Ileal pouch-anal anastomosis and end ileostomy result in equivalent graft survival following liver transplantation for inflammatory bowel disease-primary sclerosing cholangitis.

INTRODUCTION: Patients with inflammatory bowel disease and primary sclerosing cholangitis may require both liver transplantation and colectomy. There are concerns about increased rates of hepatic artery thrombosis, biliary strictures, and hepatic graft loss in patients with ileal pouch-anal anastomosis compared to those with end ileostomy. We hypothesized that graft survival was not negatively affected by ileal pouch-anal anastomosis compared to end ileostomy. MATERIALS AND METHODS: A tertiary center's database was searched for patients meeting the criteria of liver transplantation because of primary sclerosing cholangitis and total proctocolectomy with ileal pouch-anal anastomosis or end ileostomy because of ulcerative colitis. Primary endpoints were hepatic graft survival and post-transplant complications. RESULTS: Fifty-five patients met the inclusion criteria between January 1990 and December 2022. Of these, 46 (84%) underwent ileal pouch-anal anastomosis, and 9 (16%) underwent end ileostomy. The average age at total proctocolectomy (41.5 vs. 49.1 years; p = 0.12) and sex distribution (female: 26.1% vs. 22.2%; p = 0.99) were comparable. The rates of re-transplantation (21.7% vs. 22.2%; p = 0.99), hepatic artery thrombosis (10.8% vs. 0; p = 0.58), acute rejection (32.6% vs. 44.4%; p = 0.7), chronic rejection (4.3% vs. 11.1%; p = 0.42), recurrence of primary sclerosing cholangitis (23.9% vs. 22.2%; p = 0.99), and biliary strictures (19.6% vs. 33.3%; p = 0.36) were similar between the ileal pouch-anal anastomosis and end ileostomy groups, respectively. None of the end ileostomy patients developed parastomal varices. The log-rank tests for graft (p = 0.97), recipient (p = 0.3), and combined graft/recipient survival (p = 0.73) were similar. CONCLUSION: Ileal pouch-anal anastomosis did not negatively affect graft, recipient, and combined graft/recipient survival, or the long-term complications, compared to end ileostomy.

Quality of life after colectomy and ileo-jpouch-anal anastomosis in paediatric patients with ulcerative colitis.

INTRODUCTION: Ulcerative Colitis (UC) is an Inflammatory Bowel Disease (IBD). Surgery is required in cases of severe acute colitis, massive hemorrhage, toxic megacolon, and perforation; in such cases colectomy and JpouchIleoanal anastomosis (IPAA) are performed. The aim of this study was to evaluate functional outcome, and patient satisfaction and Quality of Life (QoL) after surgery. MATERIAL AND METHODS: Questionnaires were administered to 24 patients with UC undergoing surgery from 2011 to 2022. RESULTS: Mean age at IPAA was 10.8 years. Twenty patients underwent IPAA in 3 operations, 4 patients in 2. All patients underwent laparoscopic surgery. 6 months after surgery mean level of satisfaction was 8.7/10, perception of health status was 7.4. Twenty-three patients (95.8%) recommended IPAA. For 20 patients (83.3%) surgery did not cause delay in education, while 14 patients (58.3%) played sport. The lowest number of evacuations was 9.2 per day, the highest 13.3. Seventeen patients (70.8%) had no incontinence and 15 patients (62.5%) were not affected by pouchitis. After 12 months mean satisfaction level raised up to 9.2/10, perception of health status to 8.5. School absences decreased and no other patients showed any delay in education. Seventeen (70.8%) patients played sports. The number of evacuations decreased: the lowest number was 5.1 per day, the highest 7.5. Twenty patients (83.3%) were continent and 12 (50%) did not use antibiotics. CONCLUSION: Most patients show a good functional outcome in defecation frequency and continence, which has improved through time, number of pouchitis episodes has increased. Patients appear satisfied after surgery.

Transanal circumferential pouch advancement for treatment of pouch vaginal fistulae.

