Risk factors for the postoperative recurrence of ulcerative colitis-associated colorectal cancer.

PURPOSE: Although ulcerative colitis-associated colorectal cancer (UC-CRC) has been described, there are few reports regarding recurrent cases of UC-CRC. In this study, we investigated the risk factors for UC-CRC recurrence. METHODS: Recurrence-free survival (RFS) was determined for 144 stage I to III cancer patients among 210 UC-CRC patients from August 2002 to August 2019. The Kaplan‒Meier method was used to obtain the cumulative RFS rate, and the Cox proportional hazard model was used to extract recurrence risk factors. The interaction term between cancer stage and prognostic factors specific to UC-CRC was evaluated using the Cox model. The Kaplan‒Meier method was applied by cancer stage to the UC-CRC-specific prognostic factors for which interaction effects were indicated. RESULTS: There were 18 cases of recurrence involving patients with stage I to III cancer, and the recurrence rate was 12.5%. The cumulative 5-year RFS rate was 87.5%. Multivariable analysis showed that age at surgery (hazard ratio (HR): 0.95, 95% CI: 0.91-0.99, p = 0.02), undifferentiated carcinoma (HR: 4.42, 95% CI: 1.13-17.24, p = 0.03), lymph node metastasis (HR: 4.11, 95% CI: 1.08-15.69, p = 0.03), and vascular invasion (HR: 8.01, 95% CI: 1.54-41.65, p = 0.01) were significant risk factors for recurrence. Patients with stage III CRC in the young adult (age < 50 years) group had a significantly worse prognosis than those in the adult (age ≥ 50 years) group (p < 0.01). CONCLUSION: Age at surgery was identified as a risk factor for UC-CRC recurrence. Young adult patients with stage III cancer may have a poor prognosis.

Clinical features and surgical selection in colitis-associated colorectal cancer with ulcerative colitis.

PURPOSE: The aim of this study was to compare the clinical characteristics of ulcerative colitis (UC) patients who underwent surgery for cancer/dysplasia with those who underwent surgery for refractory disease and to discuss the preoperative preparation for successful hand-sewn IPAA. METHODS: Patients who underwent surgery for UC between January 2014 and December 2021 at Hyogo Medical University were included in the study. A total of 443 UC surgical cases were included in the study, which comprised 188 cancer/dysplasia patients and 255 refractory patients. Clinical records were compared retrospectively. RESULTS: The proportion of surgical UC cases with cancer/dysplasia has been on the rise, accounting for approximately 40% in recent years. The duration of disease (months) was 186 (2-590) in the cancer/dysplasia group and 48 (1-580) in the refractory group (p = 0.02). UC severity (mild/moderate/severe) was 119/69/0 in the cancer/dysplasia group and 18/157/80 in the refractory group (p < 0.01). The four nutrition factors of weight (55.2 (32.7-99.6) kg: 49.9 (20.3-85.2) kg), body mass index (21.0 (13.9-32.5) kg/m2: 18.3 (11.4-34.1)kg/m2), serum albumin level (4.3 (2.7-5.0)g/dl: 3.4 (1.4-5.2)g/dl) and prognostic nutrition index (49.2 (33.2-61.2): 40.9 (17.4-61.1)) were significantly higher in the cancer/dysplasia group (p < 0.01). The degree of obesity was also significantly higher in the cancer/dysplasia group (p < 0.01). CONCLUSION: UC patients with cancer/dysplasia were more likely than refractory patients to have mild inflammation; they also had a longer duration of UC disease and better nutritional status.

Association between preoperative biologic use and surgical morbidity in patients with Crohn's disease.

