Barriers and Facilitators of Colorectal Cancer Screening During the COVID-19 Pandemic.

BACKGROUND: COVID-19 introduced new barriers to health care including cancer screenings. This study evaluated the role of pandemic- and copay-related barriers to colonoscopy and the extent to which home-based testing methods were utilized. METHODS: A cross-sectional survey assessed colorectal cancer (CRC) attitudes and screening early in the COVID-19 pandemic. RESULTS: Respondents (342; 50.37% female) were 62.32 (SD = 6.87) years old. Roughly half were White/Caucasian (329; 48.45%); 29.75% were Black/African American (202); and 21.80% were another race (148). Roughly two-thirds were up-to-date with CRC screening (459; 67.59%). In an adjusted model, those with a higher agreement that concerns about COVID-19 delayed scheduling their colonoscopy (OR = .79; 95% CI: .08, .63; P = .045) and concerns about copays delayed scheduling their colonoscopy (OR = .73; 95% CI: .73, .57; P = .02) were less likely to be up-to-date on screening. In another adjusted model, those screened during the pandemic were significantly more likely to be screened via an at-home test (OR = 10.93; 95% CI: 5.95, 20.27; P < .001). DISCUSSION: During the COVID-19 pandemic, screening copay-related concerns persisted and were significantly higher among those not up-to-date with CRC screening. Increased at-home testing and addressing copay barriers may increase CRC screening adherence now and in future infectious disease outbreaks.

Virtual Ileostomy as an Option for Complicated Colorectal Resections.

When surgery requires a colorectal anastomosis, a diverting ostomy may be created to decrease the clinical impact of anastomotic failure. Unfortunately, diverting ileostomies are also associated with significant morbidity. Recent literature suggests that diverting ostomies are not necessary for the majority of patients undergoing colorectal anastomosis and that creation of a virtual ileostomy (VI) may spare patients the complications that accompany diverting ileostomy creation. We present 4 patients with complex medical histories who underwent colorectal resections with primary anastomoses and VI creation. None of these patients suffered anastomotic leak or required conversion of VI to defunctioning ileostomy and there were no major complications associated with VI creation. Our results, although limited by sample size, support the creation of a virtual ileostomy as a safe and effective alternative to diverting ileostomy creation at the time of colorectal anastomosis.

Prospective Cohort Study to Investigate the Safety of Preoperative Tumor Necrosis Factor Inhibitor Exposure in Patients With Inflammatory Bowel Disease Undergoing Intra-abdominal Surgery.

BACKGROUND & AIMS: Whether preoperative treatment of inflammatory bowel disease (IBD) with tumor necrosis factor inhibitors (TNFis) increases the risk of postoperative infectious complications remains controversial. The primary aim of this study was to determine whether preoperative exposure to TNFis is an independent risk factor for postoperative infectious complications within 30 days of surgery. METHODS: We conducted a multicenter prospective observational study of patients with IBD undergoing intra-abdominal surgery across 17 sites from the Crohn's & Colitis Foundation Clinical Research Alliance. Infectious complications were categorized as surgical site infections (SSIs) or non-SSIs. Current TNFi exposure was defined as use within 12 weeks of surgery, and serum was collected for drug-level analyses. Multivariable models for occurrence of the primary outcome, any infection, or SSI were adjusted by predefined covariates (age, sex, preoperative steroid use, and disease type), baseline variables significantly associated (P < .05) with any infection or SSI separately, and TNFi exposure status. Exploratory models used TNFi exposure based on serum drug concentration. RESULTS: A total of 947 patients were enrolled from September 2014 through June 2017. Current TNFi exposure was reported by 382 patients. Any infection (18.1% vs 20.2%, P = .469) and SSI (12.0% vs 12.6%, P = .889) rates were similar in patients currently exposed to TNFis and those unexposed. In multivariable analysis, current TNFi exposure was not associated with any infection (odds ratio, 1.050; 95% confidence interval, 0.716-1.535) or SSI (odds ratio, 1.249; 95% confidence interval, 0.793-1.960). Detectable TNFi drug concentration was not associated with any infection or SSI. CONCLUSIONS: Preoperative TNFi exposure was not associated with postoperative infectious complications in a large prospective multicenter cohort.

The Pathogenesis and Clinical Management of Stricturing Crohn Disease.

