Subperitoneal adenomucinosis following proctocolectomy for ulcerative colitis.

Adenomucinosis is a rare condition characterized by accumulation of large volumes of mucin, typically related to mucinous neoplasms of the appendix within the peritoneal space. Extraperitoneal adenomucinosis is an uncommon variant where mucin accumulates outside the peritoneal space and usually arises following surgery for mucinous appendiceal neoplasms. This is a case of subperitoneal adenomucinosis resulting from retention of a small fragment of rectal mucosa following proctocolectomy for ulcerative colitis 16 years prior. The patient presented with a slow-growing boggy perineal mass. Contrast-enhanced magnetic resonance imaging (MRI) showed the mass to be localized to the pelvis, without solid enhancing components, and correctly facilitated local surgical excision without the risk of peritoneal dissemination and accurately predicted benignity.

Short- and long-term costs of laparoscopic colectomy are significantly less than open colectomy.

BACKGROUND: The financial impact of laparoscopic colectomy remains poorly defined. We report the short-term costs of laparoscopic colectomy (LC) as compared with open colectomy (OC) in a high-volume tertiary care hospital, and are the first to incorporate the costs of late, colectomy-related complications in an analysis of long-term costs. METHODS: A retrospective analysis of patients undergoing elective laparoscopic (n = 76) or open (n = 162) colon resection between January 2004 and December 2006 was performed. Primary endpoints were total hospital cost of the index admission and total hospital cost for any subsequent admission for treatment of a colectomy-related complication. RESULTS: Two-hundred thirty-eight patients met inclusion criteria. Mean total hospital cost was significantly greater for patients undergoing OC (US $17,686 per patient versus US $14,518, P = 0.0003). Mean total operative costs were equivalent (US $7,451 OC versus US $7,794 LC, P = 0.274). Average length of stay was shorter for LC (5.2 versus 6.9 days, P < 0.0001). Late complication rates were 5.6% (OC) and 2.6% (LC). Integrating the cost of late complications further increased the disparity between the total cost of OC (US $18,296 per patient, 3.4% increase) as compared with LC (US $14,789, 1.9% increase). CONCLUSION: We demonstrate both short- and long-term financial benefits of LC in a high-volume tertiary care hospital.

The inflammatory bowel disease live interinstitutional and interdisciplinary videoconference education (IBD LIVE) series.

BACKGROUND: Managing patients with inflammatory bowel disease requires multidisciplinary coordination. Technological advances have enhanced access to care for patients and improved physician interactions. The primary aim of our project was to convene diverse institutions and specialties through a multisite virtual conferencing platform to discuss complex patient management. METHODS: The case conference is designed to include multiple institutions to exchange ideas, review evidence-based data, and provide input on the management of patients with Crohn's disease and ulcerative colitis. Technology is supplied and coordinated by an information technology specialist and Chorus Call, Inc., an international teleconferencing service provider. The Inflammatory Bowel Disease Live Interinstitutional Interdisciplinary Videoconference Education (IBD LIVE) initiative is accredited by the University of Pittsburgh Medical Center (UPMC) Center for Continuing Education in the Health Sciences for 1 AMA PRA Category 1 Credit per weekly session. RESULTS: IBD LIVE began in 2009 comprising only adult gastroenterology and pediatric gastroenterology from UPMC Presbyterian and Children's Hospitals. Participation steadily increased from 5 sites in 2010 to 11 sites in 2014. Maximum attendance for a single conference was 73 participants with a median of 48. The Continuing Medical Education scores (1 = worst to 5 = best) have a high median overall score (4.6, range 3.2-5.0) with positive responses with regard to the degree to which the conference changed practice. CONCLUSIONS: IBD LIVE has been successful and continues to grow. Implementation of the Crohn's and Colitis Foundation of America Virtual Preceptor Program using the IBD LIVE platform will provide expanded national physician access to this professional education activity.

Small bowel resection rates in Crohn's disease and the indication for surgery over time: experience from a large tertiary care center.

BACKGROUND: Our primary aim was to determine if the rate of small bowel resection (SBR) has declined over time among Crohn's disease (CD) patients seen at a single academic institution. A secondary aim was to establish whether the indication for surgery has changed. METHODS: Patients with a primary or secondary ICD-9 code for CD (555.0-555.9) who underwent SBR at the University of Pittsburgh were included. Patients were divided into 4 separate time periods based on when they had surgery: 1995-1998 (Period 1), 1999-2001 (Period 2), 2002-2004 (Period 3), and 2005-2007 (Period 4). Medical records were reviewed for the 6 months preceding surgery. Use of 5-ASAs, immunomodulators (IMs), tumor necrosis factor (TNF) antagonists, and corticosteroids were noted. Disease behavior was defined as nonstricturing, nonpenetrating (B1), stricturing (B2), and penetrating (B3). Proportions of patients undergoing SBR were calculated according to calendar cohort and these rates were examined for time trends. RESULTS: In all, 227 unique patients were analyzed for a total of 236 surgeries. The rates of 5-ASA, IM, and corticosteroid use were similar across the 4 time periods. By contrast, TNF antagonist usage progressively increased over time (0%, 18%, 34%, 35%; P = 0.0002). The annual rate of SBR per period did not change (1.6%, 1.9%, 1.6%, 1.9%; P = 0.93). Similarly, the disease behavior did not change over time. CONCLUSIONS: While the frequency of TNF antagonist use in CD at the University of Pittsburgh has increased over time, the rate of SBR and indication for surgery has remained unchanged. These findings may be explained by long-standing, complicated disease refractory to medical therapy.

Diffuse filiform polyposis with unique histology mimicking familial adenomatous polyposis in a patient without inflammatory bowel disease.