PURPOSE: We evaluated the influence of preoperative treatments with biologics on surgical morbidity in patients with Crohn's disease (CD). METHODS: We reviewed the surveillance data of patients with CD who underwent surgery between April 2018 and April 2021. The possible risk factors for morbidity were analyzed. RESULTS: A total of 305 surgically treated patients were included. Anti-TNF alpha agents and ustekinumab were used in 92 and 27 patients, respectively, within 12 weeks before surgery. There were no cases of mortality. In total, 70/305 (23.0%) patients developed a complication, and 42/305 (13.8%) patients developed a surgical site infection (SSI) (17 incisional SSIs and 35 organ/space SSIs). Current smoking status (OR 3.44), emergent/urgent surgery (OR 6.85), and abdominoperineal resection (APR) (OR 14.93) were identified as risk factors for total complications. Penetrating disease (OR 14.55) was identified as a risk factor for incisional SSIs. Current smoking status (OR 7.09), an American Society of Anesthesiologists (ASA) score greater than 3 (OR 5.85), a postoperative blood sugar level over 155 mg/dL (OR 4.37), and APR (OR 207.95) were identified as risk factors for organ/space SSIs. CONCLUSIONS: No correlation between preoperative treatment with biologics and surgical mortality or morbidity was found. However, we should perform further analyses on a larger number of patients because the analyses may be limited by selection bias for treatment and several confounding factors.

Being Elderly Is Associated with Infectious and Fatal Postoperative Complications in Ulcerative Colitis Patients.

INTRODUCTION: It is well known that the infectious complications and mortality rates are increased among elderly individuals with ulcerative colitis (UC) during medical treatment. However, there have been few reports on surgery in elderly individuals with UC, and some cohort studies have reported surgical complication and mortality rates similar to those in nonelderly individuals. METHODS: UC patients who underwent colectomy at the Hyogo College of Medicine between April 2012 and March 2020 were included in this study. The patients were classified as elderly (≥65) or nonelderly (<65). Characteristics and postoperative complications were analyzed and compared between the groups; possible risk factors for infectious and fatal complications were also analyzed. RESULTS: In all, 136/599 (22.7%) elderly patients were included. The incidence of infectious and fatal complications was 177/599 (29.5%) and 18/599 (3%), respectively. These complication rates were significantly higher in the elderly than the nonelderly group (p < 0.01). Age ≥65 years at surgery (OR = 2.92, 95% CI: 1.87-4.57, p < 0.01) was identified as an independent risk factor for infectious complications. Age ≥65 years at surgery (OR = 8.03, 95% CI: 2.16-29.83, p < 0.01), American Society of Anesthesiologists score ≥3 (OR = 6.00, 95% CI: 1.40-25.6 p = 0.02), and urgent/emergent surgery (OR = 16.24, 95% CI: 1.70-154.95, p = 0.02) were identified as independent risk factors for fatal complications. DISCUSSION/CONCLUSION: Age ≥65 years was identified as a risk factor for infectious and fatal complications. It is important to avoid urgent/emergent surgery in elderly patients with an ASA score >3 by emphasizing surgical and medical collaboration and optimizing the timing of surgery.

Rectal carcinoma with dual differentiation toward enteroblastic and neuroendocrine features arising in a patient with ulcerative colitis: a case report.

BACKGROUND: Colorectal carcinoma with enteroblastic differentiation is a rare subtype of colorectal carcinomas expressing at least one characteristic immunohistochemical marker among α-fetoprotein, glypican-3, and spalt-like transcription factor 4. On the other hand, colorectal carcinoma with neuroendocrine differentiation is also a unique subtype of colorectal carcinomas showing expression of at least one distinctive marker among chromogranin A, synaptophysin, and CD56. CASE PRESENTATION: We experienced an extremely rare case of rectal carcinoma with dual differentiation toward enteroblastic and neuroendocrine features in a 53-year-old male patient with long-standing ulcerative colitis (UC). Most of the tumor cells were positive for enteroblastic differentiation markers and approximately a half of them for neuroendocrine differentiation markers. Some tumor cells showed only enteroblastic differentiation, and some did only neuroendocrine feature, but some showed both enteroblastic and neuroendocrine differentiation. CONCLUSION: Colorectal carcinoma with dual differentiation toward enteroblastic and neuroendocrine features has not been reported yet. Neoplastic transformation from pluripotent stem cells in dysplastic epithelium of long-standing UC patients may be associated with such dual differentiation features.

Localization of recurrent lesions following ileocolic resection for Crohn's disease.

