Adalimumab Serum Concentrations, Clinical and Endoscopic Disease Activity in Crohn's Disease: A Cross-Sectional Multicentric Latin American Study

Despite some variability in ideal serum Adalimumab (ADA) concentrations, there is increasing evidence that higher concentrations of anti-TNF-α agents can be associated with sustained efficacy, and low or undetectable levels may lead to loss of response. This study aims to correlate serum ADA concentrations with clinical and endoscopic activity in patients with Crohn's disease (CD). A cross-sectional and multicentric study was performed with patients with CD, who used ADA for at least 24 weeks. Patients were allocated into groups according to the presence of clinical or endoscopic disease activity. Serum ADA concentrations were measured and compared between groups. Overall, 89 patients were included. A total of 27 patients had clinically active CD and 62 were in clinical remission. Forty patients had endoscopic disease activity and 49 were in endoscopic remission. The mean serum ADA concentration was 10.2 μg/mL in patients with clinically active CD and 14.3 μg/mL in patients in clinical remission (p = 0.395). The mean serum ADA concentration in patients with endoscopic activity was 11.3 μg/mL as compared to 14.5 μg/mL in those with endoscopic remission (p = 0.566). There was no difference between serum ADA concentrations regarding clinical or endoscopic activity in CD, as compared to patients in remission.

Biosimilar knowledge and viewpoints among Brazilian inflammatory bowel disease patients

BACKGROUND

In this analysis we aimed to describe Brazilian inflammatory bowel disease (IBD) patients' knowledge and perceptions regarding biosimilars and compare with viewpoints from non-Brazilian patients.

METHODS

An online survey consisting of 19 questions was made available by the European Federation of Crohn's and Ulcerative Colitis Associations between July 2018 and December 2018. Only respondents who had heard of biosimilars were asked to respond to all of the questions.

RESULTS

A total of 102 Brazilian IBD patients responded to the survey. The majority (78.4%) of patients had been exposed to anti-tumor-necrosis-factor drugs and 63.4% of them had heard of biosimilars. Brazilian respondents worried significantly more about biosimilars being less effective than the originator (62.5% versus 47.9%, p value 0.03) and molecular differences between biosimilars and originators (53.1% versus 31.8, p value 0.001) as compared with non-Brazilian IBD patients. The majority of Brazilian (75%) and non-Brazilian (64.1%) respondents thought that the lower cost of biosimilars should not come before their safety and efficacy (p value 0.09). In addition, 79.1% of Brazilian respondents believed that the arrival of biosimilars will have an impact on the management of IBD.

CONCLUSIONS

Brazilian patients reported higher rates of misconceptions regarding biosimilars than non-Brazilian IBD patients. Although patients still worry about different aspects regarding biosimilars, they also tend to be confident that biosimilars will have an impact on the management of their disease. With the recent approval of many biosimilars in Brazil and the imminent widespread use of these drugs, our data raise awareness for the need of providing patient education to prevent negative expectations toward switching to biosimilars.

BRAZILIAN IBD STUDY GROUP POSITION STATEMENT ON SARS-COV2 VACCINATION

Mass vaccination offers the best strategy to fight against COVID-19 pandemic, and SARS-CoV2 vaccines are being approved in several countries for emergency use. In Brazil, vaccine approval is expected in the next few days, however potential concerns exist regarding vaccine recommendations for specific populations, such as patients with inflammatory bowel disease (IBD). To address these questions, the Brazilian IBD Study Group (GEDIIB) provides this practical advice with key recommendations about the COVID-19 vaccines in IBD population.

Risk stratification and geographical mapping of Brazilian inflammatory bowel disease patients during the COVID-19 outbreak: Results from a nationwide survey

BACKGROUND

Coronavirus disease 2019 (COVID-19) pandemic is still evolving globally, and Brazil is currently one of the most affected countries. It is still debated whether patients with inflammatory bowel disease (IBD) are at a higher risk for developing COVID-19 or its complications.

AIM

To assess geographical distribution of IBD patients at the highest risk and correlate these data with COVID-19 mortality rates in Brazil.

