Early Initiation of Adalimumab Significantly Diminishes Postoperative Crohn's Disease Endoscopic Recurrence and Is Superior to 6-Mercaptopurine Therapy: An Open-Label, Randomized Controlled Study

Postoperative recurrence (POR) is the rule in patients with Crohn's disease (CD), mitigated with prophylactic therapy. The evidence for therapeutic choice and timing of intervention is lacking. We aimed to compare the rates of POR in patients treated early with prophylactic 6-mercaptopurine (6-MP) or adalimumab. We conducted a prospective single-center randomized open-label clinical study in which patients in surgical remission following their first ileocecectomy were randomized to receive early treatment with 6-MP or adalimumab. Patients were followed up clinically every 3 months and underwent endoscopy at weeks 32 and 58 postoperatively. The primary endpoint was endoscopic recurrence (ePOR) at 1 year (week 58), defined as a Rutgeerts score ≥ i2. We enrolled 35 patients (25 males, mean age 35 ± 1.4 years, median disease duration 5 ± 6.1 years) following ileocecectomy. Of these, seven (20%) were current smokers and nine (26%) biologics-experienced. Patients allocated to adalimumab had significantly less ePOR than patients treated with 6MP at week 32 (21% vs. 69%, p = 0.004) and 58 (47% vs. 75%), (p = 0.03, HR = 0.39, 95% CI = 0.16-0.93). POR was associated with an increased diameter of the resected small bowel surgical specimen, lower baseline body mass index (BMI), increased week 18 fecal calprotectin, increased week 18 serum alanine aminotransferase and decreased week 18 hemoglobin level. Adalimumab was more effective than 6-MP in preventing ePOR. Increased operative small bowel diameter and lower postoperative BMI were associated with ePOR. At eighteen weeks, serum hemoglobin, ALT and fecal calprotectin levels were predictive of endoscopic disease recurrence. (ClinicalTrials.gov ID NCT01629628).

Surveillance and Management of Pouch Neoplasia in Familial Adenomatous Polyposis: A Systematic Review

BACKGROUND

Patients with familial adenomatous polyposis often require prophylactic colectomy with ileal pouch-anal anastomosis to treat and/or reduce to risk of colorectal neoplasia. However, after surgery, patients are still at some risk of developing pouch polyps and even cancer in both handsewn or stapled anastomoses. Management relies mainly on endoscopic or surgical interventions, while chemopreventive agents have a limited role in the management and prevention of pouch neoplasia. Novel endoscopic techniques are evolving and may gradually overtake surgical intervention in selected cases. Since familial adenomatous polyposis is relatively rare, there is scarcity of data regarding the natural history of pouch polyps and cancer in this population.

OBJECTIVE

This systematic literature review aims to describe the evolution, characteristics, various treatment modalities and their outcomes as well as recommended surveillance strategies of pouch neoplasia.

DATA SOURCES

PubMed and Cochrane databases, the international pouch consortium (for expert opinion).

STUDY SELECTION

Studies between 1990 and 2023, in English were included. Studies reporting neoplastic outcomes of inflammatory bowel disease pouch patients only were excluded.

MAIN OUTCOME MEASURES

Incidence of pouch neoplasia and its outcomes (successful resections, surgical complications, mortality).

RESULTS

Thirty-five studies were included.

LIMITATIONS

Most studies focus on inflammatory bowel diseases pouch patients, there is scarce data regarding polyposis patients only. Most cohorts are small and retrospective. Data on interventions is mainly descriptive and no randomized controlled trials are available.

CONCLUSIONS

Pouch adenoma are common and well managed by endoscopic resections, as advanced-endoscopic techniques are becoming more available. Additional data are required for defining updated recommendations for either endoscopic or surgical intervention. Pouch cancer is a very rare event and may arise despite surveillance. Continued endoscopic surveillance is key in cancer prevention and early detection. Outcome of cancer cases is poor and management in a referral center should be advised with tumor board discussions.

Reduction in surgical site infections by localized administration with D-PLEX100 in patients with multiple risk factors undergoing colorectal surgery

BACKGROUND

D-PLEX₁₀₀ is a novel drug-eluting lipid polymer matrix that supplies a high, local concentration of doxycycline for approximately 30 days. The objective of this post-hoc analysis was to assess the efficacy of D-PLEX₁₀₀ in preventing superficial and deep SSIs in patients with ≥2 risk factors.

PATIENTS AND METHODS

A post-hoc analysis of a previously reported prospective randomized trial assessing D-PLEX₁₀₀ plus Standard of Care (SOC) versus SOC alone in colorectal surgery was performed to assess SSI rate in patients with ≥2 risk factors.

RESULTS

The overall incidence of SSI was significantly lower for the D-PLEX₁₀₀ arm (9.9%) versus SOC (21%), p = 0.033. Patients with ≥2 risk factors, SSI incidence was 37.5% for SOC and 15.8% in D-PLEX₁₀₀ treated patients.

CONCLUSIONS

D-PLEX₁₀₀ reduces the incidence of SSIs beyond benefits associated with SOC treatment alone and including patients with ≥2 risk factors. D-PLEX₁₀₀ may be a promising addition to established SSI prophylaxis bundles.

Rectal Cancer following Local Excision of Rectal Adenomas with Low-Grade Dysplasia-A Multicenter Study

Purpose: Rectal polyps with low-grade dysplasia (LGD) can be removed by local excision surgery (LE). It is unclear whether these lesions pose a higher risk for recurrence and cancer development and might warrant an early repeat rectal endoscopy. This study aims to assess the rectal cancer rate following local excision of LGD rectal lesions. Methods: A retrospective multicenter study including all patients that underwent LE for rectal polyps over a period of 11 years was conducted. Demographic, clinical, and surgical data of patients with LGD werecollected and analyzed. Results: Out of 274 patients that underwent LE of rectal lesions, 81 (30%) had a pathology of LGD. The mean patient age was 65 ± 11 years, and 52 (64%) were male. The mean distance from the anal verge was 7.2 ± 4.3 cm, and the average lesion was 3.2 ± 1.8 cm. Full thickness resection was achieved in 68 patients (84%), and four (5%) had involved margins for LGD. Nine patients (11%) had local recurrence and developed rectal cancer in an average time interval of 19.3 ± 14.5 months, with seven of them (78%) diagnosed less than two years after the initial LE. Seven of the nine patients were treated with another local excision, whilst one had a low anterior resection, and one was treated with radiation. The mean follow-up time was 25.3 ± 22.4 months. Conclusions: Locally resected rectal polyps with LGD may carry a significant risk of recurring and developing cancer within two years. This data suggests patients should have a closer surveillance protocol in place.

A prospective, randomized assessment of a novel, local antibiotic releasing platform for the prevention of superficial and deep surgical site infections

BACKGROUND

Despite significant advances in infection control guidelines and practices, surgical site infections (SSIs) remain a substantial cause of morbidity, prolonged hospitalization, and mortality among patients having both elective and emergent surgeries. D-PLEX₁₀₀ is a novel, antibiotic-eluting polymer-lipid matrix that supplies a high, local concentration of doxycycline for the prevention of superficial and deep SSIs. The aim of our study was to evaluate the safety and efficacy of D-PLEX in addition to standard of care (SOC) in preventing superficial and deep surgical site infections for patients undergoing elective colorectal surgery.

METHODS

From October 10, 2018 to October 6, 2019, as part of a Phase 2 clinical trial, we randomly assigned 202 patients who had scheduled elective colorectal surgery to receive either standard of care SSI prophylaxis or D-PLEX₁₀₀ in addition to standard of care. The primary objective was to assess the efficacy of D-PLEX₁₀₀ in superficial and deep SSI reduction, as measured by the incidence of SSIs within 30 days, as adjudicated by both an individual assessor and a three-person endpoint adjudication committee, all of whom were blinded to study-group assignments. Safety was assessed by the stratification and incidence of treatment-emergent adverse events.

RESULTS

One hundred and seventy-nine patients were evaluated in the per protocol population, 88 in the intervention arm [51 males, 37 females, median age (64.0 range: 19-92) years] and 91 in the control arm [57 males, 34 females, median age 64.5 (range: 21-88) years]. The SSI rate within 30 day post-index surgery revealed a 64% relative risk reduction in SSI rate in the D-PLEX₁₀₀ plus standard of care (SOC) group [n = 7/88 (8%)] vs SOC alone [n = 20/91 (22%)]; p = 0.0115. There was no significant difference in treatment-emergent adverse events.

CONCLUSIONS

D-PLEX₁₀₀ application leads to a statistically significant reduction in superficial and deep surgical site infections in this colorectal clinical model without any associated increase in adverse events.

Fecal Calprotectin Is Increased in Pouchitis and Progressively Increases With More Severe Endoscopic and Histologic Disease

BACKGROUND & AIMS

Data regarding fecal calprotectin (FC), commonly used for noninvasive monitoring in inflammatory bowel diseases, are scarce in patients with ileal pouch-anal anastomosis (IPAA). We aimed to assess the association between FC levels and pouch inflammation in patients with ulcerative colitis who underwent IPAA.

METHODS

A cross-sectional study of adults with ulcerative colitis who underwent IPAA with J-pouch formation prospectively followed in a dedicated pouch clinic. Patients had clinical, endoscopic, and histologic assessments within 90 days of FC sampling. Each patient encounter was evaluated separately. Pouchitis was defined as a Pouchitis Disease Activity Score of ≥7 (maximum score: 18).

RESULTS

Overall, 156 patients had 296 encounters that met inclusion criteria. A total of 52% of patients were male, median age at evaluation was 43 (IQR, 35-58) years, and median pouch age was 10 (interquartile range [IQR], 2.5-15) years. Median FC values were significantly lower in patients without compared with those with pouchitis (208 [IQR, 96-478] μg/g vs 550 [IQR, 250-1051] μg/g; P < .0001). Mean FC values increased among patients with higher endoscopic and histologic scores. FC performed better than C-reactive protein as a predictor of pouchitis. FC of >460 μg/g had >80% specificity for predicting significant endoscopic disease (Pouchitis Disease Activity Score endoscopic subscore ≥5), while an FC of <125 μg/g had over 80% specificity in predicting endoscopic remission.

