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Bronze S, Kayal M, Estevinho MM, Hahn S, Khaitov S, Colombel JF, Wong SY. Ileoanal Pouch-Related Fistulas: A Narrative Review. Inflamm Bowel Dis 2025; 31:1716-1722. [PMID: 39349403 DOI: 10.1093/ibd/izae221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Indexed: 10/02/2024]
Abstract
Ileoanal pouch-related fistula (IAPRF) is a possible complication after ileal pouch-anal anastomosis that significantly impacts pouch prognosis and the patient's quality of life. This study aimed to perform a comprehensive narrative review to better classify the epidemiology, risk factors, etiology, management, and outcomes of IAPRF, and to propose an algorithm for its systematic classification. Ten studies comprising 664 patients with IAPRF were identified, with a prevalence ranging from 4% to 45%. The reported fistula types were as follows: pouch-vaginal (n = 236, 35.5%), perineal (n = 139, 21%), enterocutaneous (n = 54, 8%), pouch-anal (n = 53, 8%), presacral (n = 18, 2%), and anastomotic (n = 15, 2%). Postsurgical pelvic sepsis occurred in 21%-37.2% of patients. Twenty additional studies regarding fistula classification divided them according to onset time and etiology, defining 5 categories: anastomotic-related, technical aspects of the surgery, Crohn's disease-like pouch inflammation, cryptoglandular, and malignancy. Pouch excision was reported in up to 70% of patients. Fistulas associated with anastomotic complications, technical surgical issues, and cryptoglandular fistulas warrant surgical management. On the other hand, fistulas associated with inflammation are preferentially managed with biologics or small molecules.
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Affiliation(s)
- Sergio Bronze
- Gastroenterology and Hepatology Department, Unidade Local de Saúde de Santa Maria, Lisbon, Portugal
| | - Maia Kayal
- The Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Sue Hahn
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sergey Khaitov
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jean-Frederic Colombel
- The Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Serre-Yu Wong
- The Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Kucharzik T, Dignass A, Atreya R, Bokemeyer B, Esters P, Herrlinger K, Kannengiesser K, Kienle P, Langhorst J, Lügering A, Schreiber S, Stallmach A, Stein J, Sturm A, Teich N, Siegmund B. Aktualisierte S3-Leitlinie Colitis ulcerosa (Version 6.2). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:769-858. [PMID: 38718808 DOI: 10.1055/a-2271-0994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Affiliation(s)
- T Kucharzik
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Städtisches Klinikum Lüneburg, Lüneburg, Deutschland
| | - A Dignass
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt, Deutschland
| | - R Atreya
- Medizinische Klinik 1 Gastroent., Pneumologie, Endokrin., Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - B Bokemeyer
- Interdisziplinäres Crohn Colitis Centrum Minden - ICCCM, Minden, Deutschland
| | - P Esters
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt, Deutschland
| | - K Herrlinger
- Innere Medizin I, Asklepios Klinik Nord, Hamburg, Deutschland
| | - K Kannengiesser
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Städtisches Klinikum Lüneburg, Lüneburg, Deutschland
| | - P Kienle
- Abteilung für Allgemein- und Viszeralchirurgie, Theresienkrankenhaus, Mannheim, Deutschland
| | - J Langhorst
- Klinik für Integrative Medizin und Naturheilkunde, Sozialstiftung Bamberg Klinikum am Bruderwald, Bamberg, Deutschland
| | - A Lügering
- Medizinisches Versorgungszentrum Portal 10, Münster, Deutschland
| | - S Schreiber
- Klinik für Innere Medizin I, Universitätsklinikum Schleswig Holstein, Kiel, Deutschland
| | - A Stallmach
- Klinik für Innere Medizin IV Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Jena, Jena, Deutschland
| | - J Stein
- Abteilung Innere Medizin mit Schwerpunkt Gastroenterologie, Krankenhaus Sachsenhausen, Frankfurt, Deutschland
| | - A Sturm
- Klinik für Innere Medizin mit Schwerpunkt Gastroenterologie, DRK Kliniken Berlin Westend, Berlin, Deutschland
| | - N Teich
- Internistische Gemeinschaftspraxis, Leipzig, Deutschland
| | - B Siegmund
- Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Charité Campus Benjamin Franklin - Universitätsmedizin Berlin, Berlin, Deutschland
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Fadel MG, Geropoulos G, Warren OJ, Mills SC, Tekkis PP, Celentano V, Kontovounisios C. Risks Factors Associated with the Development of Crohn's Disease After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis: A Systematic Review and Meta-Analysis. J Crohns Colitis 2023; 17:1537-1548. [PMID: 36961323 PMCID: PMC10588783 DOI: 10.1093/ecco-jcc/jjad051] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Following ileal pouch-anal anastomosis [IPAA] for ulcerative colitis [UC], up to 16% of patients develop Crohn's disease of the pouch [CDP], which is a major cause of pouch failure. This systematic review and meta-analysis aimed to identify preoperative characteristics and risk factors for CDP development following IPAA. METHODS A literature search of the MEDLINE, EMBASE, EMCare and CINAHL databases was performed for studies that reported data on predictive characteristics and outcomes of CDP development in patients who underwent IPAA for UC between January 1990 and August 2022. Meta-analysis was performed using random-effect models and between-study heterogeneity was assessed. RESULTS Seven studies with 1274 patients were included: 767 patients with a normal pouch and 507 patients with CDP. Age at UC diagnosis (weighted mean difference [WMD] -2.85; 95% confidence interval [CI] -4.39 to -1.31; p = 0.0003; I2 54%) and age at pouch surgery [WMD -3.17; 95% CI -5.27 to -1.07; p = 0.003; I2 20%) were significantly lower in patients who developed CDP compared to a normal pouch. Family history of IBD was significantly associated with CDP (odds ratio [OR] 2.43; 95% CI 1.41-4.19; p = 0.001; I2 31%], along with a history of smoking [OR 1.80; 95% CI 1.35-2.39; p < 0.0001; I2 0%]. Other factors such as sex and primary sclerosing cholangitis were found not to increase the risk of CDP. CONCLUSIONS Age at UC diagnosis and pouch surgery, family history of IBD and previous smoking have been identified as potential risk factors for CDP post-IPAA. This has important implications towards preoperative counselling, planning surgical management and evaluating prognosis.
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Affiliation(s)
- Michael G Fadel
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Georgios Geropoulos
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Oliver J Warren
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Sarah C Mills
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Paris P Tekkis
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Colorectal Surgery, Royal Marsden NHS Foundation Trust, London, UK
| | - Valerio Celentano
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Christos Kontovounisios
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Colorectal Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Department of Colorectal Surgery, Royal Marsden NHS Foundation Trust, London, UK
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Kucharzik T, Dignass A, Atreya R, Bokemeyer B, Esters P, Herrlinger K, Kannengiesser K, Kienle P, Langhorst J, Lügering A, Schreiber S, Stallmach A, Stein J, Sturm A, Teich N, Siegmund B. [Not Available]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:1046-1134. [PMID: 37579791 DOI: 10.1055/a-2060-0935] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Affiliation(s)
- T Kucharzik
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Städtisches Klinikum Lüneburg, Lüneburg, Deutschland
| | - A Dignass
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt, Deutschland
| | - R Atreya
- Medizinische Klinik 1 Gastroent., Pneumologie, Endokrin., Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - B Bokemeyer
- Interdisziplinäres Crohn Colitis Centrum Minden - ICCCM, Minden, Deutschland
| | - P Esters
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt, Deutschland
| | - K Herrlinger
- Innere Medizin I, Asklepios Klinik Nord, Hamburg, Deutschland
| | - K Kannengiesser
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Städtisches Klinikum Lüneburg, Lüneburg, Deutschland
| | - P Kienle
- Abteilung für Allgemein- und Viszeralchirurgie, Theresienkrankenhaus, Mannheim, Deutschland
| | - J Langhorst
- Klinik für Integrative Medizin und Naturheilkunde, Sozialstiftung Bamberg Klinikum am Bruderwald, Bamberg, Deutschland
| | - A Lügering
- Medizinisches Versorgungszentrum Portal 10, Münster, Deutschland
| | - S Schreiber
- Klinik für Innere Medizin I, Universitätsklinikum Schleswig Holstein, Kiel, Deutschland
| | - A Stallmach
- Klinik für Innere Medizin IV Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Jena, Jena, Deutschland
| | - J Stein
- Abteilung Innere Medizin mit Schwerpunkt Gastroenterologie, Krankenhaus Sachsenhausen, Frankfurt, Deutschland
| | - A Sturm
- Klinik für Innere Medizin mit Schwerpunkt Gastroenterologie, DRK Kliniken Berlin Westend, Berlin, Deutschland
| | - N Teich
- Internistische Gemeinschaftspraxis, Leipzig, Deutschland
| | - B Siegmund
- Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Charité Campus Benjamin Franklin - Universitätsmedizin Berlin, Berlin, Deutschland
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Cohen D, Silvestri C, Schwartzberg DM. Restorative pouch surgery following proctocolectomy for inflammatory bowel disease: past experience and future direction. Transl Gastroenterol Hepatol 2023; 8:27. [PMID: 37601738 PMCID: PMC10432232 DOI: 10.21037/tgh-23-28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/14/2023] [Indexed: 08/22/2023] Open
Abstract
Major advancements in surgery for patients suffering proctocolitis from ulcerative colitis (UC) or selected patients with Crohn's disease (CD) have emerged in a relatively short time. Historically, patients underwent a proctocolectomy with end ileostomy, however, a restorative proctocolectomy with an ileal pouch-anal anastomosis (IPAA) was introduced in the late 1970s in the United Kingdom and gave patients the opportunity to avoid a permanent stoma. Initially designed as a hand-sewn "S" shaped pouch, with the invention of the linear stapler, a "J" shaped pouch was described in Japan, and subsequent advances in the United States largely contributed to the pelvic pouch's evolution to the standard of care in the management of patients with inflammatory bowel disease (IBD). The procedure was then divided into different stages depending on the medical condition of the patient and minimally invasive techniques (laparoscopic & robotic surgery) have continued to advance the success of the operation. Unfortunately, pouch complications occur, and seem to be occurring at an increasing frequency with the adoption of minimally invasive surgery. The field of reoperative pouch surgery has emerged to offer patients the opportunity to restore their quality of life (QOL) without the need for a permanent ostomy. Many patients with signs of pouch failure such as pouchitis, fistulae, pain and obstruction are diagnosed with Crohn's of the pouch, but many have mechanical complications that can be corrected with surgery, rather than offering pouch excision with a permanent ostomy (continent or traditional). Patients with Crohn's may be offered an IPAA but they will not have success if they, like patients with UC, have mechanical complications leading to their pouch failure. Patients who undergo reoperative pouch surgery do well with an acceptable QOL.
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Affiliation(s)
- David Cohen
- Department of Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Caitlin Silvestri
- Department of Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - David M. Schwartzberg
- Inflammatory Bowel Disease Center, Division of Colorectal Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
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Akiyama S, Dyer EC, Rubin DT. Diagnostic and Management Considerations for the IPAA With Crohn's Disease-Like Features. Dis Colon Rectum 2022; 65:S77-S84. [PMID: 35867686 DOI: 10.1097/dcr.0000000000002547] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Patients with ulcerative colitis often develop medically refractory colonic inflammation or colorectal neoplasia, and approximately 10% to 15% of patients require surgery. The most common surgical procedure is a restorative proctocolectomy with IPAA. Even if the preoperative diagnosis is ulcerative colitis, approximately 10% of patients can develop inflammatory pouch conditions resembling a Crohn's disease phenotype. OBJECTIVE This study aimed to review the diagnostic approach, prognosis, and management of IPAA with Crohn's disease-like features. DATA SOURCES The data sources include search in electronic databases. STUDY SELECTION This narrative review included studies focusing on pouches with Crohn's disease-like features. MAIN OUTCOME MEASURES The main topics in this review included the pathogenesis, risk factors, diagnosis, phenotypes, prognosis, and medications of pouches with Crohn's disease-like features. RESULTS A diagnostic approach for the pouch conditions resembling a Crohn's disease phenotype should be based on history-taking to evaluate its risk factors and endoscopic assessment of the pouch. Prior disease history and pathology, location of pouch complications, and timing of complications offer clues for the differential diagnosis of this phenotype. We advocate for the more descriptive term "pouch with Crohn's disease-like features" and reserve the term "Crohn's disease of the pouch" for patients who undergo IPAA and have a precolectomy diagnosis of Crohn's disease or whose colectomy pathology revealed Crohn's disease. Medications, which are often used for traditional Crohn's disease, show efficacy in pouches with Crohn's disease-like features as well. The poor prognosis associated with pouches with Crohn's disease-like features, particularly the fistulizing phenotype, underscores the importance of proactive monitoring and therapeutic intervention. LIMITATIONS The limitations include no explicit criteria for article selection. CONCLUSIONS This review suggests future research should seek to understand the natural history and meaningful shorter and longer term therapeutic targets for these types of pouch phenotypes. Long-term follow-up and prospective preoperative and postoperative interventional trials of treatments and prevention strategies are needed.