BACKGROUND: Ileal pouch anal anastomosis (IPAA) circumferential pouch advancement (CPA) involves full-thickness transanal 180-360° dissection of the distal pouch, allowing the advancement of healthy bowel to cover the internal opening of a vaginal fistula. We aimed to describe the long-term outcomes of this rare procedure. METHODS: Patients with IPAA who underwent transanal pouch advancement for any indication between 2009 and 2021 were included. Demographics, operative details, and outcomes were reviewed. An early fistula was defined as occurring within 1 year of IPAA construction. Clinical success was defined as resolution of symptoms necessitating CPA, pouch retention, and no stoma at the time of follow-up. Figures represent the median (interquartile range) or frequency (%). RESULTS: Over a 12-year period, nine patients were identified; the median age at CPA was 41 (36-44) years. Four patients developed early fistula after index IPAA, and five developed late fistulae. The median number of fistula repair procedures prior to CPA was 2 (1-2). All patients were diagnosed with ulcerative colitis at the time of IPAA and all late patients were re-diagnosed with Crohn's disease. Four (44.4%) patients had ileostomies present at the time of surgery, three (33.3%) had one constructed during surgery, and two (22.2%) never had a stoma. The median follow-up time was 11 (6-24) months. Clinical success was achieved in four of the nine (44.4%) patients at the time of the last follow-up. CONCLUSIONS: Transanal circumferential pouch advancement was an effective treatment for refractory pouch vaginal fistulas and may be offered to patients who have had previous attempts at repair.

[Value of histological activity in predicting endoscopic relapse among patients of ulcerative colitis in endoscopic remission].

Objective: To investigate the value of histological evaluation in predicting endoscopic relapse among patients with ulcerative colitis (UC) who were in endoscopic remission, and to compare the usefulness of various histological scoring systems. Methods: Histological sections from 61 patients with UC who were in endoscopic remission were retrospectively analyzed, at Peking University Third Hospital, Beijing, China from January 2015 to June 2021. They were subdivided into endoscopic persistent remission group (remission group, n=31, Mayo endoscopic score 0) and endoscopic relapse group (relapse group, n=30, Mayo endoscopic score≥1) according to the results of the first endoscopic reexamination after the biopsy. Histological evaluation was performed using the Geboes score (GS) and its simplified version (SGS), the Nancy index (NI) and the Robarts histopathological index (RHI). The median and maximum histological scores for each case in all biopsies were recorded. Univariate comparisons were performed using chi-squares and multivariate analysis using binary logistic regression. The values of four histological evaluation systems for predicting endoscopic relapse among UC patients in endoscopic remission were analyzed using receiver operating characteristic (ROC) curves. Results: Significant differences were observed between the remission and relapse groups. The differences were more pronounced in the maximum histological scores; the mean and highest results of area under the ROC curve scores (AUC) for GS, SGS, NI, and RHI were 0.657, 0.668, 0.682, 0.691, and 0.866, 0.863, 0.864, 0.869, respectively. The differences were statistically significant (P<0.05). The corresponding best cut-offs were GS≥2B.1, SGS≥2B.1, NI≥2, and RHI≥2.5, respectively, which meant mild active inflammation histologically, while there was no statistical difference of AUC among the four histological scoring indices (P>0.05). Univariate and multivariate analyses revealed statistically significant differences in the number of neutrophils in the epithelium and lamina propria (P<0.05). Conclusions: Biopsies from UC patients in endoscopic remission may still have histological active inflammation which appears to correlate with endoscopic relapse. Four commonly used histological scoring systems can be used to assess the risk of endoscopic relapse among UC patients in endoscopic remission. The patients who more likely have endoscopic relapse seem to have a histological score greater than the cut-off value (i.e., mild histological activity). The maximum histological scores can accurately predict the risk of endoscopic relapse, while the presence of epithelial and laminar propria neutrophil infiltrates can independently predict the endoscopic relapse in these patients. Considering the utility and convenience in routine practice, NI is recommended for evaluating histological inflammatory activity.

Acute Pouchitis is Common in Pregnant and Postpartum Women.

INTRODUCTION: The impact of pregnancy on the development of pouchitis in women who have undergone total proctocolectomy with ileal pouch anal anastomosis for ulcerative colitis is poorly understood. METHODS: This was a retrospective study of women with ulcerative colitis who underwent total proctocolectomy with ileal pouch anal anastomosis and subsequently became pregnant at Mount Sinai Hospital. The primary outcome was acute pouchitis during pregnancy or the postpartum period defined as symptoms of increased stool frequency and urgency treated with antibiotics. RESULTS: A total of 44 women with 63 pregnancies and complete data were identified. Acute pouchitis occurred in 14 pregnancies (22.2%) in 12 women and in the postpartum period of 10 pregnancies (15.9%) in 9 women. Acute pouchitis occurred more frequently in women with a history of acute pouchitis immediately before, during, or after pregnancy. DISCUSSION: Acute pouchitis was common during pregnancy and the postpartum period, likely due to microbial shifts. Although not statistically significant, these results provide insight into the impact of pregnancy on the risk of pouchitis and establish the framework for preconception counseling that focuses on prevention and management of pouchitis during pregnancy.