CONCLUSIONS

FC levels are increased in patients with endoscopic and histologic inflammation of the pouch. FC may be a useful tool in the management of patients following IPAA.

Long-term Antibiotic Treatment in Pouchitis-Patterns of Use and Safety

INTRODUCTION

Pouchitis, often developing after colectomy and ileal pouch-anal anastomosis for ulcerative colitis, is highly responsive to antibiotics. Ciprofloxacin and/or metronidazole are commonly used, often for prolonged periods. We report patterns of antibiotic use, adverse events, and resistant infections in patients with pouchitis with long-term antibiotic treatment.

METHODS

In a cohort of patients following pouch surgery, a retrospective nested case-control analysis was performed between 2010 and 2017. Ultra-long-term use, defined as the top 10% of users, was compared with the remaining users. Patterns of antibiotic use, adverse events, and resistant infections were analyzed.

RESULTS

The cohort included 205 patients with UC, of whom 167 (81.5%) used antibiotics for pouchitis, predominantly ciprofloxacin. The long-term antibiotic use rate was 18% and 42% at 5 and 20 years postsurgery, respectively. Mean antibiotic use of at least 1, 3, and 6 months/year was noted in 54 (26.3%), 31 (15.1%), and 14 (6.8%) patients, respectively. Twenty-two (13.2%) and 4 (2.4%) patients reported mild and severe (transient) adverse events, respectively, without mortalities, tendinopathies or arrhythmias. Adverse event rates for ciprofloxacin and metronidazole were 1per 10,000 and 6 per 10,000 use-days, respectively. Longer, but not ultra-long antibiotic use, was associated with mild adverse events. There was no association between antibiotic use and resistant infections. Thirteen (6.3%) patients required ileostomy procedures-more commonly in the ultra-long-term antibiotic users.

CONCLUSIONS

Patients with pouchitis may require prolonged antibiotic treatment, reflecting clinical benefit and favorable safety profile. Few adverse events and resistant infections were observed with long-term antibiotics use. However, resistant microbial strains selection, which are potentially transmittable, warrants consideration of different therapeutic alternatives.

Does microscopic involvement of the surgical margins after ileocecectomy in Crohn's patients predict early recurrence?

OBJECTIVE

The primary aim of this study was to determine whether the microscopic presence of Crohn's disease (CD) in the resected specimen margins in patients undergoing ileocecectomy predicts disease recurrence. The secondary aim was to identify other risk factors which can predict recurrence.

METHODS

All CD patients who underwent ileocecectomy in a single colorectal unit between 2000 and 2015 were retrospectively evaluated. The diagnosis of CD and margin involvement status were retrieved from pathology reports. Recurrence was determined according to medical records or via a telephone questionnaire. Demographic, clinical, and surgical parameters were compared between patients with and without histopathologic evidence of CD in the resected margins.

RESULTS

A total of 202 CD patients were included, 49 with and 153 without evidence of microscopic involvement in the resected margins. The main demographic characteristics, surgical approach and procedure, and postoperative course, including medical treatment, clinical or endoscopic recurrence, and reoperation rates, were similar for both groups. Patients who were operated laparoscopically (n=58, p 0.016), conversion from laparoscopic to open (n=25, p 0.016), stapled anastomosis (n=150, p 0.004), when stricturoplasty was required (n=12, p 0.046), and those with perianal disease (n=32, p 0.045) had shorter time to recurrence. Male gender had increased hazard ratio (n=106, HR 1.38) for reoperation, but not significantly (p=0.058).

CONCLUSIONS

The presence of microscopic CD at the resected specimen margins was not associated with the risk of disease recurrence. Other demographic, clinical, and technical features that did correlate with early recurrence were identified. These results support a conservative approach to the extent of resection in CD patients undergoing ileocecectomy.

TRIAL REGISTRATION

Not relevant.

Patients' perceptions of surgery for inflammatory bowel disease

AIM

Surgery is indicated in selected patients with inflammatory bowel disease (IBD). However, due to a negative perception, surgery may be delayed, leading to possible unfavourable outcomes. The aim of this work was to investigate patients' perceptions of surgery and the impact on reported outcomes.

METHOD

An international multilingual online survey was used to query IBD patients' experiences of surgery, information sources, expectations and concerns, quality of life (QoL) and feelings.

RESULTS

The survey was completed by 425 of 510 participants. Crohn's disease was more frequent (61%) than ulcerative colitis (36%). Most patients primarily learned about surgery from their gastroenterologist and were informed of the risks and benefits by the surgeon. In almost one-third of patients indication for surgery was not a shared decision between gastroenterologist and surgeon. Seventy per cent of patients naïve to surgery were not aware of any surgical options. The majority of patients (80%) perceived surgery as the last option after many medical treatments rather than an alternative therapeutic option (20%). Sixteen per cent of patients obtained their primary information from the Internet, while 82.4% used the Internet to obtain additional information. Fear of surgical complications was cited by 73% of patients, while relief from symptoms was indicated by 31%. Most patients coped with their stoma better than expected or as they expected. Negative feelings decreased after surgery, while a lasting improvement in positive feelings and QoL was reported.

CONCLUSION

Despite the negative perception of surgery and the delayed involvement of surgeons as a source of information and in the decision-making process, the majority of respondents experienced positive outcomes from surgery, including improvement QoL and acceptance of the stoma.

Quality of Care Standards in Inflammatory Bowel Diseases: a European Crohn's and Colitis Organisation [ECCO] Position Paper

The management of inflammatory bowel disease [IBD] is complex, and requires tight control of disease activity, close monitoring to avoid treatment side effects, health care professionals with expertise in IBD, and an interdisciplinary, holistic approach. Despite various efforts to standardise structures, processes, and outcomes,1-8 and due to the high variability at the local, national, and international levels, there are still no clear definitions or outcome measures available to establish quality of care standards for IBD patients which are applicable in all contexts and all countries. For this reason, the European Crohn's and Colitis Organisation [ECCO] supported the construction of a list of criteria summarising current standards of care in IBD. The list comprises 111 quality standard points grouped into three main domains [structure n = 31, process n = 42, outcomes n = 38] and is based on scientific evidence, interdisciplinary expert consensus, and patient-oriented perspectives. The list of proposed criteria is intended to represent the position of ECCO regarding the optimum quality of care that should be available to patients. Since health care systems and regulations vary considerably between countries, this list may require adaptation at local and national levels. It is recognised that not all these criteria that have been identified as optimal will be available in every unit. However, ECCO will continue its efforts to develop and coordinate projects and initiatives that will help to guarantee optimal quality of care for all IBD patients.

Predominantly Antibiotic-resistant Intestinal Microbiome Persists in Patients With Pouchitis Who Respond to Antibiotic Therapy

BACKGROUND & AIMS

Pouchitis that develops in patients with ulcerative colitis after total proctocolectomy and ileal pouch anal anastomosis is usually treated with antibiotics. Some patients have recurrence of flares, or become antibiotic-dependent, and require repeated courses or prolonged periods of antibiotic therapy. We investigated microbial factors associated with response to antibiotic treatment and development of antibiotic dependence in patients with pouchitis.

METHODS

We performed a prospective study of 49 patients who had undergone pouch surgery at a tertiary center. Disease activity was determined based on clinical, endoscopic, and histologic criteria. Pouch phenotype was defined as recurrent-acute pouchitis (n = 6), chronic pouchitis and Crohn's-like disease of the pouch (n = 27), normal pouch from patient with ulcerative colitis (n = 10), and normal pouch from patient with familial adenomatous polyposis (n = 6). Fecal samples (n = 234) were collected over time during or in the absence of antibiotic treatment (ciprofloxacin and/or metronidazole). Thirty-three patients were treated with antibiotics, for a median of 425 days of cumulative antibiotic therapy, during follow-up. Calprotectin was measured and fecal DNA was sequenced using shotgun metagenomics and analyzed with specifically designed bioinformatic pipelines. Bacterial strains were isolated from fecal samples. We assessed their ciprofloxacin resistance and ability to induce secretion of inflammatory cytokines by HT-29 intestinal epithelial cells.

RESULTS

Most antibiotic-treated patients (79%) had a clinical response to each course of antibiotics; however, 89% of those who completed a 4-week course relapsed within 3 months. Median calprotectin levels decreased by 40% in response to antibiotics. Antibiotic treatment reduced disease-associated bacteria such as Clostridium perfringens, Ruminococcus gnavus, and Klebsiella pneumoniae, but also beneficial species, such as Faecalibacterium prausnitzii. The microbiomes of antibiotic-responsive patients were dominated by facultative anaerobic genera (Escherichia, Enterococcus, and Streptococcus), with multiple ciprofloxacin-resistance mutations in drug target genes and confirmed drug resistance. However, these strains had lower potential for virulence and did not induce secretion of inflammatory cytokines by epithelial cells. After antibiotic cessation, patients had an abrupt shift in microbiome composition, with blooms of oral and disease-associated bacteria. In addition, antibiotic treatment enriched for strains that acquired multidrug resistance loci, encoding enzymes that confer resistance to nonrelated antibiotics, including extended-spectrum beta-lactamases.

CONCLUSIONS

The efficacy of antibiotic treatment of pouchitis might be attributed to the establishment of an antibiotic-resistant microbiome with low inflammatory potential. This microbiome might provide resistance against colonization by bacteria that promote inflammation. To avoid progression to antibiotic-dependent disease and its consequences, strategies such as short-term alternating antibiotics and nutrition- and microbiome-based interventions should be considered.

