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Diversity studies on moths in Australia are rare, presenting various shortfalls in knowledge that impedes and understanding of their biodiversity values and their conservation. In particular, the Wet Tropics of Australia deserves attention, given the paucity of systematic moth surveys in the region and its World Heritage Area status. To fill this knowledge gap, we conducted a study to observe moths on 191 nights over a main one-year survey period at an upland rainforest locality, and uploaded all observations on iNaturalist. We also compiled other incidental observations in the general locality by other observers and observations outside the survey period. In total, we document 4,434 observations of moths represented by 1041 distinct moth morphospecies. Of these, 703 are formally named species of moths, 146 to genus and 255 to higher taxonomic designations above genus level. Despite the rather intensive main survey effort, our results suggest that we have yet to reach a plateau in documenting the moth species richness of the locality. Using this study as a model, we show that the iNaturalist platform serves as an effective means to document and digitally curate biodiversity values at a locality, whilst providing complete data transparency and enabling broader community engagement of citizen scientists. We recommend the use of iNaturalist for future moth inventories, and as a resource for follow up meta-analyses of regional moth diversity and distributions.

Background information We aimed to compare prospectively the complications and functional outcome of patients undergoing a J-Pouch (JP) or a side-to-end anastomosis (SE) for treatment of low rectal cancer at a 2-year time point after resection for rectal cancer. Methods A multicenter study was conducted on patients with low rectal cancer who were randomized to receive either a JP or SE and were followed for 24 months utilizing SF-12 and FACT-C surveys to evaluate the quality of life (QOL). Fecal incontinence was evaluated using the Fecal Incontinence Severity Index (FISI). Bowel function, complications, and their treatments were recorded. Results Two hundred thirty-eight patients (165 males) were randomized with 167 final eligible patients, 80 in the JP group and 87 in the SE group for evaluation. The mean age at surgery was 61 (range 29 to 82) years. The overall mean recurrence rate was 12 of 238, 5% and similar in both groups. Complications Overall, 37 of 190 (19%) patients reported complications, 14 of these were Clavien Dindo Grade 3b and 2 were 3a: leak 3 (2 JP,1 SE), fistula 4 (1 JP, 3 SE), small bowel obstruction 4 (3JP, 1 SE), stricture 4 (3 SE, 1 SA), pouch necrosis 2 (JP), and wound infection 5 (2 JP, 3 SE). QOL scores using either instrument between the 2 groups at 12 and 24 months were similar (P > 0.05). Bowel movements, clustering, and FISI scores were similar. Conclusion At time points of 1 and 2 years after a JP or a SE for low rectal cancer, QOL, functional outcome, and complications are comparable between the groups. Although choosing a particular procedure may depend on surgeon/patient choice or anatomical considerations at the time of surgery, SE functions similar to JP and may be chosen due to the ease of construction.

To evaluate the influence of preoperative dysplasia grade, appearance, and site on risk and location of cancer in patients with colitis.The ability to predict the presence and location of cancer in colitis patients with dysplasia is essential to facilitate recommendations regarding the necessity and type of surgery.Ulcerative and indeterminate colitis patients who underwent proctocolectomy for dysplasia were retrospectively selected. Patient characteristics and findings at colonoscopic surveillance were associated with findings on the surgical specimen by regression analysis.From 1984 to 2007, 348 proctocolectomy specimens with preoperative dysplasia showed cancer in 51 (15%) and dysplasia in 172 (49%) cases. Patients with preoperative high-grade dysplasia (HGD) had cancer in 29% compared with 3% in low-grade dysplasia (LGD) (P0.001). Patients with preoperative dysplasia-associated lesion/mass (DALM) had cancer in 25% compared with 8% in flat dysplasia (P0.001). In LGD with DALM, the risk of cancer was not significantly higher than in flat LGD (7% vs 2%, P = 0.3), but risk of cancer or HGD was higher with a threefold increase (29% vs 9%, P = 0.015). On multivariate analysis, HGD, DALM, and disease duration were independent risk factors for postoperative cancer. In patients with isolated colonic dysplasia above the sigmoid level, postoperative rectal involvement was limited.Risk of cancer for patients with HGD or DALM is substantial. Despite low risk of cancer in patients with flat LGD, threshold for surgery should be low given the high prevalence of postoperative pathologic findings. Only in selected cases, colonoscopic surveillance after discussion of associated risks may be acceptable, provided high patient compliance can be assured. Surgery should be considered in all other cases, because it is the only modality that can eliminate the risk of cancer. The location of preoperative dysplasia may allow for the clarification of the need for proctectomy especially in the poor risk surgical patient.

To evaluate the significance of hyperglycemia in patients without a preoperative diagnosis of diabetes undergoing elective colorectal surgery.Preoperative and all postoperative blood glucose measurements were retrieved for 2628 consecutive patients undergoing elective colorectal resection within 2 years at 1 center. Nondiabetic patients were identified as those without a preoperative diagnosis of diabetes and/or based on HbA1C levels. The association between any elevated postoperative random glucose value (hyperglycemia:125 mg/dL) and level of elevation (125 mg/dL or200 mg/dL) within 72 hours of surgery in nondiabetic patients with 30-day mortality and infectious and noninfectious complications was assessed.Evaluation of 16,404 postoperative glucose measurements for all 2447 nondiabetic patients who underwent surgery in 2010 and 2011 revealed that 66.7% patients experienced hyperglycemia. Degree of hyperglycemia correlated with increasing American Society of Anesthesiologists class and surgical severity (blood loss). Hyperglycemia was associated with infectious and noninfectious complications and mortality, the rates of these complications increasing parallel to the degree of hyperglycemia. Hyperglycemia was independently associated with septic complications (P = 0.024).Postoperative hyperglycemia is frequent after elective colorectal surgery in nondiabetic patients. Even a single postoperative elevated glucose value is adversely associated with morbidity and mortality; this risk is related to the degree of glucose elevation. These findings strongly support monitoring of glucose values and early consideration of management strategies for glycemic control after surgery even in nondiabetic patients.

Background When patients with stage IV colorectal cancer are deemed to have an unresectable primary colorectal cancer or extensive metastases at surgery, bypass or stoma creation may be the only surgical options. Whether this surgical approach provides extra months of life or instead leads to prohibitive post-operative morbidity and mortality has not previously been well characterized. This study was conducted to evaluate early and long-term outcomes for stage IV colorectal cancer patients with unresectable primary tumour. Methods Patients with unresectable colorectal cancer who underwent palliative bypass or stoma creation were identified from a prospective colorectal cancer database. Early and long-term outcomes were evaluated. Survival was determined using Kaplan–Meier survival curves. Results From 1980 to 2008, 81 patients with stage IV colorectal cancer had an unresectable primary or extensive metastases and underwent palliative bypass or stoma creation. Mean age was 61.5 ± 13.9 years, 44 (54.3%) were male. Location of the colorectal cancer was left-sided in 82.7%. Of the patients, 38.3% had emergency or urgent surgery. Sixty-two (76.5%) patients underwent a diverting stoma, 15 (18.5%) underwent enteric bypass procedures and 4 (4.9%) had both a diverting stoma and proximal bypass created. Twenty-five complications occurred in 24 patients (29.6%) with 2 patients (2.5%) requiring further re-operation. There was no anastomotic leak. Mean length of hospital stay was 13.8 ± 11.2 days. Thirty-day mortality rate was 16%. The median overall survival was 4.7 months, while the overall survival at 1 year was 24.7%. At 2 years, 6.1% patients were alive, all with a stoma. Conclusion Palliative bypass or stoma creation is associated with survival for several months for a significant proportion of patients with stage IV colorectal cancers, who have unresectable primaries or extensive metastases. The findings of this study support the use of bypass or diversion when faced with an unresectable primary in patients with colorectal cancer with metastases.