Causes of Colectomy in Patients with Ulcerative Colitis: Findings from an Iranian National Registry.

BACKGROUND: Ulcerative colitis (UC) is a form of inflammatory bowel disease (IBD) marked by rectal and colon inflammation, leading to relapsing symptoms. Its prevalence is increasing, particularly in developed nations, impacting patients' health. While its exact cause remains unclear, genetic and environmental factors are implicated, elevating the risk of colorectal cancer (CRC). Colectomy, though declining, is still performed in select UC cases, necessitating further study. METHODS: We analyzed data from the Iranian Registry of Crohn's and Colitis (IRCC) to examine UC patients undergoing colectomy. We collected demographic and clinical data from 91 patients, focusing on dysplasia. Statistical analyses assessed dysplasia risk factors. RESULTS: Patients with dysplasia were older at diagnosis and surgery compared to those without dysplasia. Age emerged as a significant risk factor for dysplasia in UC patients undergoing colectomy. No significant associations were found between dysplasia and other factors. CONCLUSION: Age plays a crucial role in dysplasia risk among UC patients undergoing colectomy. Older age at diagnosis and surgery may indicate a higher risk of dysplasia and CRC. Clinicians should consider age when managing UC patients and implementing screening protocols. Further research with larger samples is needed to confirm these findings.

Ulcerative colitis in a transgender woman with a sigmoid neovagina: a case report.

BACKGROUND: Sex reassignment surgery (SRS) is a necessary step in transitioning into the desired gender for male-to-female transgender individuals. This study focuses on a rare complication developed following SRS, aiming to highlight potential complications associated with this procedure. CASE PRESENTATION: This report describes a 49-year-old transgender woman with a history of SRS who developed bloody diarrhea and neovaginal bleeding 10 years later. A colonoscopy revealed features compatible with ulcerative colitis, which was confirmed by a biopsy. CONCLUSIONS: The unpredictable clinical course of this phenomenon may prompt surgeons to reconsider the use of a rectosigmoid colon to create a neovagina. This case report underscores the necessity of long-term monitoring for gastrointestinal complications in transgender women post-SRS when a rectosigmoid colon segment is utilized for neovaginal construction.

Infantile and Very Early Onset Inflammatory Bowel Disease: A Multicenter Study.

OBJECTIVES: This study described disease characteristics and long-term outcomes in patients diagnosed with very early onset inflammatory bowel disease (VEOIBD) (diagnosed before 6 years of age) and infantile-IBD (before 2 years). METHODS: Cases from 21 centers worldwide diagnosed with VEOIBD (2008-2018), with minimum 2 years of follow-up, were retrospectively reviewed. RESULTS: The cohort included 243 patients (52% males, median follow-up of 5.8 [range 2-18] years, including 69 [28%]) with infantile-IBD. IBD subtypes included Crohn's disease (CD), ulcerative colitis (UC), or IBD-unclassified (IBDU) in 30%, 59%, and 11%, respectively. Among patients with CD, 94% had colonic involvement, and among patients with UC/IBDU, 75% had pancolitis. Patients with infantile-IBD presented with higher rates of IBDU, lower hemoglobin and albumin levels, and higher C-reactive protein, and had lower response rates to first-induction therapy and corticosteroids therapy (P < .05 for all). Colectomy and diversion surgeries were performed in 11% and 4%, respectively, with no significant differences between age groups. Corticosteroid-free remission rates were 74% and 78% after 3 and 5 years, respectively, and 86% at end of follow-up. Genetic testing was performed in 96 (40%) patients. Among tested population, 15 (16%) were identified with monogenic disease. This group demonstrated lower response rates to induction therapies, higher rates of surgical intervention, and higher rates of major infections (P < .05 for all). CONCLUSIONS: Patients with VEOIBD, including infantile-IBD, exhibit low rate of complications and surgical interventions at the long term. Patients with monogenic IBD are at risk for more severe disease course.

Indications, modalities, and outcomes of surgery for ulcerative colitis in 2024.

