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Abstract Background and aims Crohn's disease (CD)‐associated intestinal cancers are characterized by their high incidence, particularly at the anorectal site in the Japanese population. Accumulating evidence revealed that younger‐onset sporadic colorectal cancer may exhibit unique biological features. To the best of our knowledge, few previous articles reported clinicopathological features in patients with CD‐associated anorectal cancer (CDAAC). Therefore, we aimed to clarify the relationship between the younger onset of cancer and clinicopathological characteristics and prognosis, and the efficacy of cancer surveillance in patients with CDAAC. Methods CD patients who had been diagnosed with intestinal cancers from 1983 to 2020 were collected from 39 Japanese institutions in this study. Of 316 patients with CD‐associated intestinal cancers, we analyzed 211 patients with CDAAC. We divided the patients into two groups according to the median age at cancer diagnosis (45 years old). Results Younger‐onset CDAAC (YO‐CDAAC) patients were significantly more likely to have a poor outcome than those with older‐onset CDAAC (OO‐CDAAC) in terms of both disease‐free survival (DFS) (p = 0.0014) and overall survival (OS) (p = 0.023). Multivariate analysis showed that age under 45 years old at diagnosis of cancer was one of the independent factors for poor DFS and OS (hazard ratios: 2.15, 95% confidence interval: 1.09–4.26, p = 0.028, hazard ratios: 1.95, 95% confidence interval: 1.05–3.60, p = 0.033, respectively). Patients detected via surveillance showed significantly better DFS and OS rates than symptomatic patients in YO‐CDAAC (p = 0.012 and 0.0031, respectively). Conclusions YO‐CDAAC may have a poorer prognosis compared with OO‐CDAAC. Surveillance could be important to improve cancer prognosis, especially in young CD patients with anorectal disease.

Introduction: Laparoscopic surgery (LAP) is now recognized as the standard procedure for colorectal surgery. However, the standard surgery for ulcerative colitis (UC) is total proctocolectomy with ileal pouch anal anastomosis (IPAA), which may be an overly complex procedure to complete laparoscopically. We conducted this systematic review and meta-analysis to evaluate the efficacy as well as the advantages and disadvantages of LAP-IPAA in patients with UC stratified by the outcome of interest. Method: We performed a systematic literature review by searching the PubMed/MEDLINE, the Cochrane Library, and the Japan Centra Reuvo Medicina databases from inception until January 2023. Meta-analyses were performed for surgical outcomes, including morbidity and surgical course, to evaluate the efficacy of LAP-IPAA. Results: A total of 707 participants, including 341 LAP and 366 open surgery (OPEN) patients in 9 observational studies and one randomized controlled study, were included. From the results of the meta-analyses, the odds ratio (OR) of total complications in LAP was 1.12 (95% CI: 0.58–2.17, p = 0.74). The OR of mortality for LAP was 0.38 (95% CI: 0.08–1.92, p = 0.24). Although the duration of surgery was extended in LAP (mean difference (MD) 118.74 min (95% CI: 91.67–145.81), p < 0.01) and hospital stay were not shortened, the duration until oral intake after surgery was shortened in LAP (MD −2.10 days (95% CI: −3.52–0.68), p = 0.004). Conclusions: During IPAA for UC, a similar morbidity rate was seen for LAP and OPEN. Although LAP necessitates extended surgery, there may be certain advantages to this procedure, including easy visibility during the surgical procedure or a shortened time to oral intake after surgery.

Abstract Purpose The aim of this study was to compare the clinical characteristics of ulcerative colitis (UC) patients who underwent surgery for cancer/dysplasia with those who underwent surgery for refractory disease and to discuss the preoperative preparation for successful hand-sewn IPAA. Methods Patients who underwent surgery for UC between January 2014 and December 2021 at Hyogo Medical University were included in the study. A total of 443 UC surgical cases were included in the study, which comprised 188 cancer/dysplasia patients and 255 refractory patients. Clinical records were compared retrospectively. Results The proportion of surgical UC cases with cancer/dysplasia has been on the rise, accounting for approximately 40% in recent years. The duration of disease (months) was 186 (2–590) in the cancer/dysplasia group and 48 (1–580) in the refractory group (p = 0.02). UC severity (mild/moderate/severe) was 119/69/0 in the cancer/dysplasia group and 18/157/80 in the refractory group (p