A minimum of 12 examined lymph nodes (LN) is recommended to ensure adequate staging and oncologic resection of patients undergoing proctectomy for rectal adenocarcinoma. However, a decreased number of LN is not unusual in patients receiving neoadjuvant chemoradiation.We hypothesized that a decreased number of LN in the proctectomy specimen of these patients may be an indicator of tumor response and be associated with improved prognosis.A single-center colorectal cancer database was queried for c-stage II-III rectal cancer patients undergoing neoadjuvant chemoradiation followed by proctectomy between 1997 and 2007. Patients were categorized into two groups according to the number of LN retrieved from the proctectomy specimen:12 LN versus ≥12 LN. Groups were compared with respect to demographics, tumor and treatment characteristics, and the following oncologic outcomes: overall-survival (OS), cancer-specific-mortality (CSM), cancer-free-survival (CFS), distant (DR), and local recurrences (LR).The query returned 237 patients. There were 173 (73 %) males, and the median age was 57 years [interquartile range (IQR) 49-66 years]. The median number of LN retrieved was 15 (IQR 10-23) and 70 (30 %) patients had less than 12 nodes examined. The12 nodes group was older [60 (IQR 51-71 years) vs. 55 (IQR 48-65 years), p = 0.009] and had more pathologic complete responders (36 vs. 19 %, p = 0.01). No12 nodes patient experienced a LR, whereas the 5-year LR rate was 11 % in the ≥12 nodes group (p = 0.004). Other oncologic outcomes were not significantly different.Retrieval of less than 12 nodes in the proctectomy specimen of rectal cancer patients treated with neoadjuvant chemoradiation does not affect OS, CSM, CFS, or DR and may be a marker of higher tumor response and, consequently, decreased LR rate.

To evaluate whether resident participation in operations influences postoperative outcomes.: Identification of potential differences in outcome associated with resident participation in operations may facilitate planning from educational and health resource perspectives.From the National Surgical Quality Improvement Program database (2005-2007), postoperative outcomes were compared for patients with and without resident participation (RES vs no-RES). Groups were matched in a 2:1 ratio, based on age, sex, specialty, surgical procedure, morbidity probability, and important comorbidities and risk factors.RES (40,474; 66.7%) and no-RES (20,237; 33.3%) groups were comparable for matched characteristics. Mortality was similar (0.18% vs 0.20%, P = 0.55). Thirty-day complications classified as "mild" (4.4% vs 3.5%, P0.001) and "surgical" (7% vs 6.2%, P0.001) were higher in RES group. Individual complications were largely similar, except superficial surgical site infection (3.0% vs 2.2%, P0.001). Operative time was longer in the RES group [mean (SD) 122 (80) vs 97 (67) minutes, P0.001]. Overall complications were lower for postgraduate year 1-2 residents than for other years. These differences persisted on multivariate analysis adjusting for confounders.Resident involvement in surgical procedures is safe. The small overall increase in mild surgical complications is mostly caused by superficial wound infections. Reasons for this are likely multifactorial but may be related to prolonged operative time.

BACKGROUND Pelvic sepsis after IPAA predisposes to pouch failure. There are limited data on long-term pouch function for patients with pelvic sepsis. OBJECTIVE The aim of this study was to investigate functional outcomes and quality of life for patients undergoing IPAA who develop pelvic sepsis and preserve their pouch long-term. DESIGN This study is based on retrospective analysis of prospectively accrued data. SETTINGS This study was conducted at a single-center institution. PATIENTS All patients undergoing IPAA from 1983 to 2007 were included. MAIN OUTCOME MEASURES The primary outcomes measured were functional outcomes (urgency, incontinence, bowel movements) and quality-of-life (restrictions, energy, happiness) parameters. RESULTS Two hundred (6.2%) of 3234 patients developed pelvic septic complications within 3 months of IPAA. In the comparison of complications at the time of IPAA for the 2 groups, patients with pelvic sepsis had higher rates of postoperative hemorrhage (13.5% vs 3.7%, p < 0.001), anastomotic leak (35% vs 3.7%, p < 0.001), wound infection (14% vs 7.4%, p < 0.001), and fistula formation (37% vs 7.1%, p < 0.001). The overall median follow-up was 7 years. Pelvic sepsis was associated with greater pouch failure (19.5% vs 4%, p < 0.001). For patients with follow-up (pelvic sepsis = 144, nonpelvic sepsis = 2677) with a retained pouch, for whom we compared functional outcomes and quality of life, incontinence was worse (never/rare: 69.5% vs 77.8%, p = 0.03). Urgency scores were lower in pelvic sepsis but not statistically significant. The overall Cleveland Global Quality of Life score (and components) in the sepsis group were significantly worse than in the nonsepsis group (0.74 vs 0.79, p < 0.001). Patients who developed sepsis were also less likely to recommend IPAA to others than patients who did not develop pelvic sepsis. LIMITATIONS This study was limited by the retrospective analysis and the use of questionnaires. CONCLUSIONS Pelvic sepsis after IPAA leads to worse functional outcomes and quality of life even when it does not lead to pouch failure. This finding argues for careful attention to preoperative and intraoperative planning and strategies aimed at reducing this complication after IPAA.

Whether smoking affects disease distribution, phenotype, and perioperative outcomes for Crohn’s disease (CD) patients undergoing surgery is not well characterized. The aim of this study is to evaluate the impact of smoking on disease phenotype and postoperative outcomes for CD patients undergoing surgery Prospectively collected data of CD patients undergoing colorectal resection were evaluated. CD patients who were current smokers (CS) were compared to nonsmokers (NS) and ex-smokers (ES) for disease phenotype, anatomic site involved, procedures performed, postoperative outcomes, and quality of life using the Cleveland Global Quality of Life instrument (CGQL). Of 691 patients with a diagnosis of CD requiring surgery 314 were classified as CS, 330 as NS, and 47 as ES. CS and ES in comparison to NS were significantly older at diagnosis of Crohn’s disease (mean, 29.3 vs. 29.2 vs. 26.3 years) (P = 0.001) and older at the time of primary surgery (mean, 42.9 vs. 48.4 vs. 39 years) (P = 0.001) with a greater frequency of diabetes. In all groups requiring surgery, there was a significant change in disease phenotype from the time of diagnosis to surgical intervention. The predominant phenotype at diagnosis was inflammatory which changed to stricturing and penetrating as the dominant phenotypes at time of surgery. All groups had a significant improvement in CGQL scores post-surgery with the greatest benefit observed in NS. Postoperative complications and 30-day readmission rates were similar between all groups. The findings of this study show that in patients with CD, disease phenotype changes over time. This occurs independent of smoking. Smoking does not appear to predispose to complications for CD patients undergoing surgery. CS and ES have a persistently reduced quality of life in comparison to NS post-surgery.

BACKGROUND There is debate whether performing the perineal part of the abdominoperineal resection in a prone position in comparison with a lithotomy position optimizes circumferential resection margins and, subsequently, cancer outcomes. OBJECTIVE The aim of this study was to compare outcomes of patients undergoing abdominoperineal in a prone vs a lithotomy position. DESIGN A single-center, prospectively maintained colorectal cancer database was queried for patients with stages I to III rectal cancer undergoing abdominoperineal resection in a prone vs a lithotomy position from 1997 to 2007. Patients were compared with respect to demographics, tumor and treatment characteristics, perioperative morbidity, and oncologic outcomes. Oncologic outcomes were adjusted for age, ASA class, tumor stage, and use of adjuvant treatments. χ², Fisher exact probability test, Wilcoxon rank-sum test, Kaplan-Meier estimates, log-rank sum test, and Cox regression models were used for the analysis. P < .05 was considered significant. RESULTS The query returned 168 patients (81 prone and 87 lithotomy), with a median age of 63 (interquartile range, 52-74) years and a median follow-up of 42 (interquartile range, 23-69) months. Prone and lithotomy patients were not statistically different regarding demographics, tumor stage, rates of R0 resection, number of harvested nodes, perioperative morbidity, follow-up time, and oncologic outcomes. CONCLUSIONS Surgical positioning during the perineal part of the abdominoperineal resection does not affect perioperative morbidity or oncologic outcomes and should be left to the surgeon's discretion.

