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Colorectal resections have relatively high rates of surgical site infections causing significant morbidity. Incisional negative-pressure wound therapy was introduced to improve wound healing of closed surgical incisions and to prevent surgical site infections.The aim of this randomized controlled trial was to investigate the effect of. incisional negative-pressure wound therapy on superficial surgical site infections in high-risk, open, reoperative colorectal surgery.Single center randomized controlled trial between July 2015-October 2020. Patients were randomized to incisional negative-pressure wound therapy or standard gauze dressing with a 1:1 ratio. A total of 298 patients were included.This study was conducted at the colorectal surgery department of a tertiary level hospital.Patients older than 18 years who underwent elective reoperative open colorectal resections were included. Those who had open surgery within the past 3 months, active surgical site infection and who underwent laparoscopic procedures were excluded.Primary outcome was superficial surgical site infection within 30 days. Secondary outcomes were deep and organ space surgical site infections within 7 days and 30 days, postoperative complications, and length of hospital stay.A total of 149 patients were included in each arm. Mean age was 51, and 49.5% were women. Demographics, preoperative comorbidities and preoperative albumin levels were comparable between the groups. Overall, the majority of surgeries were done for inflammatory bowel disease and 77% of the patients had an ostomy fashioned during the surgery. There was no significant difference between the groups in 30-day superficial surgical site infection rate (14.1% in control vs. 9.4% in incisional negative-pressure wound therapy, p = 0.28). Deep and organ-space surgical site infections rates at 7 days and 30 days were also comparable between the groups. Postoperative length of stay and complication rates (Clavien-Dindo Grade) were also comparable between the groups.The patient population included in the trial consisted of a selected group of high-risk patients.Incisional negative-pressure wound therapy was not associated with reduced superficial surgical site infection or overall complication rates in patients undergoing high risk reoperative colorectal resections. See Video Abstract at http://links.lww.com/DCR/B956.

Few studies have compared endoscopic balloon dilation (EBD) with ileocolic resection (ICR) in the treatment of primary ileocolic strictures in patients with Crohn's disease (CD).We performed a retrospective study to compare postprocedure morbidity and surgery-free survival among 258 patients with primary stricturing ileo(colic) CD (B2, L1, or L3) initially treated with primary EBD (n = 117) or ICR (n = 258) from 2000 through 2016. Patients with penetrating disease were excluded from the study. We performed multivariate analyses to evaluate factors associated with surgery-free survival.Postprocedural complications occurred in 4.7% of patients treated with EBD and salvage surgery was required in 44.4% of patients. Factors associated with reduced surgery-free survival among patients who underwent EBD included increased stricture length (hazard ratio, 2.0; 95% CI, 1.3-3.3), ileocolonic vs ileal disease (hazard ratio, 10.9; 95% CI, 2.6-45.4), and decreased interval between EBD procedures (hazard ratio, 1.2; 95% CI, 1.1-1.4). There were no significant differences in sex, age, race, or CD duration between EBD and ICR groups. Patients treated with ICR were associated with more common postoperative adverse events (32.2%; P.0001), but a reduced need for secondary surgery (21.7%; P.0001) and significantly longer surgery-free survival (11.1 ± 0.6 vs 5.4 ± 0.6 y; P.001).In this retrospective study, we found that although EBD is initially successful with minimal adverse events, there is a high frequency of salvage surgery. Initial ICR is associated with a higher morbidity but a longer surgery-free interval. The risks and benefits should be balanced in selecting treatments for individual patients.