Objectives: Anatomical understanding of the internal iliac vessels is important with the increasing frequency of minimally-invasive pelvic surgery. We aimed to investigate the branch patterns of internal iliac vessels, especially the veins. Methods: This study included 30 patients with 60 half-pelvises who underwent minimally-invasive pelvic surgery. Branch patterns were assessed on surgical videos with a multi-detector computed tomography-based three-dimensional simulation. Branch patterns of the superior gluteal artery and vein (SGA and SGV), inferior gluteal artery and vein (IGA and IGV), internal pudendal artery and vein (IPA and IPV), and obturator artery and vein (ObA and ObV) were investigated. Results: In the most frequent internal iliac vein (IIV) branch pattern, 67% of SGV branched from the IIV, 95% of the IGV branched from the IPV and 82% of the ObV branched from the IPV. According to Adachi's classification, 62% of IIVs were Type I and 33% Type IV. Although IIV branch patterns are heterogeneous, in individual patients with the most frequent branch patterns, good correlation (75-100%) of the branch patterns was observed between the internal iliac artery (IIA) and IIV, and between the right and left IIVs. Conclusions: This study clarified the branch patterns of IIV. In patients with the most frequent branch patterns, good correlation of the branch patterns was observed between the IIA and IIV, and between right and left IIV. We believe this helps secure the safety and standardization of minimally-invasive pelvic surgery.

Abstract Background The overall risk of colorectal cancer in Crohn's disease (CD) is higher than in the general population, and CD‐associated cancer (CDAC) has poorer prognosis than sporadic cancer. Developing treatment strategies for improving the prognosis of CDAC, we evaluated the characteristics of CDAC according to the underlying disease behavior, namely stricturing and penetrating. Methods This multicenter retrospective study comprises 316 CDAC patients who underwent surgery between 1985 and 2019. Clinicopathological findings including disease behavior and oncological outcomes were investigated. Results There was no association between the preoperative course of CDAC patients and disease behavior; however, postoperative information revealed distinctly different characteristics between CDAC patients with stricturing behavior and those with penetrating behavior (stricturing with lymphatic invasion and peritoneal dissemination recurrence, and penetrating with histologically poorly differentiated and local recurrence). Oncological outcome of patients with CDAC was distinctly different according to disease behavior, as penetrating provided a poor outcome (overall survival [OS]: p = 0.02; relapse‐free survival [RFS]: p = 0.002) whereas stricturing had no effect. Furthermore, penetrating behavior was identified as one of the independent risk factors for poor OS and RFS (OS: hazard ratio [HR] 1.89, 95% confidence interval [CI] 1.16–3.09, p = 0.01; RFS: HR 2.15, 95% CI 1.28–3.63, p = 0.004). Conclusions Our study highlights the different characteristics of CDAC according to the underlying disease behavior and substantiates the poor prognosis of CDAC patients with penetrating behavior. Treatment planning including screening, surgical procedures, and postoperative treatment, with awareness of these findings, may contribute to improved prognosis for CDAC patients.

Abstract Aim The purpose of this study was to examine how the clinical characteristics, indications for surgery, and postoperative course of ulcerative colitis (UC) surgical patients changed before and after the introduction of biological agents. Methods Patients who underwent surgery for UC at Hyogo Medical University between 2000 and 2019 were included in the study; those who underwent surgery between 2000 and 2009 were included in the early group (n = 864), and those who underwent surgery between 2010 and 2019 were included in the late group (n = 834); each study factor was retrospectively compared. Results The mean ages at surgery (y) were 39.7 ± 15.1 y in the early group and 46.7 ± 17.8 y in the late group (P