Stricturing of the gastrointestinal tract is a common complication in Crohn disease and is a significant cause of morbidity and mortality among this population. The inflammatory process initiates fibrosis, leading to aberrant wound healing and excess deposition of extracellular matrix proteins. Our understanding of this process has grown and encompasses cellular mechanisms, epigenetic modifications, and inherent genetic predisposition toward fibrosis. Although medications can improve inflammation, there is still no drug to attenuate scar formation. As such, management of stricturing disease requires a multidisciplinary and individualized approach including medical management, therapeutic endoscopy, and surgery. This review details the current understanding regarding the pathogenesis, detection, and management of stricturing Crohn disease.

Palliative Care in Inflammatory Bowel Disease: A New Partnership.

Background: Palliative care (PC) is being increasingly recognized for benefitting patients with a wide spectrum of chronic serious medical conditions. Methods: Care models and principles of PC for patient with inflammatory bowel disease were explored. Results: The use of a structured and systematic approach for emotionally laden conversations and the "Total Pain" paradigm are examples of PC expertise that can be applied through either primary or consultative PC models. Conclusions: PC should be considered in clinical practice and as a topic for further scholarly investigation to further define its role and benefits.

BioSphincters to treat Fecal Incontinence in Nonhuman Primates.

Loss of anorectal resting pressure due to internal anal sphincter (IAS) dysfunctionality causes uncontrolled fecal soiling and leads to passive fecal incontinence (FI). The study is focused on immediate and long-term safety and potential efficacy of bioengineered IAS BioSphincters to treat passive FI in a clinically relevant large animal model of passive FI. Passive FI was successfully developed in Non-Human Primates (NHPs) model. The implantation of autologous intrinsically innervated functional constructs resolved the fecal soiling, restored the resting pressure and Recto Anal Inhibitory Reflex (RAIR) within 1-month. These results were sustained with time, and efficacy was preserved up to 12-months. The histological studies validated manometric results with the regeneration of a well-organized neuro-muscular population in IAS. The control groups (non-treated and sham) remained affected by poor anal hygiene, lower resting pressure, and reduced RAIR throughout the study. The pathological assessment of implants, blood, and the vital organs confirmed biocompatibility without any adverse effect after implantation. This regenerative approach of implanting intrinsically innervated IAS BioSphincters has the potential to offer a better quality of life to the patients suffering from FI.

Successful Treatment of Passive Fecal Incontinence in an Animal Model Using Engineered Biosphincters: A 3-Month Follow-Up Study.

Fecal incontinence (FI) is the involuntary passage of fecal material. Current treatments have limited successful outcomes. The objective of this study was to develop a large animal model of passive FI and to demonstrate sustained restoration of fecal continence using anorectal manometry in this model after implantation of engineered autologous internal anal sphincter (IAS) biosphincters. Twenty female rabbits were used in this study. The animals were divided into three groups: (a) Non-treated group: Rabbits underwent IAS injury by hemi-sphincterectomy without treatment. (b) Treated group: Rabbits underwent IAS injury by hemi-sphincterectomy followed by implantation of autologous biosphincters. (c) Sham group: Rabbits underwent IAS injury by hemi-sphincterectomy followed by re-accessing the surgical site followed by immediate closure without implantation of biosphincters. Anorectal manometry was used to measure resting anal pressure and recto-anal inhibitory reflex (RAIR) at baseline, 1 month post-sphincterectomy, up to 3 months after implantation and post-sham. Following sphincterectomy, all rabbits had decreased basal tone and loss of RAIR, indicative of FI. Anal hygiene was also lost in the rabbits. Decreases in basal tone and RAIR were sustained more than 3 months in the non-treated group. Autologous biosphincters were successfully implanted into eight donor rabbits in the treated group. Basal tone and RAIR were restored at 3 months following biosphincter implantation and were significantly higher compared with rabbits in the non-treated and sham groups. Histologically, smooth muscle reconstruction and continuity was restored in the treated group compared with the non-treated group. Results in this study provided promising outcomes for treatment of FI. Results demonstrated the feasibility of developing and validating a large animal model of passive FI. This study also showed the efficacy of the engineered biosphincters to restore fecal continence as demonstrated by manometry. Stem Cells Translational Medicine 2017;6:1795-1802.

Robotic Rectopexy for Rectal Prolapse in Pediatric Patients.

