faecal urgency or fistula discharge (clinical remission), or any improvement in these symptoms (clinical response). Endoscopic response was evaluated using the Pouchitis Disease Activity Index (PDAI). Results In all, 63 patients were included [54% males; median age, 49 (28-77) years]. The therapy was used to treat pouchitis (n = 37) or Crohn's disease of the pouch (n = 26). The rate of clinical response, remission and non-response at 12 months were 52%, 30% and 18%, respectively. After a median follow-up of 23 months (interquartile range 11-55), 19 patients (30%) were in clinical remission, and 45 (66%) stopped therapy. Endoscopic changes were evaluated in 19 cases. PDAI score decreased from 3 (range 2-4) to 1 (range 0-3). In all, 21 patients (33%) presented adverse events and 16 (25%) needed to stop therapy. Conclusion Azathioprine may be effective in the long term for the treatment of inflammatory pouch disorders and could be included as a therapeutic option.
Collapse
Affiliation(s)
- Francisco Mesonero
- Inflammatory Bowel Disease Unit, Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Cra. Colmenar km 9.1, Madrid 28034, Spain
| | - Yamile Zabana
- Hospital Universitario Mútua Terrassa, Terrassa, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Agnès Fernández-Clotet
- Hospital Clínic Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | - Berta Caballol
- Hospital Clínic Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | - María José García
- Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | | | | | - Gerard Suris
- Hospital Universitario de Bellvitge, Barcelona, Spain
| | - Begoña Casis
- Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Margalida Calafat
- Hospital Universitario Germans Trias i Pujol, Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Itxaso Jiménez
- Hospital Universitario de Galdakao, Biocruces Bizkaia Health Research Institute, Galdakao, Spain
| | | | | | | | | | | | | | | | | | | | - Ana Gutiérrez
- Hospital General Universitario Alicante Doctor Balmis (Alicante), Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Alicia López-García
- Hospital del Mar i Institut Mar d’Investigacions Mediques (IMIM), Barcelona, Spain
| | | | - Cristina Rubín de Célix
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Coral Tejido
- Complejo Hospitalario Universitario Ourense, Ourense, Spain
| | - Eduard Brunet
- Hospital Universitari Parc Taulí, Sabadell, Spain Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | - Cristina Suárez
- Hospital Universitario La Paz, Instituto de Investigación Sanitaria del Hospital Universitario La Paz (IdiPAZ), Madrid, Spain
| | - Iago Rodríguez-Lago
- Hospital Universitario de Galdakao, Biocruces Bizkaia Health Research Institute, Galdakao, Spain
| | | | | | - Laura Ramos
- Hospital Universitario de Canarias, Santa Cruz, Spain
| | - Ana Sobrino
- Hospital General Universitario Ciudad Real, Ciudad Real, Spain
| | | | | | | | - Ruth Baltar
- Hospital Universitario Álava, Vitoria, Spain
| | | | | | | | | | | | - Ramón Pajares
- Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Spain
| | - Iria Baston-Rey
- Hospital Clínico Universitario Santiago, Santiago de Compostela, Spain
| | | | | | | |
Collapse
|
6
|
Macleod A, Parks MA, Cook CN, Petras RE, Galandiuk S. Long-term behavior and functional outcomes of ileal-pouch anal anastomosis in inflammatory bowel disease with changing phenotype. Surgery 2024; 175:765-775. [PMID: 37802743 DOI: 10.1016/j.surg.2023.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/24/2023] [Accepted: 07/08/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Ileal-pouch-anal anastomosis is the operation of choice after proctocolectomy for ulcerative colitis; some patients will develop Crohn's disease. We aim to determine long-term behavior and outcomes of inflammatory bowel disease-ileal-pouch-anal anastomosis after colectomy, where a specialist gastrointestinal pathologist re-evaluated the initial colectomy specimen. METHODS Patients with inflammatory bowel disease-ileal-pouch-anal anastomosis were identified from a single-surgeon prospective database containing 1,165 patients accrued from 1991 to 2017 and invited to complete pouch-function and quality-of-life assessments. Medical records were used to obtain clinical outcomes and subjective functional assessments for those unable to be contacted. Data were compared between patients with and without histological assessment disagreement and subsequent inflammatory bowel disease behavior subgroups. RESULTS For 138 patients included in the analysis, the median follow-up was 22.5 (range: 5-39) years. A total of 39.1% of patients had histologic diagnostic change after gastrointestinal pathologist review, and 19% and 39% developed Crohn's disease-like disease behavior at 10- and 20-year follow-ups. Pouch function and quality-of-life scores were similar across diagnostic change subgroups. Pouch failure was higher in Crohn's-like disease (31.1 vs 13.0%, P < .05). Intestinal continuity was maintained in 68.9% of Crohn's disease-like patients, 57.9% required biologics. Gastrointestinal pathologist review did not alter the time to new diagnosis (P = .419) or time to pouch failure (P = .320), mean: 11.0 and 11.41 years, respectively. CONCLUSION We describe equivocal patient-reported outcomes in patients with ileal-pouch-anal anastomosis and changing histologic and clinical diagnosis. Although pouch excision and biologic use rates are higher, many Crohn's disease-like patients maintain their pouch. Diagnostic change and pouch failure often occur >10 years after ileal-pouch-anal anastomosis creation. This supports the consideration of ileal-pouch-anal anastomosis after colectomy in carefully selected patients with inflammatory bowel disease, even those with ambiguous histology and the need for close long-term follow-up.
Collapse
Affiliation(s)
- Anne Macleod
- Price Institute of Surgical Research, University of Louisville, KY
| | - Mary Alex Parks
- Price Institute of Surgical Research, University of Louisville, KY
| | - Cheyenne N Cook
- Price Institute of Surgical Research, University of Louisville, KY
| | | | - Susan Galandiuk
- Price Institute of Surgical Research, University of Louisville, KY; Division of Colon & Rectal Surgery, Hiram C Polk Jr MD Department of Surgery, University of Louisville, KY.
| |
Collapse
|
7
|
Peery AF, Kelly CR, Kao D, Vaughn BP, Lebwohl B, Singh S, Imdad A, Altayar O. AGA Clinical Practice Guideline on Fecal Microbiota-Based Therapies for Select Gastrointestinal Diseases. Gastroenterology 2024; 166:409-434. [PMID: 38395525 DOI: 10.1053/j.gastro.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
BACKGROUND & AIMS Fecal microbiota-based therapies include conventional fecal microbiota transplant and US Food and Drug Administration-approved therapies, fecal microbiota live-jslm and fecal microbiota spores live-brpk. The American Gastroenterological Association (AGA) developed this guideline to provide recommendations on the use of fecal microbiota-based therapies in adults with recurrent Clostridioides difficile infection; severe to fulminant C difficile infection; inflammatory bowel diseases, including pouchitis; and irritable bowel syndrome. METHODS The guideline was developed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework to prioritize clinical questions, identify patient-centered outcomes, and conduct an evidence synthesis. The guideline panel used the Evidence-to-Decision framework to develop recommendations for the use of fecal microbiota-based therapies in the specified gastrointestinal conditions and provided implementation considerations for clinical practice. RESULTS The guideline panel made 7 recommendations. In immunocompetent adults with recurrent C difficile infection, the AGA suggests select use of fecal microbiota-based therapies on completion of standard of care antibiotics to prevent recurrence. In mildly or moderately immunocompromised adults with recurrent C difficile infection, the AGA suggests select use of conventional fecal microbiota transplant. In severely immunocompromised adults, the AGA suggests against the use of any fecal microbiota-based therapies to prevent recurrent C difficile. In adults hospitalized with severe or fulminant C difficile not responding to standard of care antibiotics, the AGA suggests select use of conventional fecal microbiota transplant. The AGA suggests against the use of conventional fecal microbiota transplant as treatment for inflammatory bowel diseases or irritable bowel syndrome, except in the context of clinical trials. CONCLUSIONS Fecal microbiota-based therapies are effective therapy to prevent recurrent C difficile in select patients. Conventional fecal microbiota transplant is an adjuvant treatment for select adults hospitalized with severe or fulminant C difficile infection not responding to standard of care antibiotics. Fecal microbiota transplant cannot yet be recommended in other gastrointestinal conditions.
Collapse
Affiliation(s)
- Anne F Peery
- University of North Carolina, Chapel Hill, North Carolina
| | - Colleen R Kelly
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dina Kao
- University of Alberta, Edmonton, Alberta, Canada
| | | | | | | | | | - Osama Altayar
- Washington University School of Medicine, St Louis, Missouri
| |
Collapse
|
8
|
Powers JC, Cohen BL, Rieder F, Click BH, Lyu R, Westbrook K, Hull T, Holubar S, Regueiro MD, Qazi T. Preoperative Use of Multiple Advanced Therapies Is Not Associated With Endoscopic Inflammatory Pouch Diseases. Inflamm Bowel Dis 2024; 30:203-212. [PMID: 37061838 DOI: 10.1093/ibd/izad054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Indexed: 04/17/2023]
Abstract
BACKGROUND Patients with an ileal pouch-anal anastomosis (IPAA) can experience pouch inflammation postoperatively. The use of antitumor necrosis factor (anti-TNF) biologics may be associated with pouch inflammation, but limited data exist on the impact of multiple advanced therapies on development of subsequent pouch inflammation. The aim of this study was to assess for an association between preoperative use of multiple advanced therapies and risk of endoscopically detected inflammatory pouch diseases (EIPDs). METHODS We performed a retrospective analysis of ulcerative colitis (UC) and indeterminate colitis (IBDU) patients who underwent an IPAA at a quaternary care center from January 2015 to December 2019. Patients were grouped based on number and type of preoperative drug exposures. The primary outcome was EIPD within 5 years of IPAA. RESULTS Two hundred ninety-eight patients were included in this analysis. Most of these patients had UC (95.0%) and demonstrated pancolonic disease distribution (86.1%). The majority of patients were male (57.4%) and underwent surgery for medically refractory disease (79.2%). The overall median age at surgery was 38.6 years. Preoperatively, 68 patients were biologic/small molecule-naïve, 125 received anti-TNF agents only, and 105 received non-anti-TNF agents only or multiple classes. Ninety-one patients developed EIPD. There was no significant association between type (P = .38) or number (P = .58) of exposures and EIPD, but older individuals had a lower risk of EIPD (P = .001; hazard ratio, 0.972; 95% confidence interval, 0.956-0.989). CONCLUSION Development of EIPD was not associated with number or type of preoperative advanced therapies.
Collapse
Affiliation(s)
- Joseph Carter Powers
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Benjamin L Cohen
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Florian Rieder
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin H Click
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ruishen Lyu
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland, OH, USA
| | - Katherine Westbrook
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Tracy Hull
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Stefan Holubar
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Miguel D Regueiro
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Taha Qazi
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
9
|
Miller-Ocuin JL, Ashburn JH. Cancer in the Anal Transition Zone and Ileoanal Pouch following Surgery for Ulcerative Colitis. Clin Colon Rectal Surg 2024; 37:37-40. [PMID: 38188063 PMCID: PMC10769578 DOI: 10.1055/s-0043-1762562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis remains the gold standard treatment for patients with ulcerative colitis who desire restoration of intestinal continuity. Despite a significant cancer risk reduction after surgical removal of the colon and rectum, dysplasia and cancers of the ileal pouch or anal transition zone still occur and are a risk even if an anal canal mucosectomy is performed. Surgical care and maintenance after ileoanal anastomosis must include consideration of malignant potential along with other commonly monitored variables such as bowel function and quality of life. Cancers and dysplasia of the ileal pouch are rare but sometimes difficult-to-manage sequelae of pouch surgery.