This study evaluates surgical procedures for Crohn's colitis. The risk of recurrence and how it interacts with future avoidance of permanent stoma and quality of life (QoL) is studied.Segmental and subtotal colectomy are widely used surgical options in isolated Crohn's colitis. It is not clear which procedure offers the best outcomes.Patients undergoing index resection for isolated colonic Crohn's disease (CD) from 1995 to 2009, were identified from a prospectively maintained CD database. Patients were categorized into subtotal colectomy or segmental groups. Demographics, disease characteristics, operative details, morbidity, stoma formation, recurrence requiring surgery and QoL data were extracted. Recurrence and stoma free survival was calculated for each group and independent risk factors for recurrence and stoma formation identified.One hundred and eight patients (49 segmental, 59 subtotal) underwent primary colectomy with anastomosis. Segmental colectomy patients had significantly reduced recurrence free survival (P = 0.032) but not stoma free survival P = 0.62 on univariate analysis. On multivariate analysis, the presence of perianal sepsis (P = 0.032) and1 medical comorbidity (P = 0.01), but not segmental colectomy, were associated with reduced SFS. There was no difference in Cleveland Global Quality of Life (P = 0.88), or Short Form Inflammatory Bowel Disease Questionnaire scores between groups (P = 0.92).Using a strictly defined cohort of patients, we were unable to identify segmental resection as an independent risk factor for recurrence or stoma formation and no reduction in QoL scores to suggest an adverse effect of recurrence was observed. Segmental colectomy affords good function, and our data supports the practice of a conservative approach with anastomosis in anatomically linked CD.

Some Crohn's disease (CD) patients develop rapid disease recurrence requiring reoperation. Identification of factors associated with early operative recurrence of CD may help risk-stratify patients and prevent recurrence.Prospectively collected data of CD patients undergoing bowel resection for CD with unequivocal evidence of recurrence at reoperation were retrieved. Patients with earlier recurrence (less than median time of recurrence of study cohort) were compared with those who developed later recurrence (greater than median time of recurrence) for patient and disease characteristics and risk factors for recurrence. A multivariate logistic regression model was performed to identify factors associated with earlier operative recurrence.Sixty-nine patients (45 female, 24 male) met the inclusion criteria. Median time to reoperation was 38 months (range, 3.3-236 months). One hundred six reoperations in the 69 patients were for abscess/fistula/perforation (n = 45), stricture/stenosis (n = 41), inflammation (n = 17), bleeding (n = 2), and dysplasia (n = 1). Factors associated with early rather than late reoperation included behavior of disease (stricturing, odds ratio (OR) 12.1; confidence interval (CI), 1.8-80.9; penetrating OR, 9.9; CI, 1.4-67.9 rather than nonstricturing nonpenetrating) and the development of postoperative complications at previous surgery (OR, 12.1; CI, 1.2-126.6).Earlier recurrence of CD requiring reoperation is associated with specific disease and potentially modifiable operation-related factors such as postoperative complications, i.e., anastomotic leak or intraabdominal abscess. Strategies to reduce recurrence in such patients include the identification of factors that may reduce postoperative complications.

The natural history of a pouch-related fistula in terms of timing of its development and its impact on pouch survival is poorly defined.This study aimed to evaluate factors associated with the time of onset of ileoanal pouch-related fistulas and predictors of pouch failure after the development of fistulas.This study is an evaluation of prospectively collected data from a cohort of patients with pouch-related fistulas.Patients were identified from a prospective ileoanal pouch database, with data recorded from 1983 to 2009.Patients who participated had developed a fistula after ileoanal pouch surgery. Patients were classified according to the time of onset, origin, and target of pouch fistulas into "early" and late" groups.Ileoanal pouch failure was the main outcome measure.Three hundred six patients (158 early-onset, 148 late-onset) with 373 pouch-related fistulas were identified. The early-onset group had a higher mean body mass index (P = .013) and more patients in this group developed a postoperative leak (P.001), whereas diagnosis revision to Crohn's disease was more frequent in the late-onset group (P = .018). Overall, pouch failure occurred in 89 (29%) patients. Major abdominal procedures were more common in the early-onset group (18 vs 6%). There was no difference in pouch failure between the early- and late-onset groups (P = .24). On multivariate analysis, a current Crohn's diagnosis (P.001), major fistula (P = .022), history of colectomy before ileoanal pouch (P = .005), handsewn anastomosis (P = .008), anastomotic leak (P = .012), and body mass index over 30 (P = .018) were independent risk factors for failure. No individual risk factor for failure was separately associated with either early or late fistula groups.The timing and etiology of pouch fistula appear to be interrelated. There is a temporal association between procedure-related sepsis and early and delayed diagnosis of Crohn's disease and late fistula development. Cause of the fistula and associated factors rather than timing after IPAA is associated with long term pouch retention.

Background: Irritable pouch syndrome (IPS) is a functional disorder in patients with ileal pouch–anal anastomosis (IPAA), which presents with symptoms in the absence of structural abnormalities of the pouch. Thus, it resembles other functional disorders, such as irritable bowel syndrome characterized by visceral hypersensitivity in the presence of normal rectal biomechanics. The aim was to assess pouch biomechanics and perception of balloon distension in different groups of subjects with IPAA and to correlate the findings with clinical features. Methods: Pouch tone, compliance, and sensation to balloon distension were measured in 18 patients with IPS, 11 patients with active pouch inflammation (pouchitis or Crohn's disease of the pouch), and 12 asymptomatic subjects with normal pouches. All patients were recruited from a subspecialty Pouchitis Clinic. Results: Scores of sensation of gas, urge to defecate, and pain measured by visual analog scales at various distension pressures were significantly higher in IPS than pouchitis and normal pouch patients. Pouch tone was comparable among the groups and compliance was reduced in the pouchitis group. The visual analog scale showed a trend of correlation with the Pouchitis Disease Activity Index symptom scores in IPS. Conclusions: IPS, like other gut functional disorders, is characterized by visceral hypersensitivity, with normal pouch biomechanics. (Inflamm Bowel Dis 2011)

PURPOSE: Pouchitis is the most common complication of IPAA. Identifying factors predictive of pouchitis may improve outcomes by modifying contributing factors and enhancing patient selection. The most objective means for confirming pouchitis is by histology because the clinical and endoscopic diagnoses rely on more subjective assessments. The importance of histological pouchitis in the absence of clinical or endoscopic findings is unknown. METHODS: Prospectively collected data on patients with IPAA and pouch surveillance were evaluated. Patients who developed pouchitis, defined as symptoms of pouchitis confirmed by endoscopic biopsy (group B) were compared with those without any episode of clinical, endoscopic, or histological pouchitis (group A) for pre- and intraoperative factors and outcomes. Asymptomatic patients with histological pouchitis on surveillance biopsies (group C) were further compared with group A. Patients with Crohn's disease were excluded. RESULTS: Of the 673 patients with pouch biopsies, 422 (62.7%) were in group A, 161 (23.9%) in group B, and 90 (13.4%) in group C. Mean follow-up was 9.8 (±5.1), 12.4 (±5.4), and 13.5 (±4.7) years. Of the 43 preoperative factors evaluated, those associated with group B included leukocytosis (P < .001), rheumatologic extraintestinal disease (P < .001), disease proximal to splenic flexure (P = .001), pulmonary comorbidity (P = .004), prior steroid use (P = .006), and age at operation and diagnosis (P = .018 and .021). Of the 10 intraoperative factors evaluated, pouchitis was associated with S-pouch reconstruction (P < .001), transfusion (P < .001), and 2-stage instead of 3-stage operation (P = .05), all surrogates for operative complexity. On multivariate analysis, pulmonary comorbidity (OR 3.38, 95% CI 1.62-7.07), disease proximal to splenic flexure (OR 2.37, 95% CI 1.18-4.77), extraintestinal disease manifestations (OR 1.6, 95% CI 1.01-2.54), and S-pouch reconstruction (OR 1.59, 95% CI 0.99 - 2.54) were associated with pouchitis. Patients in group B had worse outcomes, including more strictures (P = .015), bowel obstructions (P = .019), fistulas (P = .18), and lower quality of life (P < .001). Group C patients had the same outcomes as those in group A and the finding was not predicted by the above-mentioned parameters. CONCLUSION: Patients with symptomatic, biopsy-confirmed pouchitis have worse long-term outcomes than those without pouchitis. This complication is associated with specific pre- and intraoperative factors. Histological pouchitis incidentally found on surveillance biopsy in asymptomatic patients is of no clinical relevance and does not influence outcome. Identification of these preoperative factors associated with the subsequent development of pouchitis will strengthen patient counseling and may facilitate risk stratification.