// Samaneh K. Sarvestani 1, * , Steven A. Signs 1, * , Veronique Lefebvre 2 , Stephen Mack 3 , Ying Ni 4 , Andrew Morton 1, 5 , Ernest R. Chan 6 , Xiaoxia Li 7 , Paul Fox 2 , Angela Ting 4 , Matthew F. Kalady 1, 8 , Michael Cruise 9 , Jean Ashburn 10 , Jennifer Stiene 1 , Wei Lai 1 , David Liska 1, 8 , Shao Xiang 1 and Emina H. Huang 1, 8 1 Department of Stem Cell Biology and Regenerative Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA 2 Department of Cell and Molecular Medicine, Cleveland Clinic, Cleveland, Ohio, USA 3 Department of Pediatrics Baylor College of Medicine, Houston, Texas, USA 4 Department of Genomic Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA 5 Department of Pathology, Case Western Reserve University, Cleveland, Ohio, USA 6 Department of Epidemiology and Biostatistics, Institute for Computational Biology, Case Western Reserve University, Cleveland, Ohio, USA 7 Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA 8 Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio, USA 9 Department of Pathology, Cleveland Clinic, Cleveland, Ohio, USA 10 Department of Surgery, Wake Forest School of Medicine, Salem, North Carolina, USA * These authors have contributed equally to this work Correspondence to: Emina H. Huang, email: huange2@ccf.org Keywords: ulcerative colitis; organoids; inflammation; H3K27Ac enhancer chromatin mark; colitis associated cancer Received: December 09, 2017 Accepted: May 24, 2018 Published: June 19, 2018 ABSTRACT Ulcerative colitis (UC) is a prevalent form of inflammatory bowel disease (IBD) whose pathogenic mechanisms remain unclear. Elucidating these mechanisms is important to reduce UC symptoms and to prevent UC progression into colitis-associated colon cancer (CAC). Our goal was to develop and validate faithful, human-derived, UC models and analyze them at histologic, transcriptomic and epigenetic levels to allow mechanistic studies of UC and CAC pathogenesis. We generated patient-derived primary-organoid cultures from UC and non-IBD colonic epithelium. We phenotyped them histologically and used next-generation-sequencing approaches to profile whole transcriptomes and epigenomes of organoids and primary tissues. Tissue organization and expression of mucin 2 (MUC2) and lysozyme (LYZ) demonstrated histologic faithfulness of organoids to healthy and diseased colonic epithelium. Transcriptomic analyses showed increased expression of inflammatory pathways in UC patient-derived organoids and tissues. Profiling for active enhancers using the H3K27ac histone modification revealed UC-derived organoid enrichment for pathways indicative of gastrointestinal cancer, including S100 calcium-binding protein P ( S100P ), and revealed novel markers for GI cancer, including both LYZ and neuropeptide S receptor 1 ( NPSR1 ). Immunolocalization showed increased levels of LYZ, S100P, and NPSR1 proteins in UC and CAC. In conclusion, primary colonic organoid cultures from UC and non-IBD patients can be established that faithfully represent diseased or normal colonic states. These models reveal precancerous molecular pathways that are already activated in UC. The findings demonstrate the suitability of primary organoids for dissecting UC and CAC pathogenic mechanisms and suggest new targets for therapeutic intervention.

Laparoscopic ileal pouch–anal anastomosis (IPAA) is associated with recovery benefits when compared with open IPAA. There is limited data on long-term quality of life and functional outcomes, which this study aimed to assess. An IRB-approved, prospectively maintained database was queried to identify patients undergoing laparoscopic IPAA (L), case-matched with open IPAA (O) based on age ± 5 years, gender, body mass index (BMI) ± 5 kg/m2, diagnosis, date of surgery ± 3 years, stapled/handsewn anastomosis, omission of diverting loop ileostomy and length of follow-up ± 3 years. We assessed functional results, dietary, social, work, sexual restrictions and the Cleveland Clinic global quality of life score (CGQoL) at 1, 2, 3, 4, 5 and 10 years postoperatively. Functional outcomes were assessed based on number of stools (day/night) and seepage protection use (day/night). Variables were evaluated with Kaplan–Meier survival curves, uni- and multivariable analyses. Out of 4595 IPAAs, 529 patients underwent L, of whom 404 patients were well matched 1:1 to an equivalent number of O based on all criteria. Median follow-ups were 2 (0.5–17.8) versus 2.4 (0.5–22.2) years in L versus O, respectively (p = 0.18). L was associated with significantly decreased number of stools at night and less frequent pad usage at 1 year, both during the day and at night. Functional outcomes became similar during further follow-up. L was also associated with improved overall CGQoL, and energy scores at 1 year postoperatively, and decreased social restrictions for 1–2 years. There were no significant differences in quality of health, dietary, work or sexual restrictions. Laparoscopy was not associated with increased risk of pouch failure (p = 0.07) or significantly different causes of pouch failure when compared to O. Laparoscopic and open IPAA are associated with equivalent long-term functional outcomes, quality of life and pouch survival rates. Laparoscopic technique is associated with temporary benefits lasting 1 or 2 years.

Colitis-associated cancer is a relatively rare form of cancer with an unclear pathogenesis. Colitis-associated cancer serves as a prototype of inflammation-associated cancers. Advanced colonoscopic techniques are considered standard of care for surveillance in patients with long-standing colitis, especially those with other risk factors, including sclerosing cholangitis and a family history of colorectal cancer. When colitis-associated cancer is diagnosed, the standard operation involves total proctocolectomy. Restorative procedures and surveillance after colectomy require special considerations. In these contexts, new 3-dimensional human models may be used to usher in personalized medicine.