Collapse
Affiliation(s)
- Jennifer L. Miller-Ocuin
- Division of Colorectal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- Department of Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Jean H. Ashburn
- Department of Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| |
Collapse
|
10
|
Elford AT, Hirsch R, McKay OM, Browne M, Moore GT, Bell S, Swan M. Identifying the real-world challenges of dysplasia surveillance in inflammatory bowel disease: a retrospective cohort study in a tertiary health network. Intern Med J 2024; 54:96-103. [PMID: 37093665 DOI: 10.1111/imj.16102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 04/12/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND Dysplasia surveillance in inflammatory bowel disease (IBD) is often suboptimal and deviates from guidelines. AIMS To assess dysplasia surveillance behaviours and adherence to guidelines amongst a large tertiary teaching health network with a specialised IBD unit to identify areas where dysplasia surveillance could be improved. METHODS A retrospective audit of IBD surveillance colonoscopy practice over an 18-month period was performed using the Provation Endoscopy Database and the hospital's primary sclerosing cholangitis database. RESULTS The audit identified 115 dysplasia surveillance colonoscopies. A total of 37% of index dysplasia colonoscopies were outside recommended guidelines. A total of 10% had inadequate bowel preparation and only 40% had excellent bowel preparation. A total of 28% of patients underwent dye-based chromoendoscopy and 69% underwent high-definition white-light endoscopy. Dye chromoendoscopy was more likely to be used by IBD specialists than interventional endoscopists (P = 0.008) and other endoscopists (P = 0.004). Only IBD specialists and interventional endoscopists used dye chromoendoscopy. Dysplasia or colorectal cancer was detected in 3.4% of the colonoscopies. Overall, the several dysplasia examinations were lower than expected. CONCLUSIONS Dysplasia surveillance in the IBD population remains an area of improvement given the current national guidelines. IBD specialists are more likely to perform dye chromoendoscopy than other endoscopists/gastroenterologists. Dysplasia rates in this real-world contemporary setting are less than expected in historical studies and may represent improvements in IBD management principles and medications.
Collapse
Affiliation(s)
- Alexander T Elford
- Monash Health, Melbourne, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
| | - Ryan Hirsch
- Monash Health, Melbourne, Victoria, Australia
| | | | | | - Gregory T Moore
- Monash Health, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - Sally Bell
- Monash Health, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - Michael Swan
- Monash Health, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
11
|
Dunleavy KA, Santiago P, Forde G, Harmsen WS, McKenna NP, Coelho-Prabhu N, Shawki S, Raffals L. Total Proctocolectomy vs Subtotal/total Colectomy for Neoplasia in Patients With Inflammatory Bowel Disease and Primary Sclerosing Cholangitis. Inflamm Bowel Dis 2023:izad278. [PMID: 38142126 DOI: 10.1093/ibd/izad278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC) frequently undergo restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for medically refractory disease or colonic dysplasia/neoplasia. Subtotal colectomy with ileosigmoid or ileorectal anastomosis may have improved outcomes but is not well studied. Due to increased risk for colorectal cancer in PSC-IBD, there is hesitancy to perform subtotal colectomy. We aim to describe the frequency of colorectal dysplasia/neoplasia following IPAA vs subtotal colectomy in PSC-IBD patients. METHODS We completed a retrospective study from 1972 to 2022 of patients with PSC-IBD who had undergone total proctocolectomy with IPAA or subtotal colectomy. We abstracted demographics, disease characteristics, and endoscopic surveillance data from the EMR. RESULTS Of 125 patients (99 IPAA; 26 subtotal), the indication for surgery was rectal sparing medically refractory disease (51% vs 42%), dysplasia (37% vs 30%) and neoplasia (11% vs 26%) in IPAA vs subtotal colectomy patients, respectively. On endoscopic surveillance of IPAA patients, 2 (2%) had low-grade dysplasia (LGD) in the ileal pouch and 2 (2%) had LGD in the rectal cuff after an average of 8.4 years and 12.3 years of follow-up, respectively. One (1%) IPAA patient developed neoplasia of the rectal cuff after 17.8 years of surgical continuity. No subtotal colectomy patients had dysplasia/neoplasia in the residual colon or rectum. CONCLUSIONS In patients with PSC-IBD, there was no dysplasia or neoplasia in those who underwent subtotal colectomy as opposed to the IPAA group. Subtotal colectomy may be considered a viable surgical option in patients with rectal sparing PSC-IBD if adequate endoscopic surveillance is implemented.
Collapse
Affiliation(s)
- Katie Ann Dunleavy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Priscila Santiago
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Gerard Forde
- Department of Gastroenterology, Galway University Hospital, Galway, Ireland
| | - W Scott Harmsen
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | | | | | - Sherief Shawki
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - Laura Raffals
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
12
|
Bousvaros A, Zalieckas JM, Zimmerman L. Endoscopy of the Ileal Pouch Anal Anastomosis. J Pediatr Gastroenterol Nutr 2023; 77:691-694. [PMID: 37621012 DOI: 10.1097/mpg.0000000000003933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Affiliation(s)
- Athos Bousvaros
- From Boston Children's Hospital, Department of Gastroenterology and Nutrition, Boston, MA
| | | | - Lori Zimmerman
- From Boston Children's Hospital, Department of Gastroenterology and Nutrition, Boston, MA
| |
Collapse
|
13
|
Kabir M, Thomas-Gibson S, Tozer PJ, Warusavitarne J, Faiz O, Hart A, Allison L, Acheson AG, Atici SD, Avery P, Brar M, Carvello M, Choy MC, Dart RJ, Davies J, Dhar A, Din S, Hayee B, Kandiah K, Katsanos KH, Lamb CA, Limdi JK, Lovegrove RE, Myrelid P, Noor N, Papaconstantinou I, Petrova D, Pavlidis P, Pinkney T, Proud D, Radford S, Rao R, Sebastian S, Segal JP, Selinger C, Spinelli A, Thomas K, Wolthuis A, Wilson A. DECIDE: Delphi Expert Consensus Statement on Inflammatory Bowel Disease Dysplasia Shared Management Decision-Making. J Crohns Colitis 2023; 17:1652-1671. [PMID: 37171140 DOI: 10.1093/ecco-jcc/jjad083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND AND AIMS Inflammatory bowel disease colitis-associated dysplasia is managed with either enhanced surveillance and endoscopic resection or prophylactic surgery. The rate of progression to cancer after a dysplasia diagnosis remains uncertain in many cases and patients have high thresholds for accepting proctocolectomy. Individualised discussion of management options is encouraged to take place between patients and their multidisciplinary teams for best outcomes. We aimed to develop a toolkit to support a structured, multidisciplinary and shared decision-making approach to discussions about dysplasia management options between clinicians and their patients. METHODS Evidence from systematic literature reviews, mixed-methods studies conducted with key stakeholders, and decision-making expert recommendations were consolidated to draft consensus statements by the DECIDE steering group. These were then subjected to an international, multidisciplinary modified electronic Delphi process until an a priori threshold of 80% agreement was achieved to establish consensus for each statement. RESULTS In all, 31 members [15 gastroenterologists, 14 colorectal surgeons and two nurse specialists] from nine countries formed the Delphi panel. We present the 18 consensus statements generated after two iterative rounds of anonymous voting. CONCLUSIONS By consolidating evidence for best practice using literature review and key stakeholder and decision-making expert consultation, we have developed international consensus recommendations to support health care professionals counselling patients on the management of high cancer risk colitis-associated dysplasia. The final toolkit includes clinician and patient decision aids to facilitate shared decision-making.
Collapse
Affiliation(s)
- Misha Kabir
- Division of GI Services, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
| | - Siwan Thomas-Gibson
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Phil J Tozer
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Janindra Warusavitarne
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Omar Faiz
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Ailsa Hart
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Lisa Allison
- Department of Gastroenterology, Royal Free Hospital, London, UK
| | - Austin G Acheson
- Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Semra Demirli Atici
- Department of Surgery, University of Health Sciences Tepecik Training and Research Hospital, Izmir, Turkey
| | - Pearl Avery
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Mantaj Brar
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Michele Carvello
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Surgery, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Matthew C Choy
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia
- Division of Medicine, Dentistry and Health Sciences, University of Melbourne, Austin Academic Centre, Melbourne, VIC, Australia
| | - Robin J Dart
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Justin Davies
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Anjan Dhar
- Department of Gastroenterology, Darlington Memorial Hospital, County Durham & Darlington NHS Foundation Trust, Darlington, UK
- Department of Gastroenterology, Teesside University, UK, Middlesbrough, UK
| | - Shahida Din
- Edinburgh IBD Unit, NHS Lothian, Western General Hospital, Edinburgh, UK
| | - Bu'Hussain Hayee
- Department of Gastroenterology, King's College Hospital, London, UK
| | - Kesavan Kandiah
- Department of Gastroenterology, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Konstantinos H Katsanos
- Division of Gastroenterology, Department of Internal Medicine, University of Ioannina School of Health Sciences, Ioannina, Greece
| | - Christopher Andrew Lamb
- Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Gastroenterology, Royal Victoria Infirmary, Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Jimmy K Limdi
- Department of Gastroenterology, Northern Care Alliance NHS Foundation Trust, Greater Manchester, UK
- Department of Gastroenterology, University of Manchester , Manchester, UK
| | - Richard E Lovegrove
- Department of Surgery, Worcestershire Acute Hospitals NHS Trust , Worcester, UK
| | - Pär Myrelid
- Department of Surgery, Linköping University Hospital, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Nurulamin Noor
- Department of Gastroenterology, Cambridge University Hospitals, Addenbrooke's Hospital, Cambridge, UK
| | - Ioannis Papaconstantinou
- Department of Surgery, Aretaieion Hospital, National and Kapodistrian University of Athens, A thens, Greece
| | - Dafina Petrova
- Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain
- Escuela Andaluza de Salud Pública [EASP], Granada, Spain
- CIBER of Epidemiology and Public Health [CIBERESP], Madrid, Spain
| | - Polychronis Pavlidis
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Thomas Pinkney
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - David Proud
- Department of Surgery, Austin Health, Heidelberg Victoria, VIC, Australia
| | - Shellie Radford
- Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Rohit Rao
- Department of Gastroenterology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Shaji Sebastian
- Department of Gastroenterology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Jonathan P Segal
- Department of Gastroenterology, Northern Hospital Epping, University of Melbourne, Melbourne, VIC, Australia
| | - Christian Selinger
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Antonino Spinelli
- Faculty of Life Sciences and Medicine, King's College London, London, UK
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Kathryn Thomas
- Department of Surgery, Nottingham University Hospitals, UK
| | - Albert Wolthuis
- Department of Surgery, University Hospital Leuven, The Netherlands
| | - Ana Wilson
- Department of Surgery and Cancer or Department of Metabolism, Digestion and Reproduction, Imperial College London , London, UK
- Department of Gastroenterology or Department of Colorectal Surgery, St Mark's Hospital, London, UK
| |
Collapse
|
14
|
Luo Y, Schmidt N, Dubinsky MC, Jaffin B, Kayal M. Evaluating lleal Pouch Anal Anastomosis Function: Time to Expand Our ARM-amentarium. Inflamm Bowel Dis 2023; 29:1819-1825. [PMID: 36351035 PMCID: PMC11007395 DOI: 10.1093/ibd/izac234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Total proctocolectomy with ileal pouch anal anastomosis (IPAA) for medically refractory ulcerative colitis or dysplasia may be associated with structural and inflammatory complications. However, even in their absence, defecatory symptoms secondary to dyssynergic defecation or fecal incontinence may occur. Although anorectal manometry is well established as the diagnostic test of choice for defecatory symptoms, its utility in the assessment of patients with IPAA is less established. In this systematic review, we critically evaluate the existing evidence for anopouch manometry (APM). METHODS A total of 393 studies were identified, of which 6 studies met all inclusion criteria. Studies were not pooled given different modalities of testing with varying outcome measures. RESULTS Overall, less than 10% of symptomatic patients post-IPAA were referred to APM. The prevalence of dyssynergic defecation as defined by the Rome IV criteria in symptomatic patients with IPAA ranged from 47.0% to 100%. Fecal incontinence in patients with IPAA was characterized by decreased mean and maximal resting anal pressure on APM, as well as pouch hyposensitivity. The recto-anal inhibitory reflex was absent in most patients with and without incontinence. CONCLUSION Manometry alone is an imperfect assessment of pouch function in patients with defecatory symptoms, and confirmatory testing may need to be performed with dynamic imaging.
