[A case of a patient with Crohn's disease who had vaginal delivery after abdominoperineal resection for severe anorectal complications].

We report the case of a young female patient with Crohn's disease case who had vaginal delivery after abdominoperineal resection for severe perianal disease. The patient had Crohn's disease with anorectal complications for 13 years and underwent abdominoperineal resection for anorectal stenosis, complex anal fistula, and rectovaginal fistula in her early twenties. Seven years later, she got pregnant and gave birth to a healthy boy by vaginal delivery. No recurrence of Crohn's disease was observed during the perinatal period. There is no curative treatment for severe anorectal complications, which may be necessary for young patients to undergo abdominoperineal resection. Further studies are needed to determine the effects of Crohn's disease with anorectal complications on pregnancy and childbirth in affected patients.

[Pregnancy and delivery in patients with Crohn's disease who had a history of abdominal surgery].

OBJECTIVE: A few studies have focused on pregnancy and childbirth in patients with Crohn's disease (CD) who had a history of abdominal surgery. The objective of this study is to analyze the problems of pregnant patients with CD with a history of abdominal surgery. METHODS: The rates of pregnancy-related complications and adverse birth outcomes were retrospectively analyzed in 29 patients with CD (45 pregnancies) with previous intestinal surgery. RESULTS: In this study, the following outcomes were observed:normal births occurred in 55.6% of the pregnancies, preterm births in 13.3%, and spontaneous abortions in 20.0%. The vaginal birth and cesarean section rates were 45.7% and 40.0%, respectively. The rate of low-birth weight infants was 14.3%. CONCLUSION: Overall, patients with CD with previous abdominal surgery can conceive and give birth. However, care needs to be taken to avoid preterm birth, spontaneous abortion, low birth weight, and cesarean delivery.

[Preoperative diagnosis of small intestinal cancer associated with Crohn's disease: a case report].

The patient was a 46-year-old woman with a history of Crohn's disease for several years. At 45 years of age, a colonoscopy was performed, and a protruding lesion in the terminal ileum was detected. Pathological analysis of a biopsy specimen noted high suspicion for a well differentiated adenocarcinoma. The patient underwent ileocecal resection, and histological examination of the specimen revealed that infiltration of the well differentiated adenocarcinoma was limited to the mucosa. To the best of our knowledge, this is the first known case of early small intestinal cancer associated with Crohn's disease in Japan. Both endoscopy and a biopsy of any protruding lesions may be useful for making a preoperative diagnosis of small intestinal cancer associated with Crohn's disease.

Subtotal colectomy for refractory ulcerative colitis with COVID-19 infection; a first case report in Japan.

We report a 60-year-old male who was transferred to our hospital for the operation because of refractory ulcerative colitis (UC). He was diagnosed to be infected with COVID-19 for SARS-CoV-2 PCR test positive at the time of transfer. We determined emergency operation because his general condition was poor such as malnutrition and ADL decline due to exacerbation of UC and air embolization by central venous catheter removal. He underwent subtotal colectomy with a sigmoid mucous fistula and ileostomy. He was well postoperatively. This is a first case report in Japan who underwent an operation for UC with COVID-19 infection.

Clinicopathological and prognostic evaluations of anorectal cancer after fecal diversion for patients with Crohn's disease.

PURPOSE: Colorectum diversion with a proximal stoma is often the preferred surgical approach in patients with Crohn's disease-related anorectal lesions or refractory colitis. To date, few studies have assessed the incidence and prognosis of cancer in the diverted anorectal segments. This study aimed to evaluate the clinical characteristics and prognosis of anorectal cancer associated with Crohn's disease following fecal diversion. METHODS: This was a retrospective study based on medical records of patients diagnosed with Crohn's disease between 1999 and 2020. It was conducted at Yokohama Municipal Citizen's Hospital. Patients diagnosed with anorectal cancer following fecal diversion were identified, and their prognosis was the primary outcome measure. RESULTS: Among 1615 patients, 232 patients (14%) underwent colorectum diversion. Of those 232 patients, 11 were diagnosed with anorectal cancer following fecal diversion, ten were diagnosed with advanced cancer, 10 underwent abdominoperineal resection, and eight died. 1 could not undergo resection due to multiple lung metastasis and died. The overall five-year survival rate in patients diagnosed with anorectal cancer following fecal diversion was 20%. CONCLUSION: Crohn's disease-associated anorectal cancer following fecal diversion was challenging to diagnose early, and patients had a poor prognosis even after curative resection. Early abdominoperineal resection may be considered for patients with Crohn's disease who cannot benefit from cancer screening and surveillance due to difficulty accessing the anorectal stricture via endoscopy.