METHODS

The Brazilian IBD Study Group (Grupo de Estudos da Doença Inflamatória Intestinal do Brasil) developed a web-based survey adapted from the British Society of Gastroenterology guidelines. The included categories were demographic data and inquiries related to risk factors for complications from COVID-19. Patients were categorized as highest, moderate or lowest individual risk. The Spearman correlation test was used to identify any association between highest risk and mortality rates for each state of the country.

RESULTS

A total of 3568 patients (65.3% females) were included. Most participants were from the southeastern and southern regions of Brazil, and 84.1% were using immunomodulators and/or biologics. Most patients (55.1%) were at moderate risk, 23.4% were at highest risk and 21.5% were at lowest risk of COVID-19 complications. No association between the proportion of IBD patients at highest risk for COVID-19 complications and higher mortality rates was identified in different Brazilian states (r = 0.146, P = 0.467).

CONCLUSION

This study indicates a distinct geographical distribution of IBD patients at highest risk for COVID-19 complications in different states of the country, which may reflect contrasting socioeconomic, educational and healthcare aspects. No association between high risk of IBD and COVID-related mortality rates was identified.

INDUCTION THERAPEUTIC DRUG MONITORING REGIMEN WITH INFLIXIMAB: A SIMPLIFIED EVIDENCE-BASED ALGORITHM FOR INFLAMMATORY BOWEL DISEASE

Therapeutic drug monitoring (TDM) of infliximab (IFX) has been recognized as an important strategy in the management of secondary loss of response to this agent, guiding clinical decision-making in the management of inflammatory bowel diseases (IBD). Although most of the data on the application of TDM for IFX refer to the maintenance phase of treatment, many studies have associated higher drug concentrations, specially in the induction phase, with achievement of important treatment targets, such as clinical remission and mucosal healing. This brief communication aims to summarize the literature on the use of TDM during induction phase of IFX and propose application of a simplified approach which can be useful into clinical practice, aiming better outcomes to IBD patients.

Progression of Inflammatory Bowel Diseases Throughout Latin America and the Caribbean: A Systematic Review

BACKGROUND & AIMS

The incidence of inflammatory bowel diseases (IBD) is increasing in Latin America. We performed a systematic review to identify clinical and epidemiologic features of IBD in Latin America (including Mexico, Central America, and South America) and the Caribbean.

METHODS

We searched MEDLINE, EMBASE, and SciELO databases for clinical or epidemiologic studies of Crohn's disease (CD) or ulcerative colitis (UC) from Latin American and Caribbean countries and territories that reported incidence, prevalence, ratio of UC:CD, IBD phenotype, and treatment, through September 12, 2018. Data were extracted from 61 articles for analysis.

RESULTS

The incidence and prevalence of IBD have been steadily increasing in Latin America and the Caribbean. The incidence of CD in Brazil increased from 0.08 per 100,000 person-years in 1988 to 0.68 per 100,000 person-years in 1991-1995 to 5.5 per 100,000 person-years in 2015. The highest reported prevalence of IBD was in Argentina, in 2007, at 15 and 82 per 100,000 person-years for CD and UC, respectively. The ratio of UC:CD exceeded 1 in all regions throughout Latin America and the Caribbean with the exception of Brazil. Treatment with tumor necrosis factor antagonists increased steadily for patients with CD (43.4% of all patients in Brazil were treated in 2014) but less so for patients with UC (4.5% of all patients were treated in 2014). Surgery for IBD decreased with time. In Chile, surgeries were performed on 57.0% of patients with CD and 18.0% of patients with UC during the period of 1990-2002; these values decreased to 38.0% and 5.0%, respectively, during the period of 2012-2015. In Peru, 6.9% of patients with UC received colectomies in the period of 2001-2003 and 6.2% in 2004-2014.

CONCLUSIONS

In a systematic review, we found the incidence of IBD to be increasing throughout Latin America and the Caribbean. Population-based epidemiology studies are needed to evaluate the increase in IBD in these regions, which differ from other global regions in climate, culture, demographics, diet, healthcare delivery and infrastructure, and socioeconomic status.