Treatment of ulcerative colitis (UC) has been revolutionized by the arrival of biotherapies and technical progress in interventional endoscopy and surgery. (Sub)total emergency colectomy is required in the event of complicated severe acute colitis: colectasis, perforation, hemorrhage, organ failure. Corticosteroid therapy is the reference treatment for uncomplicated severe acute colitis, while infliximab and ciclosporin are 2nd-line treatments. At each step, before and after each line of treatment failure, surgery should be considered as an option. In cases refractory to medical treatment, the choice between surgery and change in medication must weigh the chronic symptoms associated with the disease against the risks of postoperative complications and functional sequelae inherent to surgery. Detection of dysplastic lesions necessitates chromoendoscopic imaging with multiple biopsies and anatomopathological verification. Endoscopic treatment of these lesions remains reserved for selected patients. These different indications call for multidisciplinary medical-surgical discussion. Total coloproctectomy with ileo-anal anastomosis (TCP-IAA) is the standard surgery, and it holds out hope for healing. Modalities depend on patient characteristics, previous emergency colectomy, and presence of dysplasia. It may be carried out in one, in two modified, or in three phases. The main complications are anastomotic fistula, short-term pouch-related fistula, ileo-anal pouch syndrome, pouchitis and long-term digestive and sexual disorders. For selected cases, an alternative can consist in total colectomy with ileo-rectal anastomosis or permanent terminal ileostomy. The objective of this update is to clarify the indications, modalities, and results of surgical treatment of ulcerative colitis in accordance with the most recent data in the literature.

Diagnosis and Medical Treatment of Acute and Chronic Idiopathic Pouchitis in Inflammatory Bowel Disease.

Despite the decreased rates in inflammatory bowel disease (IBD) colectomies due to high advances in therapeutic options, a significant number of patients still require proctocolectomy with ileal pouch-anal anastomosis (IPPA) for ulcerative colitis (UC). Pouchitis is the most common complication in these patients, where up to 60% develop one episode of pouchitis in the first two years after UC surgery with IPAA with severe negative impact on their quality of life. Acute cases usually respond well to antibiotics, but 15% of patients will still develop a refractory disease that requires the initiation of advanced immunosuppressive therapies. For chronic idiopathic pouchitis, current recommendations suggest using the same therapeutic options as for IBD in terms of biologics and small molecules. However, the available data are limited regarding the effectiveness of different biologics or small molecules for the management of this condition, and all evidences arise from case series and small studies. Vedolizumab is the only biologic agent that has received approval for the treatment of adult patients with moderately to severely active chronic refractory pouchitis. Despite the fact that IBD treatment is rapidly evolving with the development of novel molecules, the presence of pouchitis represents an exclusion criterion in these trials. Recommendations for the approach of these conditions range from low to very low certainty of evidence, resulting from small randomized controlled trials and case series studies. The current review focuses on the therapeutic management of idiopathic pouchitis.

Use of glucagon-like peptide-1 receptor agonists for type 2 diabetes mellitus and outcomes of inflammatory bowel disease.

BACKGROUND: Glucagon-like peptide-1 receptor agonists (GLP-1RA) show anti-inflammatory properties. AIM: To evaluate their clinical impact on inflammatory bowel disease (IBD) outcomes. METHODS: Retrospective cohort study utilising the TriNetX database comparing IBD-specific outcomes in patients with ulcerative colitis (UC) or Crohn's disease (CD) and type 2 diabetes mellitus (T2DM) on GLP-1RA compared to oral hypoglycaemic agents. The primary outcome was hospitalisation requiring intravenous steroids and IBD-related surgery within 3 years. We performed 1:1 propensity score matching (PSM) for demographics, co-morbid conditions, BMI, laboratory values, HbA1c, and IBD medications including steroids. RESULTS: We identified 1130 patients in the UC GLP-1RA cohort (mean age: 58.9 ± 11.6 years, 56.3% female, 70.2% White, 57.2% with obesity) and 1140 patients in the CD GLP-1RA cohort (mean age: 56.7 ± 11.5, 61.9% female, 73.6% White, 56.2% with obesity). After PSM, there was no difference in the risk of intravenous steroid use (aHR: 1.21, 95% CI: 0.92-1.59) but a lower risk of colectomy (aHR: 0.37, 95% CI: 0.14-0.97) between the UC GLP-1RA and control cohort. There was no difference in the risk of intravenous steroid use (aHR: 1.04, 95% CI: 0.80-1.34) but a lower risk of surgery (aHR: 0.55, 95% CI: 0.36-0.84) between the CD GLP-1RA and CD control cohort. There was no difference in the risk of oral steroid use or advanced therapy initiation in the UC and CD GLP-1RA than control cohorts. CONCLUSIONS: We found an association between lower risk of IBD-related surgery and GLP-1RA use for T2DM in patients with UC or CD.