Collapse
Affiliation(s)
- Yuying Luo
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Natalia Schmidt
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marla C Dubinsky
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Barry Jaffin
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maia Kayal
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
15
|
Chang S, Hong S, Hudesman D, Remzi F, Sun K, Cao W, Kani HT, Axelrad J, Sarkar SA. Histologic Predictors of Clinical Outcomes and Healthcare Utilization in Patients With Ileal Pouch-Anal Anastomosis. Inflamm Bowel Dis 2023; 29:1769-1777. [PMID: 36702534 PMCID: PMC10628915 DOI: 10.1093/ibd/izac277] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND The prognostic significance of histology in ileal pouch-anal anastomosis (IPAA) remains unclear. The aim of this study was to evaluate if histologic variables are predictive of IPAA clinical outcomes and healthcare utilization. METHODS This was a retrospective cohort study of patients with IPAA undergoing surveillance pouchoscopy at a tertiary care institution. Pouch body biopsies were reviewed by gastrointestinal pathologists, who were blinded to clinical outcomes, for histologic features of acute or chronic inflammation. Charts were reviewed for clinical outcomes including development of acute pouchitis, chronic pouchitis, biologic or small molecule initiation, hospitalizations, and surgery. Predictors of outcomes were analyzed using univariable and multivariable logistic and Cox regression. RESULTS A total of 167 patients undergoing surveillance pouchoscopy were included. Polymorphonuclear leukocytes (odds ratio [OR], 1.67), ulceration and erosion (OR, 2.44), chronic inflammation (OR, 1.97), and crypt distortion (OR, 1.89) were associated with future biologic or small molecule initiation for chronic pouchitis. Loss of goblet cells was associated with development of chronic pouchitis (OR, 4.65). Pyloric gland metaplasia was associated with hospitalizations (OR, 5.24). No histologic variables were predictive of development of acute pouchitis or surgery. In an exploratory subgroup analysis of new IPAA (<1 year), loss of goblet cells was associated with acute pouchitis (OR, 14.86) and chronic pouchitis (OR, 12.56). Pyloric gland metaplasia was again associated with hospitalizations (OR, 13.99). CONCLUSIONS Histologic findings may be predictive of IPAA outcomes. Pathologists should incorporate key histologic variables into pouchoscopy pathology reports. Clinicians may need to more closely monitor IPAA patients with significant histologic findings.
Collapse
Affiliation(s)
- Shannon Chang
- Division of Gastroenterology, New York University Grossman School of Medicine, New York, NY, USA
| | - Simon Hong
- Division of Gastroenterology, New York University Grossman School of Medicine, New York, NY, USA
| | - David Hudesman
- Division of Gastroenterology, New York University Grossman School of Medicine, New York, NY, USA
| | - Feza Remzi
- Department of Colorectal Surgery, New York University Langone Health, New York, NY, USA
| | - Katherine Sun
- Department of Pathology, New York University Langone Health, New York, NY, USA; and
| | - Wenqing Cao
- Department of Pathology, New York University Langone Health, New York, NY, USA; and
| | - H Tarik Kani
- Division of Gastroenterology, New York University Grossman School of Medicine, New York, NY, USA
- Department of Gastroenterology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Jordan Axelrad
- Division of Gastroenterology, New York University Grossman School of Medicine, New York, NY, USA
| | - Suparna A Sarkar
- Department of Pathology, New York University Langone Health, New York, NY, USA; and
| |
Collapse
|
16
|
Dalal RS, Baranov E, Li J, Hong X, Korzenik J, Hamilton M, Sasson G. Small Cells, Big Problems: Small Cell Carcinoma of the Rectal Cuff After Ileal-Pouch Anal Anastomosis in a Patient with Ulcerative Colitis. Dig Dis Sci 2023; 68:4127-4129. [PMID: 37740133 DOI: 10.1007/s10620-023-08110-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 09/24/2023]
Affiliation(s)
- Rahul S Dalal
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- The Crohn's and Colitis Center of Brigham and Women's Hospital, 850 Boylston St Suite 201, Chestnut Hill, MA, 02467, USA.
| | - Esther Baranov
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jessica Li
- Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Xuefei Hong
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Joshua Korzenik
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Matthew Hamilton
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Gila Sasson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| |
Collapse
|
17
|
Barnes EL, Desai A, Kochhar GS. The Comparative Effectiveness of Ciprofloxacin and Metronidazole for an Initial Episode of Pouchitis: A Propensity-Matched Study. Am J Gastroenterol 2023; 118:1989-1996. [PMID: 37463438 PMCID: PMC10841309 DOI: 10.14309/ajg.0000000000002412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 07/14/2023] [Indexed: 07/20/2023]
Abstract
INTRODUCTION There is minimal evidence regarding the comparative effectiveness of individual antibiotics in the treatment of pouchitis. We sought to evaluate the comparative effectiveness of ciprofloxacin monotherapy, metronidazole monotherapy, and combination therapy (ciprofloxacin and metronidazole) in the treatment of an initial episode of pouchitis after ileal pouch-anal anastomosis for ulcerative colitis (UC). METHODS We performed a retrospective cohort study in TriNetX, a global federated research network of electronic health records. Primary outcomes were failure of initial antibiotic therapy and the development of recurrent pouchitis in the first 12 months after an initial episode of pouchitis. One-to-one propensity score matching was performed for age, sex, race, primary sclerosing cholangitis, nicotine dependence, obesity, and previous exposure to tumor necrosis factor inhibitors between the cohorts. RESULTS Among 271 patients who developed pouchitis (mean age at ileal pouch-anal anastomosis 35.8 years, male sex 57%) and were treated with ciprofloxacin, metronidazole, or combination therapy, 190 (70%) developed recurrent pouchitis. After propensity score matching, there was no significant difference in the odds of early relapse or nonresponse with ciprofloxacin compared with metronidazole monotherapy (adjusted odds ratio 0.56, 95% confidence interval 0.23-1.34) or when either monotherapy was compared with combination therapy. There was also no significant difference in odds of recurrent pouchitis when comparing patients treated with ciprofloxacin with metronidazole monotherapy (adjusted odds ratio 0.86, 95% confidence interval 0.40-1.84) or either monotherapy with combination therapy. DISCUSSION In this retrospective cohort study, we demonstrated no significant difference in the real-world effectiveness of ciprofloxacin, metronidazole, or combination therapy for the initial episode of pouchitis.
Collapse
Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Aakash Desai
- Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology & Nutrition, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
18
|
Zhao P, Guo X, Hu S, Liao C. A case of familial adenomatous polyposis with rectal cancer treated by abdominoperineal resection. Asian J Surg 2023; 46:5294-5295. [PMID: 37541870 DOI: 10.1016/j.asjsur.2023.07.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 07/09/2023] [Indexed: 08/06/2023] Open
Affiliation(s)
- Ping Zhao
- Department of Thyroid and Breast Surgery, Jingmen People's Hospital, 39 Xiangshan Avenue, Dongbao District, Jingmen City, Hubei Province, 448000, PR China.
| | - Xiang Guo
- Department of Emergency Surgery, The Second Affiliated Hospital of Kunming Medical University, 374 Dian Myanmar Avenue, Wuhua District, Kunming City, Yunnan Province, 650101, PR China.
| | - Sheng Hu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Kunming Medical University, 374 Dian Myanmar Avenue, Wuhua District, Kunming City, Yunnan Province, 650101, PR China.
| | - Chen Liao
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Kunming Medical University, 374 Dian Myanmar Avenue, Wuhua District, Kunming City, Yunnan Province, 650101, PR China.
| |
Collapse
|
19
|
Fadel MG, Geropoulos G, Warren OJ, Mills SC, Tekkis PP, Celentano V, Kontovounisios C. Risks Factors Associated with the Development of Crohn's Disease After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: A Systematic Review and Meta-Analysis. J Crohns Colitis 2023; 17:1537-1548. [PMID: 36961323 PMCID: PMC10588783 DOI: 10.1093/ecco-jcc/jjad051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Following ileal pouch-anal anastomosis [IPAA] for ulcerative colitis [UC], up to 16% of patients develop Crohn's disease of the pouch [CDP], which is a major cause of pouch failure. This systematic review and meta-analysis aimed to identify preoperative characteristics and risk factors for CDP development following IPAA. METHODS A literature search of the MEDLINE, EMBASE, EMCare and CINAHL databases was performed for studies that reported data on predictive characteristics and outcomes of CDP development in patients who underwent IPAA for UC between January 1990 and August 2022. Meta-analysis was performed using random-effect models and between-study heterogeneity was assessed. RESULTS Seven studies with 1274 patients were included: 767 patients with a normal pouch and 507 patients with CDP. Age at UC diagnosis (weighted mean difference [WMD] -2.85; 95% confidence interval [CI] -4.39 to -1.31; p = 0.0003; I2 54%) and age at pouch surgery [WMD -3.17; 95% CI -5.27 to -1.07; p = 0.003; I2 20%) were significantly lower in patients who developed CDP compared to a normal pouch. Family history of IBD was significantly associated with CDP (odds ratio [OR] 2.43; 95% CI 1.41-4.19; p = 0.001; I2 31%], along with a history of smoking [OR 1.80; 95% CI 1.35-2.39; p < 0.0001; I2 0%]. Other factors such as sex and primary sclerosing cholangitis were found not to increase the risk of CDP. CONCLUSIONS Age at UC diagnosis and pouch surgery, family history of IBD and previous smoking have been identified as potential risk factors for CDP post-IPAA. This has important implications towards preoperative counselling, planning surgical management and evaluating prognosis.
Collapse
Affiliation(s)
- Michael G Fadel
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Georgios Geropoulos
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Oliver J Warren
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Sarah C Mills
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Paris P Tekkis
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Colorectal Surgery, Royal Marsden NHS Foundation Trust, London, UK
| | - Valerio Celentano
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Christos Kontovounisios
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Colorectal Surgery, Royal Marsden NHS Foundation Trust, London, UK
| |
Collapse
|
20
|
O'Shea D, Picoraro JA. De Novo Crohn's Disease in the Pediatric Pouch. Inflamm Bowel Dis 2023:izad231. [PMID: 37815461 DOI: 10.1093/ibd/izad231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Indexed: 10/11/2023]
Abstract
Children who undergo ileal pouch anal anastomosis (IPAA) surgery for refractory ulcerative colitis (UC) may ultimately develop a Crohn's disease (CD) phenotype. This de novo CD is open to broad interpretation and misattribution, and its manifestation in children is poorly understood. The surgically altered environment of the ileal pouch is at risk of a spectrum of ileal pouch disorders, which have limited description in children. In this issue of Inflammatory Bowel Diseases, a multicenter, retrospective study of children with UC who underwent IPAA and developed de novo CD highlights the challenges and opportunities of ileal pouch characterization in children.
Collapse
Affiliation(s)
- Delia O'Shea
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Joseph A Picoraro
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| |
Collapse
|
21
|
Martinelli M, Romeo E, Caldaro T, Dimakou K, Papadopoulou A, Matar M, Assa A, Dipasquale V, Romano C, Aloi M, Alvisi P, Röser D, Kolho KL, Afzal N, Ledder O, Cohen S, Bronsky J, Escher JC, Brueckner A, Shamir R, Staiano A, Miele E. De Novo Crohn's Disease in Children With Ulcerative Colitis Undergoing Ileal Pouch-Anal Anastomosis: A Multicenter, Retrospective Study From the Pediatric IBD Porto Group of the ESPGHAN. Inflamm Bowel Dis 2023:izad199. [PMID: 37816230 DOI: 10.1093/ibd/izad199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND AND AIMS We sought to define the prevalence and to characterize possible predictive factors of Crohn's disease (CD) occurring in children with ulcerative colitis (UC) after ileal pouch-anal anastomosis (IPAA). METHODS This was a multicenter, retrospective study including 15 centers of the Porto IBD group of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition. Children with a confirmed diagnosis of UC undergoing colectomy with IPAA and a minimal follow up of 6 months were identified. The following data were collected: demographic data; endoscopic and histologic data; disease activity; laboratory exams; therapeutic history; indication for surgery, type, and timing; and IPAA functional outcomes and complications. In de novo CD cases, time of diagnosis, phenotype, location, and therapies were gathered. RESULTS We identified 111 UC children undergoing IPAA from January 2008 to June 2018 (median age at colectomy: 13 years; age range: 1-18 years; female/male: 59/52). The median time from diagnosis to colectomy was 16 (range, 0-202) months. At the last follow-up, 40 (36%) of 111 children developed pouchitis. The criteria for de novo CD were met in 19(17.1%) of 111 children with a 25-month median (range, 3-61 months). At last follow-up, 12 (63.1%) of 19 were treated with biologics and in 5 (26.3%) of 19 children, the pouch was replaced with definitive ileostomy. In a multivariable logistic regression model, decreased preoperative body mass index z scores (odds ratio, 2.2; 95% confidence interval, 1.1-4.4; P = .01) resulted as the only variable associated with CD development. CONCLUSIONS Children with UC undergoing IPAA carry a high risk of developing subsequent CD. De novo CD cases showed decreased preoperative body mass index z scores, identifying a poor nutritional status as a possible predictive factor.