Introduction: The comprehensive complication index (CCI), which weights all postoperative complications according to severity and integrates them into a single formula, has been reported as a new evaluation system. We aimed to compare the CCI with the Clavien‒Dindo Classification (CDC) to patients with ulcerative colitis (UC). Methods: Patients who underwent initial surgery for UC from April 2012 to March 2020 were included. The patients were classified into a length of stay (LOS) >30 days group or an LOS ≤30 days group. We performed a multivariate analysis of risk factors for LOS >30 days in the model with the factors identified in the univariate analysis plus the CCI (the CCI model) and plus CDC (the CDC model). An ROC curve was used to test the difference in the area under the curve (AUC) between the CCI model and the CDC model. Results: The median LOS was 21 days (IQR: 16-29 days), and the rate of LOS >30 days was 119/588 (20.2%). In the CCI model, age at the time of surgery (OR=1.24, 95% CI 1.07-1.45, p=0.01), ASA score ≥3 (OR=1.94, 95% CI 1.00-3.76, p=0.04), and CCI (OR=1.07, 95% CI 1.05-1.09; p30 days. The AUC value of the CCI model (0.86) was significantly better in relation to LOS > 30 days than that of the CDC model (0.82) (p =0.02). Conclusion: The CCI was a better measure of LOS than was the CDC and was found to be a useful indicator in UC.

Despite preoperative chemoradiotherapy (CRT) and total mesorectal excision improving the local control for locally advanced rectal cancer (LARC), oncologic outcomes and survival were not significantly improved because the main prognostic factor is distant metastasis. Thus, total neoadjuvant chemotherapy (TNT) as a novel approach has been proposed to improve chemotolerance. Since the first randomized phase II trial of TNT versus standard CRT demonstrated in 2012, many prospective and retrospective studies have been published. The initial consensus from TNT studies was that pathological complete response, pathological response of the main tumor, and local control are more favorable at TNT than at CRT. Furthermore, recent studies such as the PAPIDO trial and PRODIGE 23 trial made a major breakthrough of the treatment of TNT, showing that TNT improves the disease-free survival compared to standard treatment with long-course CRT. In addition, several innovative findings of TNT were clarified by prospective phase II trial. In this review, we summarize the most recent advances in TNT based on the findings of pivotal clinical trials for patients with LARC.

Abstract Background Colorectal carcinoma with enteroblastic differentiation is a rare subtype of colorectal carcinomas expressing at least one characteristic immunohistochemical marker among α-fetoprotein, glypican-3, and spalt-like transcription factor 4. On the other hand, colorectal carcinoma with neuroendocrine differentiation is also a unique subtype of colorectal carcinomas showing expression of at least one distinctive marker among chromogranin A, synaptophysin, and CD56. Case presentation We experienced an extremely rare case of rectal carcinoma with dual differentiation toward enteroblastic and neuroendocrine features in a 53-year-old male patient with long-standing ulcerative colitis (UC). Most of the tumor cells were positive for enteroblastic differentiation markers and approximately a half of them for neuroendocrine differentiation markers. Some tumor cells showed only enteroblastic differentiation, and some did only neuroendocrine feature, but some showed both enteroblastic and neuroendocrine differentiation. Conclusion Colorectal carcinoma with dual differentiation toward enteroblastic and neuroendocrine features has not been reported yet. Neoplastic transformation from pluripotent stem cells in dysplastic epithelium of long-standing UC patients may be associated with such dual differentiation features.

Abstract Background The incidence of ulcerative colitis (UC) is increasing, but there are few reports comparing elderly UC patients undergoing colectomy for elderly-onset UC (EO) and nonelderly-onset UC (NEO). The aim of this study was to analyze the differences between EO and NEO patients who underwent UC-related surgery. Methods We identified 1973 patients with UC who underwent colectomy at Hyogo College of Medicine between January 1, 1984, and December 31, 2018. Only patients aged 65 years old and older who underwent colectomy were enrolled in this study (n = 221, 11.2%), and their clinical records were retrospectively reviewed. Patients were divided into two groups according to their age at disease onset: those with onset at younger than 60 years old (NEO) and at 60 years old or older (EO). Results In the 221 UC patients who underwent colectomy at 65 years old or older, there were 155 cases of EO and 66 cases of NEO. The main surgical indication in NEO patients was colitis-associated cancer/dysplasia (32/66, 47%). In contrast, refractory to medical treatment was the leading cause of surgery in EO patients (80/155, 52%). The distributions of surgical indications were different between the two groups (p

