Rate of Reoperation Decreased Significantly After Year 2002 in Patients With Crohn's Disease.

BACKGROUND & AIMS: Patients with Crohn's disease (CD) can require multiple intestinal surgeries. We examined time trends and risk factors for reoperation in patients with CD who underwent intestinal surgery, focusing on the effects of postoperative medical treatments. METHODS: We performed a retrospective analysis of 1871 patients with CD who underwent initial intestinal resection at 10 tertiary care institutions in Japan, with an initial surgical date after May 1982. We collected data on the background characteristics of all patients, including Montreal Classification, smoking status, and medical therapy after surgery (tumor necrosis factor antagonists [anti-TNF] agents or immunomodulators). The primary outcome was requirement for first reoperation. Rate of reoperation was estimated using the Kaplan-Meier method, and risk factors for reoperation were identified using the Cox regression model. RESULTS: The overall cumulative 5- and 10-year reoperation rates were 23.4% and 48.0%, respectively. Multivariable analysis showed that patients who underwent the initial surgery after May 2002 had a significantly lower rate of reoperation than patients who underwent surgery before April 2002 (hazard ratio [HR], 0.72; 95% CI, 0.61-0.86). Preoperative smoking (HR, 1.40; 95% CI, 1.18-1.68), perianal disease (HR, 1.50; 95% CI, 1.27-1.77), and ileocolic type of CD (HR, 1.42; 95% CI, 1.20-1.69) were significant risk factors for reoperation. Postoperative use of immunomodulators (HR, 0.60; 95% CI, 0.44-0.81) and anti-TNF therapy (HR, 0.71; 95% CI, 0.57-0.88) significantly reduced the risk. Anti-TNF was effective in the bionaive subgroup. CONCLUSIONS: The rate of reoperation in patients with CD significantly decreased after May 2002. Postoperative use of anti-TNF agents might reduce the reoperation rate for bionaive patients with CD.

Increased Quinolone-Resistant Mutations of gyrA and parC Genes after Pouchitis Treatment with Ciprofloxacin.

BACKGROUND: Oral antibiotics, such as ciprofloxacin (CFX), are widely used for the treatment of acute and chronic pouchitis. Most bacterial mutations that confer quinolone resistance are at Ser-83 and Asp-87 in the gyrA gene and Ser-80 and Glu-84 in the parC gene. METHODS: We obtained 51 stool samples from 43 patients who were diagnosed with ulcerative colitis and underwent ileal pouch-anal anastomosis. Patients were divided into 2 groups: 13 patients with CFX treatment of pouchitis and 30 patients without pouchitis. After extraction of fecal DNA, the amount of Escherichia coli 16S rRNA, gyrA, and parC gene DNA were measured using real-time polymerase chain reaction (PCR). Possible mutations at gyrA 83 and 87 and at parC 80 and 84 were investigated by PCR cloning and sequencing, and mutation rates were quantified by rapid PCR-restriction fragment length polymorphism. RESULTS: Samples from both CFX-treated and -untreated patients had comparable levels of gyrA and parC gene DNA. Nucleic acid and amino acid mutations were identified at gyrA 83 and 87, and at parC 80 and 84. We successfully quantified mutation rates at gyrA 83 and 87, and at parC 84, all of which were significantly higher in samples from CFX-treated patients (70, 84, and 38%) than from CFX-untreated patients (13, 11, and 5%). CONCLUSION: E. coli in patient pouches may have mutations in their gyrA and parC genes that produce CFX resistance. Mutation rates of these genes were significantly higher in samples from CFX-treated patients. This study contributes to understanding the decrease and loss of CFX effectiveness against pouchitis.

Resistin-like molecule beta, a colonic epithelial protein, exhibits antimicrobial activity against Staphylococcus aureus including methicillin-resistant strains.