Collapse
Affiliation(s)
- Massimo Martinelli
- Section of Pediatrics, Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
| | - Erminia Romeo
- Digestive Endoscopy and Surgery Unit, Bambino Gesu Children's Hospital-IRCCS, Rome, Italy
| | - Tamara Caldaro
- Digestive Endoscopy and Surgery Unit, Bambino Gesu Children's Hospital-IRCCS, Rome, Italy
| | - Konstantina Dimakou
- Division of Gastroenterology and Hepatology, First Department of Pediatrics, Children's Hospital Agia Sofia, University of Athens, Athens, Greece
| | - Alexandra Papadopoulou
- Division of Gastroenterology and Hepatology, First Department of Pediatrics, Children's Hospital Agia Sofia, University of Athens, Athens, Greece
| | - Manar Matar
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Sackler Faculty of Medicine, Tel-Aviv University, Petah-Tikva, Israel
| | - Amit Assa
- Juliet Keidan institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
| | - Valeria Dipasquale
- Pediatric Gastroenterology and Cystic Fibrosis Unit, University of Messina, Messina, Italy
| | - Claudio Romano
- Pediatric Gastroenterology and Cystic Fibrosis Unit, University of Messina, Messina, Italy
| | - Marina Aloi
- Pediatric Gastroenterology Unit, Department of Women's and Children's Health, Sapienza University, Rome, Italy
| | - Patrizia Alvisi
- Pediatric Gastroenterology Unit, Maggiore Hospital, Bologna, Italy
| | - Dennis Röser
- Department of Paediatrics, Hvidovre University Hospital, Copenhagen, Denmark
| | - Kaija Leena Kolho
- Children's Hospital, University of Helsinki and HUS Helsinki, Finland
| | - Nadeem Afzal
- Department of Paediatric Gastroenterology, Southampton Children's Hospital, Southampton, United Kingdom
- University of Portsmouth, Portsmouth, United Kingdom
| | - Oren Ledder
- Juliet Keidan institute of Pediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
| | - Schlomi Cohen
- Pediatric Gastroenterology Institute, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jiri Bronsky
- Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - Johanna C Escher
- Department of Pediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Annecarin Brueckner
- Dr. von Hauner Children's Hospital, Department of Pediatrics, University Hospital, Ludwig Maximilians University, Munich, Germany
| | - Raanan Shamir
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Sackler Faculty of Medicine, Tel-Aviv University, Petah-Tikva, Israel
| | - Annamaria Staiano
- Section of Pediatrics, Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
| | - Erasmo Miele
- Section of Pediatrics, Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
| |
Collapse
|
22
|
Abstract
As medical management of inflammatory bowel disease makes great advances, most patients with inflammatory bowel disease will have long life expectancies without need for total colectomy. With prolonged disease duration, however, there is increased risk of dysplasia leading to colorectal cancer. Multiple consensus and guideline documents have been published over the last decade with recommendations to optimize early detection and management of dysplastic lesions. Endoscopic technology has improved tremendously, even over the past few years. Previously invisible dysplasia has become visible in most cases with advanced imaging technologies that now allow for much clearer and more detailed mucosal inspection. New tools to facilitate endoscopic resection of visible lesions have also enabled patients to avoid colectomy, with resulting need to continue colon surveillance. There are limited or conflicting data leading to inconsistent recommendations regarding the need for random biopsies, the preferred endoscopic imaging technique, and surveillance intervals after resection of dysplasia. Similarly, there remains significant variability in the application of guidelines into daily practice and availability of and training with advanced imaging technologies. Here, we present a narrative review of which patients are at highest risk for dysplasia, the current guidelines on surveillance colonoscopy, factors affecting optimal mucosal visualization, enhanced imaging techniques, standardized reporting terminologies for surveillance colonoscopy, endoscopic management of dysplasia, indications for colectomy, and briefly on future potential technologies to assist in dysplasia detection.
Collapse
Affiliation(s)
| | - James D Lewis
- Division of Gastroenterology and Hepatology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
23
|
Ajufo A, Adigun AO, Mohammad M, Dike JC, Akinrinmade AO, Adebile TM, Ezuma-Ebong C, Bolaji K, Okobi OE. Factors Affecting the Rate of Colonoscopy Among African Americans Aged Over 45 Years. Cureus 2023; 15:e46525. [PMID: 37927674 PMCID: PMC10625396 DOI: 10.7759/cureus.46525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2023] [Indexed: 11/07/2023] Open
Abstract
African Americans continue to have a low rate of colonoscopy screening despite the U.S. Preventive Services Taskforce's (USPSTF) recommendations and its proven benefits. Colonoscopy has proven to be an effective screening and therapeutic procedure. Understanding the root cause of the problem is a crucial step toward achieving the desired colonoscopy rate among this population. This paper evaluates factors that contribute to the underutilization of colonoscopy. The paper also analyzes strategies that could be maximized to increase colonoscopy rates, minimize colorectal cancer inequalities, and promote optimal colorectal health among African Americans.
Collapse
Affiliation(s)
- Afomachukwu Ajufo
- Internal Medicine, All Saints University School of Medicine, Roseau, DMA
| | - Aisha O Adigun
- Infectious Diseases, University of Louisville, Louisville, USA
| | - Majed Mohammad
- Geriatrics, Mount Carmel Grove City Hospital, Grove City, USA
| | - Juliet C Dike
- Internal Medicine, University of Calabar, Calabar, NGA
| | - Abidemi O Akinrinmade
- Medicine and Surgery, Benjamin S. Carson School of Medicine, Babcock University, Ilishan-Remo, NGA
| | - Temitayo M Adebile
- Public Health, Georgia Southern University, Statesboro, USA
- Nephrology, Boston Medical Center, Malden, USA
| | | | | | - Okelue E Okobi
- Family Medicine, Larkin Community Hospital Palm Springs Campus, Miami, USA
- Family Medicine, Medficient Health Systems, Laurel, USA
- Family Medicine, Lakeside Medical Center, Belle Glade, USA
| |
Collapse
|
24
|
Young S, Lee B, Smukalla S, Axelrad J, Chang S. Anorectal Manometry in Patients With Fecal Incontinence After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: A Cohort Study. Crohns Colitis 360 2023; 5:otad063. [PMID: 38077748 PMCID: PMC10708921 DOI: 10.1093/crocol/otad063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Indexed: 02/12/2024] Open
Abstract
Background Fecal incontinence commonly occurs in patients with ulcerative colitis and ileal pouch-anal anastomosis. There is a paucity of manometric data in pouch patients. We aimed to better define manometric parameters in pouch patients with fecal incontinence. Methods We compared clinical and manometric variables in ulcerative colitis patients with pouch and fecal incontinence to ulcerative colitis patients with pouch without fecal incontinence and to non-ulcerative colitis patients with fecal incontinence. Manometric data for the 3 cohorts were compared to established normative data. An independent-samples t-test was performed for continuous variables, and chi-square test was used for categorical variables. Logistic regression was performed to identify predictors of incontinence in pouch patients (P < .05). Results Among 26 pouch patients with fecal incontinence (73% female), 26 pouch patients without fecal incontinence (35% female), and 84 patients with fecal incontinence without ulcerative colitis (68% female), there were no differences in anorectal pressures between patients with fecal incontinence. Lower pressures were observed in pouch patients with fecal incontinence compared to those without fecal incontinence. Resting pressure was similar between pouch patients with fecal incontinence and healthy controls (60.9 ± 36.1 mmHg vs. 66.9 ± 3.2 mmHg, P = .40). Female sex (P = .019) and defecatory disorders (P = .033) each independently predicted fecal incontinence in pouch patients. Conclusions Pouch patients with fecal incontinence have lower anorectal pressures compared to pouch patients without incontinence, though have similar pressures to non-ulcerative colitis patients with fecal incontinence. Pouch patients with fecal incontinence have similar resting pressures as healthy controls. Distinct manometric normative values for pouch patients are needed.
Collapse
Affiliation(s)
- Sigrid Young
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Briton Lee
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Scott Smukalla
- Division of Gastroenterology, NYU Langone Health, New York, NY, USA
| | - Jordan Axelrad
- Division of Gastroenterology, Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA
| | - Shannon Chang
- Division of Gastroenterology, Inflammatory Bowel Disease Center, NYU Langone Health, New York, NY, USA
| |
Collapse
|
25
|
Abstract
Importance Ulcerative colitis (UC) is a chronic inflammatory condition of the colon, with a prevalence exceeding 400 per 100 000 in North America. Individuals with UC have a lower life expectancy and are at increased risk for colectomy and colorectal cancer. Observations UC impairs quality of life secondary to inflammation of the colon causing chronic diarrhea and rectal bleeding. Extraintestinal manifestations, such as primary sclerosing cholangitis, occur in approximately 27% of patients with UC. People with UC require monitoring of symptoms and biomarkers of inflammation (eg, fecal calprotectin), and require colonoscopy at 8 years from diagnosis for surveillance of dysplasia. Risk stratification by disease location (eg, Montreal Classification) and disease activity (eg, Mayo Score) can guide management of UC. First-line therapy for induction and maintenance of remission of mild to moderate UC is 5-aminosalicylic acid. Moderate to severe UC may require oral corticosteroids for induction of remission as a bridge to medications that sustain remission (biologic monoclonal antibodies against tumor necrosis factor [eg, infliximab], α4β7 integrins [vedolizumab], and interleukin [IL] 12 and IL-23 [ustekinumab]) and oral small molecules that inhibit janus kinase (eg, tofacitinib) or modulate sphingosine-1-phosphate (ozanimod). Despite advances in medical therapies, the highest response to these treatments ranges from 30% to 60% in clinical trials. Within 5 years of diagnosis, approximately 20% of patients with UC are hospitalized and approximately 7% undergo colectomy. The risk of colorectal cancer after 20 years of disease duration is 4.5%, and people with UC have a 1.7-fold higher risk for colorectal cancer compared with the general population. Life expectancy in people with UC is approximately 80.5 years for females and 76.7 years for males, which is approximately 5 years shorter than people without UC. Conclusions and Relevance UC affects approximately 400 of every 100 000 people in North America. An effective treatment for mild to moderate UC is 5-aminosalicylic acid, whereas moderate to severe UC can be treated with advanced therapies that target specific inflammation pathways, including monoclonal antibodies to tumor necrosis factor, α4β7 integrins, and IL-12 and IL-23 cytokines, as well as oral small molecule therapies targeting janus kinase or sphingosine-1-phosphate.
Collapse
Affiliation(s)
- Beatriz Gros
- IBD Edinburgh Unit, Western General Hospital, Edinburgh, Scotland
- Department of Gastroenterology and Hepatology, Reina Sofía University Hospital, Córdoba, Spain
| | - Gilaad G Kaplan
- Division of Gastroenterology and Hepatology, Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
26
|
Baker ME, Hull T, Holubar S, Lightner A, Qazi T. Clinical issues facing pouch patients: an introduction to a special issue on the ileal pouch. Abdom Radiol (NY) 2023; 48:2913-2917. [PMID: 36334124 DOI: 10.1007/s00261-022-03723-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022]
Abstract
For over 40 years, restorative proctocolectomy has been used in patients with ulcerative colitis or familial adenomatous polyposis undergoing proctocolectomy. Radiologists are now encountering an increasing number of patients with an ileal pouch and therefore need to understand the clinical issues and concerns in these patients. This review is the introduction of a special issue on the ileal pouch and was written with both surgeon and gastroenterology input. The intent is to assist the radiologist in understanding the clinical questions posed by both the patients and their physicians. Subsequent sessions will address specific imaging modalities and techniques, how the gastroenterologists and surgeons address issues with these patients, and a final session summarizing the sessions and speculating on future investigations and approaches.
