Redo IPAA for long rectal cuff syndrome after ileoanal pouch for inflammatory bowel disease.

ABTRACT: BACKGROUND: When constructing an ileal pouch-anal anastomosis (IPAA), the rectal cuff should ideally be 1-2 cm long to avoid subsequent complications. METHODS: We identified patients from our IBD center who underwent redo IPAA for a long rectal cuff. Long rectal cuff syndrome (LRCS) was defined as a symptomatic rectal cuff ≥ 4 cm. RESULTS: Forty patients met the inclusion criteria: 42.5% female, median age at redo surgery 42.5 years. The presentation was ulcerative proctitis in 77.5% of the cases and outlet obstruction in 22.5%. The index pouch was laparoscopically performed in 18 patients (45%). The median rectal cuff length was 6 cm. The pouch was repaired in 16 (40%) cases, whereas 24 (60%) required the creation of a neo-pouch. At the final pathology, the rectal cuff showed chronic active colitis in 38 (90%) cases. After a median follow-up of 34.5 (IQR 12-109) months, pouch failure occurred in 9 (22.5%) cases. The pouch survival rate was 78% at 3 years. Data on the quality of life were available for 11 (27.5%) patients at a median of 75 months after redo surgery. The median QoL score (0-1) was 0.7 (0.4-0.9). CONCLUSION: LRCS, a potentially avoidable complication, presents uniformly with symptoms of ulcerative proctitis or stricture. Redo IPAA was restorative for the majority.

Anorectal Manifestations of Treatment-Refractory Monkeypox Requiring Surgical Intervention.

Anorectal manifestations of monkeypox are increasingly being recognized as a potentially serious complication. We present the case of an HIV-positive, tecovirimat-treated male presenting with monkeypox virus-associated severe proctitis with associated perianal pathology. Despite the use of antiviral agents and intravenous vaccinia immune globulin, the monkeypox-associated perianal lesions evolved into abscesses, requiring incision and drainage. This report highlights a multidisciplinary approach involving surgery for anorectal complications of monkeypox virus-associated proctitis and perianal lesions. Surgery may offer immediate relief and reduce the potential long-term morbidity associated with severe monkeypox virus-associated rectal and perianal manifestations refractory to available medical countermeasures.

Proctitis in patients with monkeypox infection: a single-center analysis of 42 consecutive cases from a multidisciplinary observational study on monkeypox proctitis.

BACKGROUND: The current monkeypox (MP) virus outbreak was declared an international emergency in July 2022. The aim of this report is to describe our initial experience with patients with MP, focusing on proctitis. METHODS: We conducted an observational study between 20 May and 31 July 2022, on patients with MP at a reference tertiary center in Madrid, Spain. A descriptive analysis on MP was performed, focusing on its characteristics, symptoms, diagnosis, and outcomes. RESULTS: A total of 143 positive MP cases were diagnosed in our center; 42 of them [all male, median age 39 years (range: 22-57 years)] had proctitis (29.37%), and 3 patients (2.09%/MP total cases and 7.14%/MP proctitis) required surgical drainage of a perianal abscess. CONCLUSIONS: General and digestive surgeons must be aware of the presence of proctological impairment and complications due to MP virus.

Regorafenib-Induced Radiation Recall Presenting as Acute Blood Loss Anemia With Rectal Bleeding and Severe Proctitis.

Radiation recall is a rare inflammatory reaction that occurs in an area that was subjected to prior irradiation that is usually triggered by certain drugs or chemotherapy agents. This reaction is drug-specific for each individual and occurs in about 6% to 9% of the patients receiving chemotherapy after radiation therapy. We report a case of radiation recall-induced severe proctitis which is thought to be triggered by administration of regorafenib for stage IV rectal adenocarcinoma with lung metastases. We present a 65-year-old female patient who was initially diagnosed with stage III T4N1M0 rectal adenocarcinoma that was treated with neoadjuvant concurrent chemoradiotherapy, followed by low anterior resection. The tumor was pathologically staged a ypT3 yN1 with a partial response to the treatment. After the surgery, the patient was found to have lung nodules consistent with metastatic disease, when she was treated initially with folinic acid, fluorouracil, and oxaliplatin, plus bevacizumab. The patient had further disease progression with metastases in her lungs despite treatment with several chemotherapy agents. She was started on regorafenib, an oral vascular endothelial growth factor inhibitor, as a fourth line of therapy. However, in a month after initiation of oral regorafenib, and 9 months after the prior radiation treatment, the patient presented to the emergency room with a complaint of bright red blood per rectum. She was diagnosed with severe radiation proctitis that was treated therapeutically with argon plasma coagulation. This particular case serves as a reminder that although infrequent and rare, radiation recall may result in an inflammatory reaction in an organ such as rectum. To the best of our knowledge, this regorafenib-induced severe proctitis secondary to radiation recall has not been reported in the literature before.