PURPOSE: Resistin-like molecule beta (RELMß) is a small cysteine-rich protein secreted by colonic epithelial cells. RELMß mRNA and protein expressions are dramatically induced by bacterial exposure in germ-free mice. We hypothesized that RELMß has antimicrobial activity. METHODS: The antimicrobial activity of RELMß was screened by an agar spot test and confirmed by a liquid broth test. The amount of RELMß in human stools was semi-quantified by Western blot analysis. The induction of RELMß mRNA and protein expression by bacteria was measured by quantitative RT-PCR using LS174T cells. Electron microscopic immunohistochemistry was performed using polyclonal anti-RELMß antibody. RESULTS: RELMß showed antimicrobial activity against S. aureus and all MRSAs examined in a dose- and pH-dependent fashion. Western blot study showed that the amount of RELMß in healthy human stools was comparable to that exhibiting antimicrobial activity in vitro. Both RELMß mRNA and protein expression were induced by heat-inactivated S. aureus, but not by E. coli in LS174T cells. Electron microscopic immunohistochemistry showed that RELMß bound to the cell surface of S. aureus, followed by destruction of the bacterial cytoplasm. CONCLUSIONS: RELMß is a colonic antimicrobial protein and its antibacterial activity is species selective. Because RELMß is abundant in healthy human stool, RELMß may modulate gut flora.

Surveillance Colonoscopy for Ulcerative Colitis-Associated Colorectal Cancer Offers Better Overall Survival in Real-World Surgically Resected Cases.

OBJECTIVES: To determine the effectiveness of surveillance colonoscopy (SC) and optimize its use by assessing real-world surgically resected cases of ulcerative colitis (UC)-associated colorectal cancer (CRC) and dysplasia. METHODS: Clinicopathological data of 406 (238 CRC and 168 dysplasia) patients who underwent surgical resection in 10 UC specialized institutions were retrospectively reviewed. The overall survival (OS) rates were compared between the SC and non-SC groups. The incidence of and risk factors for early-onset CRC (<8 years after UC onset) were identified. The distribution of CRC lesions was also assessed. RESULTS: Cancer stages were significantly more advanced in the non-SC group than in the SC group (P < 0.001). The patients in the SC group showed significantly better OS than those in the non-SC group (5-year OS: 89% vs 70%; log-rank test: P = 0.001). Seventeen percent of patients developed CRC within 8 years after UC onset. The age at UC onset was a risk factor and a good predictor of early-onset CRC (<8 years) (P < 0.01; AUC: 0.85). The most common sites of CRC were the rectum (51%) and sigmoid colon (20%). Multiple CRC was identified in 16% of patients. CONCLUSIONS: Surveillance colonoscopy was effective and improved the OS in patients with UC. We recommend that patients with late-onset UC (>40 years) undergo SCs earlier because of the high incidence of CRC within 8 years of UC onset. Moreover, the rectum and sigmoid colon should be more thoroughly examined.

Changes in the rate of and trends in colectomy for ulcerative colitis during the era of biologics and calcineurin inhibitors based on a Japanese nationwide cohort study.

PURPOSE: We evaluated the recent incidence of surgery and the changing surgery trends for ulcerative colitis (UC) in Japan due to the increasing use of anti-tumor necrosis factor (TNF) agents. METHODS: A questionnaire survey was performed to assess the number of surgeries, surgical indications, surgical timing, and immunosuppressive treatments before surgery between 2007 and 2017. RESULTS: A total of 3801 surgical cases were reported over 11 years. The prevalence of UC surgery decreased over the period studied. The rate of prednisolone (PSL) use did not change. The prevalence of both calcineurin inhibitors (CNIs) and anti-TNF agents increased during the period studied (p < 0.01). The prevalence of urgent/emergent surgery did not change. The most distinctive change in surgical indications was the increase in cancer/dysplasia (CAC), the prevalence of which increased from 20.2% in 2007 to 34.8%. CONCLUSION: The prevalence of UC surgery seems to be decreasing according to the increasing rate of anti-TNF agent and CNI administration. However, the indication of CAC significantly increased. Further research should evaluate whether or not long-term remission maintained with several agents can lead to increasing CAC.

Postoperative therapy with infliximab for Crohn's disease: a 2-year prospective randomized multicenter study in Japan.