Background There are scant published data in the impact of prostate cancer and its treatment on functional outcomes and quality of life (QOL) in patients with ileal pouch-anal anastomosis (IPAA). The aim of the study was to evaluate the influence of prostate cancer and its treatment on functional outcomes and QOL in patients with IPAA. Methods Patients with IPAA with prostate cancer were compared to age and pouch duration-matched controls without prostate cancer in a 1:2 ratio. Pouch function and QOL were compared between pretreatment and posttreatment for prostate cancer as well as between subjects and controls. Results A total of 30 patients with IPAA with prostate cancer and 60 matched controls were included. Treatment modalities of prostate cancer included prostatectomy (n = 22), brachytherapy (n = 5), watchful waiting (n = 2), and hormonal therapy (n = 1). The median length of follow-up was 6 (interquartile range, 2.7-8) years. Permanent fecal diversion was required in 5 (16.7%) patients with prostate cancer who developed pouch failure, as compared with 2 patients in the control group (P = 0.04). In patients who retained their pouches, the pouch functional outcomes at the latest follow-up were similar to that before prostate cancer treatment and to that of the matched controls, in terms of bowel movements, daytime seepage, nighttime bowel movements, nighttime seepage, and QOL score. Conclusions The risk of pouch failure may be increased after the diagnosis of prostate cancer with or without treatment. However, for those with retained pouches, their pouch function and QOL did not seem to be adversely affected.

Background In symptomatic patients with an ileal pouch, stool studies are often sent to diagnose enteric pathogens. Aim of this study is to find the value of routine stool studies in the evaluation of symptomatic patients and the clinical implications of such pathogens in patients with ileal pouches. Methods Consecutive ileal pouch-anal anastomosis (IPAA) patients who had stool tests out of a 2283-case registry from 2002 to 2015 were included in the study. Patients with positive stool cultures were compared with controls (symptomatic without positive stool culture) in a 1:4 ratio. Response to antibiotic therapy, recurrence rate and rate of hospitalization at 1 and 3 months were assessed. Results A total of 643 (28%) had stool cultures done and only 1.7% (11/643) were found to be positive for stool cultures. Campylobacter spp. (45%) was the most common pathogen followed by Aeromonas spp. (36%). Non-smokers and patients without any antibiotic use in the last 3 months were found to have higher prevalence of positive stool cultures than controls (p

Background Surgical technique constantly evolves in response to the pressure of progress. Ileal pouch anal anastomosis (IPAA) is a good example. We analyzed the effect of changes in practice on the technique of IPAA and its outcomes. Methods Patients undergoing primary IPAA at this institution were divided into three groups by date of IPAA: those operated from 1983-1993, 1994-2004, and 2005 – 2015. Demographics, patient comorbidity, surgical techniques, post-operative outcomes, pouch function and quality of life were analyzed. Results 4525 patients had a primary IPAA. With each decade, increasing numbers of surgeons were involved (decade I=8, II=16, III=31), patients tended to be sicker (higher ASA score) and 3-staged pouches became more common. After an initial popularity of the S pouch, J pouches became dominant and a mucosectomy rate of 12% was standard. Laparoscopic technique blossomed in the last decade. 90 day postoperative morbidity by decade was 38.3% vs. 50% vs. 48% (p

Restorative proctocolectomy with an ileal pouch-anal anastomosis (IPAA) has been an ideal surgical option for patients with chronic ulcerative colitis (UC) and familial adenomatous polyposis for nearly 4 decades. In most cases, patients enjoy excellent quality of life with a durable surgical and functional result, avoiding the need for a lifelong ileostomy. Despite great success, patients with IPAA may suffer from several pouch-related complications that are a challenge for the patient and surgeon. Pouchitis is one such challenging complication that requires thoughtful consideration and judgment for successful management. Treatment of pouchitis has historically revolved around medical therapy, but the surgeon׳s role in a multidisciplinary approach to pouchitis is critical for diagnosis, treatment, and improvement of quality of life. The focus of this review is to provide a structured approach to the challenges that the surgeon encounters when faced with a patient with chronic or refractory pouchitis and to discuss the surgical options that mitigate the morbidity caused by pouchitis in parallel with or when medical treatments fail.