Abstract Background In Japan, Crohn’s disease (CD)-related cancers occur most frequently in the anal canal. Many patients with advanced CD-related cancer require total pelvic exenteration (TPE) based on their medical history, and choosing the most effective method for urinary diversion is a major concern. We herein report the first case of CD-related cancer treatment with urinary diversion using a gastric conduit after TPE in Japan. Case presentation A 51-year-old man with a 25 year history of CD was referred to our institution after having been diagnosed with fistulae between the rectum and urethra. Sigmoidoscopy revealed stenosis of the anal canal, and histological examination of this lesion led to a diagnosis of mucinous adenocarcinoma. Magnetic resonance imaging showed that the tumor had invaded the prostate and left internal obturator muscle, and TPE with left internal obturator muscle resection was planned. Urinary diversion was performed with a gastric conduit. The gastric conduit was created by trimming a gastric tube to a 1.5 cm width via stapled resection of the greater curvature, and the branches of the right gastroepiploic artery were preserved as feeding vessels. The ureters were raised from the mesentery on the right side of the ligament of Treitz. Ureterogastric anastomosis was performed using the Wallace technique, and the entire anastomosis was then retroperitonealized. The anastomotic site had a bleeding tendency, but hemostasis was obtained by proton pump inhibitor administration and discontinuation of enoxaparin, which had been administered to prevent venous thrombosis. No other major complications occurred, and the patient’s quality of life was recovered 6 months after surgery. Conclusion Urinary diversion using a gastric conduit is a feasible treatment option for patients with CD-related anorectal cancer requiring TPE.

Objectives: The appropriate and recommended delivery mode after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) has not been sufficiently evaluated. This study was designed to compare the delivery outcomes associated with cesarean section (CS) and vaginal delivery (VD) after IPAA. Methods: We conducted a questionnaire-based survey of female patients who underwent IPAA for UC between July 1987 and May 2018. Additionally, we reviewed clinical data and collected information regarding pouch function and postpartum complications. Results: In total, 45 patients had 68 deliveries, including 64 CS deliveries and four VDs. Fecal incontinence worsened in seven patients, including six CS patients and one VD patient. The Wexner scores of these patients before and after delivery were 5.4 ± 0.4 and 14.8 ± 1.0, respectively (p = 0.005). Four patients in the CS group and one in the VD group (p = 0.32) had increased stool frequency. Bowel obstructions developed during 11/64 (17.2%) deliveries, and one patient required surgical intervention. One patient with four VDs (three before IPAA and one after IPAA) developed vaginal fistula 5 months after the final VD. Information on episiotomies could not be obtained. Conclusions: Pouch function can decline even after CS. Notably, bowel obstruction can develop after CS. However, we cannot recommend a particular delivery method after IPAA. Further analyses to elucidate the relationship between CS and postoperative complications or vaginal fistula and episiotomy in VDs should be conducted.

Objectives: Few reports are available on post-colectomy enteritis (PCE) with ulcerative colitis (UC), which can be severe and sometimes fatal. The clinical characteristics are unclear, and treatment and diagnosis protocols have not been established. We aimed to investigate the incidence, clinical characteristics, diagnostic criteria, and therapeutic outcomes of PCE in this study. Methods: Patients with UC who underwent colectomy between April 2010 and December 2019 were included in this study. We retrospectively analyzed patients who developed PCE and excluded patients with other forms of enteritis. Results: We performed 829 colectomies because of a preoperative diagnosis of UC. Eleven and four patients were diagnosed with Crohn's disease and indeterminate colitis after surgery, respectively; 22 patients developed enteritis in the perioperative period. We excluded six patients with backwash ileitis, five with prepouch ileitis, three with infectious enteritis, and one with ischemic enteritis. In total, 7/814 (0.8%) patients developed PCE. All patients with PCE had pancolitis. PCE was observed a median of 33 (12-248) days after surgery. Endoscopy showed friable and granular mucosa. The extent of disease included various types such as pan-enteritis with diffuse type, pan-enteritis and mild inflammation in the middle ileum, and only ileitis. Gastroduodenitis-associated UC developed in 6/7 cases. All patients improved with tumor necrosis factor alpha (TNFα) antagonists even if TNFα antagonists had not been effective for colitis. Conclusions: PCE was rare. The mucosal endoscopic findings were similar to those of UC, and the extent of disease varied. TNFα antagonist administration for PCE was effective.