TOFACITINIB IN THE MANAGEMENT OF ULCERATIVE COLITIS REFRACTORY TO ANTI-TNF AND ANTI-INTEGRIN THERAPIES

Janus kinases inhibitors have already been incorporated into the management of immune-mediated diseases, such as rheumatoid arthritis, and are being investigated for the treatment of psoriasis and inflammatory bowel diseases, both ulcerative colitis and Crohn's disease. Tofacitinib is an oral small-molecule drug that inhibits Janus kinases 1, Janus kinases 3, and, to a lesser extent, Janus kinases 2. This inhibition ends up blocking signals for several inflammatory cytokines that are involved in the pathogenesis of inflammatory bowel diseases and play a role in many immune signaling routes, including lymphocyte activation, function, and proliferation. We report a patient with active ulcerative colitis with primary non-response to three biologics (infliximab, adalimumab and vedolizumab), with different mechanisms of action, who refused surgical treatment and had a favorable response to tofacitinib with clinical and endoscopic remission. No adverse events were observed with the use of the agent. This case illustrates the difficulties we may face regarding the identification of the expression of proper mechanism of action involved in the pathogenesis of ulcerative colitis patients and the importance of having another treatment option with different mechanism of action, like tofacitinib.

SERUM INFLIXIMAB MEASUREMENT IN INFLAMMATORY BOWEL DISEASE PATIENTS IN REMISSION: A COMPARATIVE ANALYSIS OF TWO DIFFERENT METHODS IN A MULTICENTRIC BRAZILIAN COHORT

BACKGROUND

Infliximab (IFX) therapeutic drug monitoring is an important tool to guide therapeutic decision in inflammatory bowel disease patients. Currently, there are two methods to measure trough levels of IFX, ELISA assays or rapid tests. Despite that the ELISA assay is the most used method in therapeutic drug monitoring, the results take long to be available for clinical use, and it needs to be performed by trained personnel. In contrary, the results of a rapid test take 20 to 30 minutes to be available and can be performed by non-trained lab personnel.

OBJECTIVE

The aim of the study was to compare a rapid test (QB-IFX) for quantitative determination of IFX level to one ELISA assay in a cohort of inflammatory bowel disease patients.

METHODS

Cross-sectional multicentric study with 49 inflammatory bowel disease patients on maintenance therapy with IFX. Blood samples for IFX serum levels were collected immediately before infusion. IFX serum levels were classified as undetectable, low (<3.0 μg/mL), adequate (3.1-7.0 μg/mL) or high (>7.1 μg/mL). A sensitivity and specificity of each test and a comparison between tests was based on ROC curves.

RESULTS

Thirty-four Crohn's disease patients and 15 ulcerative colitis patients in clinical remission were evaluated. The majority of patients had low or adequate serum levels of IFX. In relation to the serum levels proportions with the two methods, there was no significant difference (P=0.84). The ROC analysis identified a concentration threshold >2.9 μg/mL with the QB-IFX test (area under the ROC, 0.82; P<0.0001, sensitivity, 100%; specificity, 61.9%), and >3.83 μg/mL using the ELISA assay (area under the ROC, 0.96; P<0.0001, sensitivity, 100%; specificity, 92.9%).

CONCLUSION

QB-IFX and ELISA assays to measure IFX levels were comparable. Both methods had accurate sensitivity and specificity to detect undetectable, low and adequate levels, but had showed low specificity for supra therapeutic levels of IFX.

ADALIMUMAB FOR ULCERATIVE COLITIS: RESULTS OF A BRAZILIAN MULTICENTER OBSERVATIONAL STUDY

BACKGROUND

Adalimumab is a monoclonal antibody, tumor necrosis factor-alpha (TNFα) inhibitor that has efficacy for inducing and maintaining remission in moderate-to-severe ulcerative colitis. Real world studies with adalimumab in Latin American ulcerative colitis patients are scarce.

OBJECTIVE

To assess the clinical remission rates in induction and maintenance with adalimumab therapy in ulcerative colitis.

METHODS

Observational, multicenter and retrospective study on a case series of patients with moderate-to-severe ulcerative colitis under adalimumab therapy. The variables analyzed were: demographic data, previous infliximab status, concomitant drugs, the Montreal Classification, disease activity (Mayo score) at weeks 0, 8, 26 and 52, or until the last follow-up. Clinical remission was defined as a partial Mayo score ≤2 and Last observation carried forward (LOCF) and Non responder imputation (NRI) analysis were used.