PURPOSE: The prevention of postoperative recurrence is a critical issue in surgery for Crohn's disease. Prospective randomized trials in Western countries have shown that the postoperative use of anti-tumor necrosis factor α-antibodies was effective in reducing the recurrence rate. We investigated the efficacy of infliximab (IFX) for the prevention of postoperative Crohn's disease recurrence. METHODS: We performed a prospective randomized multicenter study. Patients who underwent intestinal resection were assigned to groups treated with or without IFX. Immediately after surgery, patients in the IFX group received IFX at 5 mg/kg at 0, 2, and 6 weeks, followed by every 8 weeks for 2 years. The primary study outcome was the proportion of patients with endoscopic and/or clinical recurrence at 2 years after surgery. RESULTS: Thirty-eight eligible patients participated in this study: 19 in the IFX group and 19 in the non-IFX group. The disease recurrence rate in the IFX group was 52.6% (10/19), which was significantly lower than that in the non-IFX group (94.7% [18/19]). CONCLUSION: The postoperative use of IFX is effective in preventing Crohn's disease recurrence for 2 years.

Risk factors for surgical site infection in Japanese patients with ulcerative colitis: a multicenter prospective study.

PURPOSE: A prospective, multicenter, observational study was performed to investigate the risk factors of surgical site infection (SSI) in patients with ulcerative colitis (UC). METHODS: From 2009 to 2010, perioperative clinicopathological data were collected from patients who had undergone surgery for UC within the research period, for up to 6 consecutive months in 13 hospitals in Japan. The primary outcome was the development of SSI. RESULTS: A total of 195 patients with UC who underwent colorectal surgery were enrolled. SSI was diagnosed in 38 (19.5 %) patients, in the form of incisional infection in 23 (11.8 %), organ/space infection in 16 (8.2 %), and both in 1 (0.5 %). There were no significant risk factors associated with an increased risk of development of incisional SSI. An American Society of Anesthesiologists physical status of ≥ 3 was indicated as the only significant risk factor for organ/space SSI (P = 0.02) compared with other factors, such as a neutrophil count of >100 × 10(2)/mm(3), albumin level of <3.5 g/dl, perioperative packed red blood cell transfusion, fair or poor colonic cleanliness, and therapeutic use of antibiotics. CONCLUSION: Poor general physical status was the significant independent risk factor for organ/space SSI in patients with UC in Japan.

Endoscopic Lesions of Postoperative Anastomotic Area in Patients With Crohn's Disease in the Biologic Era: A Japanese Multi-Centre Nationwide Cohort Study.

BACKGROUND AND AIMS: Many patients have endoscopic evidence of recurrent Crohn's disease [CD] at 1 year after intestinal resection. These lesions predict future clinical recurrence. We endoscopically evaluated postoperative anastomotic lesions in CD patients from a large cohort of postoperative CD patients. METHODS: We retrospectively enrolled CD patients who underwent surgical resection between 2008 and 2013 at 19 inflammatory bowel disease [IBD]-specialist institutions. The initial analyses included patients who underwent ileocolonoscopy ~1 year after intestinal resection. Follow-up analyses assessed any changes in the endoscopic findings over time. We evaluated the postoperative endoscopic findings, which were classified into four categories [no lesion, mild, intermediate, severe] at the sites of the anastomotic line and peri-anastomosis. RESULTS: In total, 267 CD patients underwent postoperative ileocolonoscopy. Postoperative anastomotic lesions were widely detected in index ileocolonoscopy [61.0%] and were more frequently detected in follow-up ileocolonoscopy [74.9%]. Endoscopic severity also increased. Patients with intermediate or severe peri-anastomotic or anastomotic line lesions at the index ileocolonoscopy required significantly more interventions, including endoscopic dilatation or surgery, than patients with mild lesions or no lesions. CONCLUSIONS: Frequent anastomotic lesions were observed at the postoperative index ileocolonoscopy. These gradually increased for subsequent ileocolonoscopy, even in the biologic era. Regarding lesions on the anastomotic line, intermediate lesions on the anastomotic line [e.g. irregular or deep ulcers] might be considered recurrent disease, and mild lesions [e.g. linear superficial ulcers] might be considered non-recurrent disease. Prospective studies are needed to resolve this issue, including treatment enhancement.