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Affiliation(s)
- Shintaro Akiyama
- Department of Medicine, Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois
- Department of Gastroenterology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Emma C Dyer
- Department of Medicine, Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois
| | - David T Rubin
- Department of Medicine, Inflammatory Bowel Disease Center, University of Chicago Medicine, Chicago, Illinois
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Role of robotic approach in ileal pouch–anal anastomosis (IPAA): A systematic review of the literature. J Robot Surg 2022; 17:941-947. [DOI: 10.1007/s11701-022-01490-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 11/06/2022] [Indexed: 11/17/2022]
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Phillips MR, Brenner E, Purcell LN, Gulati AS. Pediatric Inflammatory Bowel Disease for General Surgeons. Surg Clin North Am 2022; 102:913-927. [PMID: 36209754 DOI: 10.1016/j.suc.2022.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Angriman I, Colangelo A, Mescoli C, Fassan M, D’Incà R, Savarino E, Pucciarelli S, Bardini R, Ruffolo C, Scarpa M. Validation of the Padova Prognostic Score for Colitis in Predicting Long-Term Outcome After Restorative Proctocolectomy. Front Surg 2022; 9:911044. [PMID: 35959125 PMCID: PMC9357893 DOI: 10.3389/fsurg.2022.911044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/13/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND In 10%-20% of cases it is impossible to make a differential diagnosis between ulcerative colitis and Crohn's colitis. A 50% failure rate of J pouch ilea-anal anastomosis is observed in Crohn's colitis. In 2009, we created the Padua Prognostic Score for Colitis (PPSC) to predict the long-term clinical and functional outcome and quality of life of patients undergoing restorative proctocolectomy with J pouch. The aim of the present study is to establish and validate the accuracy of a prognostic score for chronic inflammatory bowel diseases (IBD). PATIENT POPULATION AND METHODS The PPSC was created in 2009 by integrating clinical and histological information of patients undergoing RPC. It included preoperative perianal abscess or fistula, rectal sparing, terminal ileum involvement, skip lesions and histological diagnosis of indeterminate colitis or Crohn's colitis on the operative specimen. The validity of this score was tested in predicting postoperative abscess or fistula, anal canal disease, pouchitis, pouch failure and new diagnosis of Crohn's disease. Correlation analysis, ROC curve analysis and survival analysis were used to validate the PPSC in a different cohort from the previous one. RESULTS We retrospectively enrolled in this study 138 consecutive patients undergoing CPR for ulcerative colitis (n = 127) or indeterminate colitis (n = 11) in our institution since 2005 to 2020. In this period, we observed 11 patients with postoperative abscess or fistula, 3 with anal canal disease, 40 with pouchitis, 6 with pouch failure and 6 with new diagnosis of Crohn's disease. In the new validation cohort, the PPSC confirmed to have a good accuracy in predicting the onset of postoperative CD (AUC = 74.5%, p = 0.018). Kaplan Meier curves demonstrate how a PPSC over 1 can reliably predicts the long-term onset of, pouchitis (p = 0.002) and anal abscess or fistulae (p = 0.04). CONCLUSIONS In this validation study we confirmed the accuracy of the PPSC in predicting postoperative fistulas or abscesses and pouchitis. Therefore, we believe that in clinical practice patients with a PPSC score greater than 1 should be warned of this risk of possible Crohn's disease diagnosis and pouch failure.
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Affiliation(s)
- Imerio Angriman
- Clinica Chirurgica I, University Hospital of Padova, Padova, Italy
| | | | - Claudia Mescoli
- Department of Medicine, (Pathology Section), University Hospital of Padova, Padova, Italy
| | - Matteo Fassan
- Department of Medicine, (Pathology Section), University Hospital of Padova, Padova, Italy
| | - Renata D’Incà
- Department of Surgical & Gastroenterological Sciences, (Gastroenterology Section),University Hospital of Padova, Padova, Italy
| | - Edoardo Savarino
- Department of Surgical & Gastroenterological Sciences, (Gastroenterology Section),University Hospital of Padova, Padova, Italy
| | | | - Romeo Bardini
- Department of Surgical & Gastroenterological Sciences, (Gastroenterology Section),University Hospital of Padova, Padova, Italy
| | - Cesare Ruffolo
- Clinica Chirurgica I, University Hospital of Padova, Padova, Italy
| | - Marco Scarpa
- Clinica Chirurgica I, University Hospital of Padova, Padova, Italy
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Olortegui KS, Graham A, Hyman N. Staging Considerations for the Ileal Pouch-Anal Anastomosis. J Gastrointest Surg 2022; 26:1531-1536. [PMID: 35469035 DOI: 10.1007/s11605-022-05317-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/26/2022] [Indexed: 01/31/2023]
Affiliation(s)
| | - Ada Graham
- University of Chicago Medical Center, Chicago, IL, USA
| | - Neil Hyman
- University of Chicago Medical Center, Chicago, IL, USA
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Takakura WR, Mirocha J, Ovsepyan G, Zaghiyan KN, Syal G, Fleshner P. Magnitude of Preoperative C-Reactive Protein Elevation Is Associated With De Novo Crohn's Disease After Ileal Pouch-Anal Anastomosis in Patients With Severe Colitis. Dis Colon Rectum 2022; 65:399-405. [PMID: 34657077 DOI: 10.1097/dcr.0000000000002148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Total proctocolectomy with ileal pouch-anal anastomosis has become the standard procedure for patients with medically refractory ulcerative colitis, although a subset will develop de novo Crohn's disease. OBJECTIVE In this study, we investigated the association of preoperative C-reactive protein levels with the development of de novo Crohn's disease after ileal pouch-anal anastomosis. DESIGN A prospectively maintained database of patients undergoing ileal pouch-anal anastomosis was reviewed. PATIENTS Preoperative C-reactive protein levels were compared between patients who developed de novo Crohn's disease and those who did not. De novo Crohn's disease was defined as small-bowel inflammation proximal to the ileal pouch or perianal disease identified more than 3 months after ileostomy closure. To minimize the heterogeneity of the timing of preoperative C-reactive protein measurement and the severity of ulcerative colitis, only hospitalized patients who had proctocolectomy for severe ulcerative colitis were included in the study. MAIN OUTCOME MEASURES Development of de novo Crohn's disease was analyzed. RESULTS Of 105 patients, 23 (22%) developed de novo Crohn's disease. Having C-reactive protein in the third tertile significantly increased the risk of developing de novo Crohn's disease (HR 3.44, 95% CI 1.10- 10.70, p = 0.03) compared to in the first tertile. In a multivariable model, a C-reactive protein in the third or second tertile vs the first tertile and younger age was associated with the development of de novo Crohn's disease. LIMITATIONS Limited to only hospitalized patients with severe ulcerative colitis. CONCLUSIONS In hospitalized patients undergoing ileal pouch-anal anastomosis for medically refractory ulcerative colitis, higher preoperative C-reactive protein levels appear to increase the risk of developing de novo Crohn's disease. See Video Abstract at http://links.lww.com/DCR/B750.LA MAGNITUD DE LA ELEVACIÓN PREOPERATORIA DE LA PROTEÍNA C REACTIVA SE ASOCIA CON APARICIÓN DE UNA ENFERMEDAD DE CROHN DE NOVO DESPUÉS DE UNA ANASTOMOSIS DE BOLSA ILEAL AL ANO EN PACIENTES CON COLITIS SEVERAANTECEDENTES:La proctocolectomía total con anastomosis bolsa ileal-anal se ha convertido en el procedimiento estándar para los pacientes con colitis ulcerativa refractaria al tratamiento médico, aunque un subgrupo desarrollará una enfermedad de Crohn de novo.OBJETIVO:En este estudio investigamos la asociación de los niveles de proteína C reactiva preoperatoria con el desarrollo de la enfermedad de Crohn de novo, después de la anastomosis bolsa ileal-anal.DISEÑO:Se revisó una base de datos recolectada en forma prospectiva, de pacientes sometidos a anastomosis bolsa ileal-anal.PACIENTES:Se compararon los niveles de proteína C reactiva preoperatoria entre los pacientes que desarrollaron la enfermedad de Crohn de novo y los que no la desarrollaron. La enfermedad de Crohn de novo se definió como una inflamación del intestino delgado proximal a la bolsa ileal o una enfermedad perianal identificada más de 3 meses después del cierre de la ileostomía. Para minimizar la heterogeneidad del momento de la medición de la proteína C reactiva preoperatoria y la gravedad de la colitis ulcerativa, solo se incluyeron en el estudio los pacientes hospitalizados que se sometieron a una proctocolectomía por colitis ulcerativa grave.PRINCIPALES MEDIDAS DE RESULTADO:se analizó el desarrollo de la enfermedad de Crohn de novo.RESULTADOS:De 105 pacientes, 23 (22%) desarrollaron enfermedad de Crohn de novo. Tener una proteína C reactiva en el tercer tercil aumentó significativamente el riesgo de desarrollar la enfermedad de Crohn de novo (HR 3,44, IC del 95%: 1,10-10,70, p = 0,03) en comparación con el primer tercil. En un modelo multivariable, una proteína C reactiva en el tercer o segundo tercil frente al primer tercil y una edad más joven se asoció con el desarrollo de la enfermedad de Crohn de novo.LIMITACIONES:Limitado solo a pacientes hospitalizados con colitis ulcerativa grave.CONCLUSIONES:En pacientes hospitalizados sometidos a anastomosis bolsa ileal-anal por colitis ulcerativa refractaria al tratamiento médico, niveles más elevados de proteína C reactiva preoperatoria parecen aumentar el riesgo de desarrollar enfermedad de Crohn de novo. Consulte Video Resumen en http://links.lww.com/DCR/B750. (Traducción-Eduardo Londoño-Schimmer).
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Affiliation(s)
- Will R Takakura
- Division of Colon & Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - James Mirocha
- Division of Colon & Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Gayane Ovsepyan
- Division of Colon & Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Karen N Zaghiyan
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Colon & Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Gaurav Syal
- Division of Colon & Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Phillip Fleshner
- F. Widjaja Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Colon & Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Alsafi Z, Snell A, Segal JP. Prevalence of 'pouch failure' of the ileoanal pouch in ulcerative colitis: a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:357-364. [PMID: 34825957 PMCID: PMC8803821 DOI: 10.1007/s00384-021-04067-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS The ileoanal pouch (IPAA) provides patients with ulcerative colitis (UC) that have not responded to medical therapy an option to retain bowel continuity and defecate without the need for a long-term stoma. Despite good functional outcomes, some pouches fail, requiring permanent diversion, pouchectomy, or a redo pouch. The incidence of pouch failure ranges between 2 and 15% in the literature. We conducted a systematic review and meta-analysis aiming to define the prevalence of pouch failure in patients with UC who have undergone IPAA using population-based studies. METHODS We searched Embase, Embase classic and PubMed from 1978 to 31st of May 2021 to identify cross-sectional studies that reported the prevalence of pouch failure in adults (≥ 18 years of age) who underwent IPAA for UC. RESULTS Twenty-six studies comprising 23,389 patients were analysed. With < 5 years of follow-up, the prevalence of pouch failure was 5% (95%CI 3-10%). With ≥ 5 but < 10 years of follow-up, the prevalence was 5% (95%CI 4-7%). This increased to 9% (95%CI 7-16%) with ≥ 10 years of follow-up. The overall prevalence of pouch failure was 6% (95%CI 5-8%). CONCLUSIONS The overall prevalence of pouch failure in patients over the age of 18 who have undergone restorative proctocolectomy in UC is 6%. These data are important for counselling patients considering this operation. Importantly, for those patients with UC being considered for a pouch, their disease course has often resulted in both physical and psychological morbidity and hence providing accurate expectations for these patients is vital.