Inflammation of the rectal remnant endangers the outcome of ileal pouch-anal anastomosis: a case-control study.

BACKGROUND: Inflammation of the rectal remnant may affect the postoperative outcome of ileal pouch-anal anastomosis (IPAA) in patients with ulcerative colitis (UC). We aimed to determine the extent of inflammation in the anastomotic area during IPAA and to investigate the impact of proctitis on postoperative complications and long-term outcomes. METHODS: Three hundred thirty-four UC patients with primary IPAA were included in this retrospective case-control study. The histopathologic degree of inflammation in the anastomotic area was graded into three stages of no proctitis ("NOP"), mild to medium proctitis ("MIP"), and severe proctitis ("SEP"). Preoperative risk factors, 30-day morbidity, and follow-up data were assessed. Kaplan-Meier analysis was performed in the event of pouch failure. RESULTS: The prevalence of proctitis was high (MIP 40.4%, and SEP 42.8%). During follow-up, the incidence of complications was highest among SEP: resulting in re-intervention (n = 40; 28.2%, p = 0.017), pouchitis (n = 36; 25.2%, p < 0.01), and pouch failure (n = 32; 22.4%, p = 0.032). The time interval to pouch failure was 5.0 (4.0-6.9) years among NOP, and 1.2 (0.5-2.3) years in SEP (p = 0.036). ASA 3, pouchitis, and pouch fistula were independent risk factors for pouch failure. CONCLUSION: Proctitis at the time of IPAA is common. A high degree of inflammation is associated with poor long-term outcomes, an effect that declines over time. In addition, a higher degree of proctitis leads to earlier pouch failure.

[A case of ischemic proctitis caused by impaired venous blood flow 11 months after surgery for sigmoid colon cancer].

A Japanese male in his 50s was presented to our hospital with the chief complaint of positive fecal immunochemical test. He had a history of hypertension. He underwent colonoscopy and was diagnosed with sigmoid colon cancer. He also underwent laparoscopic sigmoid colectomy with D3 lymph node dissection for sigmoid colon cancer. The inferior mesenteric artery and inferior mesenteric vein were amputated at the root of the vessels. The patient received adjuvant chemotherapy and was recurrence-free. Eleven months after the surgery, lower abdominal pain during defecation appeared. Contrast-enhanced computed tomography (CT) and colonoscopy showed marked rectal mucosal edema and increased fatty tissue density (dirty fat sign) around the anorectal side of the anastomosis. Intestinal blood flow was maintained. There were many fine blood vessels around the rectal wall, and the amputated distal part of the superior rectal artery was retrogradely contrasted. Amputated superior rectal artery and superior rectal vein were dilated than before. Colonoscopy revealed mucosal redness, edema, and easy bleeding on the anorectal side of the anastomosis. Abdominal contrast-enhanced 3D-CT showed increased arterial blood flow and increased fine blood vessels around the rectal wall. It suggested the presence of an arteriovenous fistula and venous congestion. Conservative treatment with total parenteral nutrition and prednisolone infusion did not improve the patient's condition, and a colostomy was performed. After colostomy, the pain improved, and the CT scan of the abdomen showed improvement in arterial blood flow and venous congestion. Colostomy was closed after 10 months. There has been no relapse since the closure of the colostomy. There are few reports on ischemic proctitis on the anorectal side of the anastomosis after colon cancer resection due to impaired venous blood flow.

Diverting colostomy is an effective procedure for ulcerative chronic radiation proctitis patients after pelvic malignancy radiation.