[Familial adenomatous polyposis with papillary thyroid cancer:a case report].

The patient is 36-year-old woman who complained of proptosis and was diagnosed as thyroid cancer. The pathologic diagnosis of her resected specimen was papillary thyroid cancer, cribriform morular variant (CMV). Subsequently, she was suspected of having familial adenomatous polyposis (FAP), although she had no family history of it. The diagnosis of FAP was confirmed following colonoscopy, which showed multiple polyps, and the biopsies that revealed multiple adenomas and cancers with APC gene mutation. She underwent restorative proctocolectomy, rectal mucosectomy with ileal pouch anal anastomosis, and ileostomy in our department. Cancer in the adenomas was found in four polyps on histopathological examination. CMV is known to be complicated with FAP. However, the number of reported cases remains few. This case was relatively rare, with an initial diagnosis of FAP because of the coexistence of CMV. In patients with papillary thyroid cancer (CMV type), colonoscopy should be considered because of the possibility of FAP.

[A case of ulcerative colitis complicated by internal fistula between the transverse colon and stomach].

A case of ulcerative colitis (UC) with an internal fistula was reported;the patient, a 42-year-old male, was admitted to the hospital with a diagnosis of refractory UC. The preoperative examination revealed an internal fistula between the transverse colon and the stomach. UC was diagnosed preoperatively with an internal fistula, but the possibility of Crohn's disease could not be ruled out at that time. The patient underwent subtotal colectomy with end ileostomy, sigmoid colon mucous fistula, and partial gastrectomy. UC was diagnosed histopathologically, and an ileal pouch-anal anastomosis was performed. An internal fistula can complicate UC;a split surgery is recommended with the possibility of Crohn's disease in the patient.

[A case of ulcerative colitis in an 86-year-old woman undergoing restorative proctocolectomy with ileal pouch-anal canal anastomosis].

An 86-year-old woman was diagnosed with ulcerative colitis (UC) in the 1970s. A colonoscopy performed 40 years thereafter revealed a 0-Is lesion in the upper rectum, and pathological examination showed well-differentiated adenocarcinoma. The lesion was diagnosed as colitic cancer based on the pathological findings and the 40-year interval since the diagnosis of total colitis type of UC. The patient was in good overall health with good anal function, based on the clinical examination and manometric study;she wished to undergo sphincter-preserving operation. Restorative proctocolectomy with ileal pouch-anal canal anastomosis that preserved the anal canal mucosa was performed. The postoperative course was good, with a defecation frequency of 4-5 times/day without fecal incontinence, and the patient resumed her preoperative lifestyle with very few alterations. Even in elderly patients aged >80 years who have UC, restorative proctocolectomy is feasible for those in good general health and with relatively good anal function, determined based on the daily defecation activity and anal manometry.

Two cases of esophageal ulcer after surgical treatment for ulcerative colitis.

The incidence of postoperative esophageal ulcers has been rarely reported associated with severe ulcerative colitis (UC). We report two cases of esophageal ulcers accompanied by acute necrotizing esophagitis after undergoing surgery for severe UC. Both patients, 47- and 53-year-old, were diagnosed with severe UC and underwent subtotal colectomy with sigmoid mucous fistula and ileostomy. In both cases, they had epigastralgia or digestive track bleeding and upper gastrointestinal endoscopy revealed an esophageal ulcer with acute necrotizing esophagitis accompanied by a black degeneration of mucosa after surgery. Conservative treatments improved the lesions. Esophageal stricture requiring endoscopic dilatation occurred in both cases. An acute UC requiring surgery seems to warrant caution in the merger of esophageal ulcer and acute necrotizing esophagitis.

Changes in the rate of and trends in colectomy for ulcerative colitis during the era of biologics and calcineurin inhibitors based on a Japanese nationwide cohort study.

PURPOSE: We evaluated the recent incidence of surgery and the changing surgery trends for ulcerative colitis (UC) in Japan due to the increasing use of anti-tumor necrosis factor (TNF) agents. METHODS: A questionnaire survey was performed to assess the number of surgeries, surgical indications, surgical timing, and immunosuppressive treatments before surgery between 2007 and 2017. RESULTS: A total of 3801 surgical cases were reported over 11 years. The prevalence of UC surgery decreased over the period studied. The rate of prednisolone (PSL) use did not change. The prevalence of both calcineurin inhibitors (CNIs) and anti-TNF agents increased during the period studied (p < 0.01). The prevalence of urgent/emergent surgery did not change. The most distinctive change in surgical indications was the increase in cancer/dysplasia (CAC), the prevalence of which increased from 20.2% in 2007 to 34.8%. CONCLUSION: The prevalence of UC surgery seems to be decreasing according to the increasing rate of anti-TNF agent and CNI administration. However, the indication of CAC significantly increased. Further research should evaluate whether or not long-term remission maintained with several agents can lead to increasing CAC.