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Affiliation(s)
| | - Alice Snell
- Surrey and Sussex Healthcare NHS Trust, Redhill, UK
| | - Jonathan P Segal
- Department of Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
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Abstract
BACKGROUND No long-term pouch studies have included follow-up >30 years or an analysis in patients >80 years old. OBJECTIVE This study aimed to investigate pouch function and pouch failure in patients with a pouch in situ >30 years and in patients >80 years old. DESIGN This is a retrospective review. SETTING This study was conducted at an IBD referral center. PATIENTS Adult patients with ulcerative colitis who underwent an IPAA between 1983 and 1990 were selected. MAIN OUTCOME MEASURES The primary outcomes measured were pouch function and pouch failure rates. METHODS Data collection included diagnosis, age at IPAA, indication for IPAA, medications at IPAA, pathology at the time of IPAA, postoperative morbidity, functional outcomes, quality of life, pouch excision or ileostomy and indication, and date of last follow-up. All living patients were contacted in April 2020 to retrieve functional data and pouch failure rates. RESULTS A total of 566 patients had a pouch constructed between 1983 and 1990; of the 145 at most recent contact, 75 had their pouch in situ ≥30 years and 14 were ≥80 years old. Mean age at diagnosis was 25.8 years (10.6 SD), age at surgery was 34.7 years (11.3 SD), and age at last follow-up was 60.5 years (13.2 SD). At a median of 30 years (IQR, 21-32), 145 patients responded to the functional survey. Significantly increased rates of urgency (always, mostly, sometimes: 71.5% vs 23.5%) and seepage during the day (71.4% vs 22.4%) were observed in patients ≥80 years. In patients ≥80 years with a pouch in situ ≥30 years, urgency and incontinence were sometimes experienced by nearly 50% and pouch failure occurred in one third of patients. The overall rate of pouch failure was 19.4% (n = 110) at a median follow-up of 15 years; risk factors were female sex, 3-stage approach, and pelvic sepsis. LIMITATIONS A retrospective database was used. CONCLUSION Patients with IPAA maintain good pouch function even after 30 years and in patients over the age of 80 years. Pouch function declines with time and failure rates increase over time. See Video Abstract at http://links.lww.com/DCR/B684.Función De La Bolsa Ileal En El Tiempo Y En Pacientes De Edad Avanzada. ANTECEDENTES No se han efectuado estudios en pacientes con bolsa a largo plazo que incluyan un seguimiento por treinta años o más y en pacientes mayores de 80 años. OBJETIVO Investigar la funcionalidad o la falla de la bolsa en pacientes bolsa in situ por mas de treinta años y en pacientes mayors de 80 años. DISEO Revisión retrospective. ESCENARIO Centro de referencia de Enfermedad Inflamatoria Intestinal. PACIENTES Pacientes adultos con diagnóstico de colitis ulcerative sometidos a anastomosis bolsa ileal anal (IPAA) entre 1983 y 1990. PRINCIPALES PARAMETROS DE RESULTADOS Indices de efectividad y disfunción de la bolsa ileal. METODOS Recopilación de la información incluyendo diagnóstico, edad del procedimiento (IPAA), indicaciones para IPAA, medicamentos para IPAA, patología en el transcurso del IPAA, morbilidad postoperatoria, resultados funcionales, calidad de vida, excisión de la bolsa o ileostomía y su indicación y fecha de seguimiento mas reciente. Se contactaron a todos los pacientes vivos en abril de 202 para recuperar la información de los índices de funcionalidad o disfunción de la bolsa. RESULTADOS Se les construyó una bolsa a un total de 566 pacientes entre 1983 y 1990; de los 145 mas recientemente contactados, 75 permanecían con su bolsa in situ ≥ 30 años y 14 eran mayores de 80 años. La edad media en el momento de diagnóstico fue de 25.8 años (con desviación estándar de 10.6, sd), edad al momento de la cirugía fue de 34.7 años (11.3sd), y la edad en el último seguimiento de 60.5 años (13.2,sd). A una media de 30 años (IQR: 21,32), 145 pacientes respondieron al cuestionario de funcionalidad. En pacientes mayores de 80 años se observaron tasas aumentadas de urgencia (siempre, la mayor parte de las veces, algunas veces: 71.5% vs 23.5%) y fuga durante el día (71.4% versus 22.4%). En pacientes mayores de 80 años con una bolsa in situ durante 30 años o más, experimentaron urgencia e incontinencia en cerca del 50% y disfunción de la bolsa en un tercio de los pacientes. La tasa global de fallo de la bolsa fue de 19.4% (n = 110) en un seguimiento a 15 años; los factores de riesgo asociados fueron: sexo femenino, abordaje de tres tiempos y sepsis pélvica. LIMITACIONES Información retrospective. CONCLUSIONES Los pacientes con IPAA continúan con una función adecuada de la bolsa aún después de 30 años de efectuada así como en pacientes mayores de 80 años. La funcionalidad de la bolsa disminuye con el tiempo y las tasa de falla aumentan de igual forma con el tiempo. Consulte Video Resumen en http://links.lww.com/DCR/B684. (Traducción- Dr. Miguel Esquivel-Herrera).
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14
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Li H, Arslan ME, Lee EC, Qualia CM, Mikula MW, Fu Z, Petchers A, Arker SH, Kmeid M, Boguniewicz A, Lee H. Pyloric gland metaplasia: Potential histologic predictor of severe pouch disease including Crohn's disease of the pouch in ulcerative colitis. Pathol Res Pract 2021; 220:153389. [PMID: 33640710 DOI: 10.1016/j.prp.2021.153389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 02/13/2021] [Accepted: 02/15/2021] [Indexed: 12/12/2022]
Abstract
Crohn's disease of the pouch (CDP) is seen in a subset of ulcerative colitis (UC) patients following ileal pouch-anal anastomosis (IPAA). Histologic or clinical predictors of CDP are unknown. UC patients with subsequent CDP diagnosis were identified. The rationales for the diagnosis, the interval from the initial signs of CDP to the diagnosis, family history and smoking history were reviewed. Archived pathology materials were reviewed for the presence of pyloric gland metaplasia (PGM) and compared with those from UC with similar severity of pouchitis with CDP (matched UC controls), random UC controls, and ileocolectomies from primary CD patients. CDP diagnosis was made in 26 (18.1%) of 144 patients; all of them met commonly used diagnostic criteria for CDP. The diagnosis was rendered on average 15 months after the initial CD-like signs. PGM was found in 58% of CDP, more common than random UC controls but no different from primary CD and matched UC controls. PGM preceded first signs of CD in a subset. Patients with a family history of CD were more likely to develop CDP than those without a family history of any type of inflammatory bowel disease. Smoking status did not affect the likelihood of developing CDP. Finding PGM in proctocolectomy, ileostomy and follow-up biopsies in UC patients post IPAA may warrant close follow up for the potential development of pouchitis. Some of these patients, especially those with family history of CD, may further progress and develop severe disease meeting the clinical diagnostic criteria for CDP.
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Affiliation(s)
- Hua Li
- Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, NY, USA.
| | - Mustafa Erdem Arslan
- Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, NY, USA.
| | - Edward C Lee
- Department of Surgery, Albany Medical Center, Albany, NY, USA.
| | - Cary M Qualia
- Department of Pediatrics, Albany Medical Center, Albany, NY, USA.
| | | | - Zhiyan Fu
- Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, NY, USA.
| | - Adam Petchers
- Department of Surgery, Albany Medical Center, Albany, NY, USA.
| | - Soe Htet Arker
- Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, NY, USA.
| | - Michel Kmeid
- Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, NY, USA.
| | - Ann Boguniewicz
- Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, NY, USA.
| | - Hwajeong Lee
- Department of Pathology and Laboratory Medicine, Albany Medical Center, Albany, NY, USA.
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15
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Abstract
BACKGROUND Proctocolectomy with IPAA is considered curative for ulcerative colitis. However, signs of Crohn's disease can develop postoperatively in some cases. OBJECTIVE Our aim was to document the postoperative diagnosis of Crohn's disease, to identify potential preoperative predictive factors, and to review the evolution of patients on treatment. DESIGN This is a retrospective cohort study. SETTINGS This study was conducted at a tertiary care center in Montreal, Canada. PATIENTS A total of 301 patients underwent an IPAA for ulcerative colitis between 1985 and 2014. MAIN OUTCOME MEASURES The primary outcome was the cumulative incidence of the postoperative diagnosis of Crohn's disease. RESULTS During a median follow-up of 68 months, Crohn's disease was diagnosed at a median time of 77 months (8-270) in 38 patients (12.6%). The cumulative incidence of Crohn's disease was 7.5% at 5 years postoperatively and gradually increased to 17.7% and 33.0% at 10 and 20 years. The following predictive factors for Crohn's disease were observed on univariate analysis: current tobacco smoking at surgery (HR 3.56 (95% CI, 1.54-8.22)), suspicion of indeterminate colitis (HR 3.50 (95% CI, 1.69-7.24)), presence of mouth ulcers before surgery (HR 2.16 (95% CI, 1.03-4.53)), and age at diagnosis of ulcerative colitis (HR 0.94 (95% CI, 0.90-0.97)). Suspicion of indeterminate colitis (HR 3.18 (95% CI 1.46-6.93); p = 0.004) and age at diagnosis (HR 0.95 (95% CI, 0.91-0.99); p = 0.018) remained statistically significant on multivariate analysis. Postoperative inflammatory disease was controlled by medical therapy in most patients. Removal of the pouch was necessary in 16% of patients with Crohn's disease. LIMITATIONS This was a retrospective single-center study. CONCLUSIONS Diagnosis of Crohn's disease can occur at a distance from surgery with an increasing cumulative incidence over time. Preoperative predictive factors are few and should not determine candidacy for surgery. Therapeutic options are identical to those available for treatment of typical Crohn's disease and allow a favorable evolution in most patients. See Video Abstract at http://links.lww.com/DCR/B372. BROTE DE CROHN DESPUS DE UNA PROCTOCOLECTOMA CON ANASTOMOSIS DE RESERVORIO LEOANAL EN CASOS DE COLITIS ULCEROSA ANTECEDENTES:La proctocolectomía con reservorio ileo-anal se considera curativa para la colitis ulcerosa. Sin embargo, signos de enfermedad de Crohn pueden desarrollarse después de la operación en algunos casos.OBJETIVO:Nuestro objetivo fue documentar el diagnóstico postoperatorio de la enfermedad de Crohn, identificar posibles factores predictivos preoperatorios y revisar la evolución de los pacientes con tratamiento.DISEÑO:Estudio retrospectivo de cohortes.AJUSTES:Centro de atención terciaria en Montreal, Canadá.PACIENTES:301 pacientes portadores de un reservorio íleo-anal realizados por colitis ulcerosa entre 1985 y 2014.PRINCIPALES MEDIDAS DE RESULTADO:Acumulación de la incidencia en el diagnóstico postoperatorio de enfermedad de Crohn.RESULTADOS:Durante una media de 68 meses de seguimiento, la enfermedad de Crohn fué diagnosticada en un tiempo medio de 77 meses (8-270) en 38 pacientes (12,6%). La acumulación de incidencia de la enfermedad de Crohn fue del 7,5% a los 5 años después de la operación y aumentó gradualmente a 17,7 y 33,0% a los 10 y 20 años. Los siguientes factores predictivos para la enfermedad de Crohn se observaron en el análisis univariado: tabaquismo activo al momento de la cirugía (cociente de riesgo (HR) 3.56 (intervalo de confianza del 95% (IC) 1.54-8.22)), sospecha de colitis indeterminada (HR 3.50 (IC del 95% 1.69-7.24)), presencia de úlceras en la boca antes de la cirugía (HR 2.16 (IC 95% 1.03-4.53)) y edad al diagnóstico de colitis ulcerosa (HR 0.94 (IC 95% 0.90-0.97)). La sospecha de colitis indeterminada (HR 3.18 (IC 95% 1.46-6.93), p = 0.004) y la edad al momento del diagnóstico (HR 0.95 (IC 95% 0.91-0.99), p = 0.018) permanecieron estadísticamente significativos en el análisis multivariado. La reacción inflamatoria intestinal postoperatoria fue controlada con tratamiento médico en la mayoría de los pacientes. El retiro del reservorio íleo-anal fue necesario en 16% de los pacientes con enfermedad de Crohn.LIMITACIONES:Estudio retrospectivo de centro único.CONCLUSIONES:El diagnóstico de la enfermedad de Crohn puede ocurrir a distancia de la cirugía con la acumulación de incidencia creciente con el tiempo. Los factores predictivos preo-peratorios son pocos y no pueden determinar la candidatura para la cirugía. Las opciones terapéuticas son idénticas a las disponibles para el tratamiento de la enfermedad de Crohn típica y permiten una evolución favorable en la mayoría de los pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B372. (Traducción-Dr. Xavier Delgadillo).
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16
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Seifarth C, Slavova N, Degro C, Lehmann KS, Kreis ME, Weixler B. Sacral nerve stimulation in patients with ileal pouch-anal anastomosis. Int J Colorectal Dis 2021; 36:1937-1943. [PMID: 34160664 PMCID: PMC8346414 DOI: 10.1007/s00384-021-03981-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Functional results after proctocolectomy and ileal pouch-anal anastomosis (IPAA) are generally good. However, some patients suffer from high stool frequency or fecal incontinence. Sacral nerve stimulation (SNS) may represent a therapeutic alternative in these patients, but little is known about indication and results. The aim of this study was to evaluate incontinence after IPAA and demonstrate SNS feasibility in these patients. METHODS This retrospective study includes patients who received a SNS between 1993 and 2020 for increased stool frequency or fecal incontinence after proctocolectomy with IPAA for ulcerative colitis. Proctocolectomy was performed in a two- or three-step approach with ileostomy closure as the last step. Demographic, follow-up data and functional results were obtained from the hospital database. RESULTS SNS was performed in 23 patients. Median follow-up time after SNS was 6.5 years (min. 4.2-max. 8.8). Two patients were lost to follow-up. The median time from ileostomy closure to SNS implantation was 6 years (min. 0.5-max. 14.5). Continence after SNS improved in 16 patients (69%) with a median St. Marks score for anal incontinence of 19 (min. 4-max. 22) before SNS compared to 4 (0-10) after SNS placement (p = 0.012). In seven patients, SNS therapy was not successful. CONCLUSION SNS implantation improves symptoms in over two-thirds of patients suffering from high stool frequency or fecal incontinence after proctocolectomy with IPAA. Awareness of the beneficial effects of SNS should be increased in physicians involved in the management of these patients.