AIM The aim of this study was to investigate the impact of a restrictive vs liberal transfusion strategy on anastomotic leakage and infectious complications after rectal cancer surgery. METHODS Patients undergoing restorative proctectomy for rectal cancer between January 2008 and December 2013 were divided into four groups according to the perioperative lowest haemoglobin (Hgb) level and transfusion status: group 1 with Hgb level ≥ 10 g/dl; group 2 with Hgb level ≥ 7 and

The purpose of this review is to provide an overview of the etiology, diagnosis, and clinical management of the two most common polyposis; change adenomatous to polyposis hereditary colorectal cancer syndromes, familial adenomatous polyposis (FAP) and MUTYH-associated polyposis (MAP). The syndromes are caused by inherited genetic variants in the APC and MutYH genes, respectively. Both syndromes carry significant increased risk of colorectal and extracolonic cancers. Intense surveillance is required to reduce this risk, and colectomy or proctocolectomy is frequently the ultimate form of colorectal cancer risk reduction. The colorectal phenotype and extracolonic manifestations continue to evolve as more is learned about the natural history of the diseases, particularly MAP.

Background: Clostridium difficile infection (CDI) in patients with ileal pouch-anal anastomosis (IPAA) has been increasingly recognized. The aim of this study was to evaluate the outcome of fecal microbiota transplantation (FMT) in patients with pouch and CDI. Methods: All consecutive patients that underwent FMT for CDI from 2012 to 2016 were extracted from our IRB-approved, prospectively maintained Registry of Pouch Disorders. The primary outcome was negative stool tests for Clostridium difficile after FMT and the secondary outcomes were symptomatic and endoscopic responses. Results: A total of 13 patients were included in this study, with 10 being Caucasian males (76.9%). All patients had underlying ulcerative colitis for J pouch surgery. After a mean of 2.8±0.8 courses of antibiotic treatments was given and failed, 22 sessions of FMT were administered with an average of 1.7±1.1 sessions each. Within the 22 sessions, 16 were given via pouchoscopy, 4 via esophagogastroduodenoscopy and 2 via enemas. All patients tested negative on C. difficile polymerase chain reaction (PCR) after the initial FMT with a total of 7/12 (58.3%) documented patients showed symptomatic improvements and 3/11 (27.3%) patients showed endoscopic improvement according to the modified Pouchitis Disease Activity Index. During the follow-up of 1.2±1.1 years, there were a total of five patients (38.5%) that had recurrence after the successful initial treatment and four of them were successfully treated again with FMT. Conclusions: FMT appeared to be effective in eradication of CDI in patients with ileal pouches. However, FMT had a modest impact on endoscopic inflammation and recurrence after FMT and recurrence was common.

Background Patients with Crohn's disease have a higher failure rate after ileal pouch surgery compared with their counterparts with ulcerative colitis. Objective We hypothesized that risk of continent ileostomy failure can be stratified based on the timing of Crohn's disease diagnosis and aimed to assess long-term outcomes. Design This was a retrospective cohort study. Settings The investigation took place in a high-volume, specialized colorectal surgery department. Patients Patients with Crohn's disease who underwent continent ileostomy surgery between 1978 and 2013 were evaluated. Main outcome measures Functional outcomes, postoperative complications, requirement of revision surgery, and continent ileostomy failure were analyzed. Results There were 48 patients (14 male patients) with a median age of 33 years at the time of continent ileostomy creation. Crohn's disease diagnosis was before continent ileostomy (intentional) in 15 or made in a delayed fashion at a median 4 years after continent ileostomy in 33 patients. Median follow-up was 19 years (range, 1-33 y) after index continent ileostomy creation. Major and minor revisions were performed in 40 (83%) and 13 patients (27%). Complications were fistula (n = 20), pouchitis (n = 16), valve slippage (n = 15), hernia (n = 9), afferent limb stricture (n = 9), difficult intubation (n = 8), incontinence (n = 7), bowel obstruction (n = 7), valve stricture (n = 5), leakage (n = 4), bleeding (n = 3), and valve prolapse (n = 3). Median Cleveland global quality-of-life score was 0.8. Continent ileostomy failure occurred in 22 patients (46%). Based on Kaplan-Meier estimates, continent ileostomy survival was 48 % (95% CI, 33%-63%) at 20 years. Continent ileostomy failure was similar regardless of timing of diagnosis of Crohn's disease (p = 0.533). Limitations This study was limited by its retrospective and nonrandomized nature. Conclusions Outcomes of continent ileostomy in patients with Crohn's disease are poor, regardless of the timing of diagnosis. Very careful consideration should be given by both the surgeon and the patient before undertaking this procedure in patients with Crohn's disease. See Video Abstract at http://links.lww.com/DCR/A327.