RESULTS

Thirty-six patients were included in the study. With LOCF analysis, remission rates at weeks 8, 26 e 52 were of 41.7%, 47.2% and 47.2%, respectively. With NRI analysis, remission rates at weeks 8, 26 and 52 were of 41.7%, 41.7% and 27.8%, respectively.

CONCLUSION

Adalimumab was effective in the treatment of moderate-to-severe ulcerative colitis. Clinical remission was observed in approximately 40% of the patients at weeks 8 and 26, and in almost a quarter of the patients after 1 year of follow up.

Factors affecting the incidence of early endoscopic recurrence after ileocolonic resection for Crohn's disease: a multicentre observational study

AIM

Early endoscopic recurrence is frequently observed in patients following resection for Crohn's disease (CD). However, factors affecting the incidence of an early postoperative endoscopic recurrence (EPER) have not been fully determined. The aim of this study was to evaluate risk factors for EPER after ileocolonic resection for CD.

METHOD

This was a retrospective, international multicentre study, in which 127 patients with a first ileocolonoscopy conducted between 6 and 12 months after ileocolonic resection for CD were included. Endoscopic recurrence was defined as a Rutgeerts score of ≥ i2. The following variables were investigated as potential risk factors for EPER: gender, age at surgery, location and behaviour of CD, smoking, concomitant perianal lesions, preoperative use of steroids, immunomodulators and biologics, previous resection, blood transfusion, surgical procedure (open vs laparoscopic approach), length of resected bowel, type of anastomosis (side-to-side vs end-to-end), postoperative complications, granuloma and postoperative biological therapy. Variables related to the patient, disease and surgical procedure were investigated as potential risk factors for EPER, with univariate and multivariate (logistic regression) analyses.

RESULTS

43/127 (34%) patients had EPER at the time of the first postoperative ileocolonoscopy. In univariate analysis, only preoperative steroid use was significantly associated with a higher rate of EPER [21/45 patients (47%) on steroids and 22/82 patients (27%) without steroids (P = 0.04)]. In multivariate analysis, only preoperative steroid use was a significant independent risk factor for EPER (odds ratio 3.28, 95% confidence interval: 1.30-8.28; P = 0.01).

CONCLUSIONS

This study found that only preoperative steroid use was a significant risk factor for EPER after ileocolonic resection for CD. Prospective studies are necessary to evaluate precisely the impact of perioperative medications on EPER rates.

Disease duration did not influence the rates of loss of efficacy of the anti-TNF therapy in Latin American Crohn’s disease patients

BACKGROUND/AIMS

The efficacy of both Infliximab (IFX) and Adalimumab (ADA) can be reduced over time. The aim of this study was to analyze the incidence of loss of efficacy (LOE) of both IFX and ADA, and outline the influence of disease duration on its occurrence.

METHODS

Retrospective, multicenter, observational cohort study, with CD patients treated with anti-TNF therapy. LOE was defined as the need for steroids, occurrence of major abdominal surgery during treatment, dose increase, interval shortening or switching of the anti- TNF agent. Patients were allocated in three subgroups based on disease duration (DD): <24 months, between 24 and 60 months and >60 months.

RESULTS

175 patients were included in the study (117 under IFX and 58 under ADA therapy). LOE occurred in 32% of patients with DD <24 months, in 33.3% with DD between 24 and 60 months and in 31.3% of subjects with DD over 60 months (p = 0.975).

CONCLUSIONS

Disease duration (DD) did not influence LOE rates. These results suggest that in real-world observational practice, patients with early CD might have the same rates of LOE than patients with a disease prolonging for a longer duration.

Conventional Versus Biological Therapy for Prevention of Postoperative Endoscopic Recurrence in Patients With Crohn's Disease: an International, Multicenter, and Observational Study

Background/Aims

Postoperative endoscopic recurrence (PER) occurs in nearly 80% of patients 1 year after ileocecal resection in patients with Crohn's disease (CD). Biological agents were more effective in reducing the rates of PER in comparison with conventional therapy, in prospective trials. The aim of this study was to compare the PER rates of biological versus conventional therapy after ileocecal resections in patients with CD in real-world practice.