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Affiliation(s)
- C. Seifarth
- Department of General, Visceral, and Vascular Surgery, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - N. Slavova
- Department of General, Visceral, and Vascular Surgery, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - C. Degro
- Department of General, Visceral, and Vascular Surgery, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - K. S. Lehmann
- Department of General, Visceral, and Vascular Surgery, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - M. E. Kreis
- Department of General, Visceral, and Vascular Surgery, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - B. Weixler
- Department of General, Visceral, and Vascular Surgery, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
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17
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Kucharzik T, Dignass AU, Atreya R, Bokemeyer B, Esters P, Herrlinger K, Kannengießer K, Kienle P, Langhorst J, Lügering A, Schreiber S, Stallmach A, Stein J, Sturm A, Teich N, Siegmund B. [Not Available]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2020; 58:e241-e326. [PMID: 33260237 DOI: 10.1055/a-1296-3444] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Torsten Kucharzik
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Klinikum Lüneburg, Lüneburg, Deutschland
| | - Axel U Dignass
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt am Main, Deutschland
| | - Raja Atreya
- Medizinische Klinik 1, Universitätsklinikum Erlangen, Deutschland
| | - Bernd Bokemeyer
- Gastroenterologische Gemeinschaftspraxis Minden, Deutschland
| | - Philip Esters
- Medizinische Klinik I, Agaplesion Markus Krankenhaus, Frankfurt am Main, Deutschland
| | | | - Klaus Kannengießer
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Klinikum Lüneburg, Lüneburg, Deutschland
| | - Peter Kienle
- Allgemein- und Viszeralchirurgie, Theresienkrankenhaus und Sankt Hedwig-Klinik GmbH, Mannheim, Deutschland
| | - Jost Langhorst
- Klinik für Integrative Medizin und Naturheilkunde, Klinikum am Bruderwald, Bamberg, Deutschland
| | - Andreas Lügering
- Medizinisches Versorgungszentrum Portal 10, Münster, Deutschland
| | | | - Andreas Stallmach
- Gastroenterologie, Hepatologie und Infektiologie, Friedrich Schiller Universität, Jena, Deutschland
| | - Jürgen Stein
- Innere Medizin mit Schwerpunkt Gastroenterologie, Krankenhaus Sachsenhausen, Frankfurt/Main, Deutschland
| | - Andreas Sturm
- Klinik für Innere Medizin mit Schwerpunkt Gastroenterologie, DRK Kliniken Berlin Westend, Berlin, Deutschland
| | - Niels Teich
- Internistische Gemeinschaftspraxis für Verdauungs- und Stoffwechselkrankheiten, Leipzig, Deutschland
| | - Britta Siegmund
- Medizinische Klinik I, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Deutschland
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Kuwahara R, Ikeuchi H, Bando T, Sasaki H, Goto Y, Horio Y, Minagawa T, Uchino M. Clinical Results of One-stage Restorative Proctocolectomy with J-pouch Anal Anastomosis in 300 Ulcerative Colitis Patients. JOURNAL OF THE ANUS RECTUM AND COLON 2020; 4:181-185. [PMID: 33134599 PMCID: PMC7595683 DOI: 10.23922/jarc.2020-003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/25/2020] [Indexed: 12/04/2022]
Abstract
Objectives: Restorative proctocolectomy and ileal pouch anal anastomosis (IPAA), with diverting ileostomy, are established ulcerative colitis (UC) treatments. The routine use of diverting ileostomy is controversial because of the risk of stoma closure and stoma related complications. In our institution, proctocolectomy and IPAA, with mucosectomy and handsewn anastomosis without diversion (one-stage IPAA), were performed for select patients with UC. The present study aimed to evaluate the clinical and functional outcomes of patients undergoing one-stage IPAA. Methods: Between April 1999 and July 2017, 300 patients underwent one-stage IPAA in our institution. The clinical notes and prognosis were reviewed retrospectively. Results: Postoperative complications (Clavien-Dindo classification grade ≥III) occurred in 18 patients (6.0%). The most common complication was anastomotic leakage (n = 9, 3%). There were 15 patients (5.0%) who required a defunctioning ileostomy. However, 13 patients successfully underwent ileostomy closure and achieved acceptable pouch function. Finally, two patients (0.6%) required pouch excision in this series. The cumulative pouch functional rate was 99.6% / 5 years and 99.2% / 10 years. Conclusions: One-stage IPAA is a good strategy for carefully selected patients with UC.
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Affiliation(s)
- Ryuichi Kuwahara
- Department of Gastroenterology, Division of Inflammatory Bowel Disease, Hyogo College of Medicine, Nisinomiya, Japan
| | - Hiroki Ikeuchi
- Department of Gastroenterology, Division of Inflammatory Bowel Disease, Hyogo College of Medicine, Nisinomiya, Japan
| | - Toshihiro Bando
- Department of Gastroenterology, Division of Inflammatory Bowel Disease, Hyogo College of Medicine, Nisinomiya, Japan
| | - Hirohumi Sasaki
- Department of Gastroenterology, Division of Inflammatory Bowel Disease, Hyogo College of Medicine, Nisinomiya, Japan
| | - Yoshiko Goto
- Department of Gastroenterology, Division of Inflammatory Bowel Disease, Hyogo College of Medicine, Nisinomiya, Japan
| | - Yuki Horio
- Department of Gastroenterology, Division of Inflammatory Bowel Disease, Hyogo College of Medicine, Nisinomiya, Japan
| | - Tomohiro Minagawa
- Department of Gastroenterology, Division of Inflammatory Bowel Disease, Hyogo College of Medicine, Nisinomiya, Japan
| | - Motoi Uchino
- Department of Gastroenterology, Division of Inflammatory Bowel Disease, Hyogo College of Medicine, Nisinomiya, Japan
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19
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Emile SH, Gilshtein H, Wexner SD. Outcome of Ileal Pouch-anal Anastomosis in Patients With Indeterminate Colitis: A Systematic Review and Meta-analysis. J Crohns Colitis 2020; 14:1010-1020. [PMID: 31912129 DOI: 10.1093/ecco-jcc/jjaa002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Indeterminate colitis [IC] is type of inflammatory bowel disease that exhibits features of both ulcerative colitis [UC] and Crohn's disease [CD]. The present meta-analysis aimed to assess the outcomes of ileal pouch-anal anastomosis [IPAA] in patients with IC in comparison with patients with UC. METHODS A PRISMA-compliant systematic review of the outcome of IPAA in patients with IC was conducted. Electronic databases were searched, and full-text articles were reviewed to extract essential data. Main outcome measures were pouch failure and pouch-related complications. RESULTS A total of 17 studies were included in this meta-analysis. There were 1057 patients with IC and 6511 patients with UC. The weighted mean pouch failure rate in patients with IC was 7.5 (95% confidence interval [CI]: 4.8-10.2) and the weighted mean complication rate was 67 [95% CI: 53.5-80.5]. As compared with patients with UC, patients with IC had significantly higher odds of developing complications after IPAA (odds ratio [OR]: 2.6, p <0.001): pouch fistula [OR:4.98, p <0.001], pelvic sepsis [OR:3.98, p =0.002], pelvic or cuff abscess [OR: 4.5, p <0.001], perineal complications [OR: 5.13, p <0.001], and ultimate diagnosis of CD [OR: 2.57, p <0.001]. Patients with IC and UC had similar odds of pouch failure, pouchitis, anastomotic leak, stricture, and small bowel obstruction. CONCLUSIONS Patients with IC had similar pouch failure rates, yet higher overall complication rates than patients with UC. Complications that tend to be higher after IPAA for patients with IC include pouch fistula, pelvic sepsis, abscess, perineal complications, and ultimate diagnosis of Crohn's disease.
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Affiliation(s)
- Sameh Hany Emile
- Colorectal Surgery Unit, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Hayim Gilshtein
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
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20
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Chandrasinghe P, Carvello M, Wasmann K, Foppa C, Tanis P, Perry-Woodford Z, Warusavitarne J, Spinelli A, Bemelman W. Transanal Ileal Pouch-Anal Anastomosis for Ulcerative Colitis has Comparable Long-Term Functional Outcomes to Transabdominal Approach: A Multicentre Comparative Study. J Crohns Colitis 2020; 14:726-733. [PMID: 31637417 DOI: 10.1093/ecco-jcc/jjz174] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The transanal approach to ileal pouch-anal anastomosis [Ta-IPAA] provides better access to the lower pelvis with lower short-term morbidity in ulcerative colitis [UC]. The aim of this study was to assess the long-term functional outcomes after Ta-IPAA vs transabdominal IPAA [Abd-IPAA] in UC. METHODS A multicentre cohort analysis was performed between March 2002 and September 2017. Patient characteristics, surgical details and postoperative outcomes were compared. CGQL [Cleveland global quality of life] score at 12 months with a functioning pouch was considered the primary end point. RESULTS A total of 374 patients [100 Ta-IPAA vs 274 Abd-IPAA] were included. Ta-IPAA demonstrated a comparable overall quality of life [CGQL score] to Abd-IPAA [0.75 ± 0.11 vs 0.71 ± 0.14; respectively, p = 0.1]. Quality of life [7.71 ± 1.17 vs 7.30 ± 1.46; p = 0.04] and energy-level items [7.16 ± 1.52 vs 6.66 ± 1.68; p = 0.03] were significantly better after Ta-IPAA, while the quality of health item was comparable [7.68 ± 1.26 vs 7.64 ± 1.44; p = 0.96]. Analysis excluding anastomotic leaks did not change the overall CGQL scores. Stool frequencies [>10/24 h: 22% vs 21%; p = 1.0] and the rate of a single episode of major incontinence during the following 12-month period [27% vs 26%; p = 0.89] were similar. The differences in 30-day morbidity rates [33% vs 41%; p = 0.2] and anastomotic leak rates were not significant [6% vs 13%; p = 0.09]. CONCLUSIONS This study provides evidence of comparable long-term functional outcome and quality of life after Ta-IPAA and Abd-IPAA for UC.
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Affiliation(s)
- Pramodh Chandrasinghe
- Department of Surgery and Cancer, Imperial College, London, UK.,Department of Colorectal Surgery, St. Mark's Hospital, Harrow, UK.,Department of Surgery, Faculty of Medicine, University of Kelaniya, Sri Lanka
| | - Michele Carvello
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Hospital, Milan, Italy
| | - Karin Wasmann
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Caterina Foppa
- Department of Biomedical Science, Humanitas Research Hospital, Milan, Italy
| | - Pieter Tanis
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Janindra Warusavitarne
- Department of Surgery and Cancer, Imperial College, London, UK.,Department of Colorectal Surgery, St. Mark's Hospital, Harrow, UK
| | - Antonino Spinelli
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Hospital, Milan, Italy.,Department of Biomedical Science, Humanitas Research Hospital, Milan, Italy
| | - Willem Bemelman
- Department of Surgery, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
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Feinberg AE, Lavryk O, Aiello A, Hull TL, Steele SR, Stocchi L, Holubar SD. Conditional Survival After IPAA for Ulcerative and Indeterminate Colitis: Does Long-term Pouch Survival Improve or Worsen With Time? Dis Colon Rectum 2020; 63:927-933. [PMID: 32243352 DOI: 10.1097/dcr.0000000000001629] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Risk factors for pouch survival may or may not have a linear relationship with pouch loss over time. Conditional survival is a method to describe these nonlinear time-to-event relationships by reporting the expected survival at various time points. OBJECTIVE The aim of this study was to calculate conditional pouch survival based on occurrence of risk factors for pouch loss. DESIGN This was a retrospective study from an institutional database. SETTINGS The study was conducted at the Cleveland Clinic Foundation. PATIENTS Patients with ulcerative or indeterminate colitis who underwent index IPAA construction between 1986 and 2016 were included. MAIN OUTCOME MEASURES Patients were stratified based on postoperative anastomotic leak, abscess, or fistula occurrence. The Kaplan-Meier method with conditional survival was used to estimate overall and cause-specific survival at 10 years. RESULTS A total of 3468 patients underwent IPAA during the study period. The overall 10-year pouch survival rate was 0.94 (95% CI, 0.93-0.95), and after 1 year the conditional pouch survival increased to 0.95 (95% CI, 0.94-0.96), after 3 years to 0.97 (95% CI, 0.96-0.98), and after 5 years to 0.98 (95% CI, 0.98-0.99). A total of 122 patients (3.5%) developed anastomotic leak, and the 10-year IPAA survival in patients with leak was 0.85 (95% CI, 0.77-0.93). In this group, after 1 year of pouch survival, the conditional pouch survival increased to 0.89 (95% CI, 0.82-0.96) and after 3 years to 0.98 (95% CI, 0.94-1.00). A similar pattern was seen for IPAA with postoperative abscess. The conditional survival curve was stable over time for patients with a fistula. LIMITATIONS This was a retrospective, single-institution study. CONCLUSIONS Overall conditional pouch survival improved over time for patients with postoperative anastomotic leak and abscess. These novel findings can be useful to counsel patients regarding expectations for long-term pouch survival even if they develop leaks and abscesses. See Video Abstract at http://links.lww.com/DCR/B217. SUPERVIVENCIA CONDICIONAL DESPUÉS DE ANASTOMOSIS CON BOLSA ÍLEO ANAL, PARA COLITIS ULCERATIVA E INDETERMINADA: ¿LA SOBREVIDA DE LA BOLSA A LARGO PLAZO, MEJORA O EMPEORA CON EL TIEMPO?: Los factores de riesgo para la sobrevida de la bolsa, pueden o no tener una relación lineal con la pérdida de la bolsa y con el tiempo. La supervivencia condicional es un método para describir estas relaciones no lineales de tiempo, hasta el evento informando la supervivencia esperada en varios puntos de tiempo.El objetivo de este estudio fue calcular la supervivencia condicional de la bolsa, en función de aparición de factores de riesgo para la pérdida de bolsa.Estudio retrospectivo de una base de datos institucional.Cleveland Clinic Foundation.Pacientes con colitis ulcerativa o indeterminada, sometidos a una anastomosis de bolsa íleo anal, de 1986 a 2016.Los pacientes fueron estratificados en función de la fuga anastomótica postoperatoria, absceso o aparición de fístula. El método de Kaplan Meier con supervivencia condicional, se utilizó para estimar la supervivencia general y la causa específica a los 10 años.Un total de 3.468 pacientes fueron sometidos a anastomosis ileal con bolsa anal durante el período de estudio. La tasa de supervivencia global de la bolsa a 10 años, fue de 0,94 (0,93 a 0,95), y después de 1 año, la supervivencia condicional de la bolsa aumentó a 0,95 (0,94 a 0,96), después de 3 años a 0,97 (0,96 a 0,98) y después de 5 años a 0.98 (0.98 - 0.99). Un total de 122 (3,5%) pacientes desarrollaron fuga anastomótica, y la supervivencia de la anastomosis de bolsa íleo anal a 10 años en pacientes con fuga fue de 0,85 (IC del 95%: 0,77 a 0,93). En este grupo, después de 1 año de supervivencia de la bolsa, la supervivencia condicional de la bolsa aumentó a 0,89 (IC del 95%: 0,82 a 0,96), y después de 3 años a 0,98 (IC del 95%: 0,94 a 1). Se observó un patrón similar para la anastomosis de bolsa íleo anal con absceso postoperatorio. La curva de supervivencia condicional fue estable en el tiempo para los pacientes con una fístula.Estudio retrospectivo, de una sola institución.La supervivencia condicional global de la bolsa, mejoró con el tiempo para pacientes con fuga anastomótica postoperatoria y absceso. Estos nuevos hallazgos pueden ser útiles para aconsejar a los pacientes con respecto a las expectativas de supervivencia de la bolsa a largo plazo, incluso si desarrollan fugas y abscesos. Consulte Video Resumen http://links.lww.com/DCR/B217. (Traducción-Dr Fidel Ruiz Healy).