BACKGROUND: Crohn's disease (CD) recurrence can occur not only at the site of anastomosis but also elsewhere in the bowel following an ileocolic resection (ICR) procedure. The aims of the present study were to assess long-term outcomes of a primary ICR procedure for CD in consecutive patients and examine the location of the reoperation causative lesion. METHODS: We examined cases of surgery with ICR initially performed at our institution. Those with simultaneous multiple bowel resection or bowel resection with strictureplasty were excluded. RESULTS: A total of 169 patients who underwent ICR due to CD were enrolled. The median follow-up period was 12.6 years (range 4-27 years). A reoperation was needed in 45 (26.6%), of whom 14 had lesions causative of the reoperation at other than the anastomotic site. The most common causative lesion location was in the colon rather than the oral side of the small intestine. Furthermore, we investigated the relationship between presence of residual lesions following the initial surgery and lesions causative of reoperation. In the group without residual disease (n = 31), 29.0% (n = 9) had non-anastomotic lesions involved in indications for reoperation, while that was 35.7% (n = 5) in the group with residual disease (n = 14). CONCLUSIONS: Anastomotic site lesion is not the only causative factor for reoperation following ICR. Regular examinations and applicable treatment with awareness that the cause of reoperation is not limited to the site of anastomosis are important in these cases.

Prognostic impacts of tumoral expression and serum levels of PD-L1 and CTLA-4 in colorectal cancer patients.

BACKGROUND: Programmed cell death ligand-1 (PD-L1) and cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) play a pivotal role in cancer immunotherapy. Each of these molecules has a membrane-bound receptor form (mPD-L1/mCTLA-4) and a soluble form (sPD-L1/sCTLA-4). However, these prognostic impacts in colorectal cancer (CRC) remain unclear. METHODS: We immunohistochemically scored tumoral mPD-L1/mCTLA-4 expression and quantified preoperative circulating sPD-L1/sCTLA-4 levels using matched serum specimens from 131 patients with pStage I-III CRC. We also examined the association between these statuses and tumor infiltrating lymphocytes (TILs) in these patients. RESULTS: Elevated levels of mPD-L1, mCTLA-4, sPD-L1 and sCTLA-4 were significantly correlated with poor overall survival (OS) and disease-free survival (DFS). Co-high expression of tumoral mPD-L1 and mCTLA-4 or co-elevated levels of serum sPD-L1 and sCTLA-4 were strongly correlated with poor OS and DFS. Multivariate analysis revealed that both statuses were negative independent prognostic factors for OS [hazard ratio (HR) 3.86, 95% confidence interval (95% CI) 1.71-8.51, p = 0.001; HR 5.72, 95% CI 1.87-14.54, p = 0.004, respectively] and DFS (HR 2.53, 95% CI 1.23-4.95, p = 0.01; HR 6.88, 95% CI 2.42-17.13, p = 0.0008, respectively). Although low expression of tumoral mCTLA-4 was significantly correlated with increased CD8(+) TILs, there was no correlation in any other combination. CONCLUSIONS: We verified the prognostic impacts of mPD-L1, mCTLA-4, sPD-L1 and sCTLA-4 in pStage I-III CRC patients. Dual evaluation of immune checkpoint molecules in primary tissues or preoperative serum could identify a patient population with poor prognosis in these patients.

Crohn's-Like Lymphoid Reaction is Associated with Oncological Prognosis and Nutritional Status in Patients with Pathological Stage II/III Gastric Cancer.

