Impact of the Crohn's disease digestive damage score (Lémann Index) on the perioperative course in patients with Crohn's disease and ileocolic anastomosis.

BACKGROUND: Risk factors influencing the high postoperative morbidity in Crohn`s disease are controversially discussed but the role of cumulative structural bowel damage, as assessed by the Crohn's disease digestive damage score (Lémann Index), has been neglected so far. Our aim was evaluating the influence of the Lémann Index on postoperative complications and investigating its suitability for surgical decision making. METHODS: A single-center, retrospective cohort study was conducted including Crohn`s disease patients who underwent ileocolic anastomosis. Lémann Indices were calculated and, additionally, categorized into three groups [0-3; 3-10; >10] due to the strong influence of previous bowel resections on high indices. A multivariate regression model was used to analyze the index`s influence on postoperative complications. RESULTS: Patients with higher Lémann Index were more likely to need open surgery (p < .001) or stoma creation (p = .03). Overall, of the 103 patients enrolled, 18 (17.5%) showed postoperative complications Clavien-Dindo > 2. The Lémann Index was higher in patients with complications compared to those without (median 6.15 [IQR 4.16-11.98] vs. 3.88 [1.63-12.63]), but not linearly associated with postoperative complications. After categorization, patients with Lémann Index 3-10 had an 8.42 (95% CI 1.8-54.55) times higher chance to develop a complication compared to patients with Lémann Index 0-3 (p = .01). CONCLUSIONS: The Lémann Index might affect surgical decision making but is not linearly associated with postoperative morbidity. However, medium indices (3-10) - mainly accounted for by high amounts of intraabdominal active Crohn`s lesions - showed significantly higher rates of complications, potentially defining a group at risk.

[Low Anterior Resection Syndrome - Diagnosis - Therapy - Prophylaxis]. / Das Low anterior Resection Syndrome (LARS).

BACKGROUND: As 5-year survival after rectal cancer surgery has reached 80%, there is increasing interest in quality of life. Low anterior resection syndrome (LARS) is an overall measure of the postoperative functional disorder due to the surgical resection. MATERIAL AND METHODS: A thorough review of the literature was undertaken to help to define LARS and develop an understanding of its pathophysiology, diagnosis, therapy, and prophylaxis. RESULTS: LARS is observed after up to 80% of stoma sparing procedures performed for rectal carcinoma. The capacity of the rectal remnant as well as intraoperative damage to neuronal structures seem to be the most important pathogenetic factors resulting in a substantial impairment of the quality of life. Pelvic floor rehabilitation, rectal balloon distension training, biofeedback, anal irrigation, and sacral nerve stimulation are multimodal treatment options for LARS. CONCLUSIONS: Various therapeutic approaches exist to attenuate the consequences of LARS for the individual patient. Nevertheless, considerable work has to be done in the future not only to improve survival but also the quality of live after rectal carcinoma.

Pre-emptive endoscopic vacuum therapy for treatment of anastomotic ischemia after esophageal resections.

Background and study aims Endoscopic vacuum therapy (EVT) is a promising new approach for the treatment of anastomotic leakage in the gastrointestinal tract. Here, we present the first case series demonstrating successful use of EVT for the treatment of post-esophagectomy anastomotic ischemia prior to development of leakage. Patients and methods Between 2012 and 2015, intraluminal EVT was performed in eight patients with anastomotic ischemia following esophagectomy. The primary outcome measure was successful mucosal recovery. Secondary outcome measures were duration of treatment, number of sponge changes, septic course, and associated complications. Results Complete mucosal recovery was achieved in six patients (75 %) with different degrees of anastomotic ischemia. In two patients (25 %), small anastomotic leaks developed, which resolved by continuing the EVT treatment. Median duration of EVT treatment until mucosal recovery was 16 days (range 6 - 35), with a median of 5 sponge changes per patient (range 2 - 11). No EVT-associated complications were noted. Three patients developed anastomotic stenoses, which were treated by endoscopic dilation therapy. Conclusion This is the first case series to demonstrate that the early use of EVT potentially modulates clinical outcomes and infection parameters in patients with anastomotic ischemia following esophagectomy. Further studies are needed to define the indications and patients who are most likely to benefit from early EVT.