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Affiliation(s)
- Adina E Feinberg
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Olga Lavryk
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Alexandra Aiello
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Tracy L Hull
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Scott R Steele
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Luca Stocchi
- Division of Colon & Rectal Surgery, Mayo Clinic, Jacksonville, Florida
| | - Stefan D Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
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22
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Holubar SD, Hull T. Crohn's disease of the ileoanal pouch. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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23
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Lopez NE, Zaghyian K, Fleshner P. Is There a Role for Ileal Pouch Anal Anastomosis in Crohn's Disease? Clin Colon Rectal Surg 2019; 32:280-290. [PMID: 31275075 DOI: 10.1055/s-0039-1683917] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Traditionally, surgical interventions for colonic Crohn's disease (CD) have been limited to total abdominal colectomy and ileorectal anastomosis, or total proctocolectomy with end ileostomy if there is rectal involvement. However, improved understandings of the biology of CD, as well as the development of biologic therapies, have enabled more limited resections. Here, we review the indications for, and limitations of, specific procedures aiming to preserve intestinal continuity in colonic CD.
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Affiliation(s)
- Nicole E Lopez
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Karen Zaghyian
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Phillip Fleshner
- Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Factors Associated with Long-Term Quality of Life After Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis. J Gastrointest Surg 2019; 23:571-579. [PMID: 30097964 DOI: 10.1007/s11605-018-3904-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 07/24/2018] [Indexed: 01/31/2023]
Abstract
THE AIM The aim of this study was to analyze factors associated with quality of life (QoL) after ileal pouch anal anastomosis (IPAA). METHODS Patients who underwent IPAA (1983-2015) and replied to QoL questionnaire were identified from an IRB-approved prospectively maintained IPAA-database. QoL was assessed using Cleveland Global Quality of Life (CGQL) questionnaire at 1, 3, 5, and 10 years postoperatively. Patient cohort was divided in two groups: overall QoL score ≤ 0.7 (low) and > 0.7 (high). Demographics, perioperative morbidity, and functional results were analyzed. RESULTS A total of 4059 patients replied to the questionnaire at the most recent follow-up and were included. A total of 2889 (71%) had overall QoL > 0.7 (group 1) and 1170 (29%) patients had overall QoL ≤ 0.7 (group 2). Patients in group 1 had lower rates of early (44.6 vs. 50.4%, p = 0.003) and late (55.7 vs. 64.5%, p < 0.003) postoperative complications. Kaplan-Meier survival analysis demonstrated significantly higher rates of pouch failure among patients with lower QoL. Pouchitis, obstruction, fistulas, higher number of stools, and IPAA performed during the most recent decade (2005-2015) were significantly associated with lower QoL (≤ 0.7), while S-pouch configuration was associated with higher QoL (> 0.7). CONCLUSION Patient's characteristics and minimal perioperative complications impact patient's QoL following IPAA not only in the short term, but also in the long term.
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Abstract
PURPOSE OF REVIEW Ileal pouch-anal anastomosis (IPAA) is the standard restorative procedure after proctocolectomy in patients with inflammatory bowel disease who require colectomy. The ileal pouch is susceptible to a variety of adverse outcomes including mechanical insult, ischemia, and infectious agents. There is also a risk for developing low-grade dysplasia (LGD), high-grade dysplasia (HGD), or even adenocarcinoma in the pouch. The purpose of this review is to highlight risk factors, clinical presentation, surveillance, and treatment of pouch neoplasia. RECENT FINDINGS Patients with pre-colectomy colitis-associated neoplasia are at high risk for developing pouch neoplasia. Other purported risk factors include the presence of family history of colorectal cancer, the presence of concurrent primary sclerosing cholangitis, chronic pouchitis, cuffitis, or Crohn's disease of the pouch. Pouch adenocarcinoma tends to have a poor prognosis. It is recommended to have a combined clinical, endoscopic, and histologic approach in diagnosis and management. Surveillance and management algorithms of pouch neoplasia are proposed, based on the risk stratification.
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Affiliation(s)
- Freeha Khan
- Department of Gastroenterology/Hepatology/Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Bo Shen
- Department of Gastroenterology/Hepatology/Nutrition, Cleveland Clinic, Cleveland, OH, USA.
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26
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Freeha K, Bo S. Complications Related to J-Pouch Surgery. Gastroenterol Hepatol (N Y) 2018; 14:571-576. [PMID: 30846911 PMCID: PMC6384396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Restorative proctocolectomy with ileal pouch-anal anastomosis is the gold-standard surgical procedure for familial adenomatous polyposis, refractory ulcerative colitis, and colitis- associated dysplasia requiring colectomy. Numerous adverse sequelae are associated with J-pouch surgery, including anastomotic leak, stricture, and fistula formation, among other complications. Pouch failure due to structural, inflammatory, or functional complications represents a challenge to both physicians and patients. Symptom assessment should be combined with endoscopic, histologic, and radiographic examinations to make an accurate diagnosis of J-pouch-related complications.
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Affiliation(s)
- Khan Freeha
- Dr Khan is an IBD fellow and Dr Shen is director of the Inflammatory Bowel Disease Section in the Digestive Disease and Surgery Institute at Cleveland Clinic in Cleveland, Ohio
| | - Shen Bo
- Dr Khan is an IBD fellow and Dr Shen is director of the Inflammatory Bowel Disease Section in the Digestive Disease and Surgery Institute at Cleveland Clinic in Cleveland, Ohio
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27
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Khan F, Gao XH, Singh A, Philpott JR, Shen B. Vedolizumab in the treatment of Crohn's disease of the pouch. Gastroenterol Rep (Oxf) 2018; 6:184-188. [PMID: 30151202 PMCID: PMC6101609 DOI: 10.1093/gastro/goy014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 05/04/2018] [Indexed: 12/15/2022] Open
Abstract
Background Our recent study showed the efficacy and safety of vedolizumab in the treatment of chronic antibiotic-refractory pouchitis. However, there are no published studies on its efficacy and safety in Crohn’s disease (CD) of the pouch. The aim of this study was to assess the efficacy and safety of vedolizumab in those patients. Methods This case series included all eligible patients with CD of the pouch from our prospectively maintained, IRB-approved Pouchitis Registry from 2015 to 2017. Disease activity in pouch patients can be monitored using the modified Pouchitis Disease Activity Index (mPDAI). mPDAI is the 18-point pouchitis disease activity index consisting of three principal component scores: symptom (range, 0–6 points), endoscopy, (range 0–6 points), and histology (range, 2–6 points). Pre- and post- treatment (minimum 6 months) pouchoscopy and clinical visits were used to calculate mPDAI. Results A total of 12 patients were included in this study, who had restorative proctocolectomy with ileal pouch anal anastomosis for medically refractory ulcerative colitis (UC). The mean age at the time of pre-colectomy diagnosis of UC was 25.0 ± 11.5 years. The mean current age was 41.0 ± 12.1 years, nine (75.0%) were female, three (25.0%) had smoked and eight (66.7%) had used anti-tumor necrosis factor agents prior to vedolizumab use. The mean duration of vedolizumab use was 1.0 ± 6.4 years. There was a significant reduction in mPDAI symptom subscores after vedolizumab therapy (3.50 ± 1.93 vs 5.08 ± 0.79, P = 0.015). The pre- and post-treatment mean endoscopy subscores were 1.25 ± 1.36 and 0.91 ± 1.50 in the afferent limb (P = 0.583); 2.58 ± 1.68 and 2.27 ± 2.05 (P = 0.701) in the pouch body; and 2.67 ± 1.93 and 2.09 ± 2.12 (P = 0.511) in the cuff, respectively. None of the patients experienced side effects throughout the vedolizumab therapy. Conclusion The findings of our study suggests that vedolizumab appears to be effective and safe in reducing the symptoms in patients with CD of the pouch.
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Affiliation(s)
- Freeha Khan
- Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Xian-Hua Gao
- Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amandeep Singh
- Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jessica R Philpott
- Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bo Shen
- Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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Uchino M, Ikeuchi H, Sugita A, Futami K, Watanabe T, Fukushima K, Tatsumi K, Koganei K, Kimura H, Hata K, Takahashi K, Watanabe K, Mizushima T, Funayama Y, Higashi D, Araki T, Kusunoki M, Ueda T, Koyama F, Itabashi M, Nezu R, Suzuki Y. Pouch functional outcomes after restorative proctocolectomy with ileal-pouch reconstruction in patients with ulcerative colitis: Japanese multi-center nationwide cohort study. J Gastroenterol 2018; 53:642-651. [PMID: 28884201 DOI: 10.1007/s00535-017-1389-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 08/31/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although several complications capable of causing pouch failure may develop after restorative proctocolectomy (RPC) for ulcerative colitis (UC), the incidences and causes are conflicting and vary according to country, race and institution. To avoid pouch failure, this study aimed to evaluate the rate of pouch failure and its risk factors in UC patients over the past decade via a nationwide cohort study. METHODS We conducted a retrospective, observational, multicenter study that included 13 institutions in Japan. Patients who underwent RPC between January 2005 and December 2014 were included. The characteristics and backgrounds of the patients before and during surgery and their postoperative courses and complications were reviewed. RESULTS A total of 2376 patients were evaluated over 6.7 ± 3.5 years of follow-up. Twenty-seven non-functional pouches were observed, and the functional pouch rate was 98.9% after RPC. Anastomotic leakage (odds ratio, 9.1) was selected as a risk factor for a non-functional pouch. The cumulative pouch failure rate was 4.2%/10 years. A change in diagnosis to Crohn's disease/indeterminate colitis (hazard ratio, 13.2) was identified as an independent risk factor for pouch failure. CONCLUSION The significant risk factor for a non-functional pouch was anastomotic leakage. The optimal staged surgical procedure should be selected according to a patient's condition to avoid anastomotic failure during RPC. Changes in diagnosis after RPC confer a substantial risk of pouch failure. Additional cohort studies are needed to obtain an understanding of the long-standing clinical course of and proper treatment for pouch failure.