Timing of colostomy reversal following Hartmann's procedure for perforated diverticulitis

AIM

Hartmann's procedure is the surgical treatment of choice for perforated acute diverticulitis. Hartmann's reversal (HR) that is performed at a later stage may be challenging. The optimal timing for HR is still a subject for controversy. The aim of this study is to assess whether the timing of HR affects surgical outcome.

PATIENTS AND METHODS

A retrospective-cohort multi-center study was conducted, including all patients who underwent HR for acute diverticulitis from January 2004 to June 2015 in 5 medical centers. Patient data included demographics, surgical data and post-operative outcome.

RESULTS

One hundred and twenty-two patients were included in the database. Median time from Hartmann's procedure to reversal was 182.7 days, with the majority of patients (76 patients, 62.2%) operated 60 to 180 days from the Hartmann's procedure. Fifty-seven patients (46.7%) had post-operative complications, most commonly wound infections (27 patients, 22.1%). Receiver operating characteristic (ROC) curve and a propensity score match analysis (P=0.43) correlating between days to HR from the index procedure showed no specific cut-off point regarding post-operative complications (P=0.16), Major (Clavien-Dindo score of 3 or more) complications (P=0.19), Minor (Clavien Dindo 1-2) and no complications (P=0.14). Median length of stay was 10.9 days (range 3-90) and Pearson correlation failed to demonstrate a correlation between timing of surgical intervention and length of stay (P=0.4).

CONCLUSION

Hartmann's Reversal is a complex surgical procedure associated with high rates of complications. In our series, timing of surgery did not affect surgical complications rate or severity or the length of hospital stay.

Faecal Proteases from Pouchitis Patients Activate Protease Activating Receptor-2 to Disrupt the Epithelial Barrier

BACKGROUND AND AIMS

The pathogenesis of pouch inflammation may involve epithelial barrier disruption. We investigated whether faecal proteolytic activity is increased during pouchitis and results in epithelial barrier dysfunction through protease activating receptor [PAR] activation, and assessed whether the intestinal microbiome may be the source of the proteases.

METHODS

Faecal samples were measured for protease activity using a fluorescein isothiocyanate [FITC]-casein florescence assay. Caco-2 cell monolayers were exposed to faecal supernatants to assess permeability to FITC-dextran. Tight junction protein integrity and PAR activation were assessed by immunoblot and immunofluorescence. A truncated PAR2 protein in Caco-2 cells was achieved by stable transfection using CRISPR/Cas9 plasmid. PAR2 activation in pouch biopsies was examined using antibodies directed to the N-terminus of the protein. Microbial composition was analysed based on 16S rRNA gene sequence analysis.

RESULTS

Ten pouchitis patients, six normal pouch [NP] patients and nine healthy controls [HC] were recruited. The pouchitis patients exhibited a 5.19- and 5.35-fold higher faecal protease [FP] activity [p ≤ 0.05] compared to the NP and HC participants, respectively. The genus Haemophilus was positively associated with FP activity [R = 0.718, false discovery rate < 0.1]. Faecal supernatants from pouchitis patients activated PAR2 on Caco-2 monolayers, disrupted tight junction proteins and increased epithelial permeability. PAR2 truncation in Caco-2 abrogated faecal protease-mediated permeability. Pouch biopsies obtained from pouchitis patients, but not from NP patients, displayed PAR2 activation.

CONCLUSIONS

Protease-producing bacteria may increase faecal proteolytic activity that results in pouch inflammation through disruption of tight junction proteins and increased epithelial permeability in a PAR2-dependent manner. This mechanism may initiate or propagate pouch inflammation.

Fruit Consumption is Associated with Alterations in Microbial Composition and Lower Rates of Pouchitis

BACKGROUND

Patients with ulcerative colitis [UC] who undergo proctocolectomy with an ileal pouch-anal anastomosis commonly develop pouch inflammation [pouchitis]. Pouchitis develops in a previously normal small intestine and may involve environmental factors. We explored whether diet and microbiota alterations contributed to the pathogenesis of pouchitis.

METHODS

Patients were recruited and prospectively followed at a comprehensive pouch clinic. Pouch behaviour was clinically defined as a normal pouch [NP] or pouchitis. Patients completed Food Frequency Questionnaires [FFQs]. Faecal samples were analysed for microbial composition [16S rRNA gene pyrosequencing].

RESULTS

Nutritional evaluation was performed in 172 patients [59% females], and of these, faecal microbial analysis was performed in 75 patients (microbiota cohort: NP [n = 22], pouchitis [n = 53]). Of the entire cohort, a subgroup of 39 [22.6%] patients had NP at recruitment [NP cohort]. Of these, 5 [12.8%] developed pouchitis within a year. Patients at the lowest tertile of fruit consumption [<1.45 servings/day] had higher rates of pouchitis compared with those with higher consumption [30.8% vs 3.8%, log rank, p = 0.03]. Fruit consumption was correlated with microbial diversity [r = 0.35, p = 0.002] and with the abundance of several microbial genera, including Faecalibacterium [r = 0.29, p = 0.01], Lachnospira [r = 0.38, p = 0.001], and a previously uncharacterized genus from the Ruminococcaceae family [r = 0.25, p = 0.05]. Reduction in fruit consumption over time was associated with disease recurrence and with reduced microbial diversity [Δ = -0.8 ± 0.3, p = 0.008].

CONCLUSIONS

Fruit consumption is associated with modification of microbial composition, and lower consumption was correlated with the development of pouchitis. Thus, fruit consumption may protect against intestinal inflammation via alteration of microbial composition.

Starch Consumption May Modify Antiglycan Antibodies and Fecal Fungal Composition in Patients With Ileo-Anal Pouch

BACKGROUND

Inflammatory bowel diseases (IBDs) are characterized by serologic responses to glycans. Patients with ulcerative colitis (UC) after proctocolectomy with ileo-anal anastomosis (pouch surgery) may develop inflammation (pouchitis) that resembles Crohn's disease (CD). We hypothesized that patients' serologic responses were affected by their consumption of dietary sugars. This study analyzed the correlations between antiglycan antibody expression and dietary sugar consumption in patients with UC pouch and the evolution in antibody levels over time.

METHODS

Patients were followed prospectively for 2 consecutive visits. The following antiglycan carbohydrate antibodies were detected by enzyme-linked immunosorbent assay: antichitobioside (ACCA), antilaminaribioside (ALCA), antimannobioside (AMCA), and anti-Saccharomyces cerevisiae (ASCA) antibodies. Patients completed a food frequency questionnaire. The fungal community in patients' fecal samples was analyzed by sequencing the internal transcribed spacer 2 (ITS2) region of nuclear ribosomal DNA.

RESULTS

We included 75 UC pouch patients aged 45.2 ± 14 years who underwent pouch surgery 9.8 ± 6.7 years previously. Of these patients, 34.7% (n = 26) showed seropositivity for antiglycan antibodies. Starch consumption was significantly higher in patients with positive serologic responses (P = 0.05). Higher starch consumption was associated with higher AMCA and ACCA titers, which increased by 4.08% (0.8%-7.4%; P = 0.014) and 4.8% (0.7%-9.1%; P = 0.007), respectively, for each 10-g increase of dietary starch. The per-patient change in the relative abundance of Candida albicans in fecal samples correlated positively with changes in starch consumption (Spearman's r = 0.72; P = 0.012).

CONCLUSIONS

Starch consumption correlated with positive antiglycan serology (ACCA and AMCA), suggesting that increased dietary starch intake may promote a specific immune response in patients with IBD.

Comparison between laparoscopic and open Hartmann's reversal: results of a decade-long multicenter retrospective study

BACKGROUND

Hartmann's reversal is a challenging surgical procedure with significant postoperative morbidity rates. Various surgical methods have been suggested to lower the risk of postoperative complications. In this study, we aimed to compare the postoperative results between open and laparoscopic techniques for Hartmann's reversal.

METHODS

A retrospective study of all patients who underwent Hartmann's reversal in five centers in central Israel between January 2004 and June 2015 was conducted. Medical charts were reviewed, analyzing preoperative and operative parameters and short-term postoperative outcomes.

RESULTS

260 patients were included in the study. 76 patients were operated laparoscopically with a conversion rate of 26.3% (20 patients). No differences were found between patients operated laparoscopically and those operated in an open technique regarding gender (p = 0.785), age (61.34 vs. 62.64, p = 0.521), body mass index (26.6 vs. 26.2, p = 0.948), Charlson index score (1.79 vs. 1.95, p = 0.667), and cause for Hartmann's procedure (neoplastic vs. non-neoplastic, p = 0.644). No differences were seen in average time from the Hartmann's procedure to reversal (204.89 vs. 213.60 days, p = 0.688) and in overall complication rate (46.4 vs. 46.5%, p = 1). The Clavien-Dindo score for distinguishing between minor (0-2 score, p = 1) and major complications (3-5 score, p = 0.675) failed to demonstrate an advantage to laparoscopy, as well as to average length of stay (10.91 days in the laparoscopic group vs. 11.72 days in the open group, p = 0.529). An analysis based on the intention-to-treat with laparoscopy, including converted cases in the laparoscopic group, showed similar results, including overall complication rate (48.6 vs. 45.6%, p = 0.68) and Clavien-Dindo score in both minor (p = 0.24) and major complications (p = 0.44). Length of stay (10.92 vs. 11.81 days, p = 0.45) was also similar between the two groups.

CONCLUSION

In this series, a laparoscopic approach to Hartmann's reversal did not offer any short-term advantage when compared to an open surgical approach.

Considerations for Hartmann's reversal and Hartmann's reversal outcomes-a multicenter study

PURPOSE

Hartmann's procedure is commonly practiced in emergent cases with the restoration of bowel continuity planned at a second stage. This study assessed the rate of restorations following Hartmann's procedure and evaluated factors affecting decision-making.

METHODS

Data on patient demographics, comorbidities, causes for Hartmann's procedure, reversal rate, and complications were collected in a multicenter retrospective cohort study of patients who underwent Hartmann's procedure in five medical centers.