Aim We reviewed the functional results and quality of life (QOL) of patients who had had an ileoanal pouch (IPAA) for at least 15 years. Method Retrospective analysis was undertaken of data accrued prospectively into a pouch database since 1983. Patients who had retained an IPAA for at least 15 years were identified. Trends in IPAA function and QOL of the patients were determined over a time-period of 15 years after formation of the IPAA. Data were compared for patients who were 55 years of age when the IPAA was formed. Results Three hundred and ninety-six of a total of 3276 patients in the database (53% men, median age 36 years and median follow-up 17.1 years) underwent IPAA with at least 15 years of follow-up. The final pathology was ulcerative colitis in 78%; 66.4% of patients had a restorative proctocolectomy, 91.4% underwent temporary diversion, 59% had a J-pouch configuration and 63.1% a stapled anastomosis. The frequency of bowel movements remained the same over the follow-up period. There was an increase in the incidence of incontinence and urgency after 15 years with no significant change in dietary, social, work and sexual restrictions during follow-up. Patients in all three age groups experienced deterioration in pouch function at 15 years of follow up compared with the function at 5 years. The QOL of the patients remained high and stable. Conclusion There is a deterioration of pouch function after 15 years, irrespective of the age of the patient when the IPAA was formed. Despite this, QOL appears to be high for all patients who retain their pouch.

Postoperative ileus (POI) after colorectal surgery is associated with prolonged hospital stay and increased costs. The aim of this study is to investigate pre-, intra-, and postoperative risk factors associated with the development of POI in patients undergoing laparoscopic partial colectomy.Patients operated between 2004 and 2008 were retrospectively identified from a prospectively maintained database, and clinical, metabolic, and pharmacologic data were obtained. Postoperative ileus was defined as the absence of bowel function for 5 or more days or the need for reinsertion of a nasogastric tube after starting oral diet in the absence of mechanical obstruction. Associations between likelihood of POI and study variables were assessed univariably by using χ tests, Fisher exact tests, and logistic regression models. A scoring system for prediction of POI was constructed by using a multivariable logistic regression model based on forward stepwise selection of preoperative factors.A total of 413 patients (mean age, 58 years; 53.5% women) were included, and 42 (10.2%) of them developed POI. Preoperative albumin, postoperative deep-vein thrombosis, and electrolyte levels were associated with POI. Age, previous abdominal surgery, and chronic preoperative use of narcotics were independently correlated with POI on multivariate analysis, which allowed the creation of a predictive score. Patients with a score of 2 or higher had an 18.3% risk of POI (P0.001).Postoperative ileus after laparoscopic partial colectomy is associated with specific preoperative and postoperative factors. The likelihood of POI can be predicted by using a preoperative scoring system. Addressing the postoperative factors may be expected to reduce the incidence of this common complication in high-risk patients.

Laparoscopic ileocolic resection is feasible for Crohn's disease but few studies adjust for the various preoperative, intraoperative, and postoperative variables that may confound comparisons with open surgery. The aim of this study is to compare outcomes after laparoscopic (LICR) and open ileocolic resection (OICR) performed for regional enteritis using National Surgical Quality Improvement Program (NSQIP) data. Retrospective evaluation of data prospectively accrued into the NSQIP database for patients undergoing ileocolic resection for Crohn's by LICR and OICR was performed. LICR (n = 104) and OICR (n = 203) groups had similar age ( P = 0.1), body mass index ( P = 0.9), smoking history ( P = 0.6), steroid use ( P = 0.7), diabetes ( P = 0.3), serum albumin ( P = 0.07), and American Society of Anesthesiologists class ( P = 0.13). LICR group had more female patients ( P = 0.005). Complications including surgical site infections ( P = 0.5), wound dehiscence ( P = 1), pneumonia ( P = 0.1), deep vein thrombosis ( P = 0.3), pulmonary embolism ( P = 1), urinary infection ( P = 0.1), and return to the operating room ( P = 0.2) were similar. LICR had shorter length of hospital stay than OICR ( P < 0.001). In current practice, as observed with the NSQIP data, LICR, performed by experienced surgeons, is comparable in safety to OICR and is associated with a shorter hospital stay.

Background In patients with symptoms of pouchitis retractable to antibiotic therapy, serology is often ordered to exclude concurrent celiac disease. The clinical utility of celiac serology in patients with ileal pouches is unknown. The aim of this study was to investigate the clinical implications of false-positive celiac serology in patients with ileal pouches. Methods All patients with pouches who had underlying ulcerative colitis and available celiac serology were included from the subspecialty Pouchitis Clinic at the Cleveland Clinic between 2002 and 2007. Chronic antibiotic-refractory pouchitis was diagnosed based on persistent symptomatic pouchitis after a 4-week single- or dual-antibiotic therapy. Results A total of 126 patients were studied, and a false-positive celiac serology was observed in 19 patients. Chronic antibiotic-refractory pouchitis was diagnosed in 47% (9/19) of patients with false-positive celiac serology compared with 14% (15/107) of patients with a negative celiac serology (P = .003). In multivariate analysis, the association between false-positive celiac serology and chronic antibiotic-refractory pouchitis remained significant (odds ratio, 5.4; 95% confidence interval, 1.7-16.7; P = .004) after adjusting for sex (P = .03), pouch duration (P = .83), the presence of autoimmune disorders (P = .46), and extraintestinal manifestations (P = .63). Conclusion False-positive celiac serology appeared to be common in patients with ileal pouch-anal anastomosis and it may be associated with chronic antibiotic-refractory pouchitis.

Insufficient lymph node harvest in presumed stage II colon carcinomas can result in understaging and worsened cancer outcomes. The purpose of this study was to evaluate factors affecting the number of lymph node examined, their corresponding impact on cancer outcomes, and the optimal number of examined nodes with reference to the standard of 12. We evaluated all patients undergoing surgery alone for stage II colon cancer included in our colorectal cancer database since 1976. A total of 901 patients were included. Mean follow-up exceeded 8 years. The individual pathologist had no statistically significant association with the number of lymph nodes examined. Harvest of at least 12 nodes was related to surgery after 1991 (85% vs 69%, P

Objective: To report the risk of metachronous colorectal neoplasia after colectomy for cancer in Hereditary Nonpolyposis Colorectal Cancer (HNPCC) syndrome. Summary background data: Patients meeting Amsterdam criteria for diagnosis of HNPCC have a lifetime colorectal cancer risk approaching 80%, and a metachronous cancer rate of approximately 25%. Therefore, when colon cancer is diagnosed, total rather than segmental colectomy is advocated. However, information about adenoma and carcinoma risk after index surgery is still underreported. Methods: A hereditary colorectal cancer database was reviewed for patients meeting Amsterdam criteria who underwent colectomy for cancer. Patient demographics, surgical management, and results of follow-up were recorded. Metachronous colorectal adenoma and carcinoma development were the primary end points. Results: A total of 296 patients (253 with segmental colectomy and 43 with total colectomy/ileorectal anastomosis) were analyzed. Of the 253 segmental colectomy patients, 221 (88%) had postoperative endoscopic surveillance with median follow-up of 104 months. In 74 patients (33%), 256 adenomas were detected, including 140 high-risk adenomas in 48 patients (22%). Fifty-five patients (25%) developed a second colorectal cancer at a median of 69 months after index surgery. Stages of the metachronous cancers were I-16, II-18, III-12, and IV-2. By comparison, 4 of 38 patients (11%) who underwent total colectomy developed subsequent high-risk adenomas and 3 (8%) developed metachronous cancer. Conclusions: Amsterdam patients undergoing partial colectomy have a high rate of metachronous high-risk adenomas and carcinomas. Total colectomy for the index cancer is the procedure of choice. For either surgical option, yearly endoscopic surveillance is essential to remove premalignant adenomas.

BACKGROUND: The effect of narcotic use in the disease course of ulcerative colitis has not been studied. The aim of the study was to evaluate the impact of narcotic use on the requirement for colectomy in inpatients with ulcerative colitis. METHODS: All eligible patients with ulcerative colitis admitted to gastroenterology service for disease flare-ups between 2002 and 2008 were included. Excluded were patients with ulcerative colitis admitted to the colorectal surgery service for emergent or elective colectomy and patients with Crohn's disease. Demographic, clinical, and laboratory data were reviewed. The definition of narcotics use was oral or intravenous administration of the agents during hospital admission or at hospital transfer. Multivariable analysis was performed. RESULTS: A total of 223 patients were included. One hundred six patients were males. The mean age was 38.7 ± 18.1 years. Forty-four patients (19.7%) were on oral or intravenous narcotics during the hospitalization. Sixty-seven patients (30%) had colectomy during the hospitalization and the colectomy rate was similar between narcotic user and nonnarcotic users (29.5% vs 30.2%, P = .9). In multivariable analysis, only the serum albumin level remained in the model as an independent risk factor associated with colectomy (OR = 0.4; 95% CI, 0.2-0.9; P = .03). Narcotic use was not an independent risk factor for colectomy in this study (P = .5). CONCLUSION: Narcotics were commonly prescribed to patients with ulcerative colitis who were admitted to the gastroenterology service. However, narcotic use appeared not to have a significant negative impact on the colectomy rate in inpatients with ulcerative colitis. In contrast, the low albumin level at flare was associated with an increased risk for colectomy.