Postoperative functional outcomes and complications of partially intraanal canal anastomosis in stapled ileal pouch anal anastomosis for ulcerative colitis.

AIM: For ulcerative colitis (UC), stapled ileal pouch anal anastomosis (IPAA) reportedly results in better bowel function than does IPAA with mucosectomy. However, a potential cancer risk in the remnant mucosa has been observed. The clinical results of IPAA by double stapling technique (DS-IPAA) in which the anastomotic line was on the dentate line at posterior wall and the top of anal canal at anterior wall ("Partially intraanal canal anastomosis": PICA) to reduce the remnant mucosa were evaluated. METHODS: Clinical results of PICA were retrospectively compared with those by DS-IPAA with anastomosis at above the anal canal on 1 year after open surgery. Of 211 UC cases that underwent DS-IPAA, 146 cases (69%) with PICA who were confirmed by the squamous epithelium on the posterior part of the distal donuts were included. Sixty-five cases with anastomosis above the anal canal were evaluated as the control. One stage surgery underwent in 95% of PICA and 93% of control. RESULTS: One year after surgery, each group had six bowel movements daily. Nighttime evacuation was found in 16% of PICA and in 20% of control. Soiling was found in 1% of PICA and 4.8% of control. After one stage operation, anastomotic leakage that needed ileostomy was observed in 0.7% of PICA and 3% of control. CONCLUSION: Partially intraanal canal anastomosis (PICA) can reduce anal canal mucosa with the same postoperative bowel function and complication rate as DS-IPAA above the anal canal. This procedure may be feasible for UC patients who can tolerate this procedure in terms of decreasing postoperative cancer risk.

Crohn's disease manifesting as ileo-urachal fistula: Two cases reports and review of literatures.

INTRODUCTION: A fistula involving a patent urachus in a patient with Crohn's disease is rare. Here we report ileourachal fistula formation in two patients with Crohn' disease. CASE PRESENTATIONS: The first patient was a 29-year-old man with Crohn's disease and ileitis, and the second patient was a 43-year-old man with Crohn's disease and ileitis. One of the patients showed pus/fecal discharge via the umbilicus. Both patients were eventually diagnosed with an ileourachal fistula associated with Crohn's disease. In the first patient, the urachal remnant was connected to the urinary bladder and a Crohn's disease-related intestinal lesion had formed a fistula to the urachus. In the second patient, a periumbilical inflammatory lesion extended to the bladder through the urachal remnant and to a longitudinal ulcer of the ileal lesion. The first patients underwent partial ileal resection, and partial cystectomy, while the second patient underwent urachal curettage, partial ileal resection, and partial cystectomy. In both. CONCLUSION: In cases of Crohn's disease with an enterocutaneous fistula or pus discharge via the umbilicus, an examination to detect an urachal remnant with a fistula from the diseased intestine should be performed.

[Diagnosis and treatment of six patients with Crohn's disease complicated by recto-perineal-urethral fistula].

Recto-perineal-urethral fistula caused by Crohn's disease is a rare, for which fundamental treatment has not been established yet. We analyzed the clinical characteristics, diagnosis, treatment, and prognosis of six male patients with anorectal lesions caused by Crohn's disease. Three patients were treated with abdominoperineal resection and the other three with rectal excision without anastomosis. Excluding one case, which presented worsening immediately after surgery, symptoms of urethral fistula improved without urethral stenosis, dysuria, or sexual dysfunction. Recto-perineal-urethral fistula is currently treated with various treatment modalities, including colostomy and drug therapy. Although the evaluation of these modalities is required, abdominoperineal resection or rectal excision without anastomosis may be a valuable treatment option because these approaches improve the urethral fistula while sparing the urethra without any significant complications.

Surgical treatment for Crohn's disease.