BACKGROUND: Chronic radiation proctitis (CRP) with rectal ulcer is a common complication after pelvic malignancy radiation, and gradually deteriorating ulcers will result in severe complications such as fistula. The aim of this study was to evaluate effect of colostomy on ulcerative CRP and to identify associated influence factors with effectiveness of colostomy. METHODS: Between November 2011 to February 2019, 811 hospitalized patients were diagnosed with radiation-induced enteritis (RE) in Sun Yat-sen University Sixth Affiliated Hospital, among which 284 patients presented with rectal ulcer, and 61 ulcerative CRP patients were retrospectively collected and analyzed. RESULTS: The overall effective rate of colostomy on ulcerative CRP was 49.2%, with a highest effective rate of 88.2% within 12 to 24 months after colostomy. 9 (31.1%) CRP patients with ulcers were cured after colostomy and 12 (19.67%) patients restored intestinal continuity, among which including 2 (3.3%) patients ever with rectovaginal fistula. 100% (55/55) patients with rectal bleeding and 91.4% (32/35) patients with anal pain were remarkably alleviated. Additionally, multivariable analysis showed the duration of stoma [OR 1.211, 95% CI (1.060-1.382), P = 0.005] and albumin (ALB) level post-colostomy [OR 1.437, 95% CI (1.102-1.875), P = 0.007] were two independent influence factors for the effectiveness of colostomy on the rectal ulcer of CRP patients. CONCLUSIONS: Colostomy was an effective and safe procedure for treating rectal ulcer of CRP patients, and also a potential strategy for preventing and treating fistula. Duration of stoma for 12-24 months and higher ALB level could significantly improve the effectiveness of colostomy on ulcerative CRP patients.

Recommendations of the Crohn's Disease and Ulcerative Colitis Spanish Working Group (GETECCU) for the treatment of perianal fistulas of Crohn's disease. / Recomendaciones del Grupo Español de Trabajo de Enfermedad de Crohn y Colitis Ulcerosa (GETECCU) para el tratamiento de las fístulas perianales de la enfermedad de Crohn.

Recommendations are advice that is given and considered to be beneficial; however, they are still suggestions and are therefore open to different interpretations. In this sense, the final objective of the review has been to try to homogenize, with the evidence available, the approach to the diagnosis and medical/surgical treatment of one of the most complex manifestations of Crohn's disease, such as simple and complex perianal fistulas.

Efficacy and safety of radiofrequency ablation for treatment of chronic radiation proctitis: A systematic review and meta-analysis.

BACKGROUND AND AIM: Although argon plasma coagulation is the current standard endoscopic treatment for chronic radiation proctitis (CRP), radiofrequency ablation (RFA) has emerged as an attractive alternative. The aim of this study is to evaluate the efficacy and safety of RFA for the treatment of CRP. METHODS: Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed from 2004 through March 2018. Review and data abstraction were performed independently by two authors. Measured outcomes included hemoglobin, transfusion dependence, number of treatment sessions, RFA settings, and serious adverse events. RESULTS: Six studies (n = 71; mean age 73.41 ± 1.88 years; 90.14% male) were included. Thirty-eight percent of patients failed prior treatment with argon plasma coagulation. Patients underwent a mean of 1.71 ± 0.34 RFA sessions with 24.54 ± 16.47 RFA applications per session. Pooled clinical and endoscopic success of RFA was 99% (95% confidence interval [CI]: 90-100; P < 0.001) and 100% (95% CI: 94-100; P < 0.001), respectively. Serious adverse events were reported in one patient-pooled rate of 0% (95% CI: 0-3; P < 0.001). Mean pre-procedure hemoglobin was 10.38 ± 1.82 g/dL with significant improvement observed post-RFA [weighted mean difference 2.49 g/dL (95% CI: 2.16-2.82; P < 0.001)]. Among transfusion-dependent patients, 85% (95% CI: 68-97; P < 0.001) became transfusion-free post-RFA. Pooled mean follow-up was 19.73 ± 9.72 months. CONCLUSION: Despite limited long-term data on RFA for CRP, available evidence suggests RFA is an effective and safe treatment.

Efficacy and complications of argon plasma coagulation for hemorrhagic chronic radiation proctitis.

