Long-Term Outcomes of the Excluded Rectum in Crohn's Disease: A Multicenter International Study.

BACKGROUND: Many patients with Crohn's disease (CD) require fecal diversion. To understand the long-term outcomes, we performed a multicenter review of the experience with retained excluded rectums. METHODS: We reviewed the medical records of all CD patients between 1990 and 2014 who had undergone diversionary surgery with retention of the excluded rectum for at least 6 months and who had at least 2 years of postoperative follow-up. RESULTS: From all the CD patients in the institutions' databases, there were 197 who met all our inclusion criteria. A total of 92 (46.7%) of 197 patients ultimately underwent subsequent proctectomy, while 105 (53.3%) still had retained rectums at time of last follow-up. Among these 105 patients with retained rectums, 50 (47.6%) underwent reanastomosis, while the other 55 (52.4%) retained excluded rectums. Of these 55 patients whose rectums remained excluded, 20 (36.4%) were symptom-free, but the other 35 (63.6%) were symptomatic. Among the 50 patients who had been reconnected, 28 (56%) were symptom-free, while 22(44%) were symptomatic. From our entire cohort of 197 cases, 149 (75.6%) either ultimately lost their rectums or remained symptomatic with retained rectums, while only 28 (14.2%) of 197, and only 4 (5.9%) of 66 with initial perianal disease, were able to achieve reanastomosis without further problems. Four patients developed anorectal dysplasia or cancer. CONCLUSIONS: In this multicenter cohort of patients with CD who had fecal diversion, fewer than 15%, and only 6% with perianal disease, achieved reanastomosis without experiencing disease persistence.

Patients with distal Crohn's disease often undergo colon resection with a stoma to divert the intestinal stream from the rectum in hopes of achieving sufficient healing to allow ultimate re-establishment of intestinal continuity. Patients and practitioners alike should be aware of the long-term success rates of this procedure. Our retrospective study of 197 patients found that half required later proctectomy and an additional one-quarter remained symptomatic with excluded rectums. Only 14% remained symptom-free after reanastomosis, and only 6% if perianal disease was the initial surgical indication. These data provide estimation of long-term surgical outcomes.

Challenges in Endoscopic Therapy of Dysplastic Barrett's Esophagus.

PURPOSE OF REVIEW: Barrett's esophagus (BE) is the only known measurable factor associated with esophageal adenocarcinoma. The development of endoscopic eradication therapy (EET) has transformed the way BE is managed. Given the fairly recent development of EET, its role in BE is still evolving. RECENT FINDINGS: This paper discusses the challenges that endoscopists face at the preprocedural, intraprocedural, and postprocedural stages of BE management. These include challenges in risk stratification, dysplasia detection, ablation methods and dosimetry, choice of resection technique, and management of refractory disease. Despite the advances in EET in BE, there remain challenges that this review focuses on. Future research into these challenges will optimize ablation techniques and strategies in the future.

Environmental Hygiene and Risk of Inflammatory Bowel Diseases: A Systematic Review and Meta-analysis.

BACKGROUND: According to the hygiene hypothesis, individuals raised in a sanitary environment have a higher risk of developing inflammatory bowel diseases (IBD). However, results have been inconsistent. We conducted this systematic review of factors related to environmental hygiene and risk of IBD, Crohn's disease (CD) and ulcerative colitis (UC). METHODS: A systematic search was performed on MEDLINE between 1980 and 2015 to identify studies of the association between IBD and contact with pets and farm animals, number of siblings, bedroom sharing in childhood, and access to personal toilet and hot water. Random- or fixed-effect meta-analyses were performed, and analysis further stratified based on ethnicity of the included cohort. RESULTS: A total of 29 relevant studies were included. Having a pet (odds ratio [OR], 0.76; 95% confidence interval [CI], 0.63-0.88) and contact with farm animals was inversely associated with risk of IBD (OR, 0.45; 95% CI, 0.31-0.60). However, the strength of association with farm animals was statistically stronger in non-white cohorts (OR, 0.27; 95% CI, 0.02-0.53) than in white cohorts (OR, 0.55; 95% CI, 0.45-0.65) (P = 0.028). Access to toilet (OR, 0.71; 95% CI, 0.56-0.85) and hot water (OR, 0.67; 95% CI, 0.44-0.89) was inversely associated with UC in non-white populations but not whites. Having more than 2 siblings was inversely associated with risk of CD. CONCLUSIONS: Several factors pertaining to reduced environmental hygiene are inversely associated with risk of IBD. However, underlying ethnicity influences susceptibility to the effect of these factors.

Risk of liver abscess formation in patients with prior biliary intervention following yttrium-90 radioembolization.

PURPOSE: Patients without a competent sphincter of Oddi due to prior surgical or endoscopic therapy are at high risk for liver abscess following chemoembolization despite aggressive antimicrobial prophylaxis. We examined a cohort of such patients undergoing Y-90 resin radioembolization and compared them to a cohort of chemoembolized patients. METHODS: Review of our quality-assurance database identified 24 radioembolizations performed in 16 patients with prior biliary intervention. An aggressive prophylactic regimen of oral levofloxacin and metronidazole 2 days pre-procedure continuing for 14 days after, oral neomycin/erythromycin bowel prep the day before, and IV levofloxacin/metronidazole the day of treatment was prescribed. Patients underwent resin microsphere radioembolization dosed according to the BSA method. Patients had clinical, imaging, and laboratory assessment 1 month after each treatment, and then every 3 months. The chemoembolization cohort consisted of 13 patients with prior biliary intervention who had undergone 24 chemoembolization procedures. RESULTS: No radioembolization patient developed an abscess. In the cohort of chemoembolized patients who received the same prophylaxis, liver abscess occurred following 3 of 24 (12.5 %) procedures in 3 of 13 (23 %) patients, one fatal. CONCLUSIONS: This preliminary experience suggests that the risk of liver abscess among patients with prior biliary intervention may be lower following radioembolization than chemoembolization, which could potentially expand treatment options in this high-risk population.