BACKGROUND: Peritumoral lymphoid aggregates, termed Crohn's-like lymphoid reaction (CLR), are markers of an antitumor immune response, which is an important predictor of patient outcome. In this study, we investigated the prognostic utility of CLR and its relationship with nutritional status in patients with gastric cancer (GC). METHODS: The study included 170 patients who underwent curative surgery for pathological stage (pStage) II/III GC. The maximum diameters of peritumoral and normal mucosal CLR aggregates were measured, and the median peritumoral diameter (0.57 mm) was used to stratify patients into two groups (large-CLR and small-CLR). The relationships between CLR size and preoperative nutritional status (body mass index, body composition status, Onodera's prognostic nutritional index), tumor-infiltrating CD8+ T-lymphocyte count, and survival were evaluated. RESULTS: Peritumoral CLR aggregates were significantly larger than aggregates in the normal mucosa. Clinicopathological variables were not significantly different between the two patient groups; however, the large-CLR group had better cancer-specific survival (p = 0.018) and recurrence-free survival (p = 0.03) than the small-CLR group. Multivariate analysis revealed that CLR size was an independent prognostic factor for cancer-specific survival [hazard ratio (HR) 2.13, 95% confidence interval (CI) 1.3-3.56, p = 0.002] and recurrence-free survival (HR 1.96, 95% CI 1.22-3.19, p = 0.005). Nutritional status markers were significantly poorer for the small-CLR group than the large-CLR group. CD8+ T-cell tumor infiltration was positively correlated with CLR size but not with patient survival. CONCLUSIONS: CLR size correlated with patient nutritional status and prognosis and may be helpful in identifying high-risk populations of pStage II/III GC patients.

Advanced Lung Cancer Inflammation Index Predicts Outcomes of Patients With Colorectal Cancer After Surgical Resection.

BACKGROUND: The advanced lung cancer inflammation index is considered a useful prognostic biomarker of clinical outcomes in patients with malignancies. However, the prognostic value of the advanced lung cancer index in patients with colorectal cancer who underwent surgical resection remains unclear. OBJECTIVE: In this study, we evaluated the prognostic value of the advanced lung cancer index in patients with colorectal cancer. DESIGN: Prospectively obtained data of patients with colorectal cancer were retrospectively evaluated to clarify the clinical relevance of the advanced lung cancer index. SETTINGS: We conducted this study at a single expert center. PATIENTS: We enrolled 298 patients with colorectal cancer who underwent surgical resection in this retrospective study. MAIN OUTCOME MEASURES: The primary outcome was the clinical relevance of the advanced lung cancer index in patients with rectal cancer. RESULTS: Low status of advanced lung cancer index was significantly correlated with undifferentiated histology (p = 0.004), T stage progression (p < 0.001), R1/R2 resection for primary surgery (p = 0.004), and distant metastasis (p < 0.001). Multivariate analysis showed that low advanced lung cancer index status was an independent prognostic factor for both overall survival (HR = 3.21 (95% CI, 1.97-5.19); p < 0.001) and disease-free survival (HR = 2.13 (95% CI, 1.23-3.63); p = 0.008) in patients with colorectal cancer. Furthermore, the clinical burden of the advanced lung cancer index was consistent between sexes, and its prognostic value was verified in patients with clinically relevant stage III colorectal cancer. LIMITATIONS: The present study had several limitations, including retrospective observation and a small sample size of Japanese patients from a single institution. CONCLUSIONS: The advanced lung cancer index could be a useful prognostic indicator of clinical outcomes in patients who underwent surgical resection for colorectal cancer. See Video Abstract at http://links.lww.com/DCR/B267. EL ÍNDICE AVANZADO DE INFLAMACIÓN DEL CÁNCER DE PULMÓN, PREDICE LOS RESULTADOS DE LOS PACIENTES CON CÁNCER COLORRECTAL DESPUÉS DE LA RESECCIÓN QUIRÚRGICA: El índice avanzado de inflamación del cáncer de pulmón, es considerado como un útil biomarcador pronóstico, en los resultados clínicos de pacientes con neoplasias malignas. Sin embargo, aún no está claro el valor pronóstico del índice avanzado de cáncer de pulmón, en pacientes con cáncer colorrectal sometidos a resección quirúrgica.Evaluar el valor pronóstico del índice avanzado del cáncer de pulmón, en pacientes con cáncer colorrectal.Los datos obtenidos prospectivamente de pacientes con cáncer colorrectal, fueron evaluados retrospectivamente, para aclarar la relevancia clínica del índice avanzado del cáncer de pulmónEstudio realizado en un solo centro experto.Estudio retrospectivo, incluyendo 298 pacientes con cáncer colorrectal, sometidos a resección quirúrgica.El resultado primario fue la relevancia clínica del índice avanzado de cáncer de pulmón, en pacientes con cáncer rectal.Un índice avanzado de cáncer de pulmón bajo, se correlacionó significativamente con la histología indiferenciada (p = 0.004), la progresión de la etapa T (p <0.001), la resección R1 / R2 para cirugía primaria (p = 0.004) y la metástasis a distancia (p <0.001). El análisis multivariante mostró que el índice avanzado de cáncer de pulmón bajo, era un factor pronóstico independiente, tanto para la supervivencia general (HR = 3.21 IC 95% 1.97-5.19 p <0.001) como para la supervivencia libre de enfermedad (HR = 2.13, IC 95% 1.23-3.63, p = 0,008), en pacientes con cáncer colorrectal. Además, la carga clínica del índice avanzado de cáncer de pulmón, fue consistente entre los sexos y su valor pronóstico se verificó clínicamente relevante, en pacientes con cáncer colorrectal en estadio III.El presente estudio tuvo varias limitaciones, incluyendo la observación retrospectiva y la pequeña muestra de pacientes japoneses, en una sola institución.El índice avanzado de cáncer de pulmón, podría ser un indicador pronóstico útil, en los resultados clínicos de pacientes sometidos a resección quirúrgica por cáncer colorrectal. Consulte Video Resumen http://links.lww.com/DCR/B267.