Colorectal serrated polyps are intermediate lesions in the serrated neoplastic pathway, which account for up to 30% of colorectal cancers. This pathway is biologically distinct from the adenoma-to-carcinoma sequence, with associated cancers exhibiting mutations in the BRAF oncogene, DNA promoter hypermethylation, and microsatellite instability. An evolving understanding of these unique lesions has led to the development of a more accurate classification, improved endoscopic identification, and tailored clinical management guidelines. This article reviews serrated polyps and serrated polyposis syndrome.

A continent ileostomy may be offered to patients in hopes of avoiding permanent ileostomy. Data on the outcomes of continent ileostomy patients with a history of a failed IPAA are limited.This study aimed to assess whether a history of previous failed IPAA had an effect on continent ileostomy survival and the long-term outcomes.This was a retrospective cohort study.This investigation took place in a high-volume, specialized colorectal surgery department.Patients who underwent continent ileostomy construction after IPAA failure between 1982 and 2013 were evaluated and compared with patients who have no history of IPAA surgery.Functional outcomes and long-term complications were compared.A total of 67 patients fulfilled the case-matching criteria and were included in the analysis. Requirement of major (52% vs 61%; p = 0.756) and minor (15% vs 19%; p = 0.492) revisions were comparable between patients who had continent ileostomy after a failed IPAA and those who had continent ileostomy without having a previous restorative procedure. Intubations per day (5 vs 5; p = 0.804) and per night (1 vs 1; p = 0.700) were similar in both groups. Our data show no clear relationship between failure of continent ileostomy and history of failed IPAA (p = 0.638). The most common cause of continent ileostomy failure was enterocutaneous/enteroenteric fistula (n = 14). Six patients died during the study period because of other causes unrelated to continent ileostomy.This study was limited by its retrospective and nonrandomized nature.Converting a failed IPAA to a continent ileostomy did not worsen continent ileostomy outcomes in this selected group of patients. When a redo IPAA is not feasible, continent ileostomy can be offered as an alternative to conventional end ileostomy in highly motivated patients. See Video Abstract at http://links.lww.com/DCR/A803.

ObjectiveWe hypothesized that postoperative oral steroid taper after ileal pouch-anal anastomosis for inflammatory bowel disease would not be associated with pelvic septic complications.BackgroundRecent data has emphasized the possible association between biologic medication use and pelvic sepsis following ileal pouch-anal anastomosis. Limited contemporary data exist examining the effects of steroid use on these complications.MethodsConsecutive patients undergoing ileal pouch-anal anastomosis for inflammatory bowel disease at a single institution from January 2009 to December 2013 were included. Factors associated with anastomotic leak and pelvic sepsis were assessed using univariate and multivariate analysis.ResultsA total of 686 patients were included (mean age 39.5 years, 59% males). Postoperative oral steroid taper was associated with both anastomotic leak and pelvic sepsis on univariate analysis. Stress dose intravenous steroid use was not associated with complications. Multivariate analysis indicated total proctocolectomy (odds ratio [OR] 2.2; confidence interval [CI] 1.01–4.7, P = 0.047), and postoperative oral steroid taper (OR 2.3; CI 1.06–5.1; P = 0.035) as independent factors significantly associated with pelvic sepsis.ConclusionsProlonged postoperative oral steroid taper after ileal pouch-anal anastomosis should be avoided. If preoperative steroid weaning is not possible before a planned total proctocolectomy and ileal pouch-anal anastomosis, patients should undergo an initial total abdominal colectomy.

Colitis-associated cancer is a relatively rare form of cancer with an unclear pathogenesis. Colitis-associated cancer serves as a prototype of inflammation-associated cancers. Advanced colonoscopic techniques are considered standard of care for surveillance in patients with long-standing colitis, especially those with other risk factors, including sclerosing cholangitis and a family history of colorectal cancer. When colitis-associated cancer is diagnosed, the standard operation involves total proctocolectomy. Restorative procedures and surveillance after colectomy require special considerations. In these contexts, new 3-dimensional human models may be used to usher in personalized medicine.

Restorative proctocolectomy with an ileal pouch-anal anastomosis (IPAA) has been an ideal surgical option for patients with chronic ulcerative colitis (UC), familial adenomatous polyposis, and selected patients with colorectal cancer and Crohn’s disease for nearly four decades. In most cases, patients enjoy excellent quality of life with a durable surgical and functional result, avoiding the need for a permanent conventional ileostomy.