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Affiliation(s)
- Motoi Uchino
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan.
| | - Hiroki Ikeuchi
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan
| | - Akira Sugita
- Department of Inflammatory Bowel Disease, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Kitaro Futami
- Department of Surgery, Fukuoka University Chikushi Hospital, Chikusino, Japan
| | - Toshiaki Watanabe
- Department of Surgical Oncology and Vascular Surgery, The University of Tokyo, Tokyo, Japan
| | - Kouhei Fukushima
- Laboratory of Gastro Intestinal Tract Reconstruction, Tohoku University Graduate School of Biomedical Engineering, Sendai, Japan
| | - Kenji Tatsumi
- Department of Inflammatory Bowel Disease, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Kazutaka Koganei
- Department of Inflammatory Bowel Disease, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Hideaki Kimura
- Inflammatory Bowel Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Keisuke Hata
- Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
| | | | - Kazuhiro Watanabe
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tsunekazu Mizushima
- Department of Therapeutics for Inflammatory Bowel Diseases, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yuji Funayama
- Department of Surgery, Sendai Red Cross Hospital, Sendai, Japan
| | - Daijiro Higashi
- Department of Surgery, Fukuoka University Chikushi Hospital, Chikusino, Japan
| | - Toshimitsu Araki
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Masato Kusunoki
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Takeshi Ueda
- Department of Surgery, Nara Medical University, Kashihara, Japan
| | - Fumikazu Koyama
- Department of Surgery, Nara Medical University, Kashihara, Japan
| | - Michio Itabashi
- Institute of Gastroenterology, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Riichiro Nezu
- Department of Surgery, Nishinomiya Municipal Central Hospital, Nishinomiya, Japan
| | - Yasuo Suzuki
- Department of Internal Medicine, Toho University Sakura Medical Center, Sakura, Japan
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Abel AG, Chung A, Paul E, Gibson PR, Sparrow MP. Patchy colitis, and young age at diagnosis and at the time of surgery predict subsequent development of Crohn's disease after ileal pouch-anal anastomosis surgery for ulcerative colitis. JGH Open 2018; 2:8-14. [PMID: 30483556 PMCID: PMC6207023 DOI: 10.1002/jgh3.12035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 10/18/2017] [Accepted: 11/30/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIM A proportion of patients having total proctocolectomy and ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) are later diagnosed with Crohn's disease (CD). The aim of this study was to identify preoperative and perioperative predictors for the subsequent development of CD in patients who had IPAA for presumed UC. METHODS A retrospective case-control study of patients undergoing IPAA surgery for presumed UC was undertaken. Cases were patients who had a revised diagnosis of CD after surgery. Preoperative and perioperative variables were examined and analyzed. RESULTS Fifteen cases were compared with 39 controls. Patients aged ≤25 years at initial UC diagnosis were more likely to develop CD compared to those aged >25 years (odds ratio, OR [95% confidence interval, CI]: 7.1 [1.6-31.3]; P = 0.01). Patients aged ≤30 years at the time of colectomy had an increased risk of subsequent development of CD compared to those aged >30 years (OR [95% CI]: 4.5 [1.3-16.0]; P = 0.02). Cases were more likely to have patchy colitis on their colectomy specimen (OR [95% CI]: 6.7 [1.1-41.8]; P = 0.04). There was no significant difference between groups regarding transmural inflammation, ileitis, or fissuring ulcers on colectomy specimens, or preoperative C-reactive protein (CRP), albumin, family history, and smoking status. CONCLUSION Predictors of the development of CD in the pouch include young age at diagnosis and at the time of surgery, and patchy colitis in the resected colon.
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Affiliation(s)
- Alexandra G Abel
- Department of GastroenterologyThe Alfred HospitalMelbourneVictoriaAustralia
| | - Alvin Chung
- Department of GastroenterologyEastern HealthMelbourneVictoriaAustralia
| | - Eldho Paul
- School of Public Health and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Department of Clinical HematologyThe Alfred HospitalMelbourneVictoriaAustralia
| | - Peter R Gibson
- Department of GastroenterologyThe Alfred HospitalMelbourneVictoriaAustralia
| | - Miles P Sparrow
- Department of GastroenterologyThe Alfred HospitalMelbourneVictoriaAustralia
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Chang S, Shen B, Remzi F. When Not to Pouch: Important Considerations for Patient Selection for Ileal Pouch-Anal Anastomosis. Gastroenterol Hepatol (N Y) 2017; 13:466-475. [PMID: 28867978 PMCID: PMC5572960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment for patients who undergo colectomy and wish to avoid a permanent ileostomy. The overall outcomes are positive, with an improved quality of life and stable long-term pouch retention. However, certain conditions or disease states may be at a higher risk of pouch dysfunction or failure. For example, obese patients have an increased risk for postoperative complications. In addition, women with a history of obstetric complications and elderly patients with a history of sphincter damage or dysfunction may be at an increased risk for postoperative incontinence, although quality-of-life indices do not necessarily correlate with incontinence scores. Advanced age itself is not a contraindication to pouch surgery, and elderly patients can be considered for IPAA based on individual functionality and comorbidities. Pelvic radiation may lead to pouch dysfunction. Finally, patients with Crohn's disease and indeterminate colitis may have increased complications with IPAA, but highly specific patient selection leads to good rates of pouch retention. This article examines several clinical scenarios that require careful thought prior to considering IPAA.
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Affiliation(s)
- Shannon Chang
- Dr Chang is an assistant professor of medicine at the Inflammatory Bowel Disease Center at New York University Langone Medical Center in New York, New York. Dr Shen is a professor of medicine at the Center for Inflammatory Bowel Diseases at the Digestive Disease and Surgery Institute at The Cleveland Clinic Foundation in Cleveland, Ohio. Dr Remzi is a professor of surgery and director of the Inflammatory Bowel Disease Center at New York University Langone Medical Center
| | - Bo Shen
- Dr Chang is an assistant professor of medicine at the Inflammatory Bowel Disease Center at New York University Langone Medical Center in New York, New York. Dr Shen is a professor of medicine at the Center for Inflammatory Bowel Diseases at the Digestive Disease and Surgery Institute at The Cleveland Clinic Foundation in Cleveland, Ohio. Dr Remzi is a professor of surgery and director of the Inflammatory Bowel Disease Center at New York University Langone Medical Center
| | - Feza Remzi
- Dr Chang is an assistant professor of medicine at the Inflammatory Bowel Disease Center at New York University Langone Medical Center in New York, New York. Dr Shen is a professor of medicine at the Center for Inflammatory Bowel Diseases at the Digestive Disease and Surgery Institute at The Cleveland Clinic Foundation in Cleveland, Ohio. Dr Remzi is a professor of surgery and director of the Inflammatory Bowel Disease Center at New York University Langone Medical Center
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31
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Lightner AL, Tse CS, Quinn K, Bergquist JR, Enders F, Pendegraft R, Khanna S, Raffals L. Preoperative Clostridium difficile Infection Does Not Affect Pouch Outcomes in Patients with Ulcerative Colitis Who Undergo Ileal Pouch-anal Anastomosis. Inflamm Bowel Dis 2017; 23:1195-1201. [PMID: 28410344 DOI: 10.1097/mib.0000000000001122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The operation of choice for patients with chronic ulcerative colitis (CUC) is restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). Pouchitis is the most common complication after IPAA. The incidence of Clostridium difficile infection (CDI) is higher in CUC patients than the general population and can lead to significant disease flares and higher rates of colectomy. We sought to determine the risk of pouchitis in patients with precolectomy CDI and 90-day postoperative IPAA complications. METHODS A retrospective case-control study was conducted on patients with CUC who underwent an IPAA between January 1, 2000 and January 10, 2015. The study cohort was comprised of patients diagnosed with CDI within 90 days before colectomy; patients with CUC without CDI comprised the control cohort. The primary outcome measure was the frequency of pouchitis after IPAA. Secondary outcomes included time to pouchitis, 90-day postoperative pouch morbidity: surgical site infection, hemorrhage, anastomotic leak, fistula formation, pouchitis treatment and response, and pouch failure requiring end-ileostomy or fecal diversion. Univariate and multivariable analysis was used to determine differences between CDI and non-CDI groups. RESULTS Forty-eight case patients and 154 control patients were included. Patients with preoperative CDI were younger (P = 0.010), had higher rates of medically refractory disease (P = 0.002), and had greater use of biologic therapy (P = 0.046). The rate of pouchitis was 50.0% (n = 24) and 46.8% (n = 72) (P = 0.694) among patients with and without preoperative CDI, respectively. Patients with preoperative CDI who developed pouchitis post-IPAA were more likely to require medical management with an anti-TNFα (P = 0.042) and surgical management with end/diverting ileostomy (P = 0.042). Preoperative CDI was associated with higher rates of postoperative IPAA anastamotic or pouch strictures (P = 0.018). Multivariable analysis revealed primary sclerosing cholangitis (PSC) as the only variable associated with increased risk for pouchitis (OR 10.59; 95% CI, 3.07-51.08; P < 0.001). CONCLUSIONS Preoperative CDI does not seem to be associated with an increased risk of pouchitis in patients with CUC.
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Affiliation(s)
- Amy L Lightner
- *Department of Colon and Rectal Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota; Departments of †Internal Medicine, and ‡General Surgery, Mayo Clinic, Rochester, Minnesota; §Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, Minnesota; and ‖Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
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Lightner AL, Pemberton JH, Dozois EJ, Larson DW, Cima RR, Mathis KL, Pardi DS, Andrew RE, Koltun WA, Sagar P, Hahnloser D. The surgical management of inflammatory bowel disease. Curr Probl Surg 2017; 54:172-250. [PMID: 28576304 DOI: 10.1067/j.cpsurg.2017.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.
| | - John H Pemberton
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Eric J Dozois
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Robert R Cima
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Darrell S Pardi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Rachel E Andrew
- Division of Colorectal Surgery, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA
| | - Walter A Koltun
- Division of Colorectal Surgery, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA
| | - Peter Sagar
- Division of Colorecal surgery, St. James University Hospital, Leeds, England
| | - Dieter Hahnloser
- Division of Colorecal surgery, Lausanne University Hospital, Lausanne, Switzerland
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Jackson KL, Stocchi L, Duraes L, Rencuzogullari A, Bennett AE, Remzi FH. Long-Term Outcomes in Indeterminate Colitis Patients Undergoing Ileal Pouch-Anal Anastomosis: Function, Quality of Life, and Complications. J Gastrointest Surg 2017; 21:56-61. [PMID: 27832426 DOI: 10.1007/s11605-016-3306-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 10/11/2016] [Indexed: 01/31/2023]
Abstract
INTRODUCTION It is uncertain whether the outcomes of patients with indeterminate colitis (IC) undergoing ileal pouch-anal anastomosis (IPAA) deteriorate over time. The aim of this study was to determine the long-term pouch function, quality of life, complications, and incidence of Crohn's disease after IPAA for patients with IC compared to ulcerative colitis (UC). METHODS A case matched analysis was performed on patients undergoing IPAA for pathologically confirmed IC or UC, between 1985 and 2014. Patients were case matched for age ± 5 years, gender, date of surgery ± 3 years, type of anastomosis and presence of a diverting loop ileostomy. All patients were followed up for greater than six months. RESULTS 448 patients were case matched, the average age was 36.8 year old and 52.7 % of patients were male. Mean follow-up was 122.06 months (+/- 80.77 months). There were statistically and clinically comparable number of daytime bowel movements (5.7 v 5.5, p = 0.45), rates of incontinence (26.1 % v 18.3 %, p = 0.09) and nighttime seepage in patients (23.1 % v 28.4 %, p = 0.28) with IC and UC. Quality of life markers and patient restrictions were comparable between the two groups. Rates of pelvic sepsis (IC 8.5 %, UC 8.5 %, p = 0.99) and anastomotic leak (IC 3.1 %, UC 4.0 %, p = 0.61) were similar but fistula formation (IC 15.6 %, UC 8.0 %, p = 0.01) and IPAA Crohn's disease rates (IC 6.7 %, UC 2.7 %, p = 0.04) were significantly increased in IC patients. There was no statistically significant difference in pouch failure rates for IC and UC (5.8 % vs.4.9 %, p = 0.58). CONCLUSION Patients undergoing IPAA for IC have a higher risk of post-operative fistulae and development of Crohn's disease, but comparable morbidity, functional outcomes, quality of life scores and pouch failure rates when compared to UC patients. Long-term data confirms that IPAA is a good surgical option in patients with IC.
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Affiliation(s)
- Katharine L Jackson
- Department of Colorectal Surgery, 9500, Euclid Avenue, A30, Cleveland, OH, 44195, USA.
| | - Luca Stocchi
- Department of Colorectal Surgery, 9500, Euclid Avenue, A30, Cleveland, OH, 44195, USA
| | - Leonardo Duraes
- Department of Colorectal Surgery, 9500, Euclid Avenue, A30, Cleveland, OH, 44195, USA
| | - Ahmet Rencuzogullari
- Department of Colorectal Surgery, 9500, Euclid Avenue, A30, Cleveland, OH, 44195, USA
| | - Ana E Bennett
- Department of Pathology, 9500, Euclid Avenue, L25, Cleveland, OH, 44195, USA
| | - Feza H Remzi
- Department of Colorectal Surgery, 9500, Euclid Avenue, A30, Cleveland, OH, 44195, USA
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Zaghiyan K, Kaminski JP, Barmparas G, Fleshner P. De novo Crohn's Disease after Ileal Pouch-Anal Anastomosis for Ulcerative Colitis and Inflammatory Bowel Disease Unclassified: Long-Term Follow-Up of a Prospective Inflammatory Bowel Disease Registry. Am Surg 2016. [DOI: 10.1177/000313481608201026] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The risk of de novo Crohn's disease (CD) after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) versus inflammatory bowel disease unclassified (IBDU) or indeterminate colitis (IC) remains debatable. Here, we present updated results after long-term follow-up of a previously studied cohort of 334 patients with UC, IBDU, or IC who underwent IPAA during a 10-year period ending 2007. Of 334 study patients, 56 per cent were male and median age was 38 years (range: 8–81). Patients were classified as UC (n = 237) or IBDU (n = 97) preoperatively and UC (n = 236) or IC (n = 98) postoperatively. After a median follow-up of 76 months (range: 3–236), 63 patients (19%) developed CD within a median of 22 months (range: 1–213) from ileostomy closure compared with the previously published 40 patients (12%) with 26-month follow-up ( P = 0.01). The development of de novo CD was similar for patients undergoing IPAA for UC (n = 40; 17%), IBDU (n = 21; 22%) or those classified as having UC (n = 42; 18%) or IC (n = 19; 19%) postoperatively; P > 0.05. Thus, patients with IBDU and IC can expect equivalent long-term outcome to patients with UC after IPAA. Pouch failure occurred in 13 (4%) study patients and was equal among all four groups.