Methods

The MULTIPER (Multicenter International Postoperative Endoscopic Recurrence) database is a retrospective analysis of PER rates in CD patients after ileocecal resection, from 7 referral centers in 3 different countries. All consecutive patients who underwent ileocecal resections between 2008 and 2012 and in whom colonoscopies had been performed up to 12 months after surgery, were included. Recurrence was defined as Rutgeerts' score ≥i2. The patients were allocated to either biological or conventional therapy after surgery, and PER rates were compared between the groups.

Results

Initially, 231 patients were evaluated, and 63 were excluded. Of the 168 patients in the database, 96 received anti-tumor necrosis factor agents and 72 were treated with conventional therapy after resection. The groups were comparable regarding age, gender, and perianal disease. There was longer disease duration, more previous resections, and more open surgical procedures in patients on biologicals postoperatively. PER was identified in 25/96 (26%) patients on biological therapy and in 24/72 (33.3%) patients on conventional therapy (P=0.310).

Conclusions

In this retrospective observational analysis from an international database, no difference was observed between biological and conventional therapy in preventing PER after ileocecal resections in CD patients.

A qualitative study of GPs' views towards obesity: are they fighting or giving up?

OBJECTIVES

Several studies indicate that general practitioners (GPs) are not taking the issue of obesity as seriously as they should. Therefore, the aim of this study was to understand GPs' views about obesity and obese people and how these professionals perceive their role in the treatment of this disease.

STUDY DESIGN

Qualitative study using semi-structured interviews.

METHODS

Sixteen semi-structured interviews were conducted with Portuguese GPs. Data were analyzed according to thematic analysis procedures.

RESULTS

GPs are negative about their own role in obesity treatment. Although they believe it is part of their job to advise obese patients on the health risks of obesity, the majority of doctors think they are not making any difference in getting their patients to make long term lifestyle changes. GPs hold negative attitudes towards these patients blaming them for being unmotivated and non-compliant and are also pessimistic about their ability to lose weight. Doctors are facing a dilemma in their practices: they want to play an active role but, due to a set of negative beliefs and perceived barriers, they are playing a relatively passive role, feeling defeated and unmotivated, which is reflected in a decrease of efforts and a willing to give up on most of the cases.

CONCLUSIONS

This issue should be taken in to account during physicians' education since doctors should be aware of how their own beliefs and attitudes influence their behaviour and practices, compromising, therefore, the adherence to and the success in obesity treatment. They seem to need more precise guidelines and better tools for screening and management of obesity, more referral options, and improved coordination with other specialities.

Induction or exacerbation of psoriatic lesions during anti-TNF-α therapy for inflammatory bowel disease: a systematic literature review based on 222 cases

BACKGROUND

Paradoxical cases of psoriatic lesions induced or exacerbated by anti-tumor necrosis factor (TNF)-α therapy have been reported more frequently in recent years, but data related to inflammatory bowel disease (IBD) are rare. A systematic literature review was performed to provide information about this adverse effect in patients with IBD who receive anti-TNF therapy.

METHODS

Published studies were identified by a search of Medline, Embase, Cochrane, SciELO, and LILACS databases.

RESULTS

A total of 47 studies (222 patients) fulfilled the inclusion criteria and were selected for analysis. Clinical and therapeutic aspects varied considerably among these reports. Of the 222 patients, 78.38% were diagnosed with Crohn's disease, and 48.20% were female. The mean patient age was 26.50 years, and 70.72% of patients had no history of psoriasis. Patients developed psoriasiform lesions (55.86%) more often than other types of psoriatic lesions, and infliximab was the anti-TNF-α therapy that caused the cutaneous reaction in most patients (69.37%). Complete remission of cutaneous lesions was observed in 63.96% of the cases.

CONCLUSIONS

We found that psoriatic lesions occurred predominantly in adult patients with Crohn's disease who received infliximab and had no previous history of psoriasis. Most patients can be managed conservatively without discontinuing anti-TNF-α therapy.

The onset of psoriasis during the treatment of inflammatory bowel diseases with infliximab: should biological therapy be suspended?

CONTEXT

Several paradoxical cases of infliximab-induced or-exacerbated psoriatic lesions have been described in the recent years. There is disagreement regarding the need to discontinue infliximab in order to achieve the resolution of these adverse cutaneous reactions specifically in inflammatory bowel disease (IBD) patients.

OBJECTIVE

To systematically review the literature to collect information on IBD patients that showed this adverse cutaneous reaction, focusing mainly on the therapeutic approach.