Unexpected variation in outcomes following total (procto)colectomies for ulcerative colitis in New South Wales, Australia: a population-based 19-year linked-data study.

AIM: Total (procto)colectomy for ulcerative colitis (UC) is associated with significant morbidity, which is increased in the emergency setting. This study aimed to evaluate the outcomes following total (procto)colectomies at a population level within New South Wales (NSW), Australia, and identify case mix and hospital factors associated with these outcomes. METHODS: A retrospective data linkage study of patients undergoing total (procto)colectomy for UC in NSW over a 19-year period (2001-2020) was performed. The primary outcome was 90-day mortality. The influence of hospital level factors (including annual volume) and patient demographic variables on outcomes was assessed using logistic regression. Temporal trends in annual volume and evidence for centralization were assessed. RESULTS: In all, 1418 patients (mean 47.0 years [SD 18.7], 58.7% male) underwent total (procto)colectomy during the study period. The overall 90-day mortality rate was 3.2% (emergency 8.6% and elective 0.8%). After adjusting for confounding, increasing age at total (procto)colectomy, higher comorbidity burden, public health insurance (Medicare) status, emergency operation and living outside a major city were significantly associated with increased mortality. Hospital volume was significantly associated with mortality at a univariate level, but this did not persist on multivariate modelling. CONCLUSIONS: Outcomes of UC patients undergoing total (procto)colectomy in NSW Australia are comparable to international experience. Whilst higher mortality rates are observed in low volume and public hospitals, this appears attributable to case mix and acuity rather than surgical volume alone. However, as inflammatory bowel disease surgery is not centralized in Australia, only one NSW hospital performed >10 UC total (procto)colectomies annually. Variation in mortality according to insurance status and across regional/remote areas may indicate inequality in the availability of specialist inflammatory bowel disease treatment, which warrants further research.

Urgency adjusted outcomes of emergency abdominal surgery for inflammatory bowel disease.

INTRODUCTION: Patients undergoing emergency abdominal surgery for inflammatory bowel disease (IBD) are a complex cohort who are relatively poorly represented in published literature. This is partly due to the lack of consensus of the definition of the term emergency in IBD surgery. There is ongoing and recent work defining clinical urgency for unplanned surgical procedures and categorizing the high-risk surgical patient. This paper aims to report the difference in patient metrics and risks as recorded by the National Emergency Laparotomy Audit (NELA). METHODS: Complete patient data, including histology, were available in the NELA database between 2013 and 2016. Urgency categories recorded by NELA are <2 h, 2-6 h, 6-18 h, and >18 h. Patient characteristics, physiology, biochemistry, and outcomes are reported according to these urgency categories with regression analysis used to compare differences between them. RESULTS: Mortality in Crohn's disease (CD) ranged from 1.4% in the >18 h urgency to 14.6% in the most urgent. In ulcerative colitis (UC), this range was from 3.1% to 14.8%. In both CD and UC, there were significant trends in hemodynamic instability, serum white cell count, serum electrolytes and creatinine, and outcome measures length of stay and unplanned return to theater. CONCLUSIONS: Patients having emergency surgery for IBD are not a single cohort when considering physiology, blood biochemistry, or most importantly, outcomes. Risk counseling and management should reflect this. Hemodynamic changes are subtle and may be missed in this cohort.

Clinical course of ulcerative colitis: Frequent use of biologics and low colectomy rate first year after diagnosis-results from the IBSEN III inception cohort.