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Affiliation(s)
- Karen Zaghiyan
- From the Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jan P. Kaminski
- From the Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Galinos Barmparas
- From the Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Phillip Fleshner
- From the Division of Colon and Rectal Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Clinical Factors Associated with the Development of Crohn's Disease in Inflammatory Bowel Disease-unclassified Patients Undergoing Ileal Pouch-anal Anastomosis. Inflamm Bowel Dis 2016; 22:1397-402. [PMID: 26978722 DOI: 10.1097/mib.0000000000000744] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with inflammatory bowel disease-unclassified (IBDU) undergoing ileal pouch-anal anastomosis (IPAA) are at the risk of developing Crohn's disease (CD) after surgical procedure. In these patients, a clinically centered set of preoperative risk factors has not been prospectively defined. We report a single-center analysis of clinical factors associated with the development of CD after IPAA. METHODS Consecutive IBDU patients undergoing IPAA were identified. The diagnosis of IBDU was based on the presence of atypical disease distribution, presence of granulomas on endoscopic biopsy, and/or perianal disease. The diagnosis of CD after IPAA included the presence of afferent limb inflammation on pouchoscopy in the absence of nonsteroidal anti-inflammatory drug use and/or the development of pouch fistulizing disease more than 3 months after ileostomy closure. RESULTS Of the 149 study patients, 33 (22%) were diagnosed with CD after IPAA at a median of 37 months (interquartile range, 11-83 mo) after ileostomy closure. CD was diagnosed by mucosal inflammation above the pouch (n = 23; 70%), pouch fistulizing disease (n = 4; 12%), anorectal septic complications (n = 2; 6%), or the presence of ≥2 of the above complications (n = 4; 12%). The sole clinical predictor for the development of CD after IPAA was younger age at disease onset even after controlling for relevant clinical factors in a multivariate analysis. The odds of developing CD increased by 4% for each year that IBDU was diagnosed at a younger age. CONCLUSIONS Younger age at disease onset is the only clinical factor associated with the development of CD after IPAA for IBDU. Patients with IBDU undergoing IPAA with young age at disease onset should be counseled about the potentially higher risk of developing CD.
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Abstract
Crohn's disease (CD) of the pouch is an increasingly recognized diagnosis after ileal pouch-anal anastomosis. This post-ileal pouch-anal anastomosis diagnosis in conjunction with pouchitis remains the leading reason for pouch excision. Unfortunately, CD of the pouch remains a difficult diagnosis with lack of a uniform definition largely because of its similarity to common postoperative pouch complications, including pouchitis, abscess formation, or stricture at the anastomosis. Once diagnosed, treatment algorithms largely include multimodal therapy including biologics. This review focuses on the definition, etiology, diagnosis, and treatment for CD of the pouch, a postoperative de novo diagnosis of CD.
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Case-matched Comparison of Robotic Versus Laparoscopic Proctectomy for Inflammatory Bowel Disease. Surg Laparosc Endosc Percutan Tech 2016; 26:e37-40. [DOI: 10.1097/sle.0000000000000269] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Copley PC, Tyler R, Alvi A. Excision of a distended chronic non-functional large ileoanal pouch. BMJ Case Rep 2016; 2016:bcr-2015-213662. [PMID: 26759445 DOI: 10.1136/bcr-2015-213662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
| | - Robert Tyler
- Department of Colorectal Surgery, Hinchingbrooke Hospital, Huntingdon, UK
| | - Atif Alvi
- Department of Colorectal Surgery, Hinchingbrooke Hospital, Huntingdon, UK
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Dignass A, Lindsay JO, Sturm A, Windsor A, Colombel JF, Allez M, d'Haens G, d'Hoore A, Mantzanaris G, Novacek G, Öresland T, Reinisch W, Sans M, Stange E, Vermeire S, Travis S, van Assche G. [Second European evidence-based consensus on the diagnosis and management of ulcerative colitis Part 2: Current management (Spanish version)]. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2015; 80:32-73. [PMID: 25769217 DOI: 10.1016/j.rgmx.2014.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 10/23/2014] [Indexed: 02/06/2023]
Affiliation(s)
- A Dignass
- Contribuyeron por igual a este trabajo; Coordinadores del Consenso.
| | | | - A Sturm
- Contribuyeron por igual a este trabajo; Coordinadores del Consenso
| | - A Windsor
- Contribuyeron por igual a este trabajo; Coordinadores del Consenso
| | - J-F Colombel
- Contribuyeron por igual a este trabajo; Coordinadores del Consenso
| | - M Allez
- Contribuyeron por igual a este trabajo; Coordinadores del Consenso
| | - G d'Haens
- Contribuyeron por igual a este trabajo; Coordinadores del Consenso
| | - A d'Hoore
- Contribuyeron por igual a este trabajo; Coordinadores del Consenso
| | - G Mantzanaris
- Contribuyeron por igual a este trabajo; Coordinadores del Consenso
| | - G Novacek
- Contribuyeron por igual a este trabajo; Coordinadores del Consenso
| | - T Öresland
- Contribuyeron por igual a este trabajo; Coordinadores del Consenso
| | - W Reinisch
- Contribuyeron por igual a este trabajo; Coordinadores del Consenso
| | - M Sans
- Contribuyeron por igual a este trabajo; Coordinadores del Consenso
| | - E Stange
- Contribuyeron por igual a este trabajo; Coordinadores del Consenso
| | - S Vermeire
- Contribuyeron por igual a este trabajo; Coordinadores del Consenso
| | - S Travis
- Contribuyeron por igual a este trabajo; Coordinadores del Consenso
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Du P, Sun C, Ashburn J, Wu X, Philpott J, Remzi FH, Shen B. Risk factors for Crohn’s disease of the neo-small intestine in ulcerative colitis patients with total proctocolectomy and primary or secondary ileostomies. J Crohns Colitis 2015; 9:170-6. [PMID: 25518056 DOI: 10.1093/ecco-jcc/jju014] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND De novo Crohn’s disease (CD) of the neo-small intestine in ulcerative colitis (UC) patients after total proctocolectomy (TPC) is a new disease entity, which may persist even after a secondary diverting permanent ileostomy for pouch failure. We sought to compare outcomes of primary ileostomy (PI, i.e., stoma created after colectomy without trying of ileal pouch) and secondary ileostomy (SI, i.e., stoma created after pouch failure) and to evaluate factors associated with the development of CD of the neo-small intestine proximal to ileostomy. METHODS A total of 123 eligible patients were identified from our Pouch Center Registry (PI group, n = 57 and SI group, n = 66). Demographics, clinical features and outcomes (CD of theneo-small intestine, non-CD related strictures, requirement of CD-related medications use, ileostomy-associated hospitalization, ileostomy failure with stoma revision/relocation, and shortgut syndrome) were compared. Step-wise logistic regression models were performed. RESULTS The median follow-up for the whole cohort was 5.0 (2.0–12.0) years. Younger age at diagnosis and surgery, family history of IBD, toxic megacolon/fulminant colitis, pre-diversion severe diarrhea, prediversion anti-TNF biological therapy, arthralgia/arthropathy and staged surgery were more common in the SI group (p < 0.05). In multivariate analysis, the presence of SI [odds ratio (OR), 8.23; 95% confidence interval (CI), 2.43–27.85], family history of IBD (OR, 9.14; 95% CI, 3.13–26.69), and pre-diversion of weight loss (OR, 3.72; 95% CI, 1.23–11.21) were contributing factors for developing CD of the neo-small intestine. CONCLUSIONS CD of the neo-small intestine in stoma patients was associated with the presence of SI, family history of IBD, and pre-diversion poor nutrition status. Patients with secondary ileostomy due to pouch failure should be carefully monitored. Aggressive medical, endoscopic or surgical therapy may be needed in patients at risk, before permanent diversion.
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Odze RD. A contemporary and critical appraisal of 'indeterminate colitis'. Mod Pathol 2015; 28 Suppl 1:S30-46. [PMID: 25560598 DOI: 10.1038/modpathol.2014.131] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 07/29/2014] [Accepted: 07/30/2014] [Indexed: 02/06/2023]
Abstract
Distinguishing ulcerative colitis (UC) from Crohn's disease (CD) is normally based on evaluation of a variety of clinical, radiologic, serologic and pathologic findings, the latter in biopsy and/or resection specimens. Unfortunately, some patients with IBD show overlapping pathologic features of UC and CD, which makes definite distinction between these two disorders difficult or even impossible. In most instances of uncertainty, the patient shows clinical and pathologic features of UC, but in addition, the patient's colon resection specimen reveals one or more CD-like features. In this setting, a diagnosis of indeterminate colitis (IC) is often rendered. IC is not a distinct disease entity, and, thus, it has no diagnostic criteria. The most common causes of uncertainty in IBD pathology that may lead to a diagnosis of IC in a colon resection specimen includes the presence of fulminant (severe and toxic) colitis, insufficient radiologic, endoscopic, or pathologic information (including analysis of prior biopsies) on the patient, failure to utilize major diagnostic criteria as hard evidence in favor of CD, failure to recognize unusual variants of UC and CD that may mimic each other, failure to recognize non-IBD mimics and other superimposed diseases that cause unusual pathologic features in a resection specimen, an attempt to distinguish UC from CD in mucosal biopsies of the colon and ileum, or an attempt to change the patients diagnosis (of UC or CD) based on pouch or diversion-related complications. Details of each of these causes of uncertainty are discussed, in detail, in this review article. A diagnosis of IC should never be made clinically or by pathologists based on evaluation of pre-resection colonic mucosal biopsies. Ultimately, the majority of indeterminate cases represent UC, and, thus, most of these patient can be treated safely with a colectomy combined with an ileal pouch anal anastomosis procedure.
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Affiliation(s)
- Robert D Odze
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Snelgrove R, Brown CJ, O'Connor BI, Huang H, Victor JC, Gryfe R, MacRae H, Cohen Z, McLeod RS. Proctocolectomy for colorectal cancer--is the ileal pouch anal anastomosis a safe alternative to permanent ileostomy? Int J Colorectal Dis 2014; 29:1485-91. [PMID: 25319934 DOI: 10.1007/s00384-014-2027-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2014] [Indexed: 02/07/2023]
Abstract
PURPOSE Ileal pouch anal anastomosis (IPAA) is the procedure of choice in patients requiring surgery for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). There are few data on reconstruction with the IPAA in patients with colorectal cancer (CRC). This study assessed the outcomes of the IPAA compared to proctocolectomy and permanent ileostomy (PI) on these patients. METHODS Between 1983 and 2013, over 2800 patients with CRC have been treated at the Mount Sinai Hospital (MSH). Demographic, surgical, pathological, and outcome data for all patients have been maintained in a database-73 patients were treated for CRC with proctocolectomy: 39 patients with IPAA and 34 patients with PI. Clinical features, pathologic findings, and survival outcomes were compared between these groups. RESULTS Each group was similar with respect to gender, stage, and histologic grade. Patients undergoing IPAA were significantly younger. The diagnosis leading to proctocolectomy was more commonly UC or FAP in patients treated with IPAA (39/39 vs. 23/34, p = 0.001). Rectal cancer subgroups were similar in age, sex, TNM stage, T-stage, height of tumor, and histologic grade. There was no significant difference in overall or disease free survival between groups for colon or rectal primaries. Analysis using the Cochran-Armitage trend test suggests that utilization of IPAA has increased over time (p = 0.002). CONCLUSIONS The IPAA is a viable and safe option to select for patients who would otherwise require PI. Increased experience and improved outcomes following IPAA has led to its more liberal use in selected patients.
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Affiliation(s)
- Ryan Snelgrove
- Department of Surgery, University of Toronto, Toronto, ON, Canada
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M'Koma AE. Diagnosis of inflammatory bowel disease: Potential role of molecular biometrics. World J Gastrointest Surg 2014. [PMID: 25429322 DOI: 10.4240/wjgs.v6.i11.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Accurate diagnosis of predominantly colonic inflammatory bowel disease (IBD) is not possible in 30% of patients. For decades, scientists have worked to find a solution to improve diagnostic accuracy for IBD, encompassing Crohn's colitis and ulcerative colitis. Evaluating protein patterns in surgical pathology colectomy specimens of colonic mucosal and submucosal compartments, individually, has potential for diagnostic medicine by identifying integrally independent, phenotype-specific cellular and molecular characteristics. Mass spectrometry (MS) and imaging (I) MS are analytical technologies that directly measure molecular species in clinical specimens, contributing to the in-depth understanding of biological molecules. The biometric-system complexity and functional diversity is well suited to proteomic and diagnostic studies. The direct analysis of cells and tissues by Matrix-Assisted-Laser Desorption/Ionization (MALDI) MS/IMS has relevant medical diagnostic potential. MALDI-MS/IMS detection generates molecular signatures obtained from specific cell types within tissue sections. Herein discussed is a perspective on the use of MALDI-MS/IMS and bioinformatics technologies for detection of molecular-biometric patterns and identification of differentiating proteins. I also discuss a perspective on the global challenge of transferring technologies to clinical laboratories dealing with IBD issues. The significance of serologic-immunometric advances is also discussed.