Introduction: Recently, fecal calprotectin has been identified and used as an assessment tool for the confirmation of disease activity in ulcerative colitis. Although a meta-analysis suggested the usefulness of fecal calprotectin for the assessment of pouchitis, the number of participants was still insufficient. Therefore, we prospectively measured fecal calprotectin levels during pouchoscopy and analyzed their associations with pouchitis. Methods: Patients who underwent pouchoscopy after total proctocolectomy and ileal pouch-anal anastomosis for ulcerative colitis were included. Fecal samples were collected for the measurement of calprotectin during pouchoscopy. Patients either with or without suspicious pouchitis were included. Pouchitis was defined as a modified pouchitis disease activity index (m-PDAI) score of ≥5. The associations between the development of pouchitis and the m-PDAI score and fecal calprotectin and serum markers, including C-related protein, albumin, and white blood cells, were assessed. Results: A total of 170 patients were included. Seventy-two patients were diagnosed with pouchitis with an m-PDAI score of 7.3 ± 1.5. The values of fecal calprotectin were 1,500 ± 1,544 μg/g in patients with pouchitis and 259 ± 402 μg/g in patients without pouchitis (p < 0.01). The correlation coefficient between calprotectin and the m-PDAI score was significant (r2 = 0.279, p < 0.001). The cutoff value of fecal calprotectin in receiver operating characteristic analysis was 246 μg/g (area under curve 0.85, sensitivity 83.9%, specificity 71.0%). Fecal samples were able to be collected from 6 patients. The levels of fecal calprotectin significantly decreased from 2,101.3 ± 880.3 μg/g to 284.2 ± 96.9 μg/g in response to the treatment. Conclusions: Elevated fecal calprotectin appeared to be significantly correlated with pouchitis. We should consider the alteration of this marker during treatments in further studies.

Abstract Background Cap polyposis (CP) is extremely rare in Japan, and there is no established cure. We report a case in which CP was improved by surgical treatment. Case presentation A 48-year-old man was investigated at a local hospital because of diarrhea and bloody stools in 2018. The patient was treated with metronidazole for suspected amoebic dysentery, but his symptoms did not improve. Subsequent close examination revealed possible CP, but treatment with 5-aminosalicylic acid and a steroid enema had no effect. The patient was then referred to our hospital. The bloody stools, diarrhea, and abdominal pain worsened despite medical treatment, so laparoscopic-assisted total proctocolectomy and ileal J-pouch anal anastomosis with ileostomy were performed. CP has no known cause or established treatment, but Helicobacter pylori (HP) infection has been reported in many CP cases in Japan, and HP eradication is often successful. This patient was HP-negative and did not improve with antimicrobial treatment, but the symptoms improved after surgery. Conclusions Even after surgery, CP recurrence reportedly occurs within a short period in many cases. However, our patient has had no signs of CP recurrence during 1 year of follow-up.

Abstract Background Crohn’s disease (CD) recurrence can occur not only at the site of anastomosis but also elsewhere in the bowel following an ileocolic resection (ICR) procedure. The aims of the present study were to assess long-term outcomes of a primary ICR procedure for CD in consecutive patients and examine the location of the reoperation causative lesion. Methods We examined cases of surgery with ICR initially performed at our institution. Those with simultaneous multiple bowel resection or bowel resection with strictureplasty were excluded. Results A total of 169 patients who underwent ICR due to CD were enrolled. The median follow-up period was 12.6 years (range 4–27 years). A reoperation was needed in 45 (26.6%), of whom 14 had lesions causative of the reoperation at other than the anastomotic site. The most common causative lesion location was in the colon rather than the oral side of the small intestine. Furthermore, we investigated the relationship between presence of residual lesions following the initial surgery and lesions causative of reoperation. In the group without residual disease (n = 31), 29.0% (n = 9) had non-anastomotic lesions involved in indications for reoperation, while that was 35.7% (n = 5) in the group with residual disease (n = 14). Conclusions Anastomotic site lesion is not the only causative factor for reoperation following ICR. Regular examinations and applicable treatment with awareness that the cause of reoperation is not limited to the site of anastomosis are important in these cases.