Despite expected excellent outcomes of surgical resection for early stage rectal cancers, 20% of stage I and II rectal cancers recur. Identifying biologic factors that predict the subset prone to recur could allow more directed therapy. This study identifies a tumor gene expression profile that accurately predicts disease recurrence.Stage I/II rectal cancer patients treated by surgery alone at a single institution were included and classified as having recurrent or nonrecurrent cancer. Tumor mRNA was isolated from frozen tissue and evaluated for total genome gene expression by microarray analysis. Background-corrected and normalized microarray data were analyzed using BAMarray software. Selected genes were further analyzed using unsupervised clustering and nearest-centroid classification. A balanced K-fold scoring-pair algorithm using 1,000 independent replications was used for gene signature development.Sixty-nine patients with disease-free survival and 31 patients with recurrent disease were included at a median follow-up of 105 months (interquartile range 114 months) and 32 months (interquartile range 25 months), respectively. Demographics and tumor characteristics between groups were similar. Fifty-two genes from 43,148 probes were differentially expressed, and a 36-gene signature was found to be statistically associated with recurrence using a scoring-pair algorithm. Accuracy to identify recurrence as measured by area under the receiver operating characteristic curve was 0.803.Differential gene expression within rectal cancers is associated with recurrence of early stage disease. A 36-gene signature correlates with an increased risk of more or less aggressive tumor behavior. This information obtainable at biopsy may assist in determining treatment decisions.

The aim of this study was to evaluate whether stapler size used at ileal pouch-anal anastomosis (IPAA) influences outcomes.Data of patients undergoing stapled IPAA (1983-2007) were obtained. Differences between groups A (stapler size 28-29 mm) and B (31-33 mm) for pre- and perioperative factors, stricture, leak, quality of life (QOL), and function were compared. Associations between stapler size and stricture or leak were assessed with a multivariable Cox model.Groups A (n = 1,221) and B (n = 899) had comparable age, diagnosis, body mass index (BMI), and albumin level. Group B had more males (P.001) but fewer patients with ileostomy (P.001). There was no significant difference in rates of leak (4.5% vs 6.2%, P = .08) or stricture (1.9% vs 2.7%, P = .1) for groups A and B. On multivariate analysis, female gender was associated with stricture, while greater BMI and male gender were associated with leak. Group A had greater urgency at 1 year and nighttime pad use at 15 years. The other determinants of function and QOL were similar.There was no significant association between the size of stapler used at IPAA and long-term complications.

Aim The morbidity of surgical site infections (SSIs) were compared in patients who underwent open (OS) vs laparoscopic (LS) colorectal surgery. Method Data from 603 consecutive LS patients and 2246 consecutive OS patients were prospectively recorded. Morbidity of SSIs was assessed by the need for emergency department (ED) evaluation, subsequent hospital re-admission and re-operation. The cost of wound care was measured by the need for home healthcare, wound vacuum assisted closure (VAC) or independent patient wound care. Results SSIs were identified in 5.8% (n = 25) of LS patients and 4.8% (n = 65) of OS patients. ED evaluation for the infection was needed in 24% of the LS group and 42% of the OS group. Hospital re-admission was needed in one LS patient and in 52% OS patients. No LS patient needed re-operation compared with 12% of OS patients. HHC ($162/dressing change) was required in 63% of the OS group compared with 8% of LS group. A home wound VAC system ($107/day) was utilized in 12% of the OS patients but in none of the LS patients. Dressing changes were managed independently by the patient in 92% of the LS compared with 37% of the OS patients. Conclusion Laparoscopic colorectal surgery patients experience less morbidity when they develop SSIs incurring less cost compared with open colorectal surgery patients.

Few studies have evaluated factors that may be associated with the development of septic complications after restorative proctocolectomy. Therefore, the aim of this study is to evaluate preoperative and operative factors that might be associated with septic complications after restorative proctocolectomy.Patients developing abdominal and pelvic septic complications after restorative proctocolectomy were identified from a prospective database. Patients with subclinical leaks and ileostomy closure leak were not included in the septic complication group. A multivariable logistic regression model for sepsis was constructed using a forward stepwise selection with entry criterion of P0.05.From 1983 to 2007, 3233 patients (56% male) were included in the database. Eight-four percent (2597) of patients underwent proximal diversion. Two hundred patients (6.2%) developed septic complications within 3 months of restorative proctocolectomy or within 3 months of ileostomy closure. On multivariate analysis, body mass index30 (P = 0.02, OR = 1.77), final pathologic diagnosis of ulcerative/indeterminate colitis (P = 0.02, OR = 2) or Crohn's disease (P = 0.02, OR = 3.6), intraoperative (P = 0.02, OR = 1.6), and postoperative transfusions (P = 0.01, OR = 1.9) were all independently associated with septic complications. We also demonstrated an independent association among individual surgeons (P = 0.04) with decreased septic complications.Body mass index greater than 30, final pathologic diagnosis of ulcerative/indeterminate colitis or Crohn's disease, intraoperative and postoperative transfusions, and surgeon were all independent factors associated with septic complications after restorative proctocolectomy.

Objective We evaluated outcomes after hand-assisted (HALC) and straight laparoscopic (LC) techniques for the initial laparoscopic total abdominal colectomy (TAC) procedures performed by surgeons starting their laparoscopic careers. Method The first eight HALC cases of two surgeons performing TAC by this technique (Group A) were compared with the first (Group B) and last eight (Group C) TAC cases of three surgeons performing LC. Groups A and B were compared with a matched group of open total colectomy cases (Group D) and to the eight cases performed by an experienced surgeon (Group E). Demographics, intra-operative and postoperative outcomes including operation time, morbidity, conversion and readmission rates and length of hospital stay (LOS) were compared using Wilcoxon or Chi-squared tests. Results Demographics of the patients were similar. Groups A, B C and E had similar operating time (P = 0.10) which was significantly longer than Group D (P

The aim of this study was to evaluate whether downstaging impacts prognosis in patients with cII versus cIII rectal cancer. We identified from our colorectal cancer database 295 patients with primary cII and cIII rectal cancer staged by CT and ERUS/MRI who received 5-FU-based chemoradiation followed by R0 surgery after a median interval of 7 weeks during 1997–2007. The median radiotherapy dose was 5040 cGy. We excluded 58 patients with pathologic complete response (pCR) and compared among the remaining 162 patients pathologic downstaging (cII to ypI, cIII to ypII or ypI) versus no pathologic downstaging (c stage ≤ yp stage). Outcomes evaluated were 5-year overall survival, 3-year cancer-specific survival, disease-free survival, overall recurrence, local recurrence, and distant recurrence. The median age was 58 years and median follow-up was 48 months. Patients with downstaging versus no downstaging were statistically comparable with respect to demographics, chemoradiation regimen, interval time between neoadjuvant chemoradiation and surgery, tumor distance from anal verge, surgical procedures performed, and follow-up time. With the exception of local recurrence rates, downstaging resulted in significantly improved cancer outcomes for cIII but not cII. Downstaging without pCR is a significant prognostic factor for patients with stage cIII rectal cancer. Tumor response to neoadjuvant chemoradiation should be taken into account when defining the optimal adjuvant chemotherapy regimen for patients with cIII rectal cancer.