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Affiliation(s)
- Amosy E M'Koma
- Amosy E M'Koma, Department of Biochemistry and Cancer Biology, Meharry Medical College School of Medicine, Nashville, TN 37208-3599, United States
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M’Koma AE. Diagnosis of inflammatory bowel disease: Potential role of molecular biometrics. World J Gastrointest Surg 2014; 6:208-219. [PMID: 25429322 PMCID: PMC4241488 DOI: 10.4240/wjgs.v6.i11.208] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 10/16/2014] [Accepted: 10/23/2014] [Indexed: 02/06/2023] Open
Abstract
Accurate diagnosis of predominantly colonic inflammatory bowel disease (IBD) is not possible in 30% of patients. For decades, scientists have worked to find a solution to improve diagnostic accuracy for IBD, encompassing Crohn's colitis and ulcerative colitis. Evaluating protein patterns in surgical pathology colectomy specimens of colonic mucosal and submucosal compartments, individually, has potential for diagnostic medicine by identifying integrally independent, phenotype-specific cellular and molecular characteristics. Mass spectrometry (MS) and imaging (I) MS are analytical technologies that directly measure molecular species in clinical specimens, contributing to the in-depth understanding of biological molecules. The biometric-system complexity and functional diversity is well suited to proteomic and diagnostic studies. The direct analysis of cells and tissues by Matrix-Assisted-Laser Desorption/Ionization (MALDI) MS/IMS has relevant medical diagnostic potential. MALDI-MS/IMS detection generates molecular signatures obtained from specific cell types within tissue sections. Herein discussed is a perspective on the use of MALDI-MS/IMS and bioinformatics technologies for detection of molecular-biometric patterns and identification of differentiating proteins. I also discuss a perspective on the global challenge of transferring technologies to clinical laboratories dealing with IBD issues. The significance of serologic-immunometric advances is also discussed.
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45
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Twenty-year-old stapled pouches for ulcerative colitis without evidence of rectal cancer: implications for surveillance strategy? Dis Colon Rectum 2014; 57:1275-81. [PMID: 25285694 DOI: 10.1097/dcr.0000000000000219] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The risk of anal transition zone dysplasia/cancer after stapled IPAA for ulcerative colitis might be cumulative over time. OBJECTIVE The purpose of this work was to assess the long-term incidence and risk factors of anal transition zone dysplasia. DESIGN This was a retrospective study from a prospectively maintained database. SETTINGS The study was conducted at a tertiary referral center. PATIENTS Participants included those in our surveillance program of serial anal transition zone biopsies after stapled IPAA from 1986 to 1992. MAIN OUTCOME MEASURES Anal transition zone dysplasia was the main measured outcome. RESULTS Of 532 patients, 285 had 2 or more anal transition zone surveillance biopsies, including 73 with ≥20 years of regular follow-up. No adenocarcinoma was detected, and 15 patients died of unrelated causes after a median follow-up of 13.4 years (range, 2.9-19.5 years) without dysplasia. The estimated survival rates at 10, 15, and 20 years were 99.6% (95% CI, 96.9-99.9), 98.9% (95% CI, 95.7-99.7), and 92.6% (95% CI, 86.5-96.0). The estimated rates of anal transition zone dysplasia based on the 9 patients were 2.9% (95% CI, 1.5-5.7) and 3.4% (95% CI, 1.8-6.4) at 10 and 15 years. No new-onset dysplasia was identified beyond 125 months. Postoperative anal transition zone dysplasia was significantly associated with both preoperative and pathology findings of colorectal dysplasia (p < 0.001 for each) or cancer (p = 0.025 and p <0.001) and was managed expectantly or with mucosectomy (5 and 4 patients), depending on the number of positive biopsies and degree of dysplasia. Continued surveillance after detection of anal transition zone dysplasia showed no evidence of recurrent dysplasia during a median follow-up of 125 months (range, 9-256 months). LIMITATIONS Approximately half of the eligible patients were excluded from the analysis because of insufficient follow-up. CONCLUSIONS Long-term follow-up data corroborate the use of stapled IPAA for ulcerative colitis. Future studies should assess whether a less intensive surveillance strategy is safe 10 years after surgery.
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Disease course and management strategy of pouch neoplasia in patients with underlying inflammatory bowel diseases. Inflamm Bowel Dis 2014; 20:2073-82. [PMID: 25137416 DOI: 10.1097/mib.0000000000000152] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND To evaluate the disease course and management strategy for pouch neoplasia. METHODS Patients undergoing ileal pouch surgery for underlying ulcerative colitis who developed low-grade dysplasia (LGD), high-grade dysplasia, or adenocarcinoma in the pouch were identified. RESULTS All eligible 44 patients were evaluated. Of the 22 patients with initial diagnosis of pouch LGD, 6 (27.3%) had persistence or progression after a median follow-up of 9.5 (4.1-17.6) years. Family history of colorectal cancer was shown to be a risk factor associated with persistence or progression of LGD (P = 0.03). Of the 12 patients with pouch high-grade dysplasia, 5 (41.7%) had a history of (n = 2, 16.7%) or synchronous (n = 4, 33.3%) pouch LGD. Pouch high-grade dysplasia either persisted or progressed in 3 patients (25.0%) after the initial management, during a median time interval of 5.4 (2.2-9.2) years. Of the 14 patients with pouch adenocarcinoma, 12 (85.7%) had a history of (n = 2, 14.3%) or synchronous dysplasia (n = 12, 85.7%). After a median follow-up of 2.1 (0.6-5.2) years, 6 patients with pouch cancer (42.9%) died. Comparison of patients with a final diagnosis of pouch adenocarcinoma (14, 32.6%), and those with dysplasia (29, 67.4%) showed that patients with adenocarcinoma were older (P = 0.04) and had a longer duration from IBD diagnosis or pouch construction to the detection of pouch neoplasia (P = 0.007 and P = 0.0013). CONCLUSIONS The risk for progression of pouch dysplasia can be stratified. The presence of family history of colorectal cancer seemed to increase the risk for persistence or progression for patients with pouch LGD. The prognosis for pouch adenocarcinoma was poor.
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Mukewar S, Wu X, Lopez R, Shen B. Comparison of long-term outcomes of S and J pouches and continent ileostomies in ulcerative colitis patients with restorative proctocolectomy-experience in subspecialty pouch center. J Crohns Colitis 2014; 8:1227-36. [PMID: 24657364 DOI: 10.1016/j.crohns.2014.02.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 02/20/2014] [Accepted: 02/20/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND There are no published studies comparing pouch configurations and long-term adverse outcomes. AIM To evaluate outcomes of ulcerative colitis (UC) patients undergoing restorative proctocolectomy with S-, J- pouches or continent ileostomy (CI). METHODS We conducted a historical cohort study from the prospectively maintained Pouch Registry. Demographic and clinical variables were evaluated with univariate and multivariable analyses. RESULTS Fourty-five patients with S pouches and 36 with CI (33 K pouches and 3 Barnett continent ileal reservoirs) were compared with 215 J pouches serving as controls (ratio 1:2.5). In multivariable analysis, patients with S pouches were 93% less likely to develop chronic antibiotic-refractory pouchitis (CARP) than subjects with J pouches (odds ratio [OR]=0.07; 95% confidence interval: <0.001, 0.54; p<0.001). However, no significant difference in the frequency of CARP was found between the CI and J pouch groups (OR=0.68; 95% confidence interval: 0.17, 2.00, p=0.40). Patients with S pouches were 8 times more likely (95% confidence interval: 3.7, 17.5; p<0.001) and patients with CI 5.6 had times more likely (95% confidence interval: 2.4, 13.3; p<0.001) to have pouch surgery-related complications than those with J pouches. There was no difference in the rate of CD of the pouch, pouch-associated hospitalization and pouch failure between the S- pouch, CI and J- pouch groups. CONCLUSIONS Patients with J pouches appeared to have a greater risk for chronic pouchitis than those with S-pouches and but had a lower risk for developing pouch surgery-related complications than those with S pouches or CI.
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Affiliation(s)
- Saurabh Mukewar
- Departments of Gastroenterology/Hepatology, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Xianrui Wu
- Department of Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Rocio Lopez
- Department of Quantitative Health Sciences, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Bo Shen
- Departments of Gastroenterology/Hepatology, The Cleveland Clinic Foundation, Cleveland, OH, USA.
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Tan KK, Ravindran P, Young CJ, Solomon MJ. The extent of inflammation is a predictor for pouch-related complications in ileal pouches in patients with ulcerative or indeterminate colitis. Colorectal Dis 2014; 16:620-625. [PMID: 24635999 DOI: 10.1111/codi.12614] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 01/16/2014] [Indexed: 12/24/2022]
Abstract
AIM Limited data are available on the relationship between the histological features of the resected specimens in patients with ulcerative colitis (UC) or indeterminate colitis (IC) and the outcome of restorative proctocolectomy. The aim of our study was to determine if the histological features of the resected specimen in patients with UC and IC can predict ileal-pouch-related outcome. METHOD A review of all patients who had a restorative proctocolectomy created following completion proctectomy or proctocolectomy for UC and IC was performed. RESULTS Between 1992 and 2011, 142 patients (132 with UC and 10 with IC) were reviewed. After a median follow-up of 36 (3-149) months, 51 (35.9%) developed a pouch-related complication. Forty-two (29.7%) developed pouchitis while three (2.1%) developed a pouch-cutaneous fistula. Four (2.8%) had pouch failure, while stricture of the anastomosis was seen in three (2.1%) patients. The presence of extension of the inflammation into the muscularis propria of the resected specimen was associated with an increased risk of pouch-related complications (P = 0.01). The presence of submucosal oedema was also a significant risk factor (P = 0.03). CONCLUSION The extension of inflammation into the muscularis propria appears to predict pouch-related complications following restorative proctocolectomy for UC or IC.
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Affiliation(s)
- K-K Tan
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Surgical Outcomes Research Centre, Central Sydney Area Health Service and University of Sydney, Sydney, Australia
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Comparable pouch retention rate between pediatric and adult patients after restorative proctocolectomy and ileal pouches. Clin Gastroenterol Hepatol 2014; 12:1295-302. [PMID: 24361418 DOI: 10.1016/j.cgh.2013.12.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 11/27/2013] [Accepted: 12/04/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We compared long-term outcomes between adult and pediatric patients with inflammatory bowel disease (IBD) who underwent restorative proctocolectomy with ileal pouch-anal anastomosis. METHODS We performed a retrospective study that analyzed data from consecutive patients with ileal pouches who presented to the subspecialty Pouch Center at the Cleveland Clinic from 2002-2011. Pouch outcomes of 104 pediatric patients (having pouch surgery at age <18 years; 53 male) were compared with those of 1135 adults (having pouch surgery at an age 18 years or older; 632 male). RESULTS Pediatric patients had a shorter duration from time of IBD diagnosis to colectomy than adult patients. Fewer pediatric than adult patients had a history of smoking, concomitant extraintestinal manifestations, or dysplasia as the indication for colectomy. However, pediatric patients had higher rates of pouch procedure-related complications, postoperative pouch-associated hospitalization, and postoperative use of anti-tumor necrosis factor (TNF) agents. In multivariate analysis, risk factors for pouch failure included preoperative use of anti-TNF agents (hazard ratio [HR], 1.81; 95% confidence interval [CI], 1.05-3.13; P = .032), postoperative use of anti-TNF agents (HR, 2.07; 95% CI, 1.31-3.27; P = .002), Crohn's disease of the pouch (HR, 2.21; 95% CI, 1.28-3.82; P = .005), pouch procedure-related complications (HR, 2.68; 95% CI, 1.55-4.64; P < .001), and postoperative pouch-associated hospitalization (HR, 25.20; 95% CI, 14.44-43.97; P < .001). Being a pediatric patient was not significantly associated with pouch failure in univariate or multivariate analyses (HR, 0.6; 95% CI, 0.32-1.16; P = .13). CONCLUSIONS On the basis of an analysis of patients with IBD who underwent restorative proctocolectomy and presented at a subspecialized Pouch Center, patients who had the surgery at a pediatric age tend to have a higher incidence of postoperative pouch complications than adults. However, long-term rates of pouch retention were comparable.
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Turina M, Remzi FH. The J-pouch for patients with Crohn's disease and indeterminate colitis: (when) is it an option? J Gastrointest Surg 2014; 18:1343-4. [PMID: 24777433 DOI: 10.1007/s11605-014-2498-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 03/10/2014] [Indexed: 01/31/2023]
Affiliation(s)
- Matthias Turina
- Department of Colorectal Surgery; Digestive Disease Institute, Cleveland Clinic Main Campus, Mail Code A-30, 9500 Euclid Ave, Cleveland, OH, 44195, USA
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