BACKGROUND: The introduction of biologic therapies and the 'treat-to-target' treatment strategy may have changed the disease course of ulcerative colitis (UC). AIMS: To describe the early disease course and disease outcome at 1-year follow-up in a population-based inception cohort of adult patients with newly diagnosed UC. METHODS: The Inflammatory Bowel Disease in South-Eastern Norway (IBSEN) III study is a population-based inception cohort study with prospective follow-up. Patients newly diagnosed with inflammatory bowel disease during 2017-2019 were included. Patients ≥18 years at diagnosis of UC who attended the 1-year follow-up were investigated. We registered clinical, endoscopic and demographic data at diagnosis and 1-year follow-up. RESULTS: We included 877 patients with UC (median age 36 years (range: 18-84), 45.8% female). At diagnosis, 39.2% presented with proctitis, 24.7% left-sided colitis and 36.0% extensive colitis. At the 1-year follow-up, 13.9% experienced disease progression, and 14.5% had received one or more biologic therapies. The colectomy rate was 0.9%. Steroid-free clinical remission was observed in 76.6%, and steroid-free endoscopic remission in 68.7%. Anaemia and initiation of systemic steroid treatment at diagnosis were associated with biologic therapy within the first year after diagnosis. CONCLUSION: In this population-based inception cohort, colectomy rate in the first year after diagnosis was low, and a high proportion of patients were in remission at 1-year follow-up. The use of biologic therapy increases, consistent with findings from previous studies.

Laparoscopically treated bowel obstruction secondary to a lesser omental hernia resulting from a previous laparoscopic total colectomy for ulcerative colitis: A report of two cases.

Lesser omental hernias are rare; however, they should be considered in symptomatic bowel obstruction subsequent to a subtotal or total colectomy. This report describes two cases of recurrent bowel obstruction secondary to lesser omental hernias after laparoscopic total colectomies for ulcerative colitis. Initially, these patients had been treated conservatively; however, due to symptom recurrence, surgical intervention was decided on. In both cases, laparoscopic surgery revealed lesser omental hernias. The small bowel, which had entered from the dorsal aspect of the stomach, was returned to the original position, and the lesser omentum was closed. The patients were discharged uneventfully, with no recurrent bowel obstruction during the follow-up period. These cases highlight the importance of including internal hernias in the differential diagnosis relative to recurrent bowel obstruction, in patient subpopulations with a prior history of a subtotal or total colectomy. Confirmation by computed tomography is preferable.

Impact of sex and socioeconomic status on the likelihood of surgery, hospitalization, and use of medications in inflammatory bowel disease: a systematic review and meta-analysis.

BACKGROUND: Inflammatory bowel diseases (IBDs) are associated with high healthcare utilization. This systematic review aimed to summarize what is known about the impact of sex, income, and education on the likelihood of bowel surgery, hospitalization, and use of corticosteroids and biologics among patients with IBD. METHODS: We used EMBASE, MEDLINE, CINAHL, and Web of Science to perform a systematic literature search. Pooled hazard ratios (HRs) and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random effects meta-analysis for the impact of sex on the likelihood of surgery and hospitalization. In addition, we performed subgroup analyses of the effect of IBD type (Crohn's disease or ulcerative colitis) and age. Finally, meta-regression was undertaken for the year of publication. RESULTS: In total, 67 studies were included, of which 23 studies were eligible for meta-analysis. In the main meta-analysis, male sex was associated with an increased likelihood of bowel surgery (HR 1.42 (95% CI 1.13;1.78), which was consistent with the subgroup analysis for UC only (HR 1.78, 95% CI 1.16; 2.72). Sex did not impact the likelihood of hospitalization (OR 1.05 (95% CI 0.86;1.30), although the subgroup analysis revealed an increased likelihood of hospitalization in CD patients (OR 1.42, 95% CI 1.28;1.58). In 9 of 10 studies, no significant sex-based differences in the use of biologics were reported, although in 6 of 6 studies, female patients had lower adherence to biologics. In 11 of 13 studies, no significant sex-based difference in the use of corticosteroids was reported. The evidence of the impact of income and education on healthcare utilization was sparse and pointed in different directions. The substantial heterogeneity between studies was explained, in part, by differences in IBD type and age. CONCLUSIONS: The results of this systematic review indicate that male patients with IBD are significantly more likely to have surgery than female patients with IBD but are not, overall, more likely to be hospitalized, whereas female patients appear to have statistically significantly lower adherence to biologics compared to male patients. Thus, clinicians should not underestimate the impact of sex on healthcare utilization. Evidence for income- and education-based differences remains sparse. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42022315788.

Two-step versus three-step proctocolectomy for ulcerative colitis: a comparative study on nutritional status, immunosuppressive therapy, and long-term outcome.