Collapse
Affiliation(s)
- Mark E Baker
- Imaging Institute, 9500 Euclid Ave/L10, Cleveland, OH, 44195, USA.
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
- Crohn's Disease Focus Panel of the Society of Abdominal Radiology, East Dundee, USA.
| | - Tracy Hull
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Stefan Holubar
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amy Lightner
- Department of Colorectal Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Taha Qazi
- Department of Gastroenterology and Hepatology, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
- Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
27
|
Abstract
Ileal pouch surgery is the surgical gold standard treatment for patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). However, ileal pouch surgery is a technically challenging procedure and is associated with high morbidity. Clinical presentations of pouch complications are often nonspecific but imaging can identify many of these complications and is essential in clinical management. This paper will focus on magnetic resonance imaging (MRI) of the ileal pouch, including recommended MRI protocol and approach to imaging interpretation with an emphasis on those ileal pouch complications particularly well evaluated with MRI.
Collapse
Affiliation(s)
- Chenchan Huang
- NYU Langone Health, 660 First Avenue, New York, NY, 10016, USA.
| | - Bari Dane
- NYU Langone Health, 660 First Avenue, New York, NY, 10016, USA
| | | | - Justin Ream
- , 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| |
Collapse
|
28
|
Dane B, Huang C, Luk L, Ream J, Fletcher JG, Baker M. Contrast enema, CT, and small bowel series of the ileal pouch. Abdom Radiol (NY) 2023; 48:2935-2943. [PMID: 37043026 DOI: 10.1007/s00261-023-03903-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/13/2023]
Abstract
This manuscript is part of the ileal pouch symposium and will describe the water-soluble contrast enema, CT, and small bowel series. MRI and other imaging modalities are discussed elsewhere in the symposium. Water-soluble contrast enema and CT are excellent for the evaluation of the ileal pouch. Contrast enema and CT with anal contrast administration can allow for anastomotic integrity and pouch assessment. Pre-pouch ileum, extra-intestinal manifestations, and acute symptomatology are best assessed with CT. The contrast small bowel examination is of limited utility in pouch patients and should not be performed. Indications, imaging technique, and anatomic pouch assessment with water-soluble contrast enema, CT, and contrast small bowel examination will be reviewed here.
Collapse
Affiliation(s)
- Bari Dane
- NYU Langone Health, 660 1st Avenue, NewYork, NY, 10016, USA.
| | - Chenchan Huang
- NYU Langone Health, 660 1st Avenue, NewYork, NY, 10016, USA
| | - Lyndon Luk
- Columbia University, 622 West 168th Street, New York, NY, 10032, USA
| | - Justin Ream
- Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | | | - Mark Baker
- Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| |
Collapse
|
29
|
Panganiban RP, Tuan A, Hart M, Pelton M, Mikhail D, Akhtar S, Bogale K, Deiling S, Zhou S, Coates MD, Yochum GS, Koltun W. Pyoderma Gangrenosum Is Associated With Increased Risk of Inflammatory Pouch-Related Complications: A Retrospective Cohort Study. Crohns Colitis 360 2023; 5:otad024. [PMID: 37663924 PMCID: PMC10474334 DOI: 10.1093/crocol/otad024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Indexed: 09/05/2023] Open
Abstract
Background Pyoderma gangrenosum (PG) is a rare, neutrophilic dermatosis that is a well-established extraintestinal manifestation (EIM) of inflammatory bowel disease. The clinical implications of developing PG in patients with ulcerative colitis (UC) who undergo total proctocolectomy colectomy and ileal pouch anal anastomosis (TPC-IPAA) surgery remain unknown. Methods Study participants were selected from patients enrolled in the Carlino Family Inflammatory Bowel and Colorectal Disease Biobank between 1998 and 2021 with a pre-colectomy diagnosis of UC and who underwent TPC-IPAA surgery. A retrospective study comparing patients with PG and those without PG was performed. The outcomes measured included the development of pouchitis, pouchitis classification, presence of pouch fistula, anal fistula, anal stenosis, and pouch failure. Results In this study, 357 IPAA patients were included, 10 of whom suffered PG. Patients with PG and without PG had similar demographics and clinical characteristics. Both groups had similar rates of pouchitis (80% in PG patients and 64% in patients without PG, P = .504). However, IPAA patients with PG had a higher risk of developing pouch fistula (50% vs 10%, P = .002), anal fistula (40% vs 12%, P = .031), and Crohn's-like disease of the pouch (70% vs 15%, P = .003) compared to patients without PG. Patients who developed PG prior to their first episode of pouchitis were more likely to eventually experience pouch failure (odds ratio: 20.7, 95% confidence interval: 3.9, 110.7, q = 0.003 after false discovery rate adjustment). Conclusions Among UC patients who undergo TPC-IPAA surgery, the development of PG portends poor pouch outcomes and is predictive of pouch failure.
Collapse
Affiliation(s)
- Ronaldo Paolo Panganiban
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
- Division of Colorectal Surgery, Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Alyssa Tuan
- College of Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Maxwell Hart
- Department of Medicine, The University of Arizona College of Medicine Tucson, Tucson, AZ, USA
| | - Mathew Pelton
- Department of Medicine, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Daniella Mikhail
- Department of Medicine, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Sarah Akhtar
- Department of Internal Medicine, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Kaleb Bogale
- Columbia University Irving Medical Center, New York, NY, USA
| | - Susan Deiling
- Division of Colorectal Surgery, Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Shouhao Zhou
- Division of Biostatistics and Bioinformatics, Department of Public Health Science, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Mathew D Coates
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Gregory S Yochum
- Division of Colorectal Surgery, Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, USA
- Department of Biochemistry and Molecular Biology, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Walter Koltun
- Division of Colorectal Surgery, Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, USA
| |
Collapse
|
30
|
Prentice RE, Wright EK, Flanagan E, Kamm MA, Goldberg R, Ross AL, Burns M, Bell SJ. Evaluation and management of ileal pouch-anal anastamosis (IPAA) complications in pregnancy, and the impacts of an IPAA on fertility. Eur J Gastroenterol Hepatol 2023; 35:609-612. [PMID: 36966753 DOI: 10.1097/meg.0000000000002538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) remains the preferred surgical option for medically refractory ulcerative colitis. Management of individuals with an IPAA prior to and during pregnancy presents challenges that can have serious consequences. Infertility, mechanical obstructive and inflammatory pouch complications are frequently encountered in pregnant women with an IPAA. Mechanical obstructions occur due to a variety of underlying aetiologies, including stricturing disease, adhesions and pouch twists. Conservative management of such obstructions often results in resolution of symptoms without a need for endoscopic or surgical intervention, although endoscopic decompression may be attempted in isolation or as a bridge to definitive surgical intervention. Parenteral nutrition, and early delivery, may also be necessary. Faecal calprotectin and intestinal ultrasound, both of which are accurate in pregnancy, are useful in the setting of suspected inflammatory pouch complications, in some circumstances allowing for avoidance of pouchoscopy. Penicillin-based antimicrobials can be considered first line in pregnancy for the management of pouchitis and pre-pouch ileitis, and biologics can be safely instituted in the setting of refractory disease or suspected Crohn's disease-like inflammation of the pouch or pre-pouch ileum. Pragmatism, clear patient communication and multidisciplinary discussion are essential in approaching pregnant women with complications of an IPAA, particularly given the lack of definitive evidence to guide therapeutic decisions.
Collapse
Affiliation(s)
- Ralley E Prentice
- Department of Gastroenterology, St Vincent's Hospital, Melbourne
- Department of Gastroenterology, Monash Health, Clayton, Victoria
- Monash University, Clayton
| | - Emily K Wright
- Department of Gastroenterology, St Vincent's Hospital, Melbourne
- University of Melbourne, Melbourne, Australia
| | - Emma Flanagan
- Department of Gastroenterology, St Vincent's Hospital, Melbourne
- University of Melbourne, Melbourne, Australia
| | - Michael A Kamm
- Department of Gastroenterology, St Vincent's Hospital, Melbourne
- University of Melbourne, Melbourne, Australia
| | - Rimma Goldberg
- Department of Gastroenterology, Monash Health, Clayton, Victoria
- Monash University, Clayton
| | - Alyson L Ross
- Department of Gastroenterology, St Vincent's Hospital, Melbourne
| | - Megan Burns
- Department of Gastroenterology, Monash Health, Clayton, Victoria
| | - Sally J Bell
- Department of Gastroenterology, Monash Health, Clayton, Victoria
- Monash University, Clayton
- University of Melbourne, Melbourne, Australia
| |
Collapse
|
31
|
Carman N, Picoraro JA. Advances in Endoscopy for Pediatric Inflammatory Bowel Disease. Gastrointest Endosc Clin N Am 2023; 33:447-461. [PMID: 36948755 DOI: 10.1016/j.giec.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Endoscopic characterization of pediatric inflammatory bowel disease (IBD) has developed in accordance with advances in treatment and improved understanding of disease progression and complications. Reliable and consistent endoscopic reporting practices and tools continue to evolve. The roles of endoscopic ultrasonography, capsule endoscopy, and deep enteroscopy in the care of children and adolescents with IBD are beginning to be clarified. Opportunities for therapeutic intervention with endoscopy in pediatric IBD, including endoscopic balloon dilation and electroincision therapy, require further study. This review discusses the current utility of endoscopic assessment in Pediatric Inflammatory Bowel Disease, as well as emerging and evolving techniques to improve patient care.
Collapse
Affiliation(s)
- Nicholas Carman
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, CHEO Inflammatory Bowel Disease Centre, Children's Hospital of Eastern Ontario, University of Ottawa, Ontario, Canada; Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, Sickkids Inflammatory Bowel Disease Centre, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
| | - Joseph A Picoraro
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center, 622 West 168th Street, PH17-105, New York, NY 10032, USA; NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY 10032, USA
| |
Collapse
|
32
|
Travis S, Silverberg MS, Danese S, Gionchetti P, Löwenberg M, Jairath V, Feagan BG, Bressler B, Ferrante M, Hart A, Lindner D, Escher A, Jones S, Shen B. Vedolizumab for the Treatment of Chronic Pouchitis. N Engl J Med 2023; 388:1191-1200. [PMID: 36988594 DOI: 10.1056/nejmoa2208450] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
BACKGROUND Approximately half the patients with ulcerative colitis who undergo restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) will subsequently have pouchitis, and among those patients, one fifth will have chronic pouchitis. METHODS We conducted a phase 4, double-blind, randomized trial to evaluate vedolizumab in adult patients in whom chronic pouchitis had developed after undergoing IPAA for ulcerative colitis. Patients were assigned (in a 1:1 ratio) to receive vedolizumab intravenously at a dose of 300 mg or placebo on day 1 and at weeks 2, 6, 14, 22, and 30. All the patients received concomitant ciprofloxacin from weeks 1 to 4. The primary end point was modified Pouchitis Disease Activity Index (mPDAI)-defined remission (an mPDAI score of ≤4 and a reduction from baseline of ≥2 points in the mPDAI total score; scores range from 0 to 12, with higher scores indicating more severe pouchitis) at week 14. The mPDAI is based on clinical symptoms and endoscopic findings. Other efficacy end points included mPDAI-defined remission at week 34, mPDAI-defined response (a reduction from baseline of ≥2 points in the mPDAI score) at weeks 14 and 34, and PDAI-defined remission (a PDAI score of ≤6 and a reduction from baseline of ≥3 points; scores range from 0 to 18, with higher scores indicating more severe pouchitis) at weeks 14 and 34. The PDAI is based on clinical symptoms, endoscopic findings, and histologic findings. RESULTS Among the 102 patients who underwent randomization, the incidence of mPDAI-defined remission at week 14 was 31% (16 of 51 patients) with vedolizumab and 10% (5 of 51 patients) with placebo (difference, 21 percentage points; 95% confidence interval [CI], 5 to 38; P = 0.01). Differences in favor of vedolizumab over placebo were also seen with respect to mPDAI-defined remission at week 34 (difference, 17 percentage points; 95% CI, 0 to 35), mPDAI-defined response at week 14 (difference, 30 percentage points; 95% CI, 8 to 48) and at week 34 (difference, 22 percentage points; 95% CI, 2 to 40), and PDAI-defined remission at week 14 (difference, 25 percentage points; 95% CI, 8 to 41) and at week 34 (difference, 19 percentage points; 95% CI, 2 to 37). Serious adverse events occurred in 3 of 51 patients (6%) in the vedolizumab group and in 4 of 51 patients (8%) in the placebo group. CONCLUSIONS Treatment with vedolizumab was more effective than placebo in inducing remission in patients who had chronic pouchitis after undergoing IPAA for ulcerative colitis. (Funded by Takeda; EARNEST ClinicalTrials.gov number, NCT02790138; EudraCT number, 2015-003472-78.).