Modified neutrophil-platelet score as a promising marker for stratified surgical and oncological outcomes of patients with gastric cancer.

PURPOSE: Gastric cancer (GC) is a common malignancy, especially in East Asian countries. There is emerging evidence that circulating neutrophil and platelet levels correlate with cancer progression. We evaluated the short- and long-term outcomes of GC patients systemically, to compare the original neutrophil-platelet score (NPS) and our modified NPS (mNPS). METHODS: We analyzed the original pre-operative NPS and the mNPS of 621 GC patients. RESULTS: Racial differences between the United Kingdom and East Asian countries accounted for compelling deviation in classification using the original NPS, which could not reliably stratify the prognoses of Japanese GC patients. We developed the mNPS using appropriate cutoff levels for pre-operative neutrophils and platelets, and demonstrated that the pre-operative mNPS was significantly correlated with all of the well-established clinicopathological factors for disease development, including advanced T stage, venous and lymphatic vessel invasion, lymph node/peritoneal /distant metastasis, and tumor-node-metastasis stage. The pre-operative mNPS could stratify prognostication for both overall survival (OS) and disease-free survival (DFS): a high pre-operative mNPS was an independent prognostic factor for the OS and DFS of GC patients and also an independent predictor of post-operative surgical site infection after gastrectomy. CONCLUSION: Calculating the mNPS could help clinicians to stratify the surgical and oncological risks of patients with GC.

[Radiofrequency Ablation for Colorectal Liver Metastases].

AIM: The significance of radiofrequency ablation(RFA)for colorectal liver metastases(CRLM)remains to be elucidated. Therefore, this retrospective study aimed to evaluate the therapeutic efficacy of RFA for local recurrence of CRLM. SUBJECTS: Between June 2005 and June 2017, we retrospectively examined 63 patients(137 nodules)with CRLM who underwent RFA. RESULTS: The local recurrence rate was 36.5%, and the median local recurrence free survival(LRFS)was 26.3 months. We compared treatment background between the 2 groups with(50 nodules)and without(87 nodules)local recurrence. In the multivariate analysis, tumor size of the ablated lesion and method for ablation(direct tumor puncture)were independent risk factors for local recurrence. Receiver operating characteristic curve for tumor size of the ablated lesion showed an optimal cutoff value for tumor size of 1.8 cm(AUC=0.734, 95%CI: 0.612-0.855, p<0.0001). CONCLUSIONS: RFA for effective control of local recurrence of CRLM might be suitable for selected patients with tumor size of ablated lesion ofC1.8 cm and no touch ablation method.

[A Resected Case of Hilar Cholangiocarcinoma Confirmed as Pathological Complete Response Following Neoadjuvant S-1 Monotherapy].