Conceivably, the benefits of earlier recovery associated with a minimally invasive technique used in laparoscopic colectomy (LC) may be amplified for patients with comorbid disease. The dearth of evidence supporting the safety of laparoscopy for these patients led to a comparison of outcomes between LC and open colectomy (OC) for patients with American Society of Anesthesiology (ASA) classifications 3 and 4.Data for all ASA 3 and 4 patients who underwent elective LC were reviewed from a prospectively maintained laparoscopic database. The patients who underwent LC were matched with OC patients by age, gender, diagnosis, year, and type of surgery. Estimated blood loss, operation time, time to return of bowel function, length of hospital stay, readmission rate, and 30-day complication and mortality rates were compared using chi-square, Fisher's exact, and Wilcoxon tests as appropriate. A p value0.05 was considered statistically significant.In this study, 231 LCs were matched with 231 OCs. The median age of the patients was 68 years, and 234 (51%) of the patients were male. There were 44 (19%) conversions from LC to OC. More patients in the OC group had undergone previous major laparotomy (5 vs. 15%; p0.001). Estimated blood loss, return of bowel function, length of hospital stay, and total direct costs were decreased in the LC group. Wound infection was significantly greater with OC (p = 0.02). When patients with previous major laparotomy were excluded, the two groups had similar overall morbidity. The other benefits of LC, however, persisted.The findings show that LC is a safe option for patients with a high ASA classification. The LC approach is associated with faster postoperative recovery, lower morbidity rates, and lower hospital costs than the OC approach.

Inderbir S. Gill • Arnold P. Advincula • Monish Aron • Jeffrey Caddedu • David Canes • Paul G. Curcillo II • Mihir M. Desai • John C. Evanko • Tomasso Falcone • Victor Fazio • Matthew Gettman • Andrew A. Gumbs • Georges-Pascal Haber • Jihad H. Kaouk • Fernando Kim • Stephanie A. King • Jeffrey Ponsky • Feza Remzi • Homero Rivas • Alexander Rosemurgy • Sharona Ross • Philip Schauer • Rene Sotelo • Jose Speranza • John Sweeney • Julio Teixeira

INTRODUCTION: Technical complications after ileal pouch-anal anastomosis may be mislabeled as Crohn's disease. The purpose of our study is to evaluate the presentation, treatment, and outcomes of patients with a potential misdiagnosis of Crohn's disease who have undergone redo ileal pouch-anal anastomosis. METHODS: We evaluated a historical cohort of patients, initially referred from outside institutions with a diagnosis of Crohn's disease of the pouch, who subsequently had redo ileal pouch-anal anastomosis (redo pouch or pouch revision for pouch failure) at our institution. With the use of validated questionnaires, the functional outcomes and quality of life of this cohort were compared with a control group of patients who underwent primary ileal pouch-anal anastomosis to assess whether a change in the diagnosis from Crohn's disease to technical complications was appropriate. RESULTS: Thirty-three patients underwent a redo pouch procedure for a previous diagnosis of Crohn's disease of the pouch. Precolectomy diagnosis included ulcerative colitis (31 patients) and indeterminate colitis (2 patients). Findings on our further evaluation and subsequent indications for repeat pouch surgery included pouch fistula (20 patients), pelvic sepsis or anastomotic leak (17 patients), stricture (4 patients), refractory pouchitis (2 patients), long exit conduit (1 patient), and retained rectal stump (1 patient). All patients had medical treatment for Crohn's disease before referral. Median time between primary and redo pouch was 2.1 years (interquartile range, 1.8–4.9). Median follow-up was 1.7 years (interquartile range, 1.0–3.5). Pouch retention rate was 84.8%. Five patients (15.2%) had pouch failure. Seven patients (21.2%) ultimately had pathology consistent with Crohn's disease. Comparison of the redo pouch and control groups revealed that functional outcomes and quality of life were similar between groups. CONCLUSION: Patients identified as having Crohn's disease need to be carefully reevaluated because some of these patients may actually have surgery-associated complications and can have a favorable long-term outcome after redo ileal pouch-anal anastomosis.

This study was designed to evaluate functional outcome in patients treated with preoperative radiotherapy after low anterior resection and a coloanal anastomosis for low rectal cancer.Functional outcome data from patients enrolled in a prospective randomized trial comparing 3 reconstructive procedures were evaluated with respect to administration of preoperative radiotherapy. Incontinence was assessed with a questionnaire on bowel function including the Fecal Incontinence Severity Index; sexual function was assessed with the Sexual Health Inventory for Men and a gender-specific questionnaire for women. Quality of life was assessed with SF-36 scores.Of 364 patients enrolled, 153 (42%) had no radiotherapy or chemotherapy, and 211 (58%) had preoperative radiotherapy; 186 (51%) had chemotherapy in addition to radiotherapy. Comparison of irradiated vs. nonirradiated patients showed no significant differences in postoperative morbidity (29.9% vs. 35.3%; P = 0.27). Two-year follow-up of 297 patients showed greater impairment of bowel function in irradiated patients (n = 170) vs. nonirradiated patients (n = 127): e.g., mean number of daily bowel movements at 12 months, 4.2 +/- 3.5 vs. 3.5 +/- 2.6, P = 0.032; urgency, 85% vs. 67%, P = 0.002). Antidiarrheal use was significantly higher in irradiated patients vs. nonirradiated patients at 4 (P = 0.043), 12 (P = 0.002), and 24 (P = 0.001) months. Sexual Health Inventory for Men scores indicated poorer function in irradiated patients at 24 months (P = 0.039). Preoperative radiotherapy had no deleterious effects on quality of life. Multivariate analyses showed that negative effects of preoperative radiotherapy on urgency at 4 months (P = 0.002) and antidiarrheal use at 24 months were independent of reconstruction technique, but a positive effect of reconstruction with a J-pouch was still observed in patients who received radiotherapy.Preoperative radiotherapy does not increase overall morbidity but is associated with poorer functional outcome after low anterior resection with coloanal anastomosis. Preoperative radiotherapy and the J-pouch are nonconfounding predictors of functional outcome up to 24 months after surgery.

This study was designed to evaluate factors that might be predictive of readmission and early and long-term outcomes for patients readmitted after ileal pouch-anal anastomosis.Data for patients readmitted within 30 days after ileal pouch-anal anastomosis were identified from a prospectively maintained database and compared with the remaining patients. Early and delayed outcomes for readmitted patients, including long-term functional outcomes and quality of life, were evaluated. Potential predictors of readmission were assessed using a multivariate analysis of factors.Of 3,410 patients who underwent ileal pouch-anal anastomosis from 1984 to 2008, 410 (12%) were readmitted. Reasons for readmission included ileus, obstruction or dyselectrolytemia (54.9%), surgical site infection (19.8%), anastomotic problems (9.8%), and thrombotic (3.4%), hemorrhagic (3.2%), infectious (2.9%), cardiac (1.2%), and miscellaneous (4.3%) complications. Thirty-two (7.8%) patients underwent reoperation; 74 (18%) required invasive nonoperative interventions. Median hospital stay for readmission was four (range, 1-52) days. Readmitted patients had worse long-term functional results (P = 0.015) and social (P = 0.024), work (P = 0.008), and sexual (P = 0.046) restriction as compared with patients who were not readmitted. The Cleveland Global Quality of Life (P = 0.018) and physical SF-36 (P = 0.008) scores were also significantly lower for readmitted patients. On multivariate analysis, comorbid conditions (P = 0.014, odds ratio = 1.36), laparoscopic technique (P = 0.008, odds ratio = 1.8), proctocolectomy (rather than initial subtotal colectomy) at ileal pouch-anal anastomosis (P0.001, odds ratio = 1.55), and postoperative blood transfusion (P = 0.02, odds ratio = 1.54) were independently associated with readmission.Early readmission after ileal pouch-anal anastomosis is common. Associated comorbidity, laparoscopic approach, reconstruction of the ileal pouch-anal anastomosis at the index surgery, and postoperative blood transfusion are associated with readmission.

This study evaluates factors associated with a pathologic complete response (pCR) after neoadjuvant chemoradiation for rectal cancer.Approximately 20% of rectal cancer patients undergoing neoadjuvant chemoradiation achieve pCR, which has been associated with decreased local recurrence and improved recurrence-free survival. Means of predicting pCR remain incompletely defined.A total of 306 consecutive patients with stage II or stage III rectal cancer who underwent neoadjuvant chemoradiation then surgery between 1997 and 2007 were identified from a single-institution. Sixty-four patients with concurrent inflammatory bowel disease, hereditary colorectal cancer, other malignancy, urgent surgery, incomplete chemoradiation, or insufficient data were excluded. All patients received neoadjuvant 5-FU-based chemotherapy and external beam radiation. Histologic response was categorized as pCR or not-pCR, which defined the 2 study cohorts. Variables were analyzed by univariate and multivariate analysis with pCR as the dependent variable. Fisher exact test, chi2, Wilcoxon rank-sum, and logistic regression were used for analysis. P0.05 was considered statistically significant.Of the total patients, 242 were studied, including 58 (24%) that achieved pCR. The 2 groups were statistically similar in terms of age, gender, body mass index, tumor differentiation, radiation dose, and pretreatment stage. On multivariate analysis, an interval ≥ 8 weeks between treatment completion and surgical resection was significantly associated with a higher rate of pCR, which correlated with decreased local recurrence and improved overall survival.Despite traditional beliefs that certain patient and tumor factors influence pCR, an extended interval between completion of neoadjuvant therapy and surgery was the single most important determinant in achieving a pCR.