Successful closure of defects in the upper gastrointestinal tract by endoscopic vacuum therapy (EVT): a prospective cohort study.

BACKGROUND: Perforations and anastomotic leakages of the upper gastrointestinal (GI) tract cause a high morbidity and mortality rate. Only limited data exist for endoscopic vacuum therapy (EVT) in the upper GI tract. METHODS: Fifty-two patients (37 men and 15 women, ages 41-94 years) were treated (12/2011-12/2015) with EVT for anastomotic insufficiency secondary to esophagectomy or gastrectomy (n = 39), iatrogenic esophageal perforation (n = 9) and Boerhaave syndrome (n = 4). After diagnosis, polyurethane sponges were endoscopically positioned with a total of 390 interventions and continuous negative pressure of 125 mm of mercury (mmHg) was applied to the EVT-system. Sponges were changed endoscopically twice per week. Clinical and therapy-related data and mortality were analyzed. RESULTS: After 1-25 changes of the sponge at intervals of 3-5 days with a mean of 6 sponge changes and a mean duration of therapy of 22 days, the defects were healed in 94.2 % of all patients without revision surgery. In three patients (6 %), EVT failed. Two of these patients died due to hemorrhage related to EVT. Four postinterventional strictures were observed during the follow-up of up to 4 years. CONCLUSION: Esophageal wall defects of different etiology in the upper gastrointestinal tract can be treated successfully with EVT, considering that indication for EVT should be weighed carefully. EVT can be regarded as a novel life-saving therapeutic tool.

A two-step multidisciplinary approach to treat recurrent esophageal strictures in children with epidermolysis bullosa dystrophica.

In children with severe generalized recessive dystrophic epidermolysis bullosa (RDEB), esophageal scarring leads to esophageal strictures with dysphagia, followed by malnutrition and delayed development. We describe a two-step multidisciplinary therapeutic approach to overcome malnutrition and growth retardation. In Step 1, under general anesthesia, orthograde balloon dilation of the esophagus is followed by gastrostomy creation using a direct puncture technique. In Step 2, further esophageal strictures are treated by retrograde dilation via the established gastrostomy; this step requires only a short sedation period. A total of 12 patients (median age 7.8 years, range 6 weeks to 17 years) underwent successful orthograde balloon dilation of esophageal strictures combined with direct puncture gastrostomy. After 12 and 24 months in 11 children, a substantial improvement of growth and nutrition was achieved (body mass index [BMI] standard deviation score [SDS] + 0.59 and + 0.61, respectively). In one child, gastrostomy was removed because of skin ulcerations after 10 days. Recurrent esophageal strictures were treated successfully in five children. The combined approach of balloon dilation and gastrostomy is technically safe in children with RDEB, and helps to promote catch-up growth and body weight. In addition, recurrent esophageal strictures can be treated successfully without general anesthesia in a retrograde manner via the established gastrostomy.

Crohn's Disease as a Possible Risk Factor for Failed Healing in Ileocolic Anastomoses.

Anastomotic leakage (AL) after colorectal resections is a serious complication in abdominal surgery. Especially in patients with Crohn's disease (CD), devastating courses are observed. Various risk factors for the failure of anastomotic healing have been identified; however, whether CD itself is independently associated with anastomotic complications still remains to be validated. A retrospective analysis of a single-institution inflammatory bowel disease (IBD) database was conducted. Only patients with elective surgery and ileocolic anastomoses were included. Patients with emergency surgery, more than one anastomosis, or protective ileostomies were excluded. For the investigation of the effect of CD on AL 141, patients with CD-type L1, B1-3 were compared to 141 patients with ileocolic anastomoses for other indications. Univariate statistics and multivariate analysis with logistic regression and backward stepwise elimination were performed. CD patients had a non-significant higher percentage of AL compared to non-IBD patients (12% vs. 5%, p = 0.053); although, the two samples differed in terms of age, body mass index (BMI), Charlson comorbidity index (CCI), and other clinical variables. However, Akaike information criterion (AIC)-based stepwise logistic regression identified CD as a factor for impaired anastomotic healing (final model: p = 0.027, OR: 17.043, CI: 1.703-257.992). Additionally, a CCI ≥ 2 (p = 0.010) and abscesses (p = 0.038) increased the disease risk. The alternative point estimate for CD as a risk factor for AL based on propensity score weighting also resulted in an increased risk, albeit lower (p = 0.005, OR 7.36, CI 1.82-29.71). CD might bear a disease-specific risk for the impaired healing of ileocolic anastomoses. CD patients are prone to postoperative complications, even in absence of other risk factors, and might benefit from treatment in dedicated centers.