Collapse
Affiliation(s)
- Simon Travis
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Mark S Silverberg
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Silvio Danese
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Paolo Gionchetti
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Mark Löwenberg
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Vipul Jairath
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Brian G Feagan
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Brian Bressler
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Marc Ferrante
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Ailsa Hart
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Dirk Lindner
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Armella Escher
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Stephen Jones
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| | - Bo Shen
- From the Translational Gastroenterology Unit and Kennedy Institute, National Institute for Health and Care Research Oxford Biomedical Research Centre, University of Oxford, Oxford (S.T.), and the Inflammatory Bowel Disease Unit, St. Mark's Hospital and Imperial College London, London (A.H.) - both in the United Kingdom; the Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto (M.S.S.), the Department of Medicine, Division of Gastroenterology, Western University (V.J.), and Alimentiv (V.J., B.G.F.), London, ON, and the Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver (B.B.) - all in Canada; the Gastroenterology and Gastrointestinal Endoscopy Unit, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele, Milan (S.D.), and the Inflammatory Bowel Disease Unit, IRCCS Azienda Ospedaliera-Universitaria di Bologna, Bologna (P.G.) - both in Italy; the Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Academic Medical Center, Amsterdam (M.L.); the Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium (M.F.); Takeda Pharmaceuticals International, Zurich, Switzerland (D.L., A.E., S.J.); and the Interventional Inflammatory Bowel Disease Center and the Center for Ileal Pouch Disorders, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York (B.S.)
| |
Collapse
|
33
|
Kimura H, Toritani K, Kunisaki R, Tatsumi K, Koganei K, Sugita A, Endo I. Impact of the body mass index on the retention of the anorectal mucosa after double-stapled ileal pouch-anal anastomosis for ulcerative colitis. BMC Gastroenterol 2023; 23:32. [PMID: 36755253 DOI: 10.1186/s12876-023-02667-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/06/2023] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Double-stapled ileal pouch-anal anastomosis (DS-IPAA) is easy to construct and has a good functional outcome in patients with ulcerative colitis (UC). However, retention of the anorectal mucosa may lead to a subsequent risk of inflammation and neoplasia. This study aimed to identify factors associated with the retention of a large amount of anorectal mucosa after DS-IPAA. METHODS The medical records of 163 patients who had undergone one-stage total proctocolectomy and DS-IPAA for UC between 2007 and 2020 were retrospectively reviewed. The patients were divided into two groups according to the length of the retained mucosa. The high anastomosis group was defined as having a retained mucosal length of ≥ 30 mm in the anterior or posterior wall. Clinical factors were compared between the high and low anastomosis groups. RESULTS The high anastomosis group showed a significantly higher body mass index (BMI) (high vs. low: 23.2 vs. 19.0), longer operation time (304 vs. 263) and greater blood loss (357 vs. 240). In the multivariate analysis, high BMI was the only factor significantly associated with high anastomosis (odds ratio 1.32). There was a positive correlation between BMI and the length of the retained mucosa. CONCLUSIONS In DS-IPAA, BMI showed the strongest association with the retention of a large amount of the anorectal mucosa. In high BMI patients, although the risk of inability of anastomosis is little than that of IPAA with mucosectomy, the possible retention of a large amount of mucosa should be considered.
Collapse
|
34
|
Abstract
MAIN TEXT INTRODUCTION The use of biologic therapy for antibiotic-refractory pouchitis is controversial, due to few studies on the subject and lack of convincing results. OBJECTIVES To study the efficacy of biologic therapy for refractory pouchitis. MATERIALS AND METHODS In this retrospective study, patient records at the Medical and Surgical departments in our hospital during an eleven-year period were scrutinized. 25 patients treated with biologics for refractory pouchitis were identified. RESULTS The majority of these patients (n = 19, 76%) had either good or partial effect of biologic therapy for refractory pouchitis. Six of these patients did not respond until the second or third-line treatment. All naïve patients (n = 14) had good or partial response regardless if the diagnosis was idiopathic or Crohn's-like pouchitis. In comparison, only 45% (n = 5) of the patients with prior exposure to biologics (n = 11) had a positive response. Six of ten patients treated with second or third-line therapy had a good or partial response. All not naïve patients who had previously been treated with Infliximab (n = 9) had adverse reactions when the same drug was given for pouchitis. CONCLUSIONS This retrospective study suggests that biologic therapy may be effective for both idiopathic and Crohn's-like refractory pouchitis. Naïve patients seem to respond more successfully than not naïve patients. In cases without response on first-line treatment should second-line treatment be considered. Due to the high risk of adverse reactions Infliximab should be avoided to not naïve patients.
Collapse
Affiliation(s)
- Sigrid Lindh
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jonas Bengtsson
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jerzy Kaczynski
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| |
Collapse
|
35
|
Calvino-Suarez C, Ferreiro-Iglesias R, Baston Rey I, Barreiro-de Acosta M. Managing ulcerative colitis after surgery. Front Med (Lausanne) 2023; 9:1081940. [PMID: 36687422 PMCID: PMC9846502 DOI: 10.3389/fmed.2022.1081940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/05/2022] [Indexed: 01/05/2023] Open
Abstract
Management of ulcerative colitis after surgery suggested by guidelines (total proctocolectomy with ileal-pouch anal anastomosis) is a big challenge for physicians because patients who believed that their disease had been cured started experiencing very uncomfortable symptoms repeatedly. A high number of patients develop episodes of pouchitis, which is a non-specific inflammation of the pouch whose etiology is unknown. Antibiotics are the elective treatment for acute pouchitis, but regarding chronic pouchitis, this condition is very complicated to treat due to the absence of well-designed specific studies for this group of patients. Antibiotics, budesonide, and biological therapies are some of the recommended drugs for these patients, but despite their use, some need a permanent ileostomy.
Collapse
|
36
|
Castaño Llano R, Molina Meneses SP, Puerta JD, Escobar RM, Salazar Ochoa S, Puerta JE, Barreiro-de Acosta M. Ileal reservoir-associated complications in ulcerative colitis versus familial adenomatous polyposis: Impact on patient quality of life. Gastroenterol Hepatol 2023; 46:39-47. [PMID: 35605822 DOI: 10.1016/j.gastrohep.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 05/04/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Proctocolectomy with ileal reservoir is the surgical procedure of choice for patients with ulcerative colitis and familial adenomatous polyposis. OBJECTIVES To evaluate long-term postoperative complications (1994-2019) in patients operated for familial adenomatous polyposis (FAP) and ulcerative colitis (UC) and the degree of satisfaction with the procedure. METHODS Observational study based on the analysis of a retrospective database with prospective follow-up in 115 consecutive patients: 79 with UC and 36 with FAP. A total of 88 patients were followed up, 60 with UC and 28 with PFA. RESULTS 48 males (54.4%) with a mean age of 44.8 ± 10.6 years were evaluated. Indications for surgery were intractable disease in 54 patients (47%), dysplasia/cancer in 43 (37%), severe bleeding in 4 (4%) and perforation in 3 (3%). A proctectomy and mucosectomy of the rectal stump was performed in 67 (76.1%), and a double stapling technique in 21. A protective ileostomy was performed in all patients with UC and FAP. No differences were found in early complications between the two groups. Late complications showed a higher rate of reservoritis in UC patients compared to FAP (44.9 vs. 14.3%, p = 0.001), with more refractory reservoritis in the UC group (13.3 vs. 0%, p = 0.04) with no differences in bowel obstruction, strictures, or anastomotic fistulas. Overall satisfaction and adaptation were considered good in 87% of UC patients and only 57% in the FAP group (p < 0.01). CONCLUSIONS Proctocolectomy with ileal reservoir has comparable morbidity and mortality, except for the higher rate of reservoritis in patients with a history of UC, despite this contingency there is a better quality of life and greater acceptance of surgery in UC patients than in FAP patients.
Collapse
Affiliation(s)
- Rodrigo Castaño Llano
- Grupo de Gastrohepatología, Universidad de Antioquia, Instituto de Cancerología, Las Américas-AUNA, Medellín, Antioquia, Colombia
| | | | - Juan Darío Puerta
- Clínica las Américas, Docencia en Cirugía, Universidad Pontificia Bolivariana, Medellín, Antioquia, Colombia
| | | | | | | | - Manuel Barreiro-de Acosta
- Unidad de Enfermedad Inflamatoria Intestinal, Servicio de Aparato Digestivo, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, España; Digestivo, Universidad de Santiago de Compostela, Santiago de Compostela, A Coruña, España; Grupo Español de Trabajo en Enfermedad de Crohn y Colitis Ulcerosa (GETECCU), Santiago de Compostela, A Coruña, España
| |
Collapse
|
37
|
Chen SL, Faye AS, Chang S. Ileal Pouch-Anal Anastomosis in the Older Adult: a Review of Postoperative Outcomes and Pouchitis Treatment. Curr Treat Options Gastroenterol 2022; 20:564-581. [PMID: 36844648 PMCID: PMC9957085 DOI: 10.1007/s11938-022-00405-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/12/2022] [Indexed: 06/18/2023]
Abstract
PURPOSE OF REVIEW Ileal pouch-anal anastomosis (IPAA) has become the preferred surgical treatment for patients with medically refractive ulcerative colitis (UC). Previous studies have suggested that outcomes of this procedure may be worse in older patients; however, more recent reports have suggested that IPAA in select patients is safe, feasible, and results in good quality of life. In this review, we discuss the recent literature surrounding clinical considerations and treatment management of IPAA in older adults. RECENT FINDINGS IPAA complication rates and adverse events are similar in the older adult population, as compared to the younger adult patient population. Although fecal urgency and incontinence may be more common among older adults, chronological age alone is not a contraindication for IPAA surgery, as good quality of life can still be achieved. In this review, we will also discuss the development of pouchitis after IPAA, particularly among older adults, as the emergence of newer biologic drugs has shifted the treatment landscape. SUMMARY IPAA can be a safe and effective treatment modality for older adults with UC, with high self-reported patient satisfaction. Patient optimization and careful case selection are vital to achieving these outcomes, and specialized preoperative assessments and counseling can help facilitate the proper treatment.
Collapse
Affiliation(s)
- Sabrina L. Chen
- Department of Gastroenterology, New York University Grossman School of Medicine, 305 East 33rd Street, NY 10016 New York, USA
| | - Adam S. Faye
- Department of Gastroenterology, New York University Grossman School of Medicine, 305 East 33rd Street, NY 10016 New York, USA
| | - Shannon Chang
- Department of Gastroenterology, New York University Grossman School of Medicine, 305 East 33rd Street, NY 10016 New York, USA
| |
Collapse
|
38
|
Tome J, Raffals LE, Pardi DS. Management of Acute and Chronic Pouchitis. Dis Colon Rectum 2022; 65:S69-76. [PMID: 35905290 DOI: 10.1097/DCR.0000000000002562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Restorative proctocolectomy with IPAA is the procedure of choice when colectomy is needed for medically refractory ulcerative colitis. Pouchitis is one of the most common complications among patients who have undergone IPAA and represents a spectrum of disease varying in both phenotype and clinical course. OBJECTIVE This study aimed to assist clinicians and surgeons in the treatment of both acute and chronic pouchitis, including newer therapies and future directions. DIAGNOSIS AND MANAGEMENT Diagnosis is made by endoscopy of the pouch with biopsy because other conditions may produce similar symptoms such as increased stool frequency, abdominal cramps, and urgency. Pouchitis is classified by duration (acute versus chronic), disease pattern (infrequent, relapsing, and continuous), and response to antibiotics (responsive, dependent, and refractory). The Pouchitis Disease Activity Index may be used to measure disease activity. The management of pouchitis is guided by the disease phenotype. Acute episodes are treated with an initial 2-week course of antibiotics (typically ciprofloxacin or metronidazole), although patients with relapsing or chronic pouchitis may require long-term antibiotic treatment or the cycling of different antibiotics. Certain probiotics may also be used for maintenance therapy in those with chronic symptoms. For patients with chronic antibiotic refractory pouchitis, oral budesonide, immunosuppressive agents (azathioprine), or biologic therapy (infliximab, adalimumab, vedolizumab, and ustekinumab) may be required for both induction and maintenance with close monitoring for potential side effects. In rare cases, diverting ileostomy or pouch excision may be required. CONCLUSION Pouchitis represents a spectrum of disease phenotypes, ranging from acute antibiotic responsive pouchitis to chronic antibiotic refractory pouchitis. The management of pouchitis is primarily directed by the disease phenotype.