Background. A 61-year-old woman who had undergone an ileostomy closure 10 days previously presented to a tertiary medical center with abdominal pain, vomiting, diarrhea, dehydration, and oliguria. The patient had undergone a staged total proctocolectomy with ileal-pouch-anal anastomosis and a loop ileostomy 8 months previously to treat her steroid-refractory ulcerative colitis.Investigations. Physical examination, abdominal and pelvic CT scan, blood laboratory tests, pouch endoscopy, and fecal testing for Clostridium difficle toxins A and B.Diagnosis. Fulminant C. difficile-associated pouchitis and enteritis, which led to Psuedomonas aeruginosa septicemia, intravascular coagulopathy, acute renal failure, hemorrhagic ascites and respiratory failure and eventual death.Management. Intravenous hydration, aggressive therapy with oral and intravenous antibiotics, supportive care, hemodialysis, and intubation.

Aim The aim of this study was to determine preoperative clinical factors associated with subsequent diagnosis revision to Crohn’s disease (CD) following total proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) or indeterminate colitis (IC) patients. Method Presumed UC and IC patients undergoing IPAA from a large single-institution prospective database with change of diagnosis to CD were identified and compared with patients without diagnosis change. Results A total of 2814 patients (47% male, median age 37 years) with presumed UC (85%) or IC (15%) underwent primary IPAA. At a median follow up of 9.6 years, 184 (7%) had the diagnosis revised to CD from histopathological examination of the colectomy specimen immediately in 97 (53%) or at a median interval of 36 months in 87 (47%). CD and UC/IC patients had had a similar operative technique, length of stay and 30-day morbidity. The postoperative CD diagnosis was associated with a preoperative diagnosis of IC (P

Liver involvement is common in patients with inflammatory bowel disease (IBD). However, the frequency and the significance of liver function test (LFT) abnormalities in patients with ileal pouch-anal anastomosis (IPAA) for underlying IBD have not been studied. The aim of this study was to evaluate the prevalence and to identify risk factors for abnormal LFTs in patients with IPAA and underlying IBD.All patients were identified from our prospectively maintained Pouchitis Database between 2002 and 2008. Abnormal LFTs were classified as the following: (i) any abnormal elevation of transaminases, and/or alkaline phosphatase (ALP), and/or bilirubin; (ii) hepatitis, if there was more than twice the elevation of transaminases; and (iii) cholestatic, if there was more than 1.5 times elevation of ALP. Clinical, endoscopic, and histological variables were assessed using Cox proportional hazard models for evaluating risk for abnormal LFTs.A total of 545 IPAA patients with underlying IBD were identified from the database, of which 373 patients who had LFTs done after their pouch surgery were included. This included 346 patients with ulcerative colitis, 25 with indeterminate colitis, and 2 with Crohn's colitis before surgery. Their mean age was 45.9+/-13.8 years. A total of 65 patients (17.4%) (40 men, 25 women, median age: 47 years) had abnormal LFTs. Of the patients, 52 (13.9%) had abnormal transaminases, whereas 15 (4%) were classified as having hepatitis. Thirty-five (9.4%) patients had an abnormal ALP level, with 18 (4.8%) classified as cholestatic. The most common cause of an abnormal LFT was transient elevation in 32 (49.2%) patients, followed by fatty liver (fatty change on imaging with body mass index (BMI)or =25 kg/m(2) in the absence of other causes, including alcohol abuse and drug-induced hepatitis) in 10 (15.4%), drug-induced abnormal LFTs in 7 (10.7%), and chronic hepatitis B or C in 6 (9.2%). Primary sclerosing cholangitis (PSC) was responsible for abnormal LFTs in 10 patients (15.4%). Cox proportional hazard model analysis showed that BMI (hazard ratio (HR)=1.07, 95% confidence interval (95% CI): 1.02, 1.12; P=0.003), the presence of PSC (HR=4.49, 95% CI: 1.45, 13.89; P=0.009), autoimmune disorder (HR=2.54, 95% CI: 1.09, 5.93; P=0.031), a family history of IBD (HR=2.32, 95% CI: 1.29, 4.17; P=0.005), and extensive colitis before colectomy (HR=4.59, 95% CI: 2.04, 10.33; P0.001) predicted any abnormal LFTs.Abnormal LFTs were common in patients with IPAA in this cohort. The presence of co-existing autoimmune disorder, a family history of IBD, extensive colitis before colectomy, the presence of PSC, and a high BMI appear to be a significant risk factors for abnormal LFTs. Whether abnormal LFTs affect health-related quality of life, pouch survival, and selection of pouch-related medical therapy requires further investigation.

Background The Turnbull–Cutait abdominoperineal pull-through procedure (T-C) is used as a last resort to avoid permanent diversion in patients with complex anorectal conditions. The aim was to evaluate short- and long-term outcomes after T-C. Methods Patients undergoing T-C from 1996 to 2007 were reviewed retrospectively in terms of demographics, diagnosis, indications and postoperative complications. Patients were contacted to obtain functional outcomes using a standardized questionnaire. Functional outcomes were compared with those in a matched group of patients undergoing handsewn coloanal anastomosis (CAA) for rectal cancer. Results Sixty-seven patients (40 men) underwent T-C. Postoperative complications included stricture in 11 patients (16 per cent), fistula in five (7 per cent), prolapse of the colon in five (7 per cent) and leak in two (3 per cent). Mean follow-up was 5·6 (s.d. 3·2) years. The operation failed in 17 patients (25 per cent). Among 44 patients (66 per cent) who completed questionnaires, faecal (P = 0·121) and urinary (P = 0·073) incontinence, and sexual function (P = 0·063) were comparable to those in patients who had CAA. Conclusion T-C is an option for patients with complex anorectal conditions that might otherwise require permanent diversion. Functional outcomes are comparable to those of CAA.

PURPOSE: Outcomes for patients developing a leak after ileal pouch-anal anastomosis have not been well investigated. This study explored whether the use of a stapled or handsewn anastomosis was associated with different outcomes when an anastomotic leak developec PATIENTS AND METHODS: Patients were identified from a prospectively maintained pouch database. Functional outcomes regarding bowel movements, urgency, continence, and seepage were evaluated. Quality of life was assessed by the Cleveland Global Quality of Life Score. RESULTS: One hundred and seventy-five patients with anastomotic leak (141 stapled and 34 handsewn anastomosis) were identified. The two groups were similar in gender and diagnosis. Patients with handsewr anastomosis were younger (P = 0.04), had less perioperative steroid use (P = 0.05), more proximal diversion (P = 0.02), and S-pouch creation (P = 0.003). More handsewn cases had intraoperative transfusion (P = 0.04) and postoperative hemorrhage within the pelvis (P = 0.003). Long-term pouch failure was 35.3 percent in the handsewn group and 12 percent in the stapled group (P = 0.002), which was confirmed by Kaplan-Meier analysis (Log-rank P = 0.007). On multivariate analysis, leak after handsewn anastomosis was independently associated with pouch failure. Leak after stapled anastomosis carried a lower incontinence rate at 5 years (P = 0.03), while handsewn had higher nocturnal seepage rate at 3, 5, and 10 years, and most recent follow-up. Cleveland Global Quality of Life Score was comparable between the groups during follow-up. CONCLUSION: Outcomes including functional results and pouch failure rates for patients developing a leak after stapled anastomosis at ileal pouch-anal anastomosis were significantly better than outcomes for patients who develop a leak after handsewn anastomosis.