BACKGROUND: Despite novel medical therapies, rates of surgery in ulcerative colitis remain relevant. While various surgical approaches for multistep proctocolectomy are available, overall evidence is low and robust recommendations are lacking for individual procedures especially in case of refractory inflammation and signs of malnutrition. METHODS: All patients who received multistep proctocolectomy between 2010 and 2021 for ulcerative colitis were evaluated and divided into two groups (two-step/2-IPAA [ileal pouch-anal anastomosis] versus three-step/3-IPAA proctocolectomy). Patient characteristics as well as short- and long-outcomes were individually analyzed. RESULTS: Surgical techniques were explained in detail. Fifty patients were included in the study with 27 patients receiving 2-IPAA and 23 patients 3-IPAA. Rates of postoperative complications were comparable for both groups. While patients receiving 2-IPAA were more often suffering from malignancy, 3-IPAA resulted in a significant increase of hemoglobin and albumin levels as well as a reduction of immunosuppressive medication. Rates of stoma reversal trended to be reduced for 3-IPAA compared to 2-IPAA (52.2% vs. 77.8%, p = 0.06). CONCLUSION: Three-step proctocolectomy with creation of sigmoidostomy is a safe procedure and reasonable surgical approach in patients with preoperatively high dosages of immunosuppressive medication or risk factors such as persistent active inflammation and anemia.

A Propensity Score-Matched Analysis of Single-Port Vs Multiport Laparoscopic Total Abdominal Colectomy With End Ileostomy for Medically Refractory Ulcerative Colitis.

BACKGROUND: Medically refractory ulcerative colitis necessitates surgical intervention, with total abdominal colectomy with end ileostomy being a definitive treatment. The comparison between single-port and multiport laparoscopic surgery outcomes remains underexplored. OBJECTIVE: To compare the surgical outcomes of single-port versus multiport laparoscopic surgery in patients undergoing total abdominal colectomy with end ileostomy for medically refractory ulcerative colitis. DESIGN: A retrospective analysis comparing single-port to multiport surgery in patients with ulcerative colitis from 2010 to 2020. Patients were propensity score-matched 3:1 (multiport to single-port) on baseline characteristics. SETTINGS: Single-center academic hospital. PATIENTS: A total of 756 patients with medically refractory ulcerative colitis who underwent multiport vs single-port total abdominal colectomy with end ileostomy from 2010 to 2020 were included. MAIN OUTCOME MEASURES: Binary outcomes were compared using a multivariable logistic regression model, and a subset analysis was conducted for postoperative stump leak based on stump implantation during surgery. These metrics were compared between the single-port and multiport groups to assess the differences in surgical outcomes. RESULTS: The multiport and single-port groups included 642 and 114 patients, respectively. The matched cohort included 342 multiports and 114 single ports. We observed a statistically significant difference in mean operation time, with the single-port procedure taking 43 minutes less than the multiport laparoscopy. There were no significant differences between the 2 groups in postoperative stump leaks, postoperative ileus, stoma site complications, postoperative readmission within 30 days, postoperative reoperation within 30 days, and subsequent IPAA surgery. In the subset analysis, stump implantation was associated with a higher risk of stump leak in the multiport group. The single-port group had a shorter hospital stay. LIMITATIONS: Retrospective nature and being conducted at a single center. CONCLUSION: Single-incision laparoscopic total abdominal colectomy in the treatment of mucosal ulcerative colitis is a safe, effective, and efficient approach. In our cohort, single-incision laparoscopy has had shorter operation times and better overall length of stay compared with the multiport approach. Taking into account a less invasive approach, decreased abdominal trauma, and faster recovery, single-port surgery is a viable alternative to multiport surgery. See Video Abstract . UN ANLISIS EMPAREJADO POR PUNTUACIN DE PROPENSIN DE LA COLECTOMA ABDOMINAL TOTAL LAPAROSCPICA CON PUERTO NICO VERSUS PUERTO MLTIPLE CON ILEOSTOMA TERMINAL PARA LA COLITIS ULCEROSA MDICAMENTE REFRACTARIA: ANTECEDENTES:La colitis ulcerosa (CU) médicamente refractaria requiere una intervención quirúrgica, siendo la colectomía abdominal total con ileostomía terminal un tratamiento definitivo. La comparación entre los resultados de la cirugía laparoscópica con puerto único y con puerto múltiple aún no se ha explorado lo suficiente.OBJETIVO:Comparar los resultados quirúrgicos de la cirugía laparoscópica con puerto único versus con puerto múltiple en pacientes sometidos a colectomía abdominal total con ileostomía terminal para CU médicamente refractaria.DISEÑO:Un análisis retrospectivo que comparó la cirugía de puerto único con la de puerto múltiple en pacientes con CU de 2010 a 2020. Los pacientes fueron emparejados por puntuación de propensión 3:1 (puerto múltiple a puerto único) según las características iniciales.AJUSTES:Hospital académico unicentrico.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados binarios se compararon utilizando un modelo de regresión logística multivariable y se realizó un análisis de subconjunto para la fuga postoperatoria del muñón basado en la implantación del muñón durante la cirugía. Estas métricas se compararon entre los grupos de puerto único y de puerto múltiple para evaluar las diferencias en los resultados quirúrgicos.RESULTADOS:Los grupos de puerto único y multipuerto incluyeron 642 y 114 pacientes, respectivamente. La cohorte emparejada incluyó 342 puertos múltiples y 114 puertos únicos. Observamos una diferencia estadísticamente significativa en el tiempo medio de operación, ya que el procedimiento de puerto único duró 43 minutos menos que la laparoscopia de puerto múltiple. No hubo diferencias significativas entre los dos grupos en las fugas del muñón posoperatorio, el íleo posoperatorio, las complicaciones del sitio del estoma, el reingreso posoperatorio dentro de los 30 días, la reoperación posoperatoria dentro de los 30 días y la cirugía IPAA posterior. En el análisis de subconjunto, la implantación del muñón se asoció con un mayor riesgo de fuga del muñón en el grupo multipuerto. El grupo de puerto único tuvo una estancia hospitalaria más corta.LIMITACIONES:Carácter retrospectivo, realizándose en un único centro.CONCLUSIÓN:La colectomía abdominal total laparoscópica de incisión única en el tratamiento de la colitis ulcerosa mucosa es un enfoque seguro, eficaz y eficiente. En nuestra cohorte, en comparación con el abordaje multipuerto, la laparoscopia de incisión única ha mostrado tiempos de operación más cortos y una mejor duración total de la estancia hospitalaria. Teniendo en cuenta un enfoque menos invasivo, un menor traumatismo abdominal y una recuperación más rápida, la cirugía con puerto único es una alternativa viable a la cirugía con puertos múltiples. (Traducción-Dr. Mauricio Santamaria ).