BACKGROUND: Chronic radiation proctitis (CRP) is a complication which occurs in 1%-5% of patients who undergo radiotherapy for pelvic malignancies. Although a wide range of therapeutic modalities are available, there is no literature to date showing any particularly appropriate therapeutic modality for each disease stage. Argon plasma coagulation (APC) is currently recommended as the first-choice treatment for hemorrhagic CRP, however, its indication based on long-term follow-up is still unclear. On the hypothesis that the long-term efficacy and safety of APC are not fully understood, we reviewed APC treatment for patients with hemorrhagic CRP from a single center. AIM: To assess the long-term efficacy and safety of APC for hemorrhagic CRP. METHODS: This is a retrospective study of consecutive patients treated with APC for hemorrhagic CRP from January 2013 to October 2017. Demographics, clinical variables, and typical endoscopic features were recorded independently. Success was defined as either cessation of bleeding or only occasional traces of bloody stools with no further treatments for at least 12 mo after the last APC treatment. We performed univariate and multivariate analyses to identify factors associated with success and risk factors for fistulas. RESULTS: Forty-five patients with a median follow-up period of 24 mo (range: 12-67 mo) were enrolled. Fifteen (33.3%) patients required blood transfusion before APC. Successful treatment with APC was achieved in 31 (68.9%) patients. The mean number of APC sessions was 1.3 (1-3). Multivariate analysis showed that APC failure was independently associated with telangiectasias present on more than 50% of the surface area [odds ratio (OR) = 6.53, 95% confidence interval (CI): 1.09-39.19, P = 0.04] and ulcerated area greater than 1 cm2 (OR = 8.15, 95%CI: 1.63-40.88, P = 0.01). Six (13.3%) patients had severe complications involving rectal fistulation. The only factor significantly associated with severe complications was ulcerated area greater than 1 cm2 (P = 0.035). CONCLUSION: The long-term efficacy of APC for hemorrhagic CRP is uncertain in patients with telangiectasias present on > 50% of the surface area and ulceration > 1 cm2.

Endoscopic diode laser therapy for chronic radiation proctitis.

The purpose of this study is to determine the effectiveness of endoscopic diode laser therapy in patients presenting rectal bleeding due to chronic radiation proctitis (CRP). A retrospective analysis of CRP patients who underwent diode laser therapy in a single institution between 2010 and 2016 was carried out. The patients were treated by non-contact fibers without sedation in an outpatient setting. Fourteen patients (median age 77, range 73-87 years) diagnosed with CRP who had undergone high-dose radiotherapy for prostatic cancer and who presented with rectal bleeding were included. Six required blood transfusions. Antiplatelet (three patients) and anticoagulant (two patients) therapy was not suspended during the treatments. The patients underwent a median of two sessions; overall, a mean of 1684 J of laser energy per session was used. Bleeding was resolved in 10/14 (71%) patients, and other two patients showed improvement (93%). Only one patient, who did not complete the treatment, required blood transfusions after laser therapy; no complications were noted during or after the procedures. Study findings demonstrated that endoscopic non-contact diode laser treatment is safe and effective in CRP patients, even in those receiving antiplatelet and/or anticoagulant therapy.

Efficacy and safety of argon plasma coagulation in the management of extensive chronic radiation proctitis after pelvic radiotherapy for cervical carcinoma.

INTRODUCTION: Chronic radiation proctitis (CRP) usually develops 90 days or more after radiation. Currently, there is no standard available for the treatment of CRP. In argon plasma coagulation, monopolar diathermy is used to ionise the argon gas which coagulates the telengiectatic vessels in a noncontact fashion. However, there are very few studies which have reported its use in extensive CRP. We report the efficacy and safety of APC in seven patients with recurrent, extensive grade 3 radiation proctitis. MATERIALS AND METHODS: This is a retrospective analysis of patients treated with argon plasma coagulation in our institute from June 2013 to June 2016. After adequate bowel preparation, patients underwent APC at an average power of 50 W with flow rate of 5 L/min. All the visible telangiectasia was ablated which required many sittings. RESULTS: The median RPSAS symptom score for frequency of bleeding at enrolment was 5 (range 3-5). After completion of APC, the median RPSAS symptom score for frequency of bleeding decreased to 1. The median RPSAS symptom score for severity of bleeding was 5 (range 3-5). After completion of APC, the mean RPSAS symptom score for severity of bleeding decreased to 1. Mean haemoglobin level before treatment was 5.43 g/dl (SD 2.37). Mean haemoglobin level after treatment was10.04 g/dl (SD 2.0). Compared with pre-treatment levels after APC, there was a mean increase in haemoglobin of 4.61 + 1.78 [95% CI 2.97-6.25, p = 0.00]. CONCLUSION: Argon plasma coagulation is a safe, well tolerated and effective treatment option in extensive chronic radiation proctitis which is refractory to medical management.

The surgical management of radiation proctopathy.