The tripeptide KdPT protects from intestinal inflammation and maintains intestinal barrier function.

Treatment options for inflammatory bowel disease (IBD) are incompletely helpful, and surgery is often needed. One promising class of future therapeutic agents for IBD is melanocortin-related peptides, which exhibit potent immunomodulatory effects. We investigated KdPT, a tripeptide derivative of the C-terminus of α-melanocyte-stimulating hormone, as an anti-inflammatory small molecule in vivo and in vitro. Intestinal inflammation was studied after oral administration of dextran sodium sulfate and in IL-10 gene-deficient mice. The effects of KdPT on key colonic epithelial cell functions were studied in vitro and in vivo by evaluating proliferation, wound healing, transepithelial resistance, and expression of tight junction proteins. Melanin assays were performed to determine the melanotropic effects of KdPT. KdPT-treated animals showed markedly reduced severity of inflammation in both colitis models. In colonic epithelial cells, KdPT increased proliferation, accelerated closure of wounds, and improved transepithelial electrical resistance after stimulation with interferon-γ/tumor necrosis factor-α. Moreover, treatment with KdPT also prevented the loss of tight junction protein expression and improved barrier function in vivo. KdPT acted independently of IL-1 receptor type I in vivo and did not affect melanogenesis in vitro. KdPT is capable of attenuating the course of experimental colitis in different models and maintains epithelial cell function. Furthermore, KdPT does not induce pigmentation, emphasizing the potential of this small molecule for the future treatment of IBD.

Single-incision laparoscopic surgery for ileocolic resection in Crohn's disease.

BACKGROUND: Single-incision laparoscopic surgery is a development in the field of minimally invasive surgery that is being increasingly used for colorectal procedures. OBJECTIVE: We report on the short-term results of single-port laparoscopic ileocolic resection in patients with ileocecal Crohn's disease. DESIGN: This investigation is a retrospective matched-pair control study. Data were obtained from a prospectively maintained single-institution inflammatory bowel disease database. SETTINGS: This study was conducted at a tertiary care university hospital. PATIENTS: Twenty consecutive patients receiving elective single-port ileocolic resection between April 2010 and May 2011 were included (6 male, 14 female; age, 31.6 ± 10.8 years; BMI, 21.5 ± 2.6 kg/m). Their data were compared with the data of 20 individually matched patients who had undergone standard 3-trocar laparoscopic-assisted ileocolic resection between 2007 and 2010 (6 male, 14 female; age, 31.7 ± 10.7 years; BMI, 21.2 ± 2.5 kg/m). All patients had medically refractory stenosis of the terminal ileum in histologically confirmed Crohn's disease. INTERVENTIONS: Single-port laparoscopic-assisted or standard laparoscopic-assisted ileocolic resection was performed. MAIN OUTCOME MEASURES: The primary outcomes measured were the surgical details and early outcome. RESULTS: : The mean length of the paraumbilical single-port incision was 3.8 cm (range, 2.5-5.0 cm). Conversion rates were similar in both groups (1/20 vs 2/20, p = 0.55). Additional strictureplasties or short-segment small-bowel resections were performed in both groups. The overall complication rate was 20% (4/20) in both groups. There were no observed differences in postoperative pain scores and hospital stay duration. LIMITATIONS: The limitations of this study were as follows: this study was a comparison of 2 different time points with possible selection bias, there was no prestudy power calculation, and the study might be underpowered. CONCLUSIONS: Single-port ileocolic resection is a safe procedure for the surgical treatment of stenotizing Crohn's disease of the terminal ileum. Avoidance of additional trocars was the only identified benefit.

Timing of restorative proctocolectomy in patients with medically refractory ulcerative colitis: the patient's point of view.