Surgery has consistently been a mainstay in the treatment of many forms of inflammatory bowel disease including ulcerative colitis (UC). Although surgical techniques and approaches have evolved over time, the ultimate goals of surgery for UC have remained: that is, to alleviate symptoms and mitigate cancer risk while maintaining the highest quality of life. The focus of this review is to provide a structured approach to surgical management of UC. The complexities of choosing the most appropriate surgical approach to this morbid disease will be outlined, along with a discussion of several commonly debated topics in the arena of surgery for UC.

The purpose of this study was to report our large, single-center experience of transabdominal ileal pouch-anal anastomoses (IPAA) redo surgery for a failed initial IPAA.IPAA fail from 3% to 15% of the times, mainly due to technical or inflammatory conditions. There is limited information about the surgical, functional, and quality-of-life (QOL) outcomes of redo surgery for failed IPAA, especially in large series of patients.Patients undergoing transabdominal redo surgery for failed IPAA between 1983 and 2014 were evaluated. Primary endpoints were morbidity of the surgery, the proportion of patients with a functioning pouch, frequency of defecation and incidence of incontinence, and the patients' perception of QOL.There were 502 (43% males) patients with a median age of 38 years and median body mass index 24 kg/m at the time of revision surgery. A new pouch was created in 41% of patients whereas 59% had their original pouch revised and retained. Postoperative mortality was 0% and morbidity was 53%. The short-term anastomotic leak rate was 8%. At a median follow-up of 7 years after redo surgery, 101 (n = 20%) patients had redo IPAA failure. Pelvic sepsis developing after redo ileal pouch surgery was the primary indicator of pouch failure (hazard ratio, 3.691; 95% confidence interval, 2.411-5.699; P 0.0001). Overall functional outcomes and QOL scores were acceptable.Patients with a failed ileoanal pouch may be offered redo pouch surgery with a high likelihood of success in terms of function and QOL.

Background and Aim To evaluate the frequency, diagnosis and management of ileal pouch bezoars. Methods Patients diagnosed with ileal pouch bezoars at the Pouch Center at Cleveland Clinic from 2002 to 2013 were included. Demographic, clinical and endoscopic features, management and outcomes were evaluated. Results Twelve patients with ileal pouch bezoars were enrolled, including five (0.4%) of 1390 patients with J-pouch and seven (13.0%) of 54 with continent ileostomy (P

The aim of the present study was to assess the short-term and long-term consequences of diverting loop ileostomy (DLI) omission in ileal pouch-anal anastomosis (IPAA) surgery complicated by postoperative pelvic sepsis. This was a retrospective review of a prospectively maintained database. Of 4031 patients who underwent IPAA in 1983–2014, 357 developed IPAA-related pelvic sepsis with or without anastomotic dehiscence. Patients with Crohn’s disease or cancer were excluded. The patient cohort was divided into two groups, depending on the presence or absence of DLI. Patient characteristics, short-term and long-term outcomes were compared. Long-term pouch survival was estimated with the Kaplan–Meier method. Quality of life (QOL) in the groups was compared at the latest follow-up. Three hundred and twenty-six patients developing pelvic sepsis had diversion at the time of IPAA (D group) and in 31 who developed pelvic sepsis DLI had been omitted (O group). The length of hospital stay was significantly longer in the O group 11.5 (3–33) days versus 8 (2–59) days in the D group (p = 0.006). Forty-eight percent of patients from the O group with anastomotic leak underwent reoperation and had a DLI formed at this second procedure versus 12% in the D group requiring reoperation (p

Background Clostridium difficile infection (CDI) is traditionally considered a colon-affecting disease with frequent pseudomembrane formation. However, multiple case reports have documented the existence of CDI in the small bowel, and the literature on outcome of C difficile enteropathy (CDE) is sparse. The aims of our study are to identify risk factors and to assess patient-related outcomes associated with CDE. Methods This is a case-control study involving 112 patients at our tertiary care center. Patients with an ileostomy who tested positive for C difficile toxins were assigned to the study group (n = 34). The control group included patients with an ileostomy who tested negative for the C difficile toxins (n = 78). Via chart review, we collected data on baseline characteristics, laboratory values, potential risk factors, and outcome measures. Results Patients in the study and control groups were comparable in baseline and laboratory characteristics. In univariate analysis, CDE was associated with a history of smoking (hazard ratio [HR], 2.1; 95% confidence interval [CI], 1.06-4.3; P = 0.034), the presence of alcohol use (HR, 3.7; 95% CI, 1.05-12.8; P = 0.042), and older median age at the time of ileostomy (HR, 1.2; 95% CI, 1.07-1.3; P = 0.001). In multivariate analysis, no significant association between established CDI risk factors (eg, prior exposure to antibiotics and the use of proton pump inhibitors or histamine 2 receptor blockers) and the risk for the CDE was found. Only a history of alcohol intake was found to be associated with CDE (HR, 3.9; 95% CI, 1.09-14.1; P = 0.036). No significant difference in mortality was found in the study and control groups (2.9% vs 1.3%, P = 0.52), but patients with CDE were more likely to have acute kidney injury (AKI) than those without CDE (odds ratio, 4.0; 95% CI, 1.2-13.0. P = 0.023). Conclusions We identified a history of alcohol use a risk factor for CDE. Furthermore, CDE was found be associated with an increased risk for developing AKI.