A 74-year-old man was admitted to a local hospital with liver dysfunction. Imaging modalities revealed bile duct stenosis at the bifurcation of the anterior and posterior trunk. Exfoliative cytology of the bile and brushing cytology of the bile duct both revealed Class Ⅴ, and biopsy from the stenotic bile duct showed well differentiated adenocarcinoma. We diagnosed the patient with hilar cholangiocarcinoma and performed extended right bisectionectomy and biliary reconstruction after percuta- neous transhepatic right portal vein embolization(PTPE). Preoperatively, he was administered S-1(80mg/body weight/day) orally for 19 days. Histopathological assessment of the resected specimen revealed hemosiderin-laden macrophages without viable cancer cells, confirmingpatholog ical complete response(pCR).

The Comprehensive Complication Index in Ulcerative Colitis: A Comparison with the Clavien-Dindo Classification.

Introduction: The comprehensive complication index (CCI), which weights all postoperative complications according to severity and integrates them into a single formula, has been reported as a new evaluation system. We aimed to compare the CCI with the Clavien-Dindo Classification (CDC) to patients with ulcerative colitis (UC). Methods: Patients who underwent initial surgery for UC from April 2012 to March 2020 were included. The patients were classified into a length of stay (LOS) >30 days group or an LOS ≤30 days group. We performed a multivariate analysis of risk factors for LOS >30 days in the model with the factors identified in the univariate analysis plus the CCI (the CCI model) and plus CDC (the CDC model). An ROC curve was used to test the difference in the area under the curve (AUC) between the CCI model and the CDC model. Results: The median LOS was 21 days (IQR: 16-29 days), and the rate of LOS >30 days was 119/588 (20.2%). In the CCI model, age at the time of surgery (odds ratio [OR] = 1.24, 95% confidence interval [CI] 1.07-1.45, p = 0.01), ASA score ≥3 (OR = 1.94, 95% CI:1.00-3.76, p = 0.04), and CCI (OR = 1.07, 95% CI: 1.05-1.09; p < 0.01) were identified as independent risk factors for LOS >30 days. The AUC value of the CCI model (0.86) was significantly better in relation to LOS >30 days than that of the CDC model (0.82) (p = 0.02). Conclusion: The CCI was a better measure of LOS than was the CDC and was found to be a useful indicator in UC.

The Impacts of Laparoscopic Restorative Proctocolectomy for Ulcerative Colitis: Systematic Review and Meta-Analysis.

Introduction: Laparoscopic surgery (LAP) is now recognized as the standard procedure for colorectal surgery. However, the standard surgery for ulcerative colitis (UC) is total proctocolectomy with ileal pouch anal anastomosis (IPAA), which may be an overly complex procedure to complete laparoscopically. We conducted this systematic review and meta-analysis to evaluate the efficacy as well as the advantages and disadvantages of LAP-IPAA in patients with UC stratified by the outcome of interest. Method: We performed a systematic literature review by searching the PubMed/MEDLINE, the Cochrane Library, and the Japan Centra Reuvo Medicina databases from inception until January 2023. Meta-analyses were performed for surgical outcomes, including morbidity and surgical course, to evaluate the efficacy of LAP-IPAA. Results: A total of 707 participants, including 341 LAP and 366 open surgery (OPEN) patients in 9 observational studies and one randomized controlled study, were included. From the results of the meta-analyses, the odds ratio (OR) of total complications in LAP was 1.12 (95% CI: 0.58-2.17, p = 0.74). The OR of mortality for LAP was 0.38 (95% CI: 0.08-1.92, p = 0.24). Although the duration of surgery was extended in LAP (mean difference (MD) 118.74 min (95% CI: 91.67-145.81), p < 0.01) and hospital stay were not shortened, the duration until oral intake after surgery was shortened in LAP (MD -2.10 days (95% CI: -3.52-0.68), p = 0.004). Conclusions: During IPAA for UC, a similar morbidity rate was seen for LAP and OPEN. Although LAP necessitates extended surgery, there may be certain advantages to this procedure, including easy visibility during the surgical procedure or a shortened time to oral intake after surgery.

Have advances in medical therapy for ulcerative colitis impacted surgical treatment?