BACKGROUND: Development of biologic agents has led to new therapeutic options for patients with refractory ulcerative colitis, and intensive medical therapy allows delay of restorative colectomy. However, the overall rate of colectomies has not changed. The decision as to timing of the operation is difficult. OBJECTIVE: Our aim was to elucidate the patients' views about the timing of their own proctocolectomy. DESIGN: This was a retrospective review of a prospectively designed database combined with a follow-up survey questionnaire. SETTINGS AND PARTICIPANTS: We included patients who underwent proctocolectomy and ileal pouch-anal anastomosis for refractory ulcerative colitis from 1999 through 2009 at our university hospital. MAIN OUTCOME MEASURES: A questionnaire was sent to patients asking whether they would have preferred to have had the operation performed earlier, later, or at the same time as it was actually done and to give the number of years or months earlier or later that they would have preferred. They were also asked to give reasons for their preference. Patients who preferred an earlier operation were compared with those satisfied with the timing regarding measures of postoperative quality of life and pouch function collected from the institution's prospective database. RESULTS: Of 84 eligible patients, 70 (83%) responded. Of these, 37 (53%) would have preferred an earlier operation; 33 patients (47%) were satisfied with the timing. No patient would have chosen a later operation. Patients who preferred an earlier operation wished it to have been a median of 2 years earlier (range, 2-120 months). The main reasons for a preferred earlier time point were postoperative improvement of stool regulation in 89% (33/37), reduction of bleedings in 84% (31/37), and relief of pain in 68% (25/37). No significant differences were observed between groups regarding postoperative quality of life or pouch function. LIMITATIONS: Limitations of the study included lack of validation and a nonsymmetrical structure of the questionnaire. CONCLUSIONS: About half of the patients of our study would have preferred to have had proctocolectomy earlier than it had been performed, mainly because of the relief of symptoms that they experienced after the operation. For patients with an emerging refractory course of ulcerative colitis, earlier restorative proctocolectomy should be considered as an alternative to further intensified medical treatment.

Pouch function and quality of life after successful management of pouch-related septic complications in patients with ulcerative colitis.

PURPOSE: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis is associated with pouch-related septic complications (PRSC) in 10% of patients. This study questioned if PRSC have a negative impact on pouch function and quality of life. PATIENTS AND METHODS: One hundred thirty consecutive patients undergoing IPAA for ulcerative colitis between 1997 and 2009 were reviewed. At 1-year follow-up, patients were asked to complete questionnaires including a pouch function score (Oresland score, 0-16 points, 0 optimum) and two quality of life scores [Short Inflammatory Bowel Disease Questionnaire (SIBDQ), 1-7 points, 7 optimum; Gastrointestinal Quality of Life Index (GIQLI), 0-144 points, 144 optimum]. RESULTS: Twelve out of 130 patients (9.2%) undergoing IPAA developed PRSC. These included anastomotic dehiscence (five), pouch leakage (three, one patient had a combined leak), peripouchal abscess (three), pouch-anal fistula (one), and pouch-vaginal fistula (one). Omission of diverting ileostomy was a risk factor for PRSC (OR 4.62, CI 1.17-18.4). PRSC led to four pouch failures (33%), whereas no failure occurred in the control group (p < 0.001). Median 3 (range, 1-10) further operations were necessary until the pouch was salvaged or definitively lost. If the pouch was salvaged, functional Oresland score (8.2 ± 1.3 vs. 6.6 ± 0.5; p = 0.127), SIBDQ (5.0 ± 0.5 vs. 5.5 ± 0.1; p = 0.203), and GIQLI (95.8 ± 8.4 vs. 107.3 ± 2.6; p = 0.119) were not significantly inferior to uncomplicated controls. CONCLUSIONS: In case of PRSC, even multiple surgical approaches are worthwhile as the outcome of salvaged pouches in terms of function and quality of life is not substantially inferior to patients without septic complications.

Impact of defunctioning loop ileostomy on outcome after restorative proctocolectomy for ulcerative colitis.