RESULTS

Six hundred forty patients underwent Hartmann's procedure for diverticular disease (36.1%), obstructing malignancy (31.8%), benign obstruction (5%), and other reasons (23.1%). Overall, 260 (40.6%) patients underwent subsequent restoration of bowel continuity. One hundred twenty-one (46.5%) patients had post-reversal complications, with an average Clavien-Dindo score of 1.4 and a mortality rate of 0.77%. Decision to avoid reversal was mostly related to comorbidities (49.7%) and metastatic disease (21.6%). Factors associated with the decision to restore bowel continuity included male gender (P = 0.02), patient age (62.3 years in Hartmann's reversal patients vs 73.5 years in non-reversal patients; P < 0.0001), number of comorbidities (1.1 vs 1.58; P < 0.001), average Charlson score (1.93 vs 3.44; P < 0.001), and a neoplastic etiology (P < 0.0001). A sub-analysis excluding all patients who died in the 30 days following Hartmann's procedure showed similar factors associated with ostomy closure.

CONCLUSION

Many patients do not have restoration of bowel continuity after undergoing Hartmann's procedure. Hartmann's reversal is associated with a significant postoperative morbidity. Surgeons and patients should be aware of the possibility that the colostomy might become permanent.

The outcome of ulcerative colitis patients undergoing pouch surgery is determined by pre-surgical factors

BACKGROUND

Pouch surgery, a common intervention for ulcerative colitis (UC) complications, is often associated with the development of pouchitis.

AIM

To identify predictors of pouch outcome in a cohort of patients with UC.

METHODS

We conducted a retrospective unmatched case-cohort study in a tertiary IBD referral centre. Adult patients with UC were classified into the worst phenotype throughout follow-up: normal pouch, a form of chronic pouchitis (either chronic pouchitis or Crohn's like disease of pouch [CLDP]), or episodic recurrent acute pouchitis (RAP). Risk factors for pouchitis (chronic forms) were detected using statistical models.

RESULTS

Two hundred and fifty-three pouch patients were followed up for 13.1±7.3 years. Only 71 patients (28.1%) maintained a favourable outcome of a sustained normal pouch. These patients were older at UC diagnosis (27.8±12.5 vs 23.0±11.4 years), had longer UC duration until surgery (13.4±9.5 vs 8.2±7.9 years), and had higher rates of referral to surgery due to nonrefractory (dysplasia/neoplasia) complications (42.3% vs 16.2%) compared with pouchitis patients. Median survival for sustained normal pouch was 10.8 years (95% CI 8.9-12.7 years), and it was longer in the nonrefractory group (20.3 vs 9.4 years for the refractory group, HR=2.37, 95% CI 1.25-3.52, P=.004).

CONCLUSIONS

Most patients with UC undergoing pouch surgery will develop pouchitis. Patients operated for nonrefractory indications have a more favourable outcome. These results may contribute to pre- and post-surgical decision-making. The findings imply that the processes determining UC severity may be similar to that causing pouchitis.

Restorative Proctocolectomy in Elderly IBD Patients: A Multicentre Comparative Study on Safety and Efficacy

BACKGROUND AND AIMS

Restorative proctocolectomy in elderly inflammatory bowel disease [ IBD] patients is controversial and limited data are available on the outcomes of surgery. The aim of this study was to evaluate the safety, efficacy, and long-term results of ileal-pouch-anal anastomosis in elderly patients, in a multicentre survey from European referral centres.

METHODS

The International Pouch Database [IPD] combined 101 variables. Patients aged ≥ 65 years were matched on the basis of open versus laparoscopic surgery with a control group of consecutive younger unselected patients with a ratio of 1:2. Statistical analysis was performed using two-tailed t test, chi square and Fisher's exact tests, Kaplan-Meier function, and log-rank tests where appropriate.

RESULTS

In the IPD, 77 patients aged ≥ 65 years [Group A] and 154 control patients [Group B] were identified. Elderly patients had more comorbidities [p = 0.0001], longer disease duration [p = 0.001], less extensive disease [p = 0.006], more previous abdominal operations [p = 0.0006], surgery for cancer or dysplasia more frequently [p = 0.0001], fewer single-stage procedures [p = 0.03], more diversions after ileal pouch-anal anastomosis [IPAA] [p = 0.05], and a higher laparoscopic conversion rate [p = 0.04]. Postoperative complications and pouch failure were similar between the groups, but Group A had more Clavien-Dindo IV-V complications [p = 0.04], and longer length of stay [p = 0.007]. Laparoscopy was associated with a shorter duration of surgery [p = 0.0001], and length of stay [p = 0.0001], and the same complication rate as open surgery.

CONCLUSIONS

Restorative proctocolectomy can be performed in selected elderly patients, but there is a higher risk of postoperative complications and longer length of stay in this group. Laparoscopy is associated with shorter operating time and length of stay.

Does residual microscopic disease after chemoradiotherapy for locally advanced rectal cancer translate into a good clinical outcome?

AIM

This study aimed to assess the progression-free and overall survival of patients with residual microscopic disease following neoadjuvant chemoradiotherapy and rectal resection for locally advanced rectal cancer.

METHOD

Two-hundred and thirty-four consecutive rectal cancer patients who had neoadjuvant chemoradiotherapy followed by radical resection (from May 2000 to April 2012) were divided according to pathological tumour response: residual microscopic disease (MIC), complete response (pCR) and partial/no response (non-CR). Data on the neoadjuvant regime, treatment-to-surgery interval, final pathology, type of operation, operative time, postoperative complications, length of hospital stay, disease recurrence and mortality were compared between the groups.

RESULTS

There were 13 (5.5%) MIC patients, 48 (20.5%) with pCR and 173 (73.9%) with non-CR group. The groups were demographically comparable. MIC patients had more retrieved lymph nodes compared with the non-CR and pCR patients (median 13 compared with 8 and 10, respectively, P = 0.0086). The 5-year overall survival rates were 93.4% for the pCR and MIC patients vs 82.1% for the non-CR patients (P = 0.0324). The 5-year progression-free survival was 85.2% for the pCR and MIC patients vs 73.8% for the non-CR patients (P = 0.086).

CONCLUSION

We have identified and assessed a new pathological subgroup of rectal cancer patients who had residual microscopic disease after neoadjuvant therapy. The survival analysis aligned them closely with pCR patients.

Alterations of Enteric Microbiota in Patients with a Normal Ileal Pouch Are Predictive of Pouchitis

OBJECTIVE

To examine whether patients with a mature normal pouch [> 1 year post ileostomy closure] have microbial stool characteristics that can predict pouch inflammation.

DESIGN

Patients undergoing pouch surgery were recruited prospectively. Microbiota analysis of faecal samples was by 16S rRNA gene pyrosequencing. All patients had a normal pouch at baseline [T1]. Those without pouchitis during the first year of follow-up [T2] comprised the 'Normal Pouch-sustained' group and those who had experienced an episode of pouchitis comprised the 'Pre-Pouchitis' group.

RESULTS

Twenty patients were recruited (age 53.6±13.1 years, pouch age [time from ileostomy closure] 8.1±5.1 years). Seven patients developed pouchitis during follow-up [within 265±93.6 days] and they were assigned to the Pre-Pouchitis group at T1: they had a decreased microbial diversity at T1 compared with the Normal Pouch-sustained patients [n = 13]. The Shannon diversity index for the Pre-Pouchitis patients was 3.4 vs 4.23 for the Normal Pouch-sustained patients [p = 0.011]. There were no substantial group differences in high taxonomic levels [order or above]. The genus Ruminococcus was significantly decreased in the Pre-Pouchitis patients' samples compared with those of the Normal Pouch-sustained patients (0.19% vs 0.78%, respectively, false discovery rate [FDR] = 0.05). The linear discriminant analysis with effect size estimation algorithm revealed that Lachnospira and Coprococcus genera were also decreased among Pre-Pouchitis patients compared with Normal Pouch-sustained patients [0.6% vs 1.95% and 2.1% vs 4%, respectively].

CONCLUSIONS

Patients with a normal mature pouch may be predisposed to acute pouchitis when faecal microbial diversity and certain microbial groups are decreased. These findings may aid in risk stratification of those patients.

MicroRNAs Expression in the Ileal Pouch of Patients with Ulcerative Colitis Is Robustly Up-Regulated and Correlates with Disease Phenotypes

Background

Gene expression alterations are associated with disease behavior in inflammatory bowel disease (IBD). microRNAs (miRNAs) are dominant in the regulation of gene expression, and may affect IBD phenotype. Our aim was to assess mucosal miRNA expression in IBD and the correlation with intestinal inflammation.

Methods

We performed a large-scale analysis of ileal mucosal miRNA. Biopsies were retrieved from patients with ileal Crohn’s disease (CD), unoperated ulcerative colitis (UC) patients, UC patients after pouch surgery, and normal controls (NC). Pouch UC patients were classified as having a normal pouch (NP), chronic pouchitis (CP), and Crohn’s-like disease of the pouch (CLDP). miRNA expression was analyzed by parallel massive (next-generation) sequencing (NGS). Bioinformatics tools were applied for clustering and the detection of potential targets.

Results

Sixty-one subjects were recruited. The ileum of unoperated UC patients was comparable with NC. There were significant miRNA expression alterations (fold change ≥2, corrected P ≤.05) in NP (n = 6), CP (n = 40) and CLDP (n = 139), but only two expression alterations were noted in CD. More than 90% of the altered miRNAs were up-regulated, and many were predicted to be associated with significantly decreased transcripts. miRNAs alterations were generally clustered with disease phenotypes.

Conclusions

Ileal inflammation causes increased miRNA expression. miRNA alterations correlate with IBD phenotype, apparently by controlling the down-regulation of specific mRNAs.