METHODS

A systematic literature review was performed utilizing Medline, Embase, SciELO and Lilacs databases. Published studies were identified, reviewed and the data were extracted.

RESULTS

Thirty-four studies (69 IBD patients) met inclusion criteria for review. There was inconsistency in reporting of some clinical and therapeutic aspects. Most patients included had Crohn's disease (89.86%), was female (47.83%), had an average age of 27.11 years, and no reported history of psoriasis (84.05%). The patients developed primarily plaque-type psoriasis (40.58%). There was complete remission of psoriatic lesions in 86.96% of IBD patients, existing differences in the therapeutic approaches; cessation of infliximab therapy led to resolution in 47.83% of cases and 43.48% of patients were able to continue infliximab therapy.

CONCLUSION

As increasing numbers of IBD patients with psoriasis induced or exacerbated by infliximab, physicians should be aware of its clinical manifestations so that appropriate diagnosis and treatment are properly established. The decision whether to continue or discontinue infliximab should be individualized.

Infliximab-induced psoriasis during therapy for Crohn's disease

Although therapy with tumor necrosis factor-alpha inhibitors (anti-TNF) provides beneficial effects in different immune inflammatory disorders, paradoxical cases of anti-TNF-induced psoriasis have increasingly been reported, mostly in the setting of rheumatologic diseases. To date, less than 50 cases of infliximab-induced psoriasis in inflammatory bowel disease patients have been described. The present report was aimed at describing two new cases of infliximab-induced psoriasis during therapy for Crohn's disease and at carrying out a review on this intriguing phenomenon.

Instilação de formalina endoluminal como opção terapêutica da retite actínica hemorrágica

A retite actínica hemorrágica é um quadro grave que pode ocorrer em qualquer paciente submetido à radioterapia pélvica, por vezes, sendo necessária terapia transfusional e internação hospitalar. A abordagem terapêutica ainda é bastante controversa. Tanto para o tratamento inicial como para casos refratários, uma das opções é a aplicação de formalina. Este método é barato, facilmente disponível, de simples execução e eficaz no controle da hemorragia. Os autores relatam dois casos de retite actínica hemorrágica de pacientes tratados com instilação de formalina endoluminal, e sua eficácia terapêutica e complicações são discutidas

Bile acid absorption after near-total proctocolectomy in dogs: ileal pouch vs. jejunal pouch-distal rectal anastomosis

Bile acid malabsorption is often present in patients after near-total proctocolectomy and ileal pouch-anal canal anastomosis, suggesting ileal dysfunction. Experiments were performed in dogs to compare bile acid absorption after a modified procedure, in which a jejunal pouch was interposed between the terminal ileum and the distal rectum, with that after a conventional ileal pouch operation. Fecal bile acid output (equivalent to hepatic bile acid biosynthesis) and composition were determined by gas chromatography/mass spectrometry in five jejunal pouch dogs and in five ileal pouch dogs more than 6 months after operation. Fecal bile acid output in the jejunal pouch dogs (mean +/- standard deviation) was 215 +/- 59 mg/day (10.1 +/- 2.7 mg/kg-day), a value similar to that obtained in the ileal pouch dogs (261 +/- 46 mg/day [12.8 +/- 3.1 mg/kg-day]; P >0.05). These values were also similar to those reported by others for healthy unoperated dogs, indicating that increased bile acid biosynthesis occurring in response to bile acid malabsorption was not present. Fecal bile acids in pouch dogs were completely deconjugated and extensively 7-dehydroxylated (jejunal pouch = 90.4% dehydroxylated; ileal pouch = 88.6% +/- 6.6% dehydroxylated) and consisted predominantly of deoxycholic acid derivatives. We conclude that when either a jejunal pouch or an ileal pouch is used as a rectal substitute in dogs, an anaerobic pouch flora develops that efficiently deconjugates and dehydroxylates bile acids, rendering them membrane permeable. The resultant passive absorption of unconjugated bile acids appears to compensate for any loss of active ileal absorption of conjugated bile acids, and bile acid malabsorption does not occur.