PURPOSE: This study analyzes the impact of a temporary loop ileostomy on postoperative outcome after restorative proctocolectomy for ulcerative colitis in terms of complications and reoperations including ileostomy closure. METHODS: The records of 122 consecutive patients undergoing restorative proctocolectomy for ulcerative colitis during a 12-year period were reviewed. In 89 patients, a defunctioning ileostomy was created, while 33 patients had no ileostomy. Statistics were done with Chi-square test and Mann-Whitney U test, p < 0.05 considered significant. RESULTS: Both study groups were comparable concerning age, colitis activity, previous diseases, previous surgery, use of steroids, and immunosuppressives. Pouch-related septic complications (anastomotic dehiscence, pouch leakage, pelvic abscess) were significantly lower in the ileostomy group (5.6% vs. 18.2%, p = 0.031), resulting in a lower rate of emergency laparotomies following restorative proctocolectomy (4.5% vs. 30.3%, p < 0.001). Including all complications associated with scheduled closure of ileostomy, the cumulative frequency of emergency laparotomies was significantly lower in the ileostomy group (13.5% vs. 30.3%, p = 0.032). The cumulative duration of hospitalization, including all hospital stays for complications or closure of the ileostomy, was significantly longer in the ileostomy group [median 22 days (11-92) vs. 14 days (9-109), p < 0.001]. During long-term follow-up, a stricture at the pouch-anal anastomosis was more common in the ileostomy group (24.7% vs. 6.1%, p = 0.021), whereas only one stricture necessitated surgical therapy. CONCLUSIONS: Creation of a defunctioning loop ileostomy reduces pouch-related septic complications and the frequency of emergency second laparotomies after restorative proctocolectomy for ulcerative colitis.

Minor Sphincter Sparing Surgery for Successful Closure of Perianal Fistulas in Patients with Crohn's Disease.

The purpose of this study is to demonstrate that repetitive minor surgical procedures allow for a high rate of permanent closure of perianal fistulas in patients with Crohn's disease (CD). Patients with perianal fistulizing CD (PFCD) who underwent perianal surgery at the University Hospital of Muenster between 2003 and 2018 were assessed for fistula characteristics and surgical procedures. We included 45 patients (m:f = 28:17) with a mean age of 27 years at first fistula appearance. Of these, 49% suffered from a complex fistula. An average of 4.2 (1-14) procedures were performed, abscess incisions and fistula seton drainages included. Draining setons were left in place for 5 (1-54) months, until fistula closure. Final surgical techniques were fistulotomy (31.1%), seton removal with sustained biological therapy (26.7%), Anal Fistula Plug (AFP) (17.8%), Over-The Scope-Clip proctology (OTSC) (11.1%), and mucosa advancement flap (4.4%). In 8.9% of cases, the seton was kept as permanent therapy. The time from first to last surgery was 18 (0-182) months and the median follow-up time after the last surgery was 90 (15-200) months. The recurrence rate was 15.5% after 45 (17-111) months. Recurrent fistulas healed after another 1.86 (1-2) surgical re-interventions. The final success rate was 80%. Despite biological treatment, PFCD management remains challenging. However, by repeating minor surgical interventions over a prolonged period of time, high permanent healing rates can be achieved.

Endocytosis and recycling of tight junction proteins in inflammation.

A critical function of the epithelial lining is to form a barrier that separates luminal contents from the underlying interstitium. This barrier function is primarily regulated by the apical junctional complex (AJC) consisting of tight junctions (TJs) and adherens junctions (AJs) and is compromised under inflammatory conditions. In intestinal epithelial cells, proinflammatory cytokines, for example, interferon-gamma (IFN-gamma), induce internalization of TJ proteins by endocytosis. Endocytosed TJ proteins are passed into early and recycling endosomes, suggesting the involvement of recycling of internalized TJ proteins. This review summarizes mechanisms by which TJ proteins under inflammatory conditions are internalized in intestinal epithelial cells and point out comparable mechanism in nonintestinal epithelial cells.

Long-Term Quality of Life Assessment After Successful Endoscopic Vacuum Therapy of Defects in the Upper Gastrointestinal Tract Quality of Life After EVT.