Clinical recurrence and re-resection rates after extensive vs. segmental colectomy in Crohn's colitis: a retrospective cohort study

BACKGROUND

The aim of the present study was to document long-term clinical recurrence and re-resection rates of segmental and extended colectomy in patients with Crohn's colitis and to identify risk factors causing recurrence.

METHODS

Records of patients with isolated colonic Crohn's disease who underwent colectomy between 1995 and 2013 and were followed at our medical center were identified. Data on age at diagnosis, gender, smoking, disease location at diagnosis, perianal and rectal disease, indication for surgery, preoperative disease duration, type of operation, primary anastomosis at first operation, length of resected specimen, recurrence of symptoms, postoperative medication, reoperation, and total follow-up time were retrieved.

RESULTS

Thirty-five suitable patients (18 segmental colectomy, 17 extensive colectomy; 17 males; mean age at operation 36.6 years) were identified. Mean age at primary operation was 36 years. The mean preoperative disease duration was 121 months. Postoperative medical treatment was needed in 10 (56 %) patients undergoing segmental colectomy and in 16 (94 %) of those undergoing extensive colectomy (p = 0.01). There was longer reoperation-free survival in the segmental colectomy patient group (p = 0.02) and also a trend toward longer symptom-free survival compared to the extensive colectomy patient group (p = 0.105). There was no correlation between the length of resected bowel and recurrence. Patients operated on at a younger age did not have a higher rate of recurrence of symptoms. Shorter disease duration, smoking, and male gender were risk factors for clinical recurrence.

CONCLUSIONS

Segmental resection with primary anastomosis can be safely performed in patients with limited Crohn's colitis with reasonable clinical recurrence rates.

Patterns of Adenoma Recurrence in Familial Adenomatous Polyposis Patients after Ileal Pouch-Anal Anastomosis

AIM

This study aims at identifying the risk factors for the development of pre-cancerous pouch and/or cuff adenomas post ileal pouch anal anastomosis (IPAA) in familial adenomatous polyposis patients.

METHOD

We retrospectively studied 59 patients operated at a single medical center during a 26-year period. Data on the timing and location of adenoma recurrence were recorded and possible correlations with patients' gender, age, presence of desmoid tumor, duodenal adenomas, type of anastomosis and number of operation stages were analyzed.

RESULTS

Thirty-five (59%) patients had at least one adenoma in either the cuff or the pouch, including 20 with isolated cuff adenomas, 4 with isolated pouch adenomas and 11 patients with adenomas in both the pouch and cuff. There was no significant correlation between gender, age at surgery, type of anastomosis, number of operative stages and the development of pouch or cuff adenomas. Desmoid tumor and pouch adenomas were significantly correlated with cuff adenomas formation. Duodenal adenomas were associated with pouch adenomas. There was some relationship between the development of cuff adenomas and the burden of colonic polyps, as well as the presence of duodenal adenomas.

CONCLUSION

Adenomas in both the pouch and cuff commonly occur following IPAA, mandating lifelong annual endoscopic surveillance.

Pouch Inflammation Is Associated With a Decrease in Specific Bacterial Taxa

BACKGROUND & AIMS

Pouchitis is a common long-term complication in patients with ulcerative colitis (UC) undergoing proctocolectomy with ileal pouch-anal anastomosis. Because the inflammation occurs in a previously normal small bowel, studies of this process might provide information about the development of Crohn's disease. Little is known about the intestinal microbiome of patients with pouchitis. We investigated whether specific bacterial populations correlate with the pouch disease phenotype and inflammatory activity.

METHODS

We performed a prospective study of patients with UC who underwent pouch surgery (N = 131) from 1981 through 2012 and were followed at Tel Aviv Medical Center. Patients were assigned to groups based on their degree and type of pouch inflammation. Patients with familial adenomatous polyposis after pouch surgery (n = 9), individuals with intact colons undergoing surveillance colonoscopy (n = 10), and patients with UC who did not undergo surgery (n = 9) served as controls. We collected demographic and disease activity data (based on the Pouchitis Disease Activity Index) and measured levels of C-reactive protein. Fecal samples were collected, levels of calprotectin were measured, and microbiota were analyzed by 16S ribosomal RNA gene amplicon pyrosequencing.

RESULTS

Increased proportions of the Fusobacteriaceae family correlated with increased disease activity and levels of C-reactive protein in patients with UC who underwent pouch surgery. In contrast, proportions of Faecalibacterium were reduced in patients with pouchitis vs controls; there was a negative correlation between proportion of Faecalibacterium and level of C-reactive protein. There was an association between antibiotic treatment, but not biologic or immunomodulatory therapy, with reduced proportions of 11 genera and with increased proportions of Enterococcus and Enterobacteriaceae.

CONCLUSIONS

Reductions in protective bacteria and increases in inflammatory bacteria are associated with pouch inflammation in patients with UC who underwent pouch surgery. The finding that antibiotics exacerbate dysbiosis indicates that these drugs might not provide long-term benefit for patients with pouchitis. Additional studies of this form of dysbiosis could provide information about the pathogenesis of Crohn's disease.

Gene expression alterations in ulcerative colitis patients after restorative proctocolectomy extend to the small bowel proximal to the pouch

OBJECTIVES

To evaluate molecular profiles in the small bowel (SB) mucosa proximal to the pouch in ulcerative colitis (UC) patients after pouch surgery.

DESIGN

Patients were prospectively recruited and stratified according to disease behaviour: normal pouch (NP), chronic pouchitis (CP), and Crohn's-like disease of the pouch (CLDP). Biopsies obtained from the pouch and the normal-appearing proximal SB (40 cm proximal to the anal verge) were compared to ileal biopsies from normal controls (NC). A histopathological score based on the degree of polymorphonuclear and mononuclear infiltrates was used to assess inflammation in the pouch and the proximal SB. Gene expression analysis was performed using microarrays, and validated by real-time PCR. Gene ontology and clustering were evaluated by bioinformatics.

RESULTS

Thirty-six subjects were recruited (age 18-71 years, 16 males). Histopathology scores demonstrated minimal differences in the normal-appearing proximal SB of all groups. Nonetheless, significant (fold change ≥2, corrected p [FDR] ≤ 0.05) molecular alterations in the proximal SB were detected in all groups (NP n=9; CP n=80; and CLDP n=230) compared with NC. The magnitude of DUOX2 alteration in the proximal SB was highest. An increase of 6.0, 9.8 and 21.7 folds in DUOX2 expression in NP, CP, CLDP, respectively was observed. This was followed by alterations in MMP1, SLC6A14 and PGC. Gene alterations in the proximal SB overlapped with alterations within the pouch (76% and 97% overlap in CP and CLDP, respectively). Gene ontology analysis in the proximal SB and pouch were comparable.

CONCLUSIONS

Significant gene expression alterations exist in an apparently unaffected proximal SB. Alterations in the pouch and the proximal SB were comparable, suggesting that inflammation may not be limited to the pouch, but that it extends to the proximal SB.

Prognosis of primary sclerosing cholangitis in israel is independent of coexisting inflammatory bowel Disease

BACKGROUND AND AIMS

Primary sclerosing cholangitis (PSC) is a rare chronic progressive cholestatic disorder. We assessed its characteristics and natural history in Israel and compared its outcome with respect to coexisting inflammatory bowel disease (IBD).

METHODS

Data on characteristics, course and outcome were retrospectively retrieved on patients diagnosed with PSC from five large Israeli medical centers between 1988 and 2012. Patients with isolated PSC were compared with those with coexisting IBD to identify predictors of outcome.

RESULTS

Of 141 patients (56% males) with confirmed PSC, 98 (69.5%) had coexisting IBD. The average age at presentation was 38.8 ± 15.4 years and duration of follow-up was 7.93 ± 6.26 years. The crude estimated point prevalence was 4 cases per 105 persons. Demographics and clinical characteristics were similar among all patients except for symptoms at diagnosis (which were more prevalent among PSC–IBD patients) and utilization of multiple diagnostic modalities (which was more prevalent among isolated-PSC patients). More than one-third of the entire cohort had cirrhosis. A total of 15 patients (10.6%) died and 19 patients (13.5%) developed malignancy during follow-up. Nine patients (6.3%) underwent liver transplantation. Mean survival for the entire cohort was 26.3 ± 1.4 years and mean transplant-free survival was 23.5 ± 1.6 years. Cox proportional hazard regression for transplantation or death revealed two independent risk factors: cirrhosis and malignancy [hazard ratio 4.25 (p = 0.004) and 2.58 (p = 0.046), respectively].

CONCLUSIONS

Survival rate of PSC patients in Israel is longer than reported rates worldwide and is independent of coexisting IBD.

Antibodies against glycoprotein 2 are novel markers of intestinal inflammation in patients with an ileal pouch

BACKGROUND AND AIMS

The Crohn's disease (CD)-specific pancreatic auto-antibodies (PAB), have been recently identified to target glycoprotein 2 (GP2). Pouchitis is an inflammation of the small bowel developing in up to 60% of ulcerative colitis patients undergoing proctocolectomy and ileal pouch anal anastomosis. Occurrence of CD-specific antibodies was reported to be a predictor of pouchitis. We aimed to assess the prevalence of anti-GP2 antibodies (anti-GP2) in the serum and feces of pouch patients and to correlate them with clinical parameters. Furthermore, we examined mucosal expression of the GP2 protein in the pouch.

METHODS

Pouch patients were prospectively recruited and checked for clinical, endoscopic, and laboratory markers of inflammation. IgG and IgA anti-GP2 levels in serum and fecal samples were determined using ELISA. GP2 protein was assessed by immunohistochemistry.

RESULTS

Anti-GP2 was elevated in both serum and fecal samples of patients with inflamed compared to those with non-inflamed pouches and patients with familial-adenomatous polyposis after surgery (p<0.05, respectively). Moreover, patients with CD-like complications exhibited significantly higher anti-GP2 titers than those without CD-like complications (p≤0.01). High levels of anti-GP2 correlated with more frequent bowel movements per day and with the presence of at least one anti-glycan antibody (p≤0.05). GP2 itself was more abundant in the mucosa of patients with chronic pouchitis.