Ulcer associated cell lineage glands expressing trefoil peptide genes are induced by chronic ulceration in ileal pouch mucosa

BACKGROUND

Chronic ulcerative conditions in the gastrointestinal tract result in the appearance of the ulcer associated cell lineage (UACL). The glands of this new cell lineage secrete epidermal growth factor, transforming growth factor alpha, and the trefoil factor family (TFF) peptides, which are known to participate in repair processes. Pouchitis is the most frequent complication of ileal pouch-anal anastomosis.

AIM

Our aim was to determine whether the mucosal ulceration present in pouchitis can induce the development of UACL glands.

METHODS

Biopsies from ileal pouches with pouchitis (n=10), healthy pouches (n=5), and normal terminal ileum (n=5) were studied. Expression of TFF mRNA was assessed by in situ hybridisation. TFF1 and TFF2 proteins were localised by immunochemistry.

RESULTS

UACL glands containing TFF1 and TFF2 were observed in six patients with pouchitis. In some glands, there was TFF3 mRNA as has been reported for Crohn's UACL. None of the biopsies from ileal reservoirs without pouchitis showed UACL glands (p<0.05). Neither TFF1 nor TFF2 expression was detected in ileal reservoirs without pouchitis.

CONCLUSION

UACL glands arise de novo in ileal pouch mucosa of patients with pouchitis and express all three TFF peptide genes. Chronic inflammation alone, present in healthy pouches, is not enough to stimulate the growth of the UACL, and additional stimuli consequent on ulceration may be needed.

Enhancing release of peptide YY after near-total proctocolectomy: jejunal pouch vs. ileal pouch-distal rectal anastomosis

Reconstructing the enteric tract after near-total proctocolectomy by interposing a jejunal pouch between the distal ileum and the distal rectum slows small intestinal transit and decreases the number of stools per day compared to a conventional ileal pouch-distal rectal reconstruction. Our hypothesis was that the jejunal pouch operation brings about these results by protecting the ability of the ileal mucosa to secrete peptide YY, thus augmenting the hormonal ileal brake on small intestinal transit and decreasing the stool frequency. In five jejunal pouch dogs and five ileal pouch dogs, more than 6 months after the operation, serum peptide YY concentrations were determined before and at 30-minute intervals for 180 minutes after a standard meal. Fasting serum concentrations of peptide YY, measured by radioimmunoassay, were greater in jejunal pouch dogs (mean +/- SEM, 1340 +/- 143 pg/ml) than in ileal pouch dogs (804 +/- 52 pg/ml; P < 0.01). Postprandial peptide YY concentrations in jejunal pouch dogs were also greater at 30 minutes (jejunal pouch = 1524 +/- 131 pg/ml, ileal pouch = 913 +/- 67 pg/ml; P = 0.01) and 60 minutes after the meal (jejunal pouch = 1723 +/- 250 pg/ml, ileal pouch = 1001 +/- 70 pg/ml; P = 0.05) and peaked sooner (jejunal pouch = 81 +/- 17 minutes, ileal pouch = 147 +/- 12 minutes; P = 0.01). We concluded that the jejunal pouch operation results in greater ileal fasting and postprandial secretion of peptide YY than the ileal pouch operation. The greater release may account, in part, for the slower small bowel transit and decreased number of stools after the jejunal pouch operation.

The jejunal pouch as a rectal substitute after proctocolectomy

Our hypothesis was that a jejunal pouch used as a rectal substitute after proctocolectomy would slow enteric transit, delay defecation, and decrease stool frequency compared to an ileal pouch so used. Twelve dogs underwent proctocolectomy; six had a jejunal pouch-distal rectal anastomosis and six had an ileal pouch-distal rectal anastomosis. After recovery, postprandial mouth-to-anus transit was slower in jejunal pouch dogs (253 +/- 18 minutes [mean +/- SEM]) than in ileal pouch dogs (112 +/- 7.9 minutes; P <0.05). Moreover, jejunal pouch dogs passed only 4.1 +/- 0.3 stools during the 12 hours after eating, whereas ileal pouch dogs passed 6.3 +/- 0. 9 stools (P <0.05). The mean frequency of proximal ileal pacesetter potentials after feeding was less in jejunal pouch dogs (12 +/- 0.4 cycles/min) than in ileal pouch dogs (16 +/- 0.3 counts/min; P = 0. 01), and jejunal pouches had more action potentials (jejunal = 82% +/- 4.3% of pacesetter potentials had action potentials, ileal = 61% +/- 3.0%; P <0.05). In contrast, gastric emptying and pouch motility, emptying, mucosal integrity, and bacteriologic and histologic properties were similar in the two groups of dogs. We concluded that the jejunal pouch operation slowed enteric transit, delayed defecation, and decreased postprandial stooling compared to the ileal pouch operation.

