Elemental diet therapy plays a significant role in preventing surgical recurrence of Crohn's disease in the era of biologics.

PURPOSE: Most patients with Crohn's disease (CD) experience surgical recurrence. In this era of novel therapies, we conducted this study to clarify which treatments effectively decrease the risk of surgical recurrence in patients with CD. METHODS: The subjects of this retrospective study were 37 patients with CD. We created cumulative surgery rate curves and performed univariate and multivariate analyses. RESULTS: Univariate analysis revealed that patients who consumed an elemental diet (ED; ≥ 900 kcal/day), anti-tumor necrosis factor-alpha, and thiopurines had a significantly better prognosis than those who did not (p = 0.011, p = 0.025, and p = 0.0080, respectively). Multivariate analysis revealed that ED therapy and thiopurines were independent significant factors for controlling surgical recurrence (p = 0.046 and p = 0.032, respectively). Additional analyses showed that the most promising ED therapeutic dose was ≥ 1200 kcal/day, while an ED therapeutic dose of ≥ 900 kcal/day was acceptable. CONCLUSIONS: Although univariate analyses revealed that all three treatment strategies had significant effects on surgical recurrence in patients with CD, multivariate analysis revealed that only ED therapy was significantly associated with surgical recurrence rates. Thus, ED therapy plays an important role in the management of CD, even in the era of biological therapies.

A series of seton techniques involving "top-down therapy" for patients with Crohn's disease who initially presented with perianal fistulas.

OBJECTIVES: We determined the outcomes of seton treatment through a series of techniques using biological agents (BIOs) in 18 patients with Crohn's disease (CD) who initially presented with perianal fistulas. METHODS: The patients underwent seton drainage using three seton types: a Penrose tube for fistulas with massive purulent discharge, a vessel loop for a small amount of discharge, and a rubber band for unproductive fistulas. If the distal end of the fistula extended more than 4 cm from the anal orifice, the skin and subcutaneous tissue were dissected along the outer edge of the anal sphincter to divide the fistulous tract into two portions. One seton encircled the sphincter from the primary opening throughout the anal canal (medial seton), and the other was inserted through the distal tract outside the sphincter (lateral seton). A BIO was then introduced immediately. When discharge ceased, the Penrose tube or vessel loop was replaced sequentially with a rubber band, which was tied fittingly and subsequently removed in medial to lateral order. RESULTS: The mean interval between fistula onset and CD diagnosis was 2.1 years, and that between CD diagnosis and introduction of BIOs was 0.5 years. The mean follow-up duration was 4 years. The BIOs currently used were infliximab in 10 patients, adalimumab in 7, and ustekinumab in 1. The overall success rate was 94.4%, including unproductive fistulas in 10 (55.6%) patients and fistula disappearance in 7 (38.9%). CONCLUSIONS: Our seton drainage techniques via the "top-down" approach represent a promising avenue for treating perianal fistulas in patients with CD.

Anorectal fistula is an early manifestation of Crohn's disease that occurs before bowel lesions advance: a study of 11 cases.

The diagnostic significance of single-balloon enteroscopy (SBE) in patients presenting with Crohn's disease (CD)-like anorectal fistula is unknown. We experienced 11 cases undergoing SBE due to CD-like fistulas between December 2007 and April 2013. The mean interval from fistula onset to SBE was 19.2 months with a range of 1.3-44.7. Prior to SBE, all patients underwent anorectal examination under anesthesia (EUA), and 9 patients underwent total colonoscopy with terminal ileal cannulation (TCS-I). One of 7 patients undergoing upper gastrointestinal endoscopy had CD-like gastritis. EUA revealed CD fissures in 7 patients, 1 of whom had no intestinal lesion. Primary TCS-I identified early lesions, such as aphthes and small ulcers, in 4 patients. Among the other 5 patients without any intestinal lesions with TCS-I, SBE indicated early lesions in 3 patients. One of 2 patients who initially underwent SBE without TCS-I showed multiple aphthes. Of the 11 patients, only 4 patients fulfilled the definitive Japanese diagnostic criteria for CD and 7 remained 'suspected CD' cases. Intrinsic anorectal fistulas as a presenting symptom of CD may be an early predictor of bowel lesions. SBE has the potential to reveal incipient disease because an early ileal lesion is not rare for patients with anorectal fistulas.