CONCLUSIONS

Anti-GP2 exists in the serum and feces of pouch patients and correlates with pouch inflammation, and presence of other serological markers. Thus, anti-GP2 may contribute to better stratification of pouchitis, more-so when the inflammation exhibits CD-like complications.

Diet of patients after pouch surgery may affect pouch inflammation

AIM: To investigate the diet of pouch patients compared to healthy controls, and to correlate pouch patients’ diet with disease behavior.

METHODS: Pouch patients were recruited and prospectively followed-up at the Comprehensive Pouch Clinic at the Tel Aviv Sourasky Medical Center. Pouch behavior was determined based on clinical, endoscopic and histological criteria. Healthy age- and sex-matched volunteers were selected from the “MABAT” Israeli Nutrition and Public Health Governmental Study and served as the control group. All the participants completed a 106-item food frequency questionnaire categorized into food groups and nutritional values based on those used in the United States Department of Agriculture food pyramid and the Israeli food pyramid. Data on Dietary behavior, food avoidance, the use of nutritional supplements, physical activity, smoking habits, and body-mass index (BMI) were also obtained. Pouch patients who had familial adenomatous polyposis (n = 3), irritable pouch syndrome (n = 4), or patients whose pouch surgery took place less than one year previously (n = 5) were excluded from analysis.

RESULTS: The pouch patients (n = 80) consumed significantly more from the bakery products food group (1.2 ± 1.4 servings/d vs 0.6 ± 1.1 servings/d, P < 0.05) and as twice as many servings from the oils and fats (4.8 ± 3.4 servings/d vs 2.4 ± 2 servings/d, P < 0.05), and the nuts and seeds food group (0.3 ± 0.6 servings/d vs 0.1 ± 0.4 servings/d, P < 0.05) compared to the controls (n = 80). The pouch patients consumed significantly more total fat (97.6 ± 40.5 g/d vs 84.4 ± 39 g/d, P < 0.05) and fat components [monounsaturated fatty acids (38.4 ± 16.4 g/d vs 30 ± 14 g/d, P < 0.001), and saturated fatty acids (30 ± 15.5 g/d vs 28 ± 14.1 g/d, P < 0.00)] than the controls. In contrast, the pouch patients consumed significantly fewer carbohydrates (305.5 ± 141.4 g/d vs 369 ± 215.2 g/d, P = 0.03), sugars (124 ± 76.2 g/d vs 157.5 ± 90.4 g/d, P = 0.01), theobromine (77.8 ± 100 mg/d vs 236.6 ± 244.5 mg/d, P < 0.00), retinol (474.4 ± 337.1 μg/d vs 832.4 ± 609.6 μg/d, P < 0.001) and dietary fibers (26.2 ± 15.4 g/d vs 30.7 ± 14 g/d, P = 0.05) than the controls. Comparisons of the food consumption of the patients without (n = 23) and with pouchitis (n = 45) showed that the former consumed twice as many fruit servings as the latter (3.6 ± 4.1 servings/d vs 1.8 ± 1.7 servings/d, respectively, P < 0.05). In addition, the pouchitis patients consumed significantly fewer liposoluble antioxidants, such as cryptoxanthin (399 ± 485 μg/d vs 890.1 ± 1296.8 μg/d, P < 0.05) and lycopene (6533.1 ± 6065.7 μg/d vs 10725.7 ± 10065.9 μg/d, P < 0.05), and less vitamin A (893.3 ± 516 μg/d vs 1237.5 ± 728 μg/d, P < 0.05) and vitamin C (153.3 ± 130 mg/d vs 285.3 ± 326.3 mg/d, P < 0.05) than the patients without pouchitis. The mean BMI of the pouchitis patients was significantly lower than the BMI of the patients with a normal pouch: 22.6 ± 3.2 vs 27 ± 4.9 (P < 0.001).

CONCLUSION: Decreased consumption of antioxidants by patients with pouchitis may expose them to the effects of inflammatory and oxidative stress and contribute to the development of pouchitis.

Restorative proctocolectomy impairs fertility and pregnancy outcomes in women with ulcerative colitis

AIM

The effect of restorative proctocolectomy (RPC) on fertility and pregnancy in women with ulcerative colitis (UC) was evaluated.

METHOD

Post-RPC female patients with UC who were attempting to become pregnant filled out questionnaires on fertility and pregnancy. Demographic and pouch data of pregnancies ending with delivery were collected from a prospective database.

RESULTS

Forty-one women, 44 ± 10 years of age, completed the questionnaires. The median follow-up period post-RPC was 167 (range, 20-352) months. Before RPC, 26 women had 70 pregnancies and 62 deliveries. After RPC, 17 women had 32 pregnancies and 26 deliveries (P = 0.0035). Post-RPC, 10 (37%) of 27 patients failed to conceive compared with 26/26 successful attempts before RPC (P = 0.0006). The number of offspring per patient was 2.38 ± 1.27 before, and 0.68 ± 0.93 after, RPC (P < 0.0001). A higher number of spontaneous pregnancies occurred before (56/62; 90%) than after (15/25; 60%) RPC (P = 0.0004). The time to conception was longer (5.0 ± 11.6 vs 16.3 ± 25.1 months; P = 0.039) and there were more in-vitro fertilization procedures (three vs six) post-RPC. The gestation period was similar, but after RPC more deliveries were by Caesarean section (12.9% vs 46.2%; P = 0.0007). Babies born before RPC weighed more than those born after RPC (3.16 ± 0.61 kg vs 2.79 ± 0.68 kg, respectively; P = 0.0327).

CONCLUSION

RPC is associated with an increased risk of infertility, similar duration of gestation and lower birthweight. Female candidates for RPC who have not finished family planning should be counselled accordingly.

Risk factors for chronic pouchitis after ileal pouch-anal anastomosis: a prospective cohort study

AIM

The association between various demographic, clinical and pathological parameters and the evolution of chronic pouchitis was evaluated.

METHOD

All ulcerative colitis patients who underwent ileal pouch anal anastomosis (1981-2009) were followed prospectively in a comprehensive pouch clinic. We examined risk factors including the presence of appendiceal inflammation and backwash ileitis in the colonic specimen, gender, ethnicity, age at disease onset, disease duration, extent of colitis, presence of extraintestinal manifestations (e.g. primary sclerosing cholangitis), family history of inflammatory bowel disease, indication for surgery, medical treatment, age at operation, staged procedure, diverting ileostomy and length of follow-up. Univariate analysis was performed on all risk factors followed by logistic regression analysis.

RESULTS

The 201 enrolled patients (106 women, age at surgery 35 ± 15 years) were followed for a mean of 108 months. One hundred and thirty-eight (69%) had either a normal pouch or episodes of acute pouchitis and 63 (31%) developed chronic pouchitis. On univariate analysis the presence of an ileostomy (P = 0.017), pancolitis (P = 0.008), shorter disease duration (P = 0.04) and longer follow-up (P = 0.01) were identified as risk factors for chronic pouchitis. Multivariate analysis showed that patients with pancolitis (OR 3.26, 95% CI 1.20-8.85) and longer follow-up (OR 1.09, 95% CI 1.01-1.18) were more likely to develop chronic pouchitis. There was also an association to disease duration but this did not reach a level of significance.

CONCLUSIONS

Pancolitis and longer follow-up are directly related to the development of chronic pouchitis.

Colorectal carcinoma in inflammatory bowel disease: a comparison between Crohn's and ulcerative colitis

AIM

The study assessed the clinicopathological features and survival rates of inflammatory bowel disease (IBD) patients with colorectal carcinoma (CRC), which accounts for ∼ 15% of all IBD associated death.

METHOD

The medical records of patients operated on for CRC in three institutions between 1992 and 2009 were reviewed, and those with Crohn's colitis (CC) and ulcerative colitis (UC) were identified. Data on age, gender, disease duration, colitis severity, surgical procedure, tumour stage and survival were retrieved.

RESULTS

Fifty-three patients (40 UC and 13 CC, 27 men, mean age at operation 54 years) were found. All parameters were comparable between the groups. Mean disease duration before CRC was 22.7 years for UC and 16.6 years for CC patients (P = 0.04). CRC was diagnosed preoperatively in 43 (81%) patients. Twenty-eight patients had colon cancer, 23 had rectal cancer and two patients had more than one cancer. All malignancies were located in segments with colitis. Over one-half were diagnosed at an advanced stage (36% stage III; 17% stage IV). At a mean follow up of 56 ± 65 months, 60% were alive (54% disease free) and 40% were dead from cancer-related causes. The 5-year survival rate was 61% for the UC and 37% for the CC patients (P = NS).

CONCLUSION

CRC in IBD patients is frequently diagnosed at an advanced stage, a factor that contributes to poor prognosis. The risk of CRC in CC patients is comparable to those with UC. Long-term surveillance is recommended for patients with long-standing CC and UC.

The effect of neoadjuvant Imatinib therapy on outcome and survival after rectal gastrointestinal stromal tumour

AIM

The study aimed to characterize the pathological and clinical response of rectal gastrointestinal stromal tumours (GISTs) to neoadjuvant Imatinib.

METHOD

The medical records of patients with rectal GISTs who were diagnosed and treated in five medical centres in Israel between January 2002 and January 2009 were retrospectively examined. Twelve patients who fulfilled the inclusion criteria of nonmetastatic rectal GIST for which preoperative neoadjuvant treatment with Imatinib was considered were suitable for enrollment.

RESULTS

Of the 12 patients, nine received neoadjuvant treatment with Imatinib. The three patients who had immediate surgery were excluded. There were five men and four women with a median age of 63 years and a median follow up of 32 months. All tumours were located in the lower two-thirds of the rectum. One patient had a complete clinical response, six had a partial response and two had stable disease. Seven patients subsequently underwent surgery; six had an R0 resection and one had an R1 resection. Three patients had recurrence. There was no disease-related mortality. The reduction in both tumour size and mitotic activity during preoperative Imatinib therapy was significant.