Nearly half of all incidental splenectomies caused by iatrogenic splenic injury occur during colorectal surgery. This study evaluates factors associated with incidental splenic procedures during colorectal surgery and their impact on short-term outcomes using a nationwide database. Patients who underwent colorectal resections between 2005 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program database according to Current Procedural Terminology codes. Patients were classified into two groups based on whether they underwent a concurrent incidental splenic procedure at the time of the colorectal procedure. All splenic procedures except a preoperatively intended splenectomy performed in conjunction with colon or rectal resections were considered as incidental. Perioperative and short-term (30 day) outcomes were compared between the groups. In total, 93633 patients who underwent colon and/or rectal resection were identified. Among these, 215 patients had incidental splenic procedures (153 open splenectomy, 17 laparoscopic splenectomy, 36 splenorraphy, and 9 partial splenectomy). Open colorectal resections were associated with a significantly increased likelihood of incidental splenic procedures (OR 6.58, p

Radiotherapy not only plays a pivotal role in the cancer care pathways of many patients with pelvic malignancies, but can also lead to significant injury of normal tissue in the radiation field (pelvic radiation disease) that is sometimes as challenging to treat as the neoplasms themselves. Acute symptoms are usually self-limited and respond to medical therapy. Chronic symptoms often require operative intervention that is made hazardous by hostile surgical planes and unforgiving tissues. Management of these challenging patients is best guided by the utmost caution and humility.

Refractory pouchitis is a risk factor for pouch failure and surgical excision. While TNFa inhibitors have been reported to be effective as treatment for pouchitis there is no data regarding the use of vedolizumab in refractory pouchitis. In this study we evaluated the clinical and endoscopic response to vedolizumab in refractory pouchitis. This is an open label case series. Three patients were identified as having refractory pouchitis with loss or lack of response to antibiotics, corticosteroids, and at least one TNFa inhibitor along with a variety of other modalities of therapy. Each patient underwent pouch endoscopy before initiation of vedolizumab and repeat endoscopy within 4 months of initiation of treatment. Vedolizumab was administered as per standard dosing regimen. The Pouch Disease Activity Index (PDAI) endoscopic subscore was evaluated by the 2 investigators independently and reported as an average. The clinical record was reviewed to determine patient reported response to therapy. Patient 1, a 54 year old male, had undergone colectomy and IPAA in 2000 for medically refractory ulcerative colitis (UC). He suffered from ankylosing spondylitis and chronic pouchitis. He had been treated serially with antibiotics, budesonide, infliximab, methotrexate, adalimumab, in combination with hyperbaric oxygen therapy with severe diarrhea. His pouchoscopy prior to initiation revealed confluent ulceration with PDAI endoscopic subscore of 4. Endoscopy 4 months after the initiation of vedolizumab therapy revealed visual improvement, with few small ulcers noted, with PDAI endoscopic subscore of 3. He experienced improvement in clinical symptoms and has avoided surgical resection of his pouch but did require maintenance therapy with budesonide. Patient 2, a 54 year old female underwent colectomy and IPAA in 1991 for medically refractory UC. She developed recurrent stricturing at the pouch inlet and afferent limb and pouchitis, treated with surgical stricturoplasty, antibiotics, thiopurines, mesalamine, intravenous immunoglobulin therapy, fecal microbiota transplant, and adalimumab. She continued to have symptoms of diarrhea and pain. Pouch endoscopy revealed chronic pouchitis with edema and loss of vascular pattern consistent with a PDAI score of 5, along with cuffitis, and ulcerated strictures in the neo-terminal ileum. She underwent pouchoscopy 4 months after the therapy with vedolizumab which revealed improvement in pouchitis, normal appearing mucosa and PDAI endoscopic subscore 1, but ongoing ulceration at cuff and inlet. Patient 3, a 54 year old female post restorative proctocolectomy for refractory UC in 2012 had required pouch redo surgery in 2014 for severe pouch dysfunction. She suffered from diarrhea requiring intravenous hydration despite use of antibiotics, infliximab with azathioprine, and mesalamine. Her pouchoscopy revealed pouchitis and ileitis with a PDAI score of 3. Pouch endoscopy 4 months after initiation of vedolizumab which revealed improved mucosa of the pouch with PDAI score of 1. She noted improvement in symptoms of diarrhea. All 3 patients had improved endoscopic scores and reported clinical improvement in terms of diarrhea and pain. Vedolizumab in open label use for chronic antibiotic- and anti- TNFα-refractory, chronic pouchitis demonstrated improvement in both symptoms and endoscopy scores.