Collapse
|
39
|
Akiyama S, Dyer EC, Rubin DT. Diagnostic and Management Considerations for the IPAA With Crohn's Disease-Like Features. Dis Colon Rectum 2022; 65:S77-84. [PMID: 35867686 DOI: 10.1097/DCR.0000000000002547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Patients with ulcerative colitis often develop medically refractory colonic inflammation or colorectal neoplasia, and approximately 10% to 15% of patients require surgery. The most common surgical procedure is a restorative proctocolectomy with IPAA. Even if the preoperative diagnosis is ulcerative colitis, approximately 10% of patients can develop inflammatory pouch conditions resembling a Crohn's disease phenotype. OBJECTIVE This study aimed to review the diagnostic approach, prognosis, and management of IPAA with Crohn's disease-like features. DATA SOURCES The data sources include search in electronic databases. STUDY SELECTION This narrative review included studies focusing on pouches with Crohn's disease-like features. MAIN OUTCOME MEASURES The main topics in this review included the pathogenesis, risk factors, diagnosis, phenotypes, prognosis, and medications of pouches with Crohn's disease-like features. RESULTS A diagnostic approach for the pouch conditions resembling a Crohn's disease phenotype should be based on history-taking to evaluate its risk factors and endoscopic assessment of the pouch. Prior disease history and pathology, location of pouch complications, and timing of complications offer clues for the differential diagnosis of this phenotype. We advocate for the more descriptive term "pouch with Crohn's disease-like features" and reserve the term "Crohn's disease of the pouch" for patients who undergo IPAA and have a precolectomy diagnosis of Crohn's disease or whose colectomy pathology revealed Crohn's disease. Medications, which are often used for traditional Crohn's disease, show efficacy in pouches with Crohn's disease-like features as well. The poor prognosis associated with pouches with Crohn's disease-like features, particularly the fistulizing phenotype, underscores the importance of proactive monitoring and therapeutic intervention. LIMITATIONS The limitations include no explicit criteria for article selection. CONCLUSIONS This review suggests future research should seek to understand the natural history and meaningful shorter and longer term therapeutic targets for these types of pouch phenotypes. Long-term follow-up and prospective preoperative and postoperative interventional trials of treatments and prevention strategies are needed.
Collapse
|
40
|
Abstract
BACKGROUND In patients with ulcerative colitis or familial adenomatous polyposis who develop neoplasia or fail medical therapy and require colectomy, restorative proctocolectomy with IPAA is often indicated. Although often well tolerated, IPAA can be complicated by cuffitis or inflammation of the remaining rectal cuff. Although much has been published on this subject, there is no clear and comprehensive synthesis of the literature regarding cuffitis. METHODS Our systematic literature review analyzes 34 articles to assess the frequency, cause, pathogenesis, diagnosis, classification, complications, and treatment of cuffitis. RESULTS Cuffitis occurs in an estimated 10.2% to 30.1% of pouch patients. Purported risk factors include rectal cuff length >2 cm, pouch-rectal anastomosis, stapled anastomosis, J-pouch configuration, 2- or 3-stage IPAA, preoperative Clostridium difficile infection, toxic megacolon, fulminant colitis, preoperative biologic use, medically refractory disease, immunomodulator/steroids use within 3 months of surgery, extraintestinal manifestations of IBD, and BMI <18.5 kg/m2 at the time of colectomy. Adverse consequences associated with cuffitis include decreased quality-of-life scores, increased risk for pouchitis, pouch failure, pouch excision, and pouch neoplasia. CONCLUSIONS Given the similarities between pouchitis and cuffitis, diagnosis and treatment of cuffitis should proceed according to the International Ileal Pouch Consortium guidelines. This review found that the majority of the current literature fails to distinguish between classic cuffitis (a form of reminant ulcerative proctitis) and nonclassic cuffitis (resulting from other causes). Further work is needed to distinguish the unique risk factors and endoscopic characteristics associated with each subtype, and further randomized clinical trials should be conducted to strengthen the evidence for treatment options.
Collapse
|
41
|
Lee KE, Shen B. Endoscopic Therapy for Pouch Leaks and Strictures: A Systematic Review. Dis Colon Rectum 2022; 65:S92-S104. [PMID: 35797499 DOI: 10.1097/DCR.0000000000002538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Patients with ulcerative colitis refractory to medication or familial adenomatous polyposis may require ileal pouch-anal anastomosis after a colectomy. IPAA is generally well tolerated. However, patients can experience posttreatment complications, including pouch strictures and leaks. Medical therapy has a limited role in mechanical fibrotic strictures, whereas surgery is invasive and costly. In the past few decades, endoscopic therapies have provided a less invasive and less costly intervention for pouch strictures and leaks. OBJECTIVE This systematic literature review aimed to describe the status of advancements in endoscopic therapy for pouch leaks and strictures. DATA SOURCES The sources used were PubMed and Cochrane databases. STUDY SELECTION Studies between January 1990 and January 2022, in any language, were included. Articles regarding surgical management or pouches other than adult ileal pouch-anal anastomosis were excluded. INTERVENTIONS Endoscopic management of acute and chronic leaks and strictures ileal pouch-anal anastomosis was included. MAIN OUTCOME MEASURES Successful management (including persistent leak or stricture, pouch failure, subsequent endoscopy, or surgery) was measured. RESULTS Sixty-one studies were included in this review, including 4 meta-analyses or systematic reviews, 11 reviews, 17 cohort studies, and 18 case series. LIMITATIONS The limitations include qualitative review of all study types, with no randomized controlled studies available. CONCLUSION Ileal pouch-anal anastomosis leaks are various in configuration, and endoscopic therapies have included clipping leaks at the tip of the "J" as well as endoscopic sinusotomy. Endoscopic therapies for pouch strictures have included endoscopic balloon dilation, endoscopic stricturotomy, and endoscopic stricturoplasty, which are now considered first-line therapies for pouch strictures. Endoscopic balloon dilation has shown safety and efficacy in single, short, and straight strictures and endoscopic stricturotomy for refractory long, fibrotic, anastomotic strictures. Endoscopic therapies can delay or prevent invasive surgeries. Key tenets of successful endoscopic therapy include patient and lesion candidacy, an experienced endoscopist, and adequate rescue surgery plans.
Collapse
|
42
|
Sugita A, Koganei K, Tatsumi K. Management of Pouch Neoplasia. Dis Colon Rectum 2022; 65:S129-35. [PMID: 35895865 DOI: 10.1097/DCR.0000000000002552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Pouch neoplasia occurs following ileal pouch-anal anastomosis, with or without mucosectomy in ulcerative colitis and familiar adenomatous polyposis. OBJECTIVES This study aimed to review available literature and make recommendations regarding pouch neoplasia. DATA SOURCES Data were collected from specialty hospitals, and a literature review was conducted due to the lack of published large-scale studies. Recommendations for treatment were made based on the literature review and expert opinions. STUDY SELECTION Large-scale studies of pouch neoplasia were selected. INTERVENTION The intervention was studies with details of pouch neoplasia. MAIN OUTCOME MEASURES We aimed to identify the management modalities for pouch neoplasia based on the type. RESULTS Pouch neoplasia can occur in each component of the pouch-afferent limb, pouch body, cuff, and anal transitional zone. In patients with ulcerative colitis, pouch neoplasia is treated because colitis-associated neoplasia comprises a multifocal lesion, which most commonly involves the cuff and anal transitional zone. Close surveillance or endoscopic complete resection is optimal for low-grade dysplasia. For adenocarcinoma, high-grade dysplasia, and low-grade dysplasia with difficult complete resection, pouch excision is recommended. In familiar adenomatous polyposis patients with adenomas of the afferent limb or pouch body, endoscopic resection is optimal. Endoscopic resection is feasible for discrete adenoma in the cuff and anal transitional zone, and surgical excision is optimal for laterally spreading, extensive, large, or flat adenoma. For adenocarcinomas involving any component, pouch excision is recommended. LIMITATIONS Published large-scale studies were lacking because of disease rarity. CONCLUSION Pouch neoplasia occurs in each pouch component. In patients with ulcerative colitis, pouch excision is recommended for adenocarcinomas and high-grade dysplasia, whereas endoscopic intervention may be preferable to low-grade dysplasia. In familiar adenomatous polyposis patients, pouch excision is necessary for adenocarcinoma, and endoscopic resection or excisional surgery is optimal for adenoma.
Collapse
|
43
|
Ballentine S, Lee H, Liu X. Histopathology of Pouch and Para-Pouch Inflammatory and Neoplastic Disorders. Dis Colon Rectum 2022; 65:S57-68. [PMID: 35895870 DOI: 10.1097/DCR.0000000000002553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is used to treat patients with ulcerative colitis or familial adenomatous polyposis who need colectomy. While this procedure substantially improves patient's quality of life and reduces cancer risk, it is associated with a variety of sequelae' including surgical complications, inflammatory disorders, and neoplasia. Pouchitis, cuffitis, and Crohn's disease of the pouch are the most common inflammatory disorders of the pouch and para-pouch. OBJECTIVE This study aimed to elaborate on the histopathology of common inflammatory and neoplastic disorders of the pouch and para-pouch. DATA SOURCES A Medline search for English language studies published between 1981 and 2021 using the PubMed search engine. The terms "ileal pouch-anal anastomosis," "pouchitis," "pouchitis activity score," "secondary pouchitis," "Crohn's disease of the pouch," "Crohn's-like conditions of the pouch," "pre-pouch ileitis," "cuffitis," "pouch adenocarcinoma," and "pouch neoplasia" were used. STUDY SELECTION The published human studies that reported histopathology of common inflammatory and neoplastic disorders of the ileal pouch were selected and reviewed. CONCLUSIONS Histologic examination plays an essential role in confirming inflammation in pouchitis, identifying etiology and clues for secondary pouchitis, and diagnosing neoplasia. A standardized, simple, and reproducible histologic grading system for pouchitis is needed. Pouch and para-pouch glandular dysplasia diagnosis is challenging and should always be reviewed by at least one gastrointestinal pathologist.
Collapse
|
44
|
Roussel BN, Shah SA. Diagnosis and Management of Functional Pouch Disorders: A Systematic Review. Dis Colon Rectum 2022; 65:S113-8. [PMID: 36399771 DOI: 10.1097/DCR.0000000000002586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Functional disorders impart significant morbidity in patients with inflammatory bowel disease who undergo restorative proctocolectomy. OBJECTIVE This systematic review aimed to summarize the management strategies for various functional disorders of the pouch. DATA SOURCES A database search of PubMed was conducted to identify relevant clinical studies assessing the management of various functional disorders in patients who underwent restorative proctocolectomy. STUDY SELECTION Published clinical studies investigating a functional disorder of the pouch in patients who previously underwent a colectomy with ileal pouch-anal anastomosis. INTERVENTIONS Restorative proctocolectomy was completed in patients with inflammatory bowel disease or other indications such as a diagnosis of familial adenomatous polyposis. MAIN OUTCOME MEASURES The primary outcomes described in this review include the prevalence of functional disorders of the pouch in patients undergoing restorative proctocolectomy and the relevant management strategies. RESULTS Ten clinical studies were identified using the predetermined search terms and screened for relevancy to patients with inflammatory bowel disease who previously underwent colectomy with ileal pouch-anal anastomosis. A qualitative summary was developed on the basis of data from these studies and from current guidelines developed for the management of inflammatory bowel disease. LIMITATIONS This systematic review is limited by the small number and low quality of the clinical studies included as well as the nonquantitative summary of the findings. CONCLUSIONS Functional disorders of the pouch are likely underdiagnosed. Although a source of significant morbidity, these diseases require additional clinical studies to better elucidate effective management strategies.