Aim: The purpose of this study was to examine how the clinical characteristics, indications for surgery, and postoperative course of ulcerative colitis (UC) surgical patients changed before and after the introduction of biological agents. Methods: Patients who underwent surgery for UC at Hyogo Medical University between 2000 and 2019 were included in the study; those who underwent surgery between 2000 and 2009 were included in the early group (n = 864), and those who underwent surgery between 2010 and 2019 were included in the late group (n = 834); each study factor was retrospectively compared. Results: The mean ages at surgery (y) were 39.7 ± 15.1 y in the early group and 46.7 ± 17.8 y in the late group (P < .01). Antitumor necrosis factor agents were used (%) in 2 (0.2) patients in the early group and 317 (38.0) patients in the late group (P < .01). The number of cancer or dysplasia patients for whom surgery was indicated was significantly higher in the late group (11%/26%, P = .01). With regard to surgery in elderly individuals, the number of elderly patients (65 y and older) undergoing surgery was significantly higher in the late group (8.0%/18.6%, P < .01). For emergency surgery, the mortality rates were 16.7% (2/12) in the early surgery group and 15.7% (8/51) in the late surgery group (P = .61). Conclusion: The characteristics of UC patients requiring surgery in Japan have changed. The distribution of surgical indications changed, and the number of patients with cancer and dysplasia requiring surgery increased. The prognosis of elderly patients who underwent emergency surgery was poor.

Associations between Pouchitis and Fecal Calprotectin after Restorative Proctocolectomy in Patients with Ulcerative Colitis.

Introduction: Recently, fecal calprotectin has been identified and used as an assessment tool for the confirmation of disease activity in ulcerative colitis. Although a meta-analysis suggested the usefulness of fecal calprotectin for the assessment of pouchitis, the number of participants was still insufficient. Therefore, we prospectively measured fecal calprotectin levels during pouchoscopy and analyzed their associations with pouchitis. Methods: Patients who underwent pouchoscopy after total proctocolectomy and ileal pouch-anal anastomosis for ulcerative colitis were included. Fecal samples were collected for the measurement of calprotectin during pouchoscopy. Patients either with or without suspicious pouchitis were included. Pouchitis was defined as a modified pouchitis disease activity index (m-PDAI) score of ≥5. The associations between the development of pouchitis and the m-PDAI score and fecal calprotectin and serum markers, including C-related protein, albumin, and white blood cells, were assessed. Results: A total of 170 patients were included. Seventy-two patients were diagnosed with pouchitis with an m-PDAI score of 7.3 ± 1.5. The values of fecal calprotectin were 1,500 ± 1,544 µg/g in patients with pouchitis and 259 ± 402 µg/g in patients without pouchitis (p < 0.01). The correlation coefficient between calprotectin and the m-PDAI score was significant (r2 = 0.279, p < 0.001). The cutoff value of fecal calprotectin in receiver operating characteristic analysis was 246 µg/g (area under curve 0.85, sensitivity 83.9%, specificity 71.0%). Fecal samples were able to be collected from 6 patients. The levels of fecal calprotectin significantly decreased from 2,101.3 ± 880.3 µg/g to 284.2 ± 96.9 µg/g in response to the treatment. Conclusions: Elevated fecal calprotectin appeared to be significantly correlated with pouchitis. We should consider the alteration of this marker during treatments in further studies.

Clinical Features and Therapeutic Outcomes of Post-colectomy Enteritis with Ulcerative Colitis.

OBJECTIVES: Few reports are available on post-colectomy enteritis (PCE) with ulcerative colitis (UC), which can be severe and sometimes fatal. The clinical characteristics are unclear, and treatment and diagnosis protocols have not been established. We aimed to investigate the incidence, clinical characteristics, diagnostic criteria, and therapeutic outcomes of PCE in this study. METHODS: Patients with UC who underwent colectomy between April 2010 and December 2019 were included in this study. We retrospectively analyzed patients who developed PCE and excluded patients with other forms of enteritis. RESULTS: We performed 829 colectomies because of a preoperative diagnosis of UC. Eleven and four patients were diagnosed with Crohn's disease and indeterminate colitis after surgery, respectively; 22 patients developed enteritis in the perioperative period. We excluded six patients with backwash ileitis, five with prepouch ileitis, three with infectious enteritis, and one with ischemic enteritis. In total, 7/814 (0.8%) patients developed PCE. All patients with PCE had pancolitis. PCE was observed a median of 33 (12-248) days after surgery. Endoscopy showed friable and granular mucosa. The extent of disease included various types such as pan-enteritis with diffuse type, pan-enteritis and mild inflammation in the middle ileum, and only ileitis. Gastroduodenitis-associated UC developed in 6/7 cases. All patients improved with tumor necrosis factor alpha (TNFα) antagonists even if TNFα antagonists had not been effective for colitis. CONCLUSIONS: PCE was rare. The mucosal endoscopic findings were similar to those of UC, and the extent of disease varied. TNFα antagonist administration for PCE was effective.