CONCLUSION

Preoperative Imatinib therapy can shrink large rectal GISTs, improving the chances of successful radical surgery and decreasing the risk of considerable morbidity.

Reciprocal regulation of CXCR4 and CXCR7 in intestinal mucosal homeostasis and inflammatory bowel disease

IBDs are characterized by increased influx of immune cells to the mucosa of genetically susceptible persons. Cellular migration to injury sites is mediated by chemokines. CXCL12 is a ubiquitous, constitutive chemokine that participates in stem cell proliferation and migration and mediates T lymphocyte migration to inflamed tissues. We have recently reported that CXCL12 and its receptor, CXCR4, are expressed in normal and more prominently, inflamed human intestinal mucosa. However, the interactions and roles of CXCL12 and its receptors, CXCR4 and the recently discovered CXCR7, in intestinal inflammation have not been defined. In the present study, we further dissected the effects of CXCL12 on lymphocytes in intestinal homeostasis and inflammation and delineated the interplay between CXCL12 and its receptors CXCR4 and CXCR7. To that end, fresh mononuclear cells were isolated from mucosa and PB of healthy or IBD patients. Phenotypical and functional assays were conducted using flow cytometry, Transwell migration chambers, and ELISA. The data show that CXCL12-mediated migration of T cells is CXCR4- but not CXCR7-dependent. T cell activation reciprocally regulates CXCR7 and CXCR4 expression and migratory capacity. IBD PBTs expressed more CXCR7 than normal PBTs. Finally, T cells attracted by CXCL12 are mostly of a memory phenotype. In conclusion, the present study suggests that the interplay between CXCL12 and its receptors affects homeostasis and inflammation in the intestinal mucosa.

Three-dimensional endoanal ultrasonography of external anal sphincter defects in patients with faecal incontinence: correlation with symptoms and manometry

AIM

Anal sphincter anatomy on two-dimensional endoanal -ultrasonography (EUS) does not always correlate with the clinical data. The purpose of this study was to determine whether three-dimensional (3D) measurements yield a better correlation.

METHOD

The study group included consecutive patients who underwent 3D EUS for faecal incontinence over a 2-year period. The medical charts were reviewed for Cleveland Clinic Foundation Fecal Incontinence (CCF-FI) score and manometric pressures. Endoanal ultrasonographic images were reviewed for the presence of an external anal sphincter (EAS) defect and its extent, as determined by the radial angle, length in the sagittal plane and percentage volume deficit. Correlational analyses were performed between the clinical and imaging data.

RESULTS

Sixty-one patients of median age 53 years (range 15-82) were evaluated. Thirty-two patients had either a complete (17) or partial (15) EAS defect, and 29 patients had an intact sphincter. The CCF-FI scores were similar in patients with and without an EAS defect (12.5 ± 5.6 and 11.4 ± 5.5, respectively). The intact-sphincter group had a significantly greater EAS length (3 ± 0.4 vs 2 ± 0.62 cm, P = 0.02) and higher mean maximal squeeze pressure (MMSP; 99.7 ± 52.6 vs 66.9 ± 52.9 mmHg, P = 0.009). There were no statistically significant correlations between MMSP, CCF-FI score and EAS status on 3D EUS. Mean percentage volume of the defect was similar in patients with complete and partial tears (14.5 ± 5.5 and 17.5 ± 7.2%, P = 0.25) and showed no correlation with physiological tests or symptom scores.

CONCLUSION

Improvements in external anal sphincter imaging have not yielded a better association with the clinical findings. The lack of clinical differences between patients with different EAS tears may reflect their similar volumetric defects.

Evaluation of the NiTi Shape Memory BioDynamix ColonRing™ in colorectal anastomosis: first in human multi-center study

BACKGROUND

Shape-memory compression bowel anastomosis using a nickel and titanium alloy may reduce leak rates and eliminate foreign anastomotic material. Its safety and efficacy had been demonstrated by animal studies. We conducted the first prospective multi-center clinical evaluation of the safety and effectiveness of BioDynamix anastomosis with ColonRing™ for large-bowel end-to-end or side-to-end anastomosis.

MATERIALS AND METHODS

The ColonRing™ was compared to the standard double-stapled colorectal/colocolonic anastomosis. Intraoperative and immediate postoperative and 1- and 3-month postoperative follow-up data were recorded.

RESULTS

Ten study patients (four males, median age 62 years, range 35-75) were compared to 13 demographically matched controls (six males, median age 62 years, range 47-82). Colorectal neoplasia was the most frequent indication for surgery (21/23 patients, 91%). The median anastomotic distance from the anal verge for both groups was 10 cm (6-20 cm). The first postoperative bowel movement was on day 5 ±2.2 (study group) and on day 4 ±1.8 (controls), and the median hospital stay was 8 days (6-14 days) and 7 days (6-13 days), respectively. There were no anastomotic leaks. There were three minor complications in each group, unrelated to the device in the study group. Two patients required transanal digital extraction of the ring which was detached but not expelled (one had a soft anastomotic stricture).

CONCLUSIONS

Our preliminary results in this first study on humans indicate that the safety and efficacy of BioDynamix anastomosis with ColonRing™ in colorectal anastomosis in human is comparable to standard staples technology and warrant larger studies for further validation.

A longitudinal study of quality of life and functional outcome of patients with ulcerative colitis after proctocolectomy with ileal pouch-anal anastomosis

PURPOSE

Ileal pouch-anal anastomosis is considered the surgical treatment of choice for patients with ulcerative colitis. It is safe and effective but associated with long-term complications, making functional outcome and quality of life important factors in determining patient outcome. Longitudinal studies on long-term functional outcome and quality of life are sparse. The purpose of this study was to longitudinally evaluate the long-term functional outcome and quality of life of ulcerative colitis patients who underwent proctocolectomy with ileal pouch-anal anastomosis.

METHODS

The study group was composed of ulcerative colitis patients who underwent pouch operation in our institution between 1990 and 2001 who had filled in quality of life and functional outcome questionnaires 60 months (mean) after ileostomy closure and responded to the same questionnaires at 133 months (mean) after ileostomy closure. They served as their own controls. Quality of life was scored using the Medical Outcomes Study Short Form 36. Global Assessment of Functioning Scale was used to evaluate functional outcome.

RESULTS

Data were obtained for 63 of the 77 patients (82%) who had answered the first questionnaire. The mean interval between responding to the 2 questionnaires was 73 +/- 3 months. Functional outcome did not deteriorate over time. Some quality of life scores (bodily pain, general health perception, and the physical component summary) worsened over time, whereas the other scales of the Short Form 36 scores did not change.

CONCLUSION

The functional outcome of ulcerative colitis patients after a pouch operation did not change significantly over time. The overall quality of life was generally stable, however, some aspects did deteriorate over time. These findings merit further investigation.

Long-term outcome of loose seton for complex anal fistula: a two-centre study of patients with and without Crohn's disease

OBJECTIVE

Complex anal fistulas traverse a significant portion of the external sphincter muscle, making their treatment a surgical challenge. Several surgical options are used with conflicting results. The aim of this study was to analyse the results of permanent loose seton in the management of high anal fistulas in Crohn's disease (CD) patients and two-stage seton fistulotomy in patients without CD.

METHOD

We retrospectively reviewed the clinical records of 77 patients with complex anal fistula treated by loose seton over a 4-year period, in two medical centres. Recorded parameters included demographics, medical history, type of fistula, disease duration, previous surgery, morbidity, recurrence and mortality.

RESULTS

Sixty patients without CD underwent 107 fistula-related surgical procedures, and 17 CD patients underwent 29 procedures. Early postoperative complications were recorded in eight (10%) patients. Perioperative complications, mainly local sepsis or bleeding, were recorded in eight (10%) patients. Long-term complications were observed in nine non-CD and four CD patients. During a median follow-up period of 24 months, the recurrence rate was 40% in CD patients and 47% in patients without CD. Five patients (four non-CD patients and one CD patient) developed some degree of faecal incontinence.

CONCLUSION

The fistula recurrence rate following two-stage seton fistulotomy in non-CD patients was high. In CD patients the use of permanent loose seton is effective in controlling local sepsis in about half of patients and has low rates of subsequent incontinence.

CXCL12 is a constitutive and inflammatory chemokine in the intestinal immune system

BACKGROUND

Inflammatory bowel disease (IBD) is characterized by increased lymphocytic infiltrate to the lamina propria (LP) and upregulation of inflammatory chemokines and receptors. CXCL12 is a constitutive chemokine involved in lung, brain, and joint inflammation. We hypothesized that CXCL12 and its receptor, CXCR4, would have a constitutive and inflammatory role in the gut.

METHODS

Intestinal epithelial cells (IECs) and T lymphocytes were isolated from intestinal mucosa of IBD and control patients undergoing bowel resection. Autologous T cells were isolated from peripheral blood (PB). CXCL12 and CXCR4 expression by IECs was assessed by polymerase chain reaction and immunohistochemistry, lymphocyte phenotype by flow cytometry, and migration by Transwells.

RESULTS

IECs expressed CXCL12 and expression was increased and more diffuse in IBD compared to normal crypts (ulcerative colitis [UC] > Crohn's disease [CD], inflamed > noninflamed). CXCR4 was expressed by IECs, LP T cells (LPTs), and PB T cells (PBTs), and CXCR4+ cells were increased in IBD LP in situ. PBTs and LPTs from all patients had a high and comparable migration toward CXCL12 (P < 0.0001 and P < 0.05 vs. medium, respectively). Migration toward IBD-IEC-derived supernatant was significantly higher compared to normal. Antibodies against CXCR4 and CXCL12 blocked migration.