A shift from colon- to ileum-predominant bacteria in ileal-pouch feces following total proctocolectomy.

BACKGROUND: We previously investigated fecal flora of the pouch after total proctocolectomy using terminal restriction fragment polymorphism analysis. Although the results of the cluster analysis demonstrated clearly that bacterial populations, including an unidentified bacteria generating a 213-bp PCR fragment, moved toward a colon-like community in the pouch, it did not track changes in the individual species of fecal bacteria. AIMS: The aim of the present study was to estimate genome copy number of ten bacterial species, clusters, groups, or subgroups (including the bacteria generating 213-bp fragment in the previous study) in feces samples from pouches at various times following ileostomy closure. METHODS: A total of 117 stool samples were collected from patients with ulcerative colitis after surgery as well as healthy volunteers. We used real-time polymerase chain reaction of the 16S rRNA gene to estimate genome copy numbers for the nine bacterial populations and the bacteria generating 213-bp fragment after identification by DNA sequencing. RESULTS: We demonstrated a time-dependent increase in the number of anaerobic and colon-predominant bacteria (such as Clostridium coccoides, C. leptum, Bacteroides fragilis and Atopobium) present in proctocolectomy patients after stoma closure. In contrast, numbers of ileum-predominant bacterial species (such as Lactobacillus and Enterococcus faecalis) declined. CONCLUSIONS: Our data confirm previous findings that fecal flora in the pouch after total proctocolectomy changes significantly, and further demonstrate that the number and diversity of ileal bacteria decreases while a more colon-like community develops. The present data are essential for the future analysis of pathological conditions in the ileal pouch.

Ulcerative colitis-related severe enteritis: an infrequent but serious complication after colectomy.

BACKGROUND AND AIM: After colectomy for ulcerative colitis (UC), very severe and sometimes lethal enteritis can develop. However, the clinical features remain uncertain because of the low incidence, diversity of symptoms, and undefined diagnostic criteria. The aim of this study was to define postoperative ulcerative colitis-related severe enteritis (UCRSE) and to investigate its clinical features. METHODS: A retrospective multicenter study was performed as a survey of major medical facilities utilizing surgical supplies for inflammatory bowel disease in Japan from 2001 to 2014. UCRSE was defined as a case with massive intestinal bleeding, intestinal perforation, high-output stoma, and/or a requirement for medications, such as steroids and biologics. Patients with gastroduodenal lesions or pouchitis alone were excluded. The incidence, symptoms, involvement of bacteria, cytomegalovirus reactivation, treatment, and prognosis were examined for patients with UCRSE after colectomy. RESULTS: Forty-two (0.8%) out of 5284 cases met the criteria for UCRSE. Major symptoms were massive intestinal bleeding (76.2%), which required a median of 3850 (560-18900) mL blood transfusion; high-output stoma (38.1%) with excretion of fluid of 5000 (2000-7800) mL/day; and intestinal perforation (7.1%). Hypovolemic shock (35.7%) and/or disseminated intravascular coagulation (31.0%) developed as serious complications. Tests for cytomegalovirus reactivation were positive in 26.2% of cases. The presence of pathogenic bacteria was confirmed in only 5 cases. Corticosteroids or infliximabs were effective in half of the patients. Thirteen cases (31.0%) were treated surgically and 22 cases (56.4%) required maintenance therapy. The mortality rate was 11.9%. CONCLUSION: UCRSE is a rare but serious complication after colectomy and is sometimes life-threatening.

What determines the later clinical course of patients who do not undergo colectomy at the first attack? A Japanese cohort study on ulcerative colitis.