BACKGROUND: There is sparse evidence guiding the optimum surgical management of patients with radiation proctopathy (RP). The purpose of this review is to analyse all the literature on the surgical management of RP in order to guide physicians and surgeons as to when and what surgery should be employed for these patients. METHODS: A literature search of PubMed, EMBASE, MEDLINE, Ovid, and Cochrane Library using the MeSH terms "radiation proctopathy", "proctitis", "surgical management", and related terms as keywords was performed. The review included all articles that reported on the surgical management of patients with radiation proctopathy. All relevant articles were cross-referenced for further articles and any unavailable online were retrieved from hard-copy archive libraries. Eighteen studies including one prospective cohort study, fifteen retrospective cohort studies, and three small case series are included. CONCLUSION: Surgery is indicated for patients with RP for rectal obstruction, perforation, fistulae, or a failure of medical measures to control the symptoms of RP. Surgery centres mainly on diversion version resection. Diversion alone does not remove the damaged tissue leaving the patient at risk of continued complications including bleeding, perforation, occlusion, and abscess formation; however, major resectional surgery carries higher risks. Morbidity and mortality vary 0-44% and 0-11% for diversion only versus 0-100% and 0-14% for resectional surgery. There is no universally agreed surgical first-line approach. The data supports both resection with defunctioning stoma or diversion only as reasonable first-line surgical options for patients requiring surgery for RP.

Radiofrequency ablation for gastric antral vascular ectasia and radiation proctitis.

Gastric antral vascular ectasia (GAVE) and chronic radiation proctitis (CRP) are well-known causes of repeated gastrointestinal bleeding and iron deficiency anemia. Argon plasma coagulation (APC) is the most common endoscopic therapy used, but some patients need multiple APC sessions. Radiofrequency ablation (RFA) is recently used in GAVE and CRP treatment with promising results. In this case series, we analyzed data for 15 patients with GAVE and 5 patients with CRP that had multiple prior APC treatment. They were treated with RFA HALO 90 catheter (HALO90 Ablation Catheter System; Covidien, GI Solutions, Sunnyvale, CA) in our tertiary referral center. A total of 20 patients received 32 RFA procedures (8 in the CRP group and 24 in the GAVE group). The median number of the procedures was 2 (range 1-4). The hemoglobin levels in the GAVE group were 83 g/L pre-RFA and 98 g/L post-RFA and in the CRP group, 86 g/L pre-RFA and 103 g/L post-RFA. A total of 16/20 patients (80%) were transfusion-free after the completion of RFA treatment. Technical success of the treatment was 95% (19/20 patients). RFA can be safely and successfully used in APC refractory GAVE and CRP patients.

Colostomy is a simple and effective procedure for severe chronic radiation proctitis.

AIM: To assess the efficacy and safety of diverting colostomy in treating severe hemorrhagic chronic radiation proctitis (CRP). METHODS: Patients with severe hemorrhagic CRP who were admitted from 2008 to 2014 were enrolled into this study. All CRP patients were diagnosed by a combination of pelvic radiation history, clinical rectal bleeding, and endoscopic findings. Inclusion criteria were CRP patients with refractory bleeding with moderate to severe anemia with a hemoglobin level < 90 g/L. The study group included patients who were treated by diverting colostomy, while the control group included patients who received conservative treatment. The remission of bleeding was defined as complete cessation or only occasional bleeding that needed no further treatment. The primary outcome was bleeding remission at 6 mo after treatment. Quality of life before treatment and at follow-up was evaluated according to EORTC QLQ C30. Severe CRP complications were recorded during follow-up. RESULTS: Forty-seven consecutive patients were enrolled, including 22 in the colostomy group and 27 in the conservative treatment group. When compared to conservative treatment, colostomy obtained a higher rate of bleeding remission (94% vs 12%), especially in control of transfusion-dependent bleeding (100% vs 0%), and offered a better control of refractory perianal pain (100% vs 0%), and a lower score of bleeding (P < 0.001) at 6 mo after treatment. At 1 year after treatment, colostomy achieved better remission of both moderate bleeding (100% vs 21.5%, P = 0.002) and severe bleeding (100% vs 0%, P < 0.001), obtained a lower score of bleeding (0.8 vs 2.0, P < 0.001), and achieved obvious elevated hemoglobin levels (P = 0.003), when compared to the conservative treatment group. The quality of life dramatically improved after colostomy, which included global health, function, and symptoms, but it was not improved in the control group. Pathological evaluation after colostomy found diffused chronic inflammation cells, and massive fibrosis collagen depositions under the rectal wall, which revealed potential fibrosis formation. CONCLUSION: Diverting colostomy is a simple, effective and safe procedure for severe hemorrhagic CRP. Colostomy can improve quality of life and reduce serious complications secondary to radiotherapy.