CONCLUSIONS

CXCL12 is expressed by normal IECs and upregulated and differentially distributed in IBD IECs. CXCR4 is expressed by IECs and LPTs, and CXCR4+ cells are significantly increased in IBD LP. CXCL12 is chemotactic for both PBTs and LPTs. Thus, CXCL12 and CXCR4 have a constitutive and inflammatory role in the intestinal mucosa and their selective therapeutic manipulation may be considered in IBD management.

Urinary bladder catheter drainage following pelvic surgery--is it necessary for that long?

PURPOSE

Urinary bladder drainage for several days after pelvic surgery is a common surgical practice, despite insufficient evidence supporting its routine use. The aim of this study was to prospectively evaluate the utility of urinary bladder drainage after pelvic colorectal surgery.

METHODS

Patients undergoing pelvic surgery were prospectively randomly assigned to 3 groups. In group A, the Foley catheter was removed on postoperative day 1, and in groups B and C it was removed on postoperative days 3 and 5, respectively. Male patients with severe prostatic symptoms were excluded from the study. The main outcome criterion was acute urinary retention requiring reinsertion of the Foley catheter.

RESULTS

A total of 118 patients (68 males) at a mean age of 55 years were included in this study (group A, 41 patients; group B, 38; and group C, 39). Overall, urinary retention after removal of the Foley catheter occurred in 12 (10%) of the patients: 6 (14.6%) in group A, 2 (5.3%) in group B, and 4 (10.5%) in group C (P = .39). Symptomatic urinary tract infection was diagnosed in 5 patients in group A, 3 in group B, and 9 in group C, but this difference did not reach statistical significance. Likewise, there were no significant differences in anastomotic leak and intra-abdominal abscess rates among the 3 groups.

CONCLUSIONS

Routine prolonged urinary bladder catheterization after pelvic surgery may not be required, and the Foley catheter may be safely removed on postoperative day 1. Larger studies are needed to confirm the findings of this study.

Long-term results of local excision for T1 rectal carcinoma: the experience of two colorectal units

BACKGROUND

Local excision for early rectal cancer has low morbidity and good functional results. Its use is limited by the inability to assess regional lymph nodes and by the uncertainty of oncologic outcome.

METHODS

We conducted a retrospective chart review of all patients who underwent local excision of early rectal cancer in two colorectal units between 1995 and 2007. The retrieved and analyzed data were patient age and gender, tumor size, tumor distance from the anal verge, tumor differentiation, and additional treatment.

RESULTS

There were 42 patients with T1 rectal cancer: 24 underwent transanal endoscopic microsurgery and 18 had a transanal excision. The surgical margins were free of tumor in 39 patients (93%), they were involved by tumor in one (2%) and margin status was unclear in two (5%). Seven patients (16%) had postoperative complications. There was no postoperative mortality. The mean hospital stay was 67 h. Thirty-nine patients (93%) were followed up for 57 months (mean). Two patients had local recurrence, at 7 and 41 months post-surgery. They had a tumor that invaded into the lower third of the submucosa, sm3. Both received chemoradiotherapy, and underwent an abdominoperineal resection and a low anterior resection. One of them died of metastatic disease 13 months later and the other is alive with no evidence of disease. Another two patients had salvage low anterior resection, one for suspected local recurrence and one for lymphovascular invasion: the specimens were tumor free. Six patients died of unrelated causes.

CONCLUSIONS

Local excision of early rectal cancer is a feasible and acceptable alternative to radical resection. It has low complication and recurrence rates and a short postoperative hospital stay.

Galectin-3 expression in pouchitis in patients with ulcerative colitis who underwent ileal pouch-anal anastomosis (IPAA)

Galectin-3, an endogenous pleiotropic beta-galactoside-binding protein, which is expressed by various malignant and normal cells, regulates many biological and pathological processes, including inflammation. In the present study, we tested a possible correlation between the severity of pouchitis in patients with ulcerative colitis who underwent ileal pouch-anal anastomosis (IPAA) and the presence of galectin-3(+) macrophages in pouch mucosa. Paraffin-embedded pouch biopsies from patients with normal pouch function or chronic and recurrent acute pouchitis were immunohistostained with galectin-3, CD68, and smooth muscle actin (SMA) antibodies. Microscopic examination was performed in a blinded fashion. There was a significant decrease in the staining index of galectin-3 in the subepithelial macrophages in patients with chronic pouchitis (0.53, P=0.001; n=12) or recurrent acute pouchitis (0.43, P=0.008; n=10) when compared to patients with no clinical manifestations of pouchitis (0.63, n=12). No significant differences were noted in the lamina propria of small intestine biopsies from the same patients (from 0.63 to 0.68, P=0.24). Galectin-3 staining was restricted to CD68(+) macrophages and not present in myofibroblasts. Clinical manifestation of pouchitis is inversely correlated with galectin-3 expression in the pouches' subepithelial lamina propria macrophages.

Comprehensive pouch clinic concept for follow-up of patients after ileal pouch anal anastomosis: report of 3 years' experience in a tertiary referral center

BACKGROUND

We designed and evaluated a novel concept in enhancing postoperative care of patients following restorative proctocolectomy (RPC) for ulcerative colitis (UC) and determined the risk factors, incidence, and nature of RPC-associated complications in this population.

METHODS

The study cohort consisted of consecutive UC patients post-RPC attending a comprehensive pouch clinic run by a gastroenterologist and a colorectal surgeon in a tertiary care medical center (from January 2003 to December 2005). Data were collected on their medical history, physical examination, laboratory tests, pouch endoscopy and biopsies, and anonymous in-house patient satisfaction questionnaires mailed to the first 90 patients. Assessment was also done on data regarding risk factors, incidence, and nature of RPC-associated complications.

RESULTS

A total of 120 UC patients with a functioning pouch visited the clinic: mean age 37 years, range 13-75; 57 males; mean disease duration 11 years; mean follow-up 65 months. Of the 55 patients who responded to the questionnaire, 48 (87%) felt that the comprehensive clinic significantly improved the quality of their care. The major complications were pouchitis (52%), extraintestinal manifestations, pouch-related fistula, and mechanical dysfunction. The risk factors for the development of pouchitis were time since surgery, >1-stage surgery, and reason for surgery (acute exacerbation/intractable disease more than dysplasia/cancer); the latter was the only independent risk factor.

CONCLUSIONS

The pouch clinic concept significantly enhanced patient satisfaction. The most common RPC-associated complication was pouchitis. Risk factors for developing pouchitis were duration since operation, >1-stage operation, and indication for surgery.

An interval >7 weeks between neoadjuvant therapy and surgery improves pathologic complete response and disease-free survival in patients with locally advanced rectal cancer

BACKGROUND

We assessed whether the time interval between neoadjuvant therapy and surgery affects the operative and postoperative morbidity and mortality, the pathologic complete response (pCR) rate, and disease recurrence in locally advanced rectal cancer.

METHODS

One-hundred and thirty-two patients with locally advanced low- and mid-rectal cancer underwent neoadjuvant chemoradiation followed by radical resection (October 2000 to December 2006). Data on the neoadjuvant regime, neoadjuvant-surgery interval, final pathology, type of operation, operative time, intraoperative blood transfusions, postoperative complications, length of hospital stay, disease recurrence, and mortality were reviewed. The patients were divided into two groups according to the neoadjuvant-surgery interval: </=7 weeks (group A, n = 48), and >7 weeks (group B, n = 84).

RESULTS

The groups were demographically comparable except for the group A patients being younger at operation. The median interval between chemoradiation and surgery was 56 days (range 13-173 days). Thirty-seven patients (28%) had a pCR and near pCR. Fifty three patients (40%) had complications. There was no in-hospital mortality. Surgery type, operative time, number of intraoperative blood transfusions, postoperative complications, and length of hospitalization were not influenced by the interval length. The pCR and near pCR rates were higher with longer interval: 17% in group A, 35% in group B (P = 0.03). Patients operated at an interval >7 weeks had significantly better disease-free survival (P = 0.05).

CONCLUSIONS

A neoadjuvant-surgery interval >7 weeks was associated with higher rates of pCR and near pCR, decreased recurrence and improved disease-free survival.

Intestinal pseudoobstruction

Intestinal pseudoobstruction is an uncommon clinical condition of varied etiologies. Confusion in its characterization and diagnosis often results in delay in diagnosis as well as inappropriate treatment involving repeated surgery. The various aspects and characteristics of intestinal pseudoobstruction are described by representative case reports of three patients treated in our department with a review of the literature. Heightened awareness, understanding of the physiological dynamics and recognition of the spectrum of its clinical presentation and diagnostic modalities should result in more efficacious treatment.

[New horizons in the treatment of fecal incontinence]

Fecal incontinence affects the quality of life, and causes significant embarrassment. Incontinence mostly affects elderly females. The majority of affected individuals do not seek medical attention because of embarrassment and unawareness of treatment options. Assessment of the severity of incontinence and its effect on the quality of life and evaluation of the anatomy and function of the pelvic floor, rectum and anus, are essential for the proper selection of treatment options. In mild to moderate incontinence, non-invasive treatment with diet and biofeedback may be worthwhile. Invasive treatments include minor procedures, such as "bulking" of the internal sphincter, using injectable agents or radiofrequency energy, and major surgical procedures such as neosphincter operations using the gracilis muscle or artificial bowel sphincter. This review focuses on the new treatment modalities of fecal incontinence.

Recto-vaginal/urethral fistula: repair with gracilis muscle transposition

This study was designed to assess the efficacy of gracilis muscle transposition in repairing recto-vaginal and rectourethral fistula. All patients had fecal diversion as a preliminary or concurrent step to fistula repair. Success was defined as healed fistula after stoma closure.

RESULTS

Six females and four males underwent gracilis muscle transposition from 1999 to 2006. Gracilis muscle transposition is a viable option for repairing fistulas between the urethra, vagina and the rectum, especially after failed perineal or trans-anal repair. It is associated with low morbidity and good success rate. Underlying Crohn's disease and previous radiation are associated with poor prognosis.