Recovery of the rectoanal inhibitory reflex after restorative proctocolectomy: does it correlate with nocturnal continence?

PURPOSE: The rectoanal inhibitory reflex has an important role in fecal sampling and discrimination of rectal contents. The aim of this study was to determine the significance of rectoanal inhibitory reflex after restorative proctocolectomy with ileal pouch-anal anastomosis for mucosal ulcerative colitis. METHODS: The medical records of 345 patients who underwent ileal pouch-anal anastomosis from September 1988 to May 1999 were retrospectively reviewed. One hundred patients who underwent double-stapled ileal pouch-anal anastomosis and had anorectal physiology testing within 3 months before surgery as well as after ileostomy closure (mean, 23.1; range, 3-77 months) were analyzed. Anorectal physiology testing included detecting the presence of the rectoanal inhibitory reflex, sensory threshold volume, and rectal or pouch capacity and compliance. Parameters to determine incontinence included daytime and nocturnal bowel movement frequency, nocturnal spotting, status of continence for solid or liquid stool, gas, use of pads, and lifestyle alteration were surveyed in 62 of the 100 patients at a mean of 3.9 (range, 1-9.1) years to determine the incontinence score. RESULTS: Whereas the rectoanal inhibitory reflex was noted in 96 (96 percent) patients before surgery, it was found in only 53 (53 percent) after ileostomy closure (P < 0.0001). Incontinence status data was available in only 62 of the 100 patients (32 RAIR-positive; 30 RAIR-negative). There were no significant differences between the rectoanal inhibitory reflex-positive and the rectoanal inhibitory reflex-negative groups relative to the interval between surgery and manometry (22 vs 25 months), postoperative threshold sensation volume (32 vs 31 ml), postoperative compliance (19 vs 12 cm H(2)O/ml), postoperative capacity (85 66 ml), daytime/nighttime stool frequency (6.2/2 vs 5.5/1.5), or postoperative incontinence score (3.9 vs 1.8). However, there were significant differences relative to the incidence of nocturnal soiling (12/30 (40 percent) 23/32 (72 percent), P = 0.0012) favoring the presence of the rectoanal inhibitory reflex. CONCLUSION: Preservation of the rectoanal inhibitory reflex correlated with a decrease in the incidence of nocturnal soiling after double-stapled ileoanal reservoir construction.

How consistent is the anal transitional zone in the double-stapled ileoanal reservoir?

BACKGROUND AND AIMS: The double-stapled ileoanal reservoir (DSIAR) has become a preferred method for ileal pouch anal anastomosis in restorative proctocolectomy. This investigation assessed the relative ratio of epithelial tissue types within the anal transition zone after a DSIAR and reviewed functional physiological differences. PATIENTS AND METHODS: All 138 patients who underwent restorative proctocolectomy with a DSIAR for mucosal ulcerative colitis were stratified into two groups according to histological evidence of epithelium types in the distal excised rectal donut. In group I a squamous or a squamous mixed with columnar epithelium was present (n=40) whereas in group II only columnar epithelium was seen (n=98). Anal physiological parameters were measured by anal manometry preoperatively, prior to ileostomy closure, and 1 year after surgery. RESULTS: None of the preoperative resting and squeeze pressure parameters showed a significant difference between the two groups. Postoperative mean and maximal resting pressures were significantly decreased in both groups. Postoperative mean and maximum squeeze pressures were decreased in group I. Postoperative mean length of the high-pressure zone tended to be decreased in both groups. The decrease in rectoanal inhibitory reflex was significant in both groups. Postoperative functional parameters measured as maximal tolerable volume and compliance were significantly improved from preoperative values in both groups. CONCLUSION: The tissue type in the anal transitional zone after DSIAR has a wide variability at a similar level (height) of the anastomosis. However, these different epithelial types were not associated with substantial physiological functional differences. Thus, if technically feasible, it is desirable for DSIAR to construct the anastomosis as close to the dentate line as possible.