Increased antibiotic use and antibiotic homogeneity cause selective pressure. This study investigated the correlation between antibiotic diversity and antimicrobial resistance (AMR) in Gram-negative organisms. The days of therapy/100 patient-days (DOT) for four broad-spectrum antibiotic classes were evaluated for 2015–2022. The antibiotic heterogeneity index (AHI) for the equal use of four classes (25%) and the modified AHI for the equal use of three classes (30%), excluding fluoroquinolones (10%), were measured (target: 1.0). Quarterly antibiotic use markers and the resistance rates against ≥2 anti-Pseudomonas antibiotics were compared. The DOT value was 9.94, and the relative DOT were 34.8% for carbapenems, 32.1% for piperacillin/tazobactam, 24.3% for fourth generation cephalosporins/ceftazidime/aztreonam, and 8.9% for fluoroquinolones. Although no correlation was found between the total DOT and the resistance rate for any bacterium, a significant negative correlation was found between the heterogeneity indices and resistance rates for Pseudomonas aeruginosa and Klebsiella pneumoniae. The significant cutoffs that discriminate the risk of resistance were 0.756 for the AHI and 0.889 for the modified AHI for K. pneumoniae. Antibiotic diversity is more important in preventing AMR than overall antibiotic use. The ideal ratio of broad-spectrum antibiotics should be studied for diversified use to prevent AMR.

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.

Abstract Background A trough concentration (Cmin) ≥20 μg/mL of teicoplanin is recommended for the treatment of serious methicillin-resistant Staphylococcus aureus (MRSA) infections. However, sufficient clinical evidence to support the efficacy of this target Cmin has not been obtained. Even though the recommended high Cmin of teicoplanin was associated with better clinical outcome, reaching the target concentration is challenging. Methods Pharmacokinetics and adverse events were evaluated in all eligible patients. For clinical efficacy, patients who had bacteremia/complicated MRSA infections were analyzed. The primary endpoint for clinical efficacy was an early clinical response at 72–96 h after the start of therapy. Five dosed of 12 mg/kg or 10 mg/kg was administered as an enhanced or conventional high loading dose regimen, respectively. The Cmin was obtained at 72 h after the first dose. Results Overall, 512 patients were eligible, and 76 patients were analyzed for treatment efficacy. The proportion of patients achieving the target Cmin range (20–40 μg/mL) by the enhanced regimen was significantly higher than for the conventional regimen (75.2% versus 41.0%, p

Abstract Background The aim of the present study was to develop a risk calculator predictive of postoperative pneumonia in patients undergoing gastroenterological surgery. Methods We analyzed data from 382 124 patients undergoing eight main gastroenterological surgeries between 2011 and 2013 using the National Clinical Database in Japan. A risk model was developed using multivariate logistic regression analysis with patient data from 2011 to 2012 (n = 247 604) and validated using data from 2013 (n = 134 520). Results Pneumonia was observed in 11 105 patients (2.9%). After the input of significant primary disease and surgical procedures, 18 patient characteristics including gender, chronic obstructive pulmonary disease, sepsis, and need for any assistance in the activities of daily living, six laboratory parameters, and two intraoperative factors were used for risk calculation. Area under the receiver‐operating characteristic curve was 0.822 (95% confidence interval, 0.817‐0.826) in the derivation group and 0.826 (0.819‐0.832) in the validation group. Conclusion The risk calculator accurately predicted the occurrence of pneumonia following gastroenterological surgery.

A long-course antibiotic therapy increases the risk of antibiotic resistance. A 7- to 14-day duration of therapy has been traditionally adopted in patients with intra-abdominal infections (IAIs). Prophylactic antibiotic use is warranted in uncomplicated IAIs, in which the infection involves a single organ, and the source of the infection is completely eradicated by a surgical procedure. A large, randomized clinical trial of the treatment of complicated IAIs recently demonstrated that a fixed 4-day course of antibiotic therapy was as effective as a long-course therapy in patients who underwent adequate source control. Considering the poor prognosis and lack of clear evidence available for shortening the duration of antibiotic therapy in patients who are critically ill or those with ongoing signs of sepsis, the duration of therapy for complicated IAIs should be individually determined according to the clinical course. Limiting therapy to no more than 7 days seems to be warranted in patients who are critically ill with a good clinical response.

Area under the concentration–time curve (AUC)-guided vancomycin treatment is associated with decreased nephrotoxicity. It is preferable to obtain two samples to estimate the AUC. This study examined the usefulness of AUC estimation via trough concentration (Cmin)-only sampling of 260 adults infected with methicillin-resistant Staphylococcus aureus (MRSA) who received vancomycin. The exact Cmin sampling time was used for Bayesian estimation. A significantly higher early treatment response was observed in patients with a day 2 AUC ≥ 400 µg·h/mL than those with min measurement. However, assessment with two samples might be required in patients with q24 administration or high/moderate-risk MRSA infections.