Controversies in IPAA for Ulcerative Colitis: A Systematic Review of Different Anastomotic Techniques.

BACKGROUND: Available techniques for IPAA in ulcerative colitis include handsewn, double-stapled, and single-stapled anastomoses. There are controversies, indications, and different outcomes regarding these techniques. OBJECTIVE: To describe technical details, indications, and outcomes of 3 specific types of anastomoses in restorative proctocolectomy. DATA SOURCE: Systematic literature review for articles in the PubMed database according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. STUDY SELECTION: Studies describing outcomes of the 3 different types of anastomoses, during pouch surgery, in patients undergoing restorative proctocolectomy for ulcerative colitis. INTERVENTION: IPAA technique. MAIN OUTCOME MEASURES: Postoperative outcomes (anastomotic leaks, overall complication rates, and pouch function). RESULTS: Twenty-one studies were initially included: 6 studies exclusively on single-stapled IPAA, 2 exclusively on double-stapled IPAA, 6 studies comparing single-stapled to double-stapled techniques, 6 comparing double-stapled to handsewn IPAA, and 1 comprising single-stapled to handsewn IPAA. Thirty-seven studies were added according to authors' discretion as complementary evidence. Between 1990 and 2015, most studies were related to double-stapled IPAA, either only analyzing the results of this technique or comparing it with the handsewn technique. Studies published after 2015 were mostly related to transanal approaches to proctectomy for IPAA, in which a single-stapled anastomosis was introduced instead of the double-stapled anastomosis, with some studies comparing both techniques. LIMITATIONS: A low number of studies with handsewn IPAA technique and a large number of studies added at authors' discretion were the limitations of this strudy. CONCLUSIONS: Handsewn IPAA should be considered if a mucosectomy is performed for dysplasia or cancer in the low rectum or, possibly, for re-do surgery. Double-stapled IPAA has been more widely adopted for its simplicity and for the advantage of preserving the anal transition zone, having lower complications, and having adequate pouch function. The single-stapled IPAA offers a more natural design, is feasible, and is associated with reasonable outcomes compared to double-stapled anastomosis. See video from symposium.