BACKGROUND: Accumulating evidence indicates that anastomotic leakages and perforations of the upper gastrointestinal tract (uGIT) can be treated successfully with endoscopic vacuum therapy (EVT). So far, no data is available regarding the long-term quality of life (QoL) after successful EVT of defects in the uGIT. METHODS: We present a prospective survey on long-term Qol of 52 patients treated by EVT for defects of the uGIT. Results are compared with 63 of 221 patients treated by esophagectomy without anastomotic insufficiency (w/o EVT) between 12/2011 and 12/2015. The Gastrointestinal Quality of Life-Index (GIQLI) score was determined by a 36-item questionnaire of 25 respondents with EVT and 50 respondents w/o EVT. RESULTS: The response rate was 78.95% (75/95) including 25 survey respondents who were treated with EVT for anastomotic insufficiency secondary to esophagectomy or gastrectomy (n = 19), iatrogenic esophageal perforation (n = 4), and Boerhaave syndrome (n = 2) and 50 respondents with complication-free esophagectomy w/o EVT. The median follow-up was 19 months for EVT patients and 21 months for patients w/o EVT. Except for "social function" (p = 0.009) in favor for patients w/o EVT, the median GIQLI score did not differ significantly between both study groups concerning the categories 'symptoms', 'emotions', 'physical functions', and 'medical treatment' resulting in a total median GIQLI score of 83 in EVT versus 96.5 in patients w/o EVT (p = 0.185). Spearman Rho analysis revealed that a high GIQLI score correlated with a low ASA score (p < 0.001), a benign pathology (p = 0.001), and a hospital stay less than 21 days (p < 0.001). CONCLUSION: EVT in the uGIT is well tolerated by the patients and accompanied by a satisfactory long-term QoL.

Endoscopic ultrasound with conventional probe and miniprobe in preoperative staging of esophageal cancer.

BACKGROUND: Using an endoscopic ultrasound (EUS) miniprobe, even highly stenotic esophageal cancers precluding the passage of a conventional probe can be examined without prior dilatation. OBJECTIVE: To assess: (1) staging accuracy of conventional EUS probe and miniprobe, (2) variables influencing staging accuracy, (3) endoscopic features predicting tumor stage. METHODS: Ninety-seven consecutive patients with esophageal cancer undergoing complete surgical resection were included. Preoperative EUS was performed using a conventional probe in nonstenotic tumors and a miniprobe in stenotic tumors. Accuracy of EUS for T and N stages was compared to pathohistological staging. RESULTS: Overall EUS staging accuracy was 73.2% for T stage and 74.2% for N stage. It was similar for the miniprobe used in stenotic tumors vs the conventional probe used in nonstenotic tumors. Based on EUS, 84.5% of the patients would have been assigned to the appropriate therapy protocol (primary surgery vs neoadjuvant therapy). Endoscopic tumor features had no influence on staging accuracy. Tumor length >5 cm predicted advanced T and nodal positive stages. CONCLUSIONS: The miniprobe allows adequate EUS staging of stenotic esophageal tumors precluding the passage of a conventional probe. Therefore, dilatation therapy of stenotic cancers to conduct conventional EUS should be avoided.

Segmental resection of the duodenum for gastrointestinal stromal tumor (GIST).

BACKGROUND: Gastrointestinal stromal tumors (GIST) are the most frequent mesenchymal tumors of the gastrointestinal tract. The biological appearance of these tumors reaches from small lesions with benign appearance to aggressive sarcomas. Only 3-5% of GISTs are localized in the duodenum. There is a controversy, if duodenal GISTs should be treated by a duodenopancreatectomy or by a limited resection of the duodenum. CASE PRESENTATION: A 29-year-old man presented with an acute upper gastrointestinal bleeding from a submucosal tumor located in the proximal part III of the duodenum, 3 cm distal of the papilla of Vater. After an emergency laparotomy with ligation of tumor-feeding vessels in a primary hospital, definitive surgical therapy was performed by partial resection of the duodenum with a duodenojejunostomy. Histology revealed a GIST with a diameter of 2.5 cm and <5 mitoses/50 high power fields, indicating a low risk of malignancy. Therefore no adjuvant therapy with Imatinib was initiated. CONCLUSION: GISTs of the duodenum are a rare cause of upper gastrointestinal bleeding. Partial resection of the duodenum is a warranted alternative to a duodenopancreatectomy, as this procedure has a lower operative morbidity, while providing comparable oncological results.

Syndecan-4 Modulates Epithelial Gut Barrier Function and Epithelial Regeneration in Experimental Colitis.