Objectives: Hange-Shashin-To (HST), which is a combination of seven herbs, has previously been used in the treatment of inflammatory or ulcerative gut disease. The aim of this study was to evaluate the safety and efficacy of HST for the treatment of chronic pouchitis. Methods: Nineteen patients with chronic pouchitis, defined as either frequent episodes ( three episodes per six months) of pouchitis or persistent symptoms that required continuous antibiotic therapies, were selected and treated with ciprofloxacin (CPFX) 600 mg/day for 2 weeks (week 0~2) and HST 3,750 mg/day for 32 weeks (week 0~32). The Pouchitis Disease Activity Index (PDAI) score was measured at week 0 and 6 for short-term evaluation. For long-term evaluation, total CPFX dose in the 26-week period prior to study entry (from 30 weeks before study entry to 5 weeks before study entry) was compared with the total CPFX dose during the 26-week study period (week 7~32). Although no concomitant administration of CPFX was permitted from week 2-6, patients whose condition deteriorated were prescribed CPFX from week 7 to week 32. Results: Fourteen patients completed this 32-week study. The PDAI scores of eight patients decreased below seven. The mean total PDAI scores decreased significantly from 11 ± 2.5 to 6.5 ± 2.5 (P < 0.001). The mean value of total CPFX dose decreased significantly from 491.6 ± 182.4 mg/kg to 392.5 ± 184.0 mg/kg (P < 0.05). No severe adverse events were noted. Conclusions: Our data suggest that HST has a positive effect on chronic pouchitis with no adverse effects.

Objectives: Although the aetiology of pouchitis after restorative proctocolectomy in ulcerative colitis (UC) remains unknown, infliximab (IFX) is often effective for this condition. However, indicators and predictors of treatment efficacy remain unclear. In this study, the association between serum tumor necrosis factor-alpha (TNF-α) levels and refractory pouchitis was evaluated. Methods: We conducted a prospective study between January 2014 and April 2016. Patients with antibiotic-refractory pouchitis were treated with IFX. Serum TNF-α levels were measured before IFX induction. Diagnoses were confirmed using the modified Pouchitis Disease Activity Index (m-PDAI). Responders were defined as patients with an m-PDAI score lower than 5. Recurrence was defined as an m-PDAI score exceeding 5 during maintenance treatment or a need for additional treatments. Associations between serum TNF-α level and efficacy of IFX during 52 weeks of maintenance therapy were evaluated. Results: Thirteen patients were eligible for this study. The short-term efficacy was 8/13 (61.5%). Four patients could not be maintained with IFX alone. The cumulative maintenance ratio was 30.8%/52 weeks, and the cut-off value for serum TNF-α was 1.93 pg/mL for short-term response. Although there was no significant association between serum TNF-α and treatment response, IFX treatment was unsuccessful for all five patients with TNF-α levels below 1.93 pg/mL, including four short-term non-responders and one long-term non-responder. Conclusion: Serum TNF-α level was not an independent predictor of IFX efficacy for refractory pouchitis. However, IFX may be effective for patients with elevated serum TNF-α. Future studies should assess this possibility.

Abstract Background Ulcerative colitis (UC) is known as an immune disorder of the colon that generally involves the rectum, but an atypical distribution of inflamed mucosa has previously been noted in certain subtypes of UC, such as the rectal-sparing type (RST). As noted in a previous report, patients with the RST may be at elevated risk for disease refractoriness, but the clinical significance of RST remains unknown. Methods UC patients who underwent surgery between January 2010 and April 2015 were included. Patients were classified as having the RST or a non-RST based on colectomy specimens or a pre-operative endoscopy. Possible risk factors for urgent/emergent surgery were analyzed. We specifically determined whether the RST is a significant predictor for urgent/emergent surgery. Results In total, 46/482 patients were classified as having the RST. Disease severity was significantly worse in patients with the RST than in other patients (p = 0.02). Urgent/emergent surgery was required for 24/46 patients with the RST, compared with 107/436 non-RST patients (p