Rectal prolapse is the protrusion of the rectum out of the anus. Surgical correction can be accomplished via open and minimally invasive abdominal approaches, as well as from the perineum. Robotic rectopexy is an option for minimally invasive treatment of rectal prolapse. There are no studies that have established the efficacy of robotic rectopexy for rectal prolapse in the pediatric population. The aim of this study was to review the experience of robotic rectopexy at a single institution. This is a retrospective review of our pediatric robotic rectopexy experience from 2012 to 2015. Information was obtained from chart review of both operative notes and clinic visits. Four pediatric patients underwent a robotic rectopexy for rectal prolapse from 2012 to 2015. Three patients were male and one was female. The mean age was 15.5 years (range 13-17). Two patients had rectal prolapse with chronic constipation. One patient had rectal prolapse from Ehlers Danlos syndrome, and the last had rectal prolapse after imperforate anus repair as an infant. Three patients received a bowel preparation. Three patients were completed robotically, and one patient required conversion to an open procedure. The average postoperative length of stay was 3.25 days (range 2-4). There were no episodes of recurrent prolapse. Two patients had improvement in constipation, one had no improvement, and one had no documented change. Average postoperative follow-up was 11.5 months (range 3-29). This study was a review of one institution's experience with pediatric robotic rectopexy. With short-term follow-up, there was no recurrence of prolapse. Robotic rectopexy provided a safe, reliable, and short-term resolution of rectal prolapse in pediatric patients.

Colonic Polyps: Diagnosis and Surveillance.

Colorectal cancer begins as a polyp that is a benign growth on the mucosal surface of the colon or rectum. Over a period of 5 to 15 years, polyps can degenerate into a cancer, thus invading the colonic wall. Colorectal screening methods are designed to diagnose and remove polyps before they acquire invasive potential and develop into cancer. Screening for colorectal cancer can prevent and reduce mortality. Given the benefits and effectiveness of screening, guidelines exist from multiple organizations. These guidelines risk-stratify patients to determine the age of screening initiation and the interval for repeat screening. Categories of colorectal cancer risk include average risk, increased risk, and high risk based on individual and family medical history. Screening methods vary widely in the ability to diagnose and treat polyps and in the degree of invasiveness or risk of complication to the patient. Colonoscopy is held as the "gold standard" by which all other methods are compared; however, less-invasive modalities including computed tomographic colonography are increasing in popularity.

Indications and Options for Surgery in Ulcerative Colitis.

Ulcerative colitis affects differing lengths of the colon and rectum. Surgical treatment is considered curative when the entire colon and rectum is removed. However, surgical treatment of ulcerative colitis should only be pursued for additional complicating factors of the disease. In addition, the current physiologic status as well as the patient's desire to retain intestinal continuity should be considered. This article outlines the current indications for surgical treatment in patients with ulcerative colitis, the various surgical options, and the techniques used to accomplish these goals.

Incidence and Operative Excision of Presacral Masses: An Institutional Analysis.

Presacral masses are rare lesions that encompass a broad range of pathologic findings. Most presacral masses are benign. The aim of this study was to analyze the clinical presentation, pathology, and surgical treatment of presacral masses at a single academic institution over a decade. In this retrospective study, we reviewed all surgically excised presacral tumors between 2003 and 2013. Clinical and pathologic data were recorded. Thirteen patients had surgical excision of a presacral mass. The median age was 42 years (standard deviation ± 19.7) and average follow-up was 11.9 months (standard deviation ± 17.5). The majority of patients were symptomatic. Forty-six per cent (6/13) had sacral or rectal pain. Thirty-eight per cent (5/13) of patients had a palpable mass on digital rectal examination. Sixty-nine per cent of patients had an MRI, 84.6 per cent a CT, and 61.5 per cent multimodality imaging. Most presacral masses were benign (10/13, 77%). Twenty-three per cent (3/13) were malignant. A majority were excised via posterior approach (9/13, 69%), but 31 per cent (4/13) required an anterior or combined approach. Presacral masses are rare, even at a high-volume tertiary care center. They are commonly evaluated with a multiple imaging modalities, are most likely benign, and can be excised via posterior approach.

Rectovaginal fistulas.

Rectovaginal fistulas are abnormal epithelial-lined connections between the rectum and vagina. They can be quite bothersome to both the patient and the surgeon due to their irritating and embarrassing symptoms and high failure rate after repair. An individualized, systematic approach to these fistulas based on their size, location, and etiology provides a more concise treatment plan. Treatment options of medical therapy, advancement flaps, plugs, fistula ligation, and tissue interposition are discussed.

Gastroduodenal artery pseudoaneurysm associated with hemosuccus pancreaticus and obstructive jaundice.

A 42-year-old male was admitted with recurrent gastrointestinal bleeding and new-onset jaundice. Computed tomography showed a persistent gastroduodenal artery pseudoaneurysm and dilated intrahepatic and extrahepatic ducts consistent with obstructive jaundice. This patient had two previous coil embolizations, which failed to prevent recurrent bleeding. The patient underwent pancreaticoduodenectomy for definitive treatment of his pseudoaneurysm. We report this case and review the literature.