Filiform polyposis is an uncommon entity that is most often encountered in the colon of patients with a history of inflammatory bowel disease (IBD). Filiform polyposis is characterized by a large number of "wormlike" polyps lined by histologically normal colonic mucosa. These polyps can mimic adenomatous polyps. Only rare cases without a history or evidence of IBD have been reported. Neuromuscular and vascular hamartoma of the small bowel is a rare, focal disorder characterized by disorganized smooth muscle fascicles throughout the submucosa accompanied by fibrosis, nerve fibers, ganglion cells, and vessels. To our knowledge, there is only one report of this lesion in the large bowel (cecum), where it presented as a mass. Here we report the case of a 50-year-old man with no known history or symptoms of IBD presenting with filiform polyposis involving the entire colon, clinically mimicking familial adenomatous polyposis, and showing histologic features similar to neuromuscular and vascular hamartoma of the small bowel.

Neoadjuvant imatinib in gastrointestinal stromal tumor of the rectum: report of a case.

Gastrointestinal stromal tumors are rare tumors of the gastrointestinal tract. Gastrointestinal stromal tumors involving the rectum are uncommon. We describe a case of a 43-year-old female with a gastrointestinal stromal tumor of the rectum who declined abdominoperineal resection. Neoadjuvant treatment with imatinib decreased her tumor size, permitting sphincter-sparing transanal excision. She had no evidence of disease for 24 months postoperatively until she recurred with lung metastases. Microdissection genotyping of the recurrent lesion revealed a deletion in exon 11. Further mutational analysis showed that her metastatic lesion was concordant with her primary rectal lesion, suggesting that systemic micrometastasis was previously present at initial diagnosis. Deletion in exon 11 predicts for response with imatinib treatment and is associated with a longer event-free and overall survival. Current studies are underway that may help us optimize the treatment for patients with gastrointestinal stromal tumors.

Molecular and functional observations on the donor intestinal muscularis during human small bowel transplantation.

BACKGROUND & AIMS: Ischemia-reperfusion injury or intestinal manipulation evokes an inflammatory response within the intestinal muscularis that is associated with intestinal dysmotility. We hypothesize that human small intestinal transplantation induces an analogous response. METHODS: Human intestinal graft specimens were obtained during transplantation and compared with specimens removed early during elective bowel resections. Inflammatory gene expression was quantified by real-time reverse-transcription polymerase chain reaction. Histochemistry and immunohistochemistry were used to characterize leukocyte infiltration and macrophage activation. In vitro circular muscle contractility and intracellular electric neuromuscular transmission in response to electric field stimulation (EFS) were measured. RESULTS: Messenger RNA (mRNA) values were significantly elevated before reperfusion and further increased during reperfusion (4 hour reperfusion: interleukin [IL]-6, 311-fold; monocyte chemoattractant protein [MCP-1, 122-fold; IL-8, 338-fold; epithelial neutrophil-activating peptide-78 [ENA-78], 56-fold; intercellular adhesion molecule-1 [ICAM-1], 9-fold; and cyclooxygenase-2 [COX2], 37-fold) over elective specimens. Neutrophils and monocytes extravasated in increased numbers in whole mounts before and after reperfusion over the elective specimens. Activated resident macrophages were identified as a major source of inflammatory mediators. Muscle contractions and neuromuscular transmission were markedly attenuated in the grafts. CONCLUSIONS: The data suggest that manipulation during organ harvesting initiates a functionally relevant molecular and cellular inflammatory response within the graft muscularis that is potentiated during the reperfusion period. Significant mechanical and neuromuscular functional alterations occurred during the transplant process.

Intra-abdominal activation of a local inflammatory response within the human muscularis externa during laparotomy.

OBJECTIVE: To investigate the initiation of a complex inflammatory response within the human intestinal muscularis intraoperatively so as to determine the clinical applicability of the inflammatory hypothesis of postoperative ileus. SUMMARY BACKGROUND DATA: Mild intestinal manipulation in rodents initiates the activation of transcription factors, upregulates proinflammatory cytokines, and increases the release of kinetically active mediators (nitric oxide and prostaglandins), all of which results in the recruitment of leukocytes and a suppression in motility (i.e., postoperative ileus). METHODS: Human small bowel specimens were harvested during abdominal procedures at various times after laparotomy. Histochemical and immunohistochemical techniques were applied to intestinal muscularis whole-mounts. Reverse transcriptase-polymerase chain reaction (RT-PCR) was performed for interleukin (IL)-6, IL-1beta, tumor necrosis factor (TNF)-alpha, inducible nitric oxide synthase (iNOS), and cyclooxygenase-2 (COX-2). Signal transducers and activators of transcription (STAT) protein phosphorylation was determined by electromobility shift assay. Organ bath experiments were performed on jejunal circular smooth muscle strips. GW274150C and DFU were used in vitro as iNOS and COX-2 inhibitors. RESULTS: Normal human muscularis externa contained numerous macrophages that expressed increased lymphocyte function associated antigen-1 (LFA-1) immunoreactivity as a function of intraoperative time. RT-PCR demonstrated a time-dependent induction of IL-6, IL-1beta, TNF-alpha, iNOS, and COX-2 mRNAs within muscularis extracts after incision. Mediators were localized to macrophages with STAT protein activation in protein extracts demonstrating local IL-6 functional activity. DFU alone or in combination with GW274150C increased circular muscle contractility. Specimens harvested after reoperation developed leukocytic infiltrates and displayed diminished in vitro muscle contractility. CONCLUSIONS: These human data demonstrate that surgical trauma is followed by resident muscularis macrophage activation and the upregulation, release, and functional activity of proinflammatory cytokines and kinetically active mediators.