Collapse
|
45
|
Shaffer SR, Bernstein CN. Controversies in Crohn's Disease Before and After Pouch Surgery. Dis Colon Rectum 2022; 65:S45-9. [PMID: 35895863 DOI: 10.1097/DCR.0000000000002550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND IPAA is rarely performed in patients with a known diagnosis of Crohn's disease, although it may be done in highly selected patients with an absence of perianal disease or small bowel inflammation. Patients with a preoperative diagnosis of Crohn's disease are, however, at increased risk of developing Crohn's disease of the pouch. Crohn's disease of the pouch can also occur in people with a preoperative diagnosis of ulcerative colitis; however, it is unknown whether this phenotype is similar to classic Crohn's disease involving an intact bowel, or whether it is a distinct entity. OBJECTIVE This study aimed to describe Crohn's disease of the pouch, including luminal inflammation, and fibrostenotic and perforating phenotypes, as well as management of these conditions. RESULTS Crohn's disease of the pouch can present in similar ways as classic Crohn's disease, classified as either inflammatory, fibrostenotic, or penetrating. Criteria involving the diagnosis of Crohn's disease of the pouch are stringent to prevent unnecessary treatments, because a diagnosis of Crohn's disease after IPAA for presumed ulcerative colitis can cause mental anguish. Treatment of Crohn's disease of the pouch depends on the presenting phenotype, although therapies are similar to classic Crohn's disease. Endoscopic, or even surgical treatment, may be required for fibrostenotic and fistulizing diseases. LIMITATIONS Crohn's disease of the pouch is a newly described disease of patients who undergo an ileoanal pouch anastomosis; and therefore, most of the evidence comes from retrospective trials in patients with an initial diagnosis of ulcerative colitis. CONCLUSIONS While Crohn's disease of the pouch is controversial and perhaps a distinct disease within the spectrum of inflammatory bowel diseases, it nonetheless requires long-term medical therapy and close follow-up.
Collapse
|
46
|
Pal P, Ramchandani M, Banerjee R, Inavolu P, Nabi Z, Rughwani H, Singh APH, Patel R, Vijayalaxmi P, Singh JR, Rebala P, Rao GV, Reddy DN, Tandan M. Role of Interventional Inflammatory Bowel Disease (IBD) in the Management of Complex IBD: Initial Prospective Experience from a Tertiary Center in India. Journal of Digestive Endoscopy 2022. [DOI: 10.1055/s-0042-1757470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background/Aims With the growing multidisciplinary model of practice in the management of complex inflammatory bowel disease (IBD) and rising incidence of IBD, interventional IBD (IIBD) promises to play a key role. We aimed to evaluate current the role of IIBD in India and its short-term outcomes.
Methods IBD patients undergoing IIBD procedures for stricture, bleeding, colitis-associated neoplasia, therapeutic small bowel endoscopy including retained capsule retrieval and postsurgical complications were enrolled prospectively between September 2021 and May 2022. Demographic and disease details, indications, initial and redo procedure details, technical/clinical success, and complications were recorded.
Results IIBD procedures were performed in total 54 patients (61% males, median age: 37.5 years, range: 21–74 years, Crohn's disease [CD]: 42, ulcerative colitis [UC]: 12 between September 2021 and April 2022). Endoscopic balloon dilation (EBD) was performed in 44 patients (56 strictures, 9% anastomotic, 9% pouch) who underwent total 83 EBD procedures in 63 sessions. Short-term clinical efficacy after maximal dilation, technical success (i.e., scope passage after EBD), and complications (all mild) were noted in 95.4, 81.8, and 9.1%, respectively. Recurrent symptoms were seen in 27.3% on short-term follow-up (1–8 months, median: 5 months) for which redilation, surgery, and endoscopic stricturotomy were done in 22.7, 2.3, and 2.3% respectively. During small bowel EBD, motorized spiral enteroscopy-guided retained capsule endoscope retrieval was done in four patients. Ulcerative colitis-associated neoplasia (UCAN) was resected endoscopically in six patients (endoscopic submucosal dissection (ESD)—1, endoscopic mucosal resection (EMR)—5). High-grade dysplasia was resected in two patients (1 ESD for recurrent UCAN, 1 EMR had residual neoplasia on follow-up treated with underwater EMR). R0 resection was achieved in 83.3%. Endoscopic hemostasis was done with hemoclipping and sclerotherapy for UC-related bleeding in two, whereas a case of CD with proximal ileal bleeding was controlled with antegrade single-balloon enteroscopy-assisted hemoclipping.
Conclusions IIBD is a promising modality in resource-limited settings like India acting as a bridge between medical therapy and surgery. Surgery can be avoided in a significant proportion with good short-term outcomes. Long-term outcomes need to be evaluated.
Collapse
Affiliation(s)
- Partha Pal
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Mohan Ramchandani
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Rupa Banerjee
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Pradev Inavolu
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Zaheer Nabi
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Hardik Rughwani
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | | | - Rajendra Patel
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Polina Vijayalaxmi
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Jagdeesh Rampal Singh
- Department of Interventional Radiology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Pradeep Rebala
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Guduru Venkat Rao
- Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - D Nageshwar Reddy
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Manu Tandan
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| |
Collapse
|
47
|
Parigi TL, Nardone OM, Iacucci M. Image-Enhanced Endoscopy Surveillance of Colon and Pouch Dysplasia in IBD. Dis Colon Rectum 2022; 65:S119-28. [PMID: 35867688 DOI: 10.1097/DCR.0000000000002548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Patients with longstanding ulcerative colitis and Crohn's colitis are at risk for developing colorectal cancer and need regular endoscopic surveillance to detect and remove precursor lesions. To do so, different technologies are available. DATA SOURCES The sources are observational and controlled studies, meta-analysis, and expert consensus articles available on PubMed. STUDY SELECTION The selected materials include articles reporting outcomes of and recommendations on endoscopic surveillance and resection of dysplasia in the gastrointestinal tract, including the ileoanal pouch and the anal transition zone, in patients with inflammatory bowel disease. MAIN OUTCOME MEASURES Incidence and detection rate of dysplasia and cancer with different endoscopic techniques in patients with inflammatory bowel disease. RESULTS Risk of cancer is proportional to the duration and extent of the disease, and surveillance interval should be tailored on the individual risk in a range of 1 to 5 years. High-definition imaging and virtual chromoendoscopy have improved the detection of dysplasia and are now comparable with conventional dye spray chromoendoscopy. After restorative proctocolectomy with ileoanal pouch, the risk of cancer is modest, but its high mortality warrants endoscopic surveillance. The evidence to guide pouch surveillance is limited, and recently, the first expert consensus provided a framework of recommendations, which include an initial assessment 1 year after surgery and follow-up depending on individual risk factors. LIMITATIONS The limitation includes scarcity of data on ileoanal pouch surveillance. CONCLUSIONS Virtual chromoendoscopy and high-definition imaging have improved endoscopic surveillance, and more progress is expected with the implementation of artificial intelligence systems.
Collapse
|
48
|
Barnes EL, Darlington K, Herfarth HH. Disease Monitoring of the Ileoanal Pouch: How to Utilize Biomarkers, Imaging, and Pouchoscopy. Curr Gastroenterol Rep 2022; 24:127-136. [PMID: 36255602 DOI: 10.1007/s11894-022-00850-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2022] [Indexed: 12/04/2022]
Abstract
PURPOSE OF REVIEW Restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis has been associated with multiple short- and long-term complications. In this review, we examine the role of biomarkers, imaging, and pouchoscopy in the assessment of patients after ileal pouch-anal anastomosis, with a particular focus on the emergence of novel biomarkers and techniques for evaluating and risk stratifying patients after this procedure in the hopes of improving outcomes in this specific population. RECENT FINDINGS There are indications that that the incidence of pouchitis may be increasing in recent decades. Calprotectin and other non-invasive imaging tests such as ultrasound may offer advantages in distinguishing patients with inflammatory conditions of the pouch from other etiologies. In the search for other biomarkers that may identify patients at risk for inflammatory conditions of the pouch, the stool microbiota and metabolomics may play a key role in identifying those patients at greatest risk for complications. Advances in biomarkers, imaging, and standardized pouchoscopy scoring offer immediate improvements in clinical care and will prompt future research efforts.
Collapse
Affiliation(s)
- Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Campus Box #7080 130 Mason Farm Road, 27599-7080, Chapel Hill, NC, USA. .,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. .,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Kimberly Darlington
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Campus Box #7080 130 Mason Farm Road, 27599-7080, Chapel Hill, NC, USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Campus Box #7080 130 Mason Farm Road, 27599-7080, Chapel Hill, NC, USA.,Multidisciplinary Center for Inflammatory Bowel Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
49
|
Sriranganathan D, Vinci D, Pellino G, Segal JP. Ileoanal pouch cancers in ulcerative colitis and familial adenomatous polyposis: A systematic review and meta-analysis. Dig Liver Dis 2022; 54:1328-1334. [PMID: 35817683 DOI: 10.1016/j.dld.2022.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/14/2022] [Accepted: 06/15/2022] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Restorative proctocolectomy results in the formation of a pouch that adapts to a more colonic phenotype. The incidence of cancer of the pouch is thought to be low with most societal guidelines differing on their recommendations for surveillance. AIMS We conducted a systematic review with meta-analysis to report the incidence of cancer in all pouch patients. METHODS The Embase, Embase classic and PubMed databases were searched between June 1979- June 2021. A random effects model was performed to find the pooled incidence of pouch cancer. In addition, we also looked for risk factors for pouch cancers. RESULTS Forty-six studies were included. In 19,964 patients with Ulcerative Colitis (UC) the pooled incidence of pouch cancer was 0.0030 (95% CI: 0.0016 -0.0055). In 3741 patients with Familial Adenomatous Polyposis (FAP) the pooled incidence of pouch cancer was 0.01 (95% CI: 0.01 - 0.02). In UC most pouch cancers were found to occur in the pouch body (0.59 (95% CI: 0.29-0.84)). CONCLUSIONS The findings suggest that the pooled incidence of pouch cancer in UC is similar to that which was previously published, and this is the first meta-analysis to report a pooled incidence for pouch cancer in FAP.
Collapse
Affiliation(s)
- Danujan Sriranganathan
- Department of Medicine, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, HA1 3UJ, United Kingdom
| | - Danilo Vinci
- Department of Surgical Science, University Tor Vergata, 00133, Rome, Italy
| | - Gianluca Pellino
- Department of Advanced Medical and Surgical Sciences, Universitá degli Studi della Campania "Luigi Vanvitelli", Naples, Italy; Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain.
| | - Jonathan P Segal
- Department of Gastroenterology, Northern Hospital, Epping, Melbourne, Australia; Department of Medicine, University of Melbourne, Parkville, Melbourne, Australia.
| |
Collapse
|
50
|
Bakes D, Kiran RP. Overview of Common Complications in Inflammatory Bowel Disease Surgery. Gastrointest Endosc Clin N Am 2022; 32:761-776. [PMID: 36202515 DOI: 10.1016/j.giec.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The complication rate after surgery in patients with inflammatory bowel disease is high owing to chronic inflammatory and suboptimal physiologic state, the effect of steroids and immunosuppressive medication, and the inherent complexity of the surgical procedures. Although some of the complications after surgery are similar for Crohn disease and ulcerative colitis, others are specific to the diagnosis. Complications are divided into early postoperative and late complications. Specific complications are related to more extensive surgery such as a proctocolectomy or reoperative procedures or with complex reconstructive procedures such as the ileoanal pouch and continent ileostomy.
Collapse
Affiliation(s)
- Debbie Bakes
- Division of Colorectal Surgery, Columbia University Medical Center, New York Presbyterian Hospital, 161 Fort Washington Avenue, 8th Floor, Herbert Irving Pavilion, New York, NY 10032, USA
| | - Ravi Pokala Kiran
- Division of Colorectal Surgery, Columbia University Medical Center, New York Presbyterian Hospital, 161 Fort Washington Avenue, 8th Floor, Herbert Irving Pavilion, New York, NY 10032, USA.
| |
Collapse
|