Autoimmune disorders (ADs) frequently coexist with inflammatory bowel disease. The aim of the study was to determine whether coexisting AD in patients with ileal pouches increases the risk for chronic antibiotic-refractory pouchitis (CARP) and other inflammatory conditions of the pouch.A total of 622 patients seen in our Pouchitis Clinic were enrolled. We compared the prevalence of adverse outcomes of the pouch (including CARP, Crohn's disease of the pouch, and pouch failure) in patients with or without concurrent AD and assessed the factors for these adverse outcomes.There were seven pouch disease categories: normal (N=60), irritable pouch syndrome (N=112), active pouchitis (N=131), CARP (N=67), Crohn's disease (N=131), cuffitis (N=83), surgical complications (N=36), and anismus (N=2). The prevalence of AD in these pouch disease categories was 4.5%, 12.5%, 9.2%, 13.4%, 10.7%, 3.8%, 1.5%, and 0%, respectively. The presence of at least one AD at time of pouch surgery was shown to be associated with a twofold increase in the risk for CARP (hazard ratio=2.29; 95% CI: 1.52, 3.46; P0.001) and for pouch-associated hospitalization (hazard ratio=2.39; 95% CI: 1.59, 3.58; P0.001). The presence of AD was not associated with increased risk for irritable pouch syndrome, active pouchitis, Crohn's disease, cuffitis, surgical complications, or pouch failure. Patients with Crohn's disease of the pouch had a 2.42 times higher risk for pouch failure (P=0.042) than these without. Active smoking or a history of smoking was shown to be associated with an increased risk for pouch-associated hospitalization and pouch failure.AD appears to be associated with an increased risk for CARP, and the presence of the association between these AD and pouch disorders may stimulate further research on the link of these organ systems on an immunological basis.

Background: Although wireless capsule endoscopy (WCE) is widely used in the assessment of small bowel pathology, its application in patients with ileal pouches has not been evaluated. Persistent anemia has been observed in patients with ileal pouches, for which identification of etiology can be challenging. Aim: To assess the utility of WCE in ileal pouch patients with persistent anemia in conjunction with other diagnostic modalities. Methods: Ulcerative colitis patients with persistent anemia (hemoglobin < 10g/dL) at least 12 months after either ileal pouch-anal anastomosis or continent ileostomy surgery were studied. Esophagogastroduodenoscopy, pouch endoscopy, WCE, and celiac disease serology were studied. The final diagnosis of the etiology of anemia was based on the results from the combined assessment of clinical, endoscopic, histologic, and laboratory data. Results: Seventeen ileal pouch patients (10 females, 7 males) with underlying inflammatory bowel disease were studied with a mean age 42.1 ± 15.2 years. Nine patients (52.9%) had active pouchitis and 3 (17.6%) had Crohn's disease (CD). WCE was successfully completed in 16 patients (94.1%). Suspected causes of anemia were identified in 5 patients (29.4%): 2 patients with CD of the pouch and 1 patient with celiac disease, detected by esophagogastroduodenoscopy, pouch endoscopy, small bowel biopsy, and celiac disease serology, and 1 patient with CD of the small bowel and 1 patient with small bowel arterio-venous malformations shown on WCE only. Conclusions: WCE seemed to be feasible and well tolerated in patients with ileal pouches. WCE provided additional diagnostic information in the pouch patients with anemia.

BACKGROUND: Irritable pouch syndrome (IPS) is a functional disease in patients with ileal pouch-anal anastomosis following colectomy for ulcerative colitis (UC). The pathophysiology of IPS is characterized by the presence of visceral hypersensitivity, similar to that seen in irritable bowel syndrome. However, the exact etiology and pathogenesis of IPS are not known. We hypothesized that serotonin-containing enteroendocrine cells or enterochromaffin (EC) cell hyperplasia and alterations in the mucosal immune cells may contribute to the patients' symptoms. The aim of the study was to assess EC cell hyperplasia and alterations in the mucosal immune cells in IPS. METHODS: The Pouchitis Disease Activity Index (PDAI) was used to quantify symptoms and mucosal inflammation in 36 patients with IPS and 25 patients with normal pouches. The histology and immunohistochemistry of pouch mucosal biopsies were assessed by a blinded gastrointestinal pathologist for intraepithelial lymphocytes (IEL), CD3+ T cells, CD25- (interleukin [IL]-2 receptor), tryptase- (mast cells), and serotonin-expressing cells. The numbers of IEL and immune-stained cells were compared between the two groups. RESULTS: Both groups were compatible demographically in terms of age, gender, duration of UC, stage, indication, and duration of the pouch surgery. There were no differences in the number of IEL, CD3+ T cells, CD25+ cells, and mast cells between the IPS and normal control groups. However, there were a significantly larger number of EC cells in the IPS group than that in the control group (54.8 +/- 24.9 vs 36.7 +/- 17.5 per 4 200x epithelial cells, P < 0.005). The number of EC cells appeared to be correlated with the symptom score (r = 0.276, P= 0.032). There were no significant correlations between the PDAI endoscopy and histology scores and the number of EC cells or between the PDAI scores and the number of IEL or other immune-stained cells. CONCLUSIONS: A greater number of EC cells were found in the IPS group than the normal pouch group, and the number of EC cells appeared to be correlated with the clinical symptoms of IPS. EC cell hyperplasia may be a contributing mechanism of visceral hypersensitivity and symptoms in IPS.

The clinical features of postoperative bleeding from the ileal pouch-anal anastomosis(IPAA) vary and its management can be difficult. There is no published literature regarding pouch bleeding and its treatment.Pouch bleeding was defined as the passage of blood or clots transanally or into the ileostomy bag with or without hypotension or a drop in hemoglobin within 30 days after surgery. Patients were identified from a prospectively maintained pouch database.Pouch bleeding developed in 47 (1.5%) patients out of 3,194 patients undergoing IPAA since 1983. Forty-two patients had inflammatory bowel disease, four had familial adenomatous polyposis, and one had colonic inertia. Sixty-six percent of bleeding occurred within 7 days postoperatively and 59.6% required transfusion; 72.3% patients developed transanal bleeding, nine from ileostomy and two from both. After initial fluid resuscitation, five patients were observed while 28 patients had pouch endoscopy and clot evacuation followed by cauterization or epinephrine(1:100,000) enemas, 27 of these had cessation within 24 h. Epinephrine enema was used as initial treatment in the remaining 12 patients. Overall success rate of epinephrine enema was 96%.Postoperative pouch bleeding after IPAA is uncommon, and it usually requires nonsurgical intervention. Epinephrine enema appears to be successful in managing this complication.

Background: Crohn's disease (CD) of the pouch is one of the leading causes of pouch failure in patients with restorative proctocolectomy. Risk factors for pouch failure in these patients are yet to be identified. The aim of the study was to assess risk factors associated with pouch failure in patients with CD of the pouch. Methods: All patients with a confirmed diagnosis of CD of the pouch in the Pouchitis Clinic between 2002 and 2007 were evaluated. Patients with familial adenomatous polyposis, normal pouches, pouchitis, cuffitis, surgical complications, and other diseased pouch conditions were excluded. Pouch failure was defined as the requirement for a permanent diversion or pouch resection. Demographic and clinical factors were studied with univariable and multivariable analyses. Results: A total of 137 patients with CD of the pouch were included. Twenty-two patients (16%) developed pouch failure a median of 6 years after ileostomy takedown. Four of 50 patients (8.0%) with inflammatory CD, 4 of 30 (13.3%) with fibrostenotic CD, and 14 of 57 (24.6%) with fistulizing CD had pouch failure. A Kaplan-Meier plot for time to pouch failure by CD phenotype showed a trend toward association (P = 0.054) in patients with fistulizing CD. Adjusting for age, smoking status, and the use of immunomodulators or biologics, fistulizing CD was not found to be significantly associated with a higher hazard for pouch failure. Younger age, being an ex-smoker, and the use of immunomodulators or biologics were found to increase the hazard of pouch failure. Conclusions: Younger age, being an ex-smoker, and the requirement for immunomodulators or biologics were associated with pouch failure. The identification of these risk factors may help delineate the natural history of CD of the pouch and shed light on proper clinical management and prognosis. (Inflamm Bowel Dis 2008)

Restorative proctocolectomy with ileal pouchanal anastomosis (IPAA) is the surgical treatment of choice for complicated ulcerative colitis. Development of ileal pouch-related cancer is a rare event and usually occurs in association with backwash ileitis or chronic pouchitis. We report a case of adenocarcinoma at the inlet of an ileal pouch in a 68-year-old Caucasian male, 14 years after restorative proctocolectomy for ulcerative colitis in the absence of severe chronic pouchitis or backwash ileitis. The operative technique is described, with a review of the literature on ileal pouch cancer.