BACKGROUND:The incidence of ocular candidiasis (OC) in patients with candidemia varies across different reports, and the issue of whether routine ophthalmoscopy improves outcomes has been raised. This study investigated the incidence of OC and evaluate whether the extent of OC impacts the clinical outcomes. METHODS:This retrospective study included non-neutropenic patients with candidemia who underwent treatment at one of 15 medical centers between 2010 and 2016. Chorioretinitis without other possible causes for the ocular lesions and endophthalmitis was classified as a probable OC. If signs of chorioretinitis were observed in patients with a systemic disease that causes similar ocular lesions, they were classified as a possible OC. RESULTS:In total, 781 of 1089 patients with candidemia underwent an ophthalmic examination. The prevalence of OC was 19.5%. The time from the collection of a positive blood culture to the initial ophthalmic examination was 5.0 ± 3.9 days in patients with OC. The leading isolate was Candida albicans (77.9%). Possible OC was associated with unsuccessful treatments (resolution of ocular findings) (odds ratio: 0.354, 95% confidence interval: 0.141-0.887), indicating an overdiagnosis in patients with a possible OC. If these patients were excluded, the incidence fell to 12.8%. Endophthalmitis and/or macular involvement, both of which require aggressive therapy, were detected in 43.1% of patients; a significantly higher incidence of visual symptoms was observed in these patients. CONCLUSION:Even when early routine ophthalmic examinations were performed, a high incidence of advanced ocular lesions was observed. These results suggest that routine ophthalmic examinations are still warranted in patients with candidemia.

Refractory ulcerative colitis (UC) that does not respond to medical therapy often requires surgery even during pregnancy. Although surgical cases of UC during pregnancy were reported previously, the standard surgical strategy for both colitis and pregnancy was unclear. Herein, fetal and maternal safety as well as the strategy for this unusual surgical procedure during pregnancy in patients with UC are considered. A 28-year-old woman was diagnosed with left-sided moderate UC at 12 weeks of pregnancy; toxic megacolon was suspected, and surgery was required. Although the baby's gestational age was 23 weeks and 3 days, a cesarean section was performed before the colectomy. In a next case, a 28-year-old woman had a 2-year history of left-sided UC. Her colitis flared up at 11 weeks of pregnancy. Colectomy was performed because her colitis was unresponsive to conservative therapy, and the pregnancy was continued, with a transvaginal delivery at 36 weeks. In patients with UC, the need for surgery should be determined promptly based on disease severity, whether or not the patient is pregnant. The need for surgery should not be affected by pregnancy. The pregnancy should be continued for as long as possible when there are no fetal and maternal complications. Both cesarean section and colectomy should be performed independently if necessary.

Background: Granulocyte and monocyte apheresis (GMA) has shown therapeutic efficacy in active ulcerative colitis (UC). We thought that in patients with pouchitis after proctocolectomy for UC, GMA might produce immunological effects in the intestinal mucosa, and improve clinical symptoms. This prospective study was to evaluate the efficacy of GMA for antibiotic-refractory pouchitis after proctocolectomy for UC. Methods: A total of 13 patients with pouchitis disease activity index (PDAI) > 7 unresponsive to 2 weeks of antibiotic therapy were included. All patients received 10 GMA sessions at 2 sessions/week over 5 consecutive weeks. The primary endpoints were response (a decrease of ⩾3 points in the PDAI) and remission (PDAI < 4). Secondary endpoints included reduction of white blood cells (WBCs), C-reactive protein (CRP), faecal markers (calprotectin and lactoferrin), reduction of the PDAI endoscopic subscore, and GMA safety. Results: The median PDAI score was significantly decreased from 11 (range, 9–15) at entry to 9 (range, 6–13) after the GMA therapy ( p = 0.02). A total of six patients (46%) responded to the treatment, but none achieved remission. The median endoscopic subscore (maximum: 6) was 5 (range, 4–6) at entry and 5 (range, 1–6) after the treatment ( p = 0.10). None of the laboratory markers (WBCs, CRP, faecal calprotectin and lactoferrin) significantly changed during the treatment. Transient adverse events (AEs) were observed in two patients (15%), dyspnoea in one and headache in one. The AEs were not serious, and all patients completed the 10 GMA sessions. Conclusions: GMA has a good safety profile, but its efficacy appears to be limited in the management of chronic refractory pouchitis. However, a large controlled study should be conducted to evaluate the efficacy of GMA therapy in patients with pouchitis at an earlier clinical stage, before the disease has become refractory to conventional medical therapy.