[The physiology of intestinal pouches]

To summarize, J-shaped and W-shaped ileal pouches serve as adequate neorectal reservoirs after proctocolectomy. These pouches anastomosed directly to the anal canal are as distensible and capacious and as readily evacuated as the rectum in health. However, the use of S- or H-shaped ileal pouches, which have efferent limbs positioned between the pouch and the anal canal, sometimes leads to outflow obstruction and incomplete evacuation. There is little doubt that neorectums made of ileum can allow patients to have entirely "normal" patterns of fecal continence. Nonetheless, with pouch distension, large-amplitude, propulsive pouch contractions occur. These large pressure waves bring on the urge to defecate. They stress the anal sphincters more acutely than either the infrequent, small-amplitude, nonpropulsive contractions or clustered contractions of the healthy rectum. Nonetheless, patients learn to recognize the different signals heralding the impending need for evacuation from the ileal pouch and deal with them. Jejunal pouches, because of their greater distensibility and larger capacity, and the greater frequency of interdigestive migrating myoelectric complexes (MMCs) occurring in them, hold the promise of being a better rectal substitute than ileal pouches. They are more difficult to construct, however. Colonic pouches, when anastomosed to the anal canal after rectal resection, also act as adequate fecal reservoirs. Their main drawback is the inability of some patients to empty them. Small (5 cm) colonic pouches seem to empty better than larger (10-15 cm) ones. Jejunal pouches and colonic segments used as gastric substitutes after gastrectomy provide a better reservoir for ingested food than straight jejunal segments. The main drawback of the pouches is their inability to triturate the solid content of a meal and to regulate the rate of its emptying into the small intestine. Liquids and solids likely empty from these pouches at the same rate, in contrast to the slower emptying rate of solids from the healthy stomach. This likely leads to maldigestion of solids, perhaps contributing to the weight loss often found after gastrectomy.

Use of a colonic pouch as a rectal substitute after rectal excision

Mid or distal rectal resection with straight coloanal anastomosis effectively treats distal rectal cancer and avoids a permanent stoma. However, the straight colonic segment is a poor reservoir for stools, and patients usually experience varying degrees of impaired rectal function after operation, including frequent bowel movements, incontinence, tenesmus, and soiling. In contrast, a J-shaped colonic pouch provides an adequate neorectal reservoir after operation. Patients with a colonic pouch-anal canal anastomosis have fewer bowel movements per day than patients with straight colorectal or coloanal anastomosis. Furthermore, the morbidity of the colonic pouch is not greater than that of the straight coloanal anastomosis. An important technical aspect of the colonic pouch procedure is that the limbs used to form the pouch must be no longer than 5 to 6 cm. Patients with larger pouches experience emptying difficulties. Also, the level of the anastomosis between the pouch and the anal canal must be no more than 4 cm from the anal verge, again to avoid problems with defecation. With these caveats, the operation should be considered in patients who require excision of the mid and distal rectum for cancer.

[Technical aspects of esophagocardiomyotomy with divulsion for the surgical treatment of non advanced chagasic megaesophagus]

BACKGROUND

The authors describe a Heller's technique alteration used for treatment of early Chagasic megaesphagus (ECM): esophagocardiomyotomy with divulsion plus esophagocardiopexy.

PATIENTS AND METHODS

Between June 1988 and March 1996, fifty patients were operated on at Surgery Department of FAMEMA. All had chagasic megaesophagus degrees I, II and III.

RESULTS

The results were excellent in 86% (43/50) and good in 14% (7/50), for 6 months to 7.6 years of follow up. The radiological and endoscopic studies showed neither esophagic stasis nor food residues and esophagitis.

CONCLUSION

The authors concluded that esophagocardiomyotomy with divulsion plus esophagocardiogastropexy is efficient in ECM degrees I, II e III and emphasize both technical facility and security.