Delivery Mode after Ileal Pouch-Anal Anastomosis among Pregnant Women with Ulcerative Colitis.

OBJECTIVES: The appropriate and recommended delivery mode after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) has not been sufficiently evaluated. This study was designed to compare the delivery outcomes associated with cesarean section (CS) and vaginal delivery (VD) after IPAA. METHODS: We conducted a questionnaire-based survey of female patients who underwent IPAA for UC between July 1987 and May 2018. Additionally, we reviewed clinical data and collected information regarding pouch function and postpartum complications. RESULTS: In total, 45 patients had 68 deliveries, including 64 CS deliveries and four VDs. Fecal incontinence worsened in seven patients, including six CS patients and one VD patient. The Wexner scores of these patients before and after delivery were 5.4 ± 0.4 and 14.8 ± 1.0, respectively (p = 0.005). Four patients in the CS group and one in the VD group (p = 0.32) had increased stool frequency. Bowel obstructions developed during 11/64 (17.2%) deliveries, and one patient required surgical intervention. One patient with four VDs (three before IPAA and one after IPAA) developed vaginal fistula 5 months after the final VD. Information on episiotomies could not be obtained. CONCLUSIONS: Pouch function can decline even after CS. Notably, bowel obstruction can develop after CS. However, we cannot recommend a particular delivery method after IPAA. Further analyses to elucidate the relationship between CS and postoperative complications or vaginal fistula and episiotomy in VDs should be conducted.

Potential problems of partial resection for colitis-associated cancer in a patient with ulcerative colitis: case report.

Total proctocolectomy and an ileal pouch-anal anastomosis are recommended as the standard procedure for ulcerative colitis (UC)-colitis-associated cancer (CAC). However, several studies have reported the partial colectomy and endoscopic resection of UC-CAC in recent years. We present a surgical case of UC-CAC that was detected at a site that had not been diagnosed preoperatively, and we report potential problems of partial colectomy and endoscopic resection through this case. Considerations of synchronous and metachronous cancer/dysplasia are important before partial resection is planned for CAC in UC. Moreover, it should be noted that endoscopic resection at the anal site can be a risk factor for pouch surgery failure due to fibrosis after resection.

Cap polyposis treated with laparoscopic-assisted total proctocolectomy and ileal J-pouch anal anastomosis: a case report.

BACKGROUND: Cap polyposis (CP) is extremely rare in Japan, and there is no established cure. We report a case in which CP was improved by surgical treatment. CASE PRESENTATION: A 48-year-old man was investigated at a local hospital because of diarrhea and bloody stools in 2018. The patient was treated with metronidazole for suspected amoebic dysentery, but his symptoms did not improve. Subsequent close examination revealed possible CP, but treatment with 5-aminosalicylic acid and a steroid enema had no effect. The patient was then referred to our hospital. The bloody stools, diarrhea, and abdominal pain worsened despite medical treatment, so laparoscopic-assisted total proctocolectomy and ileal J-pouch anal anastomosis with ileostomy were performed. CP has no known cause or established treatment, but Helicobacter pylori (HP) infection has been reported in many CP cases in Japan, and HP eradication is often successful. This patient was HP-negative and did not improve with antimicrobial treatment, but the symptoms improved after surgery. CONCLUSIONS: Even after surgery, CP recurrence reportedly occurs within a short period in many cases. However, our patient has had no signs of CP recurrence during 1 year of follow-up.