Surgery has important role in the management for Crohn's disease, although medical treatment had been developed in recent years. Surgical indications are as follows, massive bleeding, perforation, cancer, abscess, stenosis with obstruction, internal and external fistulas, severe anorectal disease, and medical failure. The principle of surgery is a minimal resection of intestine responsible for uncontrolled symptoms and repair of involved organs such as intestine, urinary bladder and abdominal wall. Strictureplasties are an effective alternative for stenosis which preserve the intestine. Seton treatment is often employed for complex perianal fistula. Surgery relieves the refractory symptoms well and should be employed at optimal time for the patients with severe symptoms which impaired their quality of lives.

A case of Crohn's disease complicated with simultaneous double cancers of the small bowel.

A case of Crohn's disease complicated with simultaneous double cancers of the small bowel is reported. The patient is a 66-year-old man who had suffered from Crohn's disease for 20 years. He underwent surgery to identify the source of repeated episodes of intestinal obstruction. Two short segments of strictures and proximal dilatations were found in the distal ileum. Therefore, we performed an en bloc resection of the two stenotic sections instead of strictureplasty. Histological examination of the resected specimen revealed not only Crohn's disease but also a well-differentiated adenocarcinoma within each of the two strictures. One had invaded to the muscular layer and the other to the subserosal layer. In cases of Crohn's disease with longstanding stenosis, the probability of carcinoma should be considered.

Epidemiology of colitis complicating cancer-postoperative cancer in ulcerative colitis and anorectal cancer in Crohn's disease.

Colitis complicating inflammatory bowel disease is gradually increasing in Japan. Although the postoperative cancer in ulcerative colitis is rare, careful postoperative follow up is nec- essary. Anorectal cancer including cancer of anal fistulae in Crohn's disease is the most common cancer in Japan and our original cancer surveillance program in which biopsy for anorectal lesion is performed for longstanding anal lesion (more than 10 years) is suggested to be effective for the detection of early cancer.

[Recent advances in medical and surgical treatment of ulcerative colitis].

Recent advances in both medical and surgical treatment of ulcerative colitis have been remarkable. Changes in medical treatment are mainly good results of therapy with the anti-TNF-α antibody, tacrolimus, and those in surgical treatment are an expansion of the surgical indications to include patients with intractable disease, such as treatment refractoriness and chronic corticosteroid dependence, by a better postoperative clinical course after pouch surgery, improred selection of surgical procedures and the timing of surgery in elderly patients. To offer the optimal treatment for patients with ulcerative colitis, new medical therapies should be analyzed from the standpoint of the efficacy and limitations of effect. Long postoperative clinical course of surgical patients including colitic cancer, prevention of postoperative complications should be also analyzed.

[Long-term outcomes of ileal pouch-anal canal anastomosis in children with ulcerative colitis].

The present study investigated the long-term outcomes of restorative proctocolectomy in pediatric patients with ulcerative colitis (UC). We report a series of 25 patients who underwent total proctocolectomy with ileal pouch-anal canal anastomosis (IACA). Surgery was performed for medically intractable colitis and severe colitis in 14 and 11 patients, respectively. Early and late complications were observed in 6 (24%) and 14 (56%) patients, respectively. The long-term quality of life outcomes were satisfactory, including both bowel function and social function. Growth retardation was observed in 6 patients. Five patients exhibited catch-up growth and 3 patients overcame growth retardation. Patients with growth retardation tended to have a younger onset and longer duration of UC, as well as a longer duration and higher total dose of steroid use. In conclusion, the long-term outcomes of pediatric patients with UC undergoing IACA are satisfactory. Furthermore, to minimize the risk of growth retardation, surgery should be performed without delay.

Cancer of the small intestine in patients with Crohn's disease.

Due to an increase in the number of long-term cases of Crohn's disease, the risk of combined cancer in these patients has been assessed in numerous articles. Most of these reports have involved patients with cancer of the large intestine, while cases of cancer of the small intestine combined with Crohn's disease are very rare. We experienced two cases of cancer of the small intestine combined with Crohn's disease. In both cases, the patients had suffered from Crohn's disease for over 10 years and a second operation was performed after a long period without treatment following the first operation, which had achieved a favorable outcome. In both cases of combined cancer, the patients experienced ileus; however, it was difficult to discern this from ileus due to the presence of Crohn's disease. Therefore, making a definitive diagnosis of combined cancer was not possible before surgery, and the definitive diagnosis was obtained based on an intraoperative pathological diagnosis. It is thought that tumor markers transition in a manner parallel to the progression of cancer, providing a clue for cancer diagnosis. In patients with Crohn's disease, there is a pressing need to establish a method for diagnosing cancer of the small intestine at an early stage.