The impact of gender on the development of chronic ileal pouch disorders following ileal pouch-anal anastomosis (IPAA) has not been evaluated. This study was aimed to assess the association between gender and pouch outcomes.Comparisons of long-term pouch outcomes between male and female patients were performed using both univariate and multivariate analyses.Of all patients enrolled (n = 1564), 881(56.3 %) were males. Male patients were older at the time of inflammatory bowel disease (IBD) diagnosis and pouch construction. The frequencies of neoplasia as the indication for colectomy and significant comorbidity were higher in males, while fewer male patients had IBD-related extra-intestinal manifestations or concurrent autoimmune disorders. There was no significant difference between the genders in other clinicopathological characteristics. More male patients (n = 144, 16.3 %) developed chronic antibiotic-refractory pouchitis (CARP) than females (n = 73, 10.7 %) (P = 0.001). Seventy-four males (8.4 %) had ileal pouch anastomotic sinus versus 22 female patients (3.2 %) (P 0.001). Multivariate logistic regression analyses confirmed the association between male gender and CARP (odds ratio (OR) 1.64, 95 % confidence interval (CI) 1.21-2.24, P = 0.002) and male gender and ileal pouch anastomotic sinus (OR 2.85, 95 % CI 1.48-5.47, P = 0.002). After a median follow-up of 9.0 (interquartile range 4.0-14.0) years, pouch failed in a total of 126 patients (8.1 %). No significant difference was identified between male and female patients in pouch failure (P = 0.61).Among the pouch patients referred to our subspecialty Pouch Center, male patients were found to have an increased risk for the CARP and ileal pouch sinus. The pathogenic mechanisms of the association warrant further study.

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 the neo-small intestine, non-CD related strictures, requirement of CD-related medications use, ileostomy-associated hospitalization, ileostomy failure with stoma revision/relocation, and short-gut 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, pre-diversion 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. * Abbreviations : CD : Crohn’s disease CDNSI : Crohn’s disease of the neo-small intestine CI : confidence interval EI : end ileostomy EIM : extra-intestinal manifestations FAP : familiar adenomatous polyposis IBD : inflammatory bowel disease IPAA : ileal pouch–anal anastomosis IPS : irritable pouch syndrome IQR : interquartile range IRB : the Institutional Review Board NSAID : non-steroidal anti-inflammatory drugs OR : odds ratio RR : relative risk PI : primary ileostomy RPC : restorative proctocolectomy SI : secondary ileostomy TNF : anti-tumor-necrosis factor TPC : total proctocolectomy UC : ulcerative colitis

The continent ileostomy (CI) was first described in 1969 as an important advancement in the surgical treatment of patients with ulcerative colitis, providing an option for fecal continence to patients who would otherwise require a conventional ileostomy. The CI enjoyed a brief period of relative popularity during the 1970s before being displaced by today's gold standard for the surgical treatment of ulcerative colitis, the restorative proctocolectomy (ileal pouch-anal anastomosis [IPAA]). Although the CI is only rarely performed today, it still has a role to play in the treatment of patients with inflammatory bowel disease who have failed medical treatment. Current indications are patients with failed IPAAs who are not candidates for redo-IPAA, patients who require total proctocolectomy but cannot be reconstructed with IPAA, and patients with an existing conventional ileostomy that is adversely affecting their quality of life. CI, however, is a complex procedure that carries significant risk of both postoperative complications and the need for reoperation over the long term due to slippage of the nipple valve. Patients being considered for this procedure should undergo extensive preoperative counseling and must have a thorough understanding of the associated risks and a realistic vision of anticipated benefits. In well-selected and properly motivated patients, however, CI can be durable in the majority with long-term pouch survival rates approaching 80%. Published data suggest that these patients enjoy greater quality of life than their counterparts with a conventional ileostomy and that 95% would choose to undergo the procedure again or recommend it to another.

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.