Background: The transmembrane heparan sulfate proteoglycan Syndecan-4 (Sdc4) plays an important role in the regulation of various inflammatory disorders. However, the involvement of Sdc4 in intestinal inflammation remains unknown. Therefore, we assessed the impact of Sdc4 deficiency on experimental colitis and epithelial wound healing in vitro and in vivo. Methods: Dextran sulfate sodium (DSS)-induced colitis was monitored in wild type and Sdc4-deficient (Sdc4-/-) mice by assessment of body weight, histology, inflammatory cellular infiltration, and colon length. Syndecan-4 expression was measured by immunohistochemistry, Western blot, and quantitative real-time PCR. Epithelial permeability was evaluated by Evans blue measurements, Western blot, and immunohistological analysis of tight junction protein expression. Impact of Sdc4 on epithelial wound healing was determined by scratch assay in vitro and by colonoscopy following mechanical wounding in vivo. Results: In Sdc4-/- mice, colitis-like symptoms including severe weight loss, shortened colon length, histological damage, and invasion of macrophages and granulocytes were markedly aggravated compared with wild type (WT) animals. Moreover, colonic epithelial permeability in Sdc4-/- mice was enhanced, while tight junction protein expression decreased. Furthermore, Sdc4-/- colonic epithelial cells had lower cell proliferation and migration rates which presented in vivo as a prolonged intestinal wound healing phenotype. Strikingly, in WT animals, Sdc4 expression was reduced during colitis and was elevated during recovery. Conclusions: The loss of Sdc4 aggravates the course of experimental colitis, potentially through impaired epithelial cell integrity and regeneration. In view of the development of current treatment approaches involving Sdc4 inhibition for inflammatory disorders like arthritis, particular caution should be taken in case of adverse gastrointestinal side-effects.

Endoscopic Vacuum Therapy (EVT)-a New Concept for Complication Management in Bariatric Surgery.

BACKGROUND: Bariatric surgery is the most efficient therapy for morbid obesity. Staple line and anastomotic leakage are the most feared postoperative complications after Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy (LSG). Traditional treatment options like revisional surgery and endoscopic stent placement are associated with high morbidity and mortality as well as variable success rates. Endoscopic vacuum therapy (EVT) has shown to be a new successful and feasible treatment option for leaks of different etiology after major gastro-esophageal surgery. METHOD: We report a case of the EVT principle being applied in a patient with three major leaks located apart from each other within the gastric staple line after LSG for morbid obesity (BMI 62.7). EVT was initiated on postoperative day 8. RESULTS: In total, 18 endoscopic interventions were performed in 72 days, the vacuum sponge being replaced endoscopically every 4 days. Hospital length of stay was 106 days. No relevant procedure related complications were observed during the course of therapy and during the follow up. CONCLUSION: EVT of postoperative leaks in the upper GI tract has been shown to be feasible and safe. It combines defect closure and effective drainage and allows a periodic inspection of the wound cavity. In case of therapeutic failure, it does not jeopardize surgical repair or stent placement. Even though the techniques and materials used in EVT still vary considerably according to local expertise, EVT has the potential to succeed as a nonsurgical, feasible, safe, and effective treatment option for postoperative leaks in bariatric surgery.

Temporary fecal diversion in the management of colorectal and perianal Crohn's disease.

Aim. To evaluate the results of temporary fecal diversion in colorectal and perianal Crohn's disease. Method. We retrospectively identified 29 consecutive patients (14 females, 15 males; median age: 30.0 years, range: 18-76) undergoing temporary fecal diversion for colorectal (n = 14), ileal (n = 4), and/or perianal Crohn's disease (n = 22). Follow-up was in median 33.0 (3-103) months. Response to fecal diversion, rate of stoma reversal, and relapse rate after stoma reversal were recorded. Results. The response to temporary fecal diversion was complete remission in 4/29 (13.8%), partial remission in 12/29 (41.4%), no change in 7/29 (24.1%), and progress in 6/29 (20.7%). Stoma reversal was performed in 19 out of 25 patients (76%) available for follow-up. Of these, the majority (15/19, 78.9%) needed further surgical therapies for a relapse of the same pathology previously leading to temporary fecal diversion, including colorectal resections (10/19, 52.6%) and creation of a definitive stoma (7/19, 36.8%). At the end of follow-up, only 4/25 patients (16%) had a stable course without the need for further definitive surgery. Conclusion. Temporary fecal diversion can induce remission in otherwise refractory colorectal or perianal Crohn's disease, but the chance of enduring remission after stoma reversal is low.