BACKGROUND/AIMS: Several earlier studies on factors predicting the long-term outcome of ulcerative colitis only encompassed treatment failure for one severe episode, or suffered from a lack of multivariate analyses. We aimed to identify factors assessable at diagnosis or after the first induction therapy which predicted relapse or later colectomy in patients with mild to severe ulcerative colitis. METHODS: Clinical parameters (age, sex, disease extent, and disease activity at diagnosis) and laboratory data (hemoglobin, albumin, C-reactive protein, and erythrocyte sedimentation rate at diagnosis and 4 weeks after the first induction therapy) were evaluated in 296 patients (median follow-up 87 months). Factors predicting relapse and later colectomy were sought using the Cox proportional hazard model. RESULTS: The presence of moderate or severe disease at diagnosis were significant predictors of relapse [adjusted hazard ratio (95% CI) 2.07 (1.48-2.89) and 1.70 (1.06-2.72), respectively] and later colectomy [3.40 (1.09-10.54) and 6.77 (1.92-23.86)]. After the first induction therapy, hemoglobin and albumin were associated with relapse [0.87 (0.76-0.99) and 0.58 (0.41-0.83)] and later colectomy [0.60 (0.47-0.77) and 0.11 (0.06-0.22)]. CONCLUSION: Relapse and later colectomy were associated with (1) disease activity at diagnosis and (2) lower levels of hemoglobin and albumin after the first induction therapy.

Hand-assisted laparoscopic vs. open subtotal colectomy for severe ulcerative colitis.

PURPOSE: This study aimed to assess the feasibility and safety of undergoing emergency subtotal colectomy with hand-assisted laparoscopic surgery in patients with severe ulcerative colitis. METHODS: We reviewed the medical records of 60 patients who underwent emergency subtotal colectomy with hand-assisted laparoscopic technique (30 cases) or open technique (30 cases) for severe ulcerative colitis. RESULTS: No intraoperative complications occurred in either group. One patient in the laparoscopic group required conversion to open surgery. The median operative time was significantly longer in the laparoscopic group (242 vs. 191 minutes; P < 0.001). The rate of early postoperative complications in the laparoscopic group was significantly less than that in the open group (37 percent vs. 63 percent; P = 0.041). In the open group, four patients required relaparotomy because of peritoneal abscess or strangulation ileus, whereas no patient required relaparotomy in the laparoscopic group (P = 0.040). In the laparoscopic group, the median duration of postoperative food prohibition was significantly shorter (4.8 vs. 5.9 days; P = 0.007), and the median length of hospital stay was significantly shorter (23.0 vs. 33.0 days; P = 0.001). CONCLUSIONS: Although the operative time was elongated in the laparoscopic group, intraoperative safety and postoperative recovery were satisfactory. For severe ulcerative colitis, hand-assisted laparoscopic surgery can be an alternative to conventional open surgery.

The effect of growth hormone releasing peptide-2 on upper gastrointestinal contractile activity and food intake in conscious dogs.

BACKGROUND: The aim of this study was to evaluate the effect of growth hormone releasing peptide (GHRP)-2, a synthetic ligand for the growth hormone secretagogue receptor, on upper gastrointestinal motility and food intake. METHODS: Five neurally intact dogs and five dogs with vagotomy and pyloroplasty were equipped with strain gauge force transducers on the stomach, duodenum and jejunum. GHRP-2 (0.5-10 microg/kg) was administered intravenously in neurally intact dogs in the interdigestive state and after feeding. To study the mechanism of GHRP-2-induced inhibition on postprandial contractions, various antagonists were administered intravenously prior to GHRP-2. The effect of GHRP-2 on postprandial contractions was also studied in dogs with vagotomy. GHRP-2 was also administered immediately before feeding in each group, and its effect on food intake was assessed. RESULTS: GHRP-2 did not evoke gastrointestinal contractions in the interdigestive state. GHRP-2 induced contractile inhibition continuing for 2-3 min in neurally intact dogs and dogs with vagotomy. This inhibitory effect was reversed by the alpha- and alpha(2)-blockers. GHRP-2 increased food intake in neurally intact dogs, but not in dogs with vagotomy. CONCLUSIONS: These results indicate that in the upper gut GHRP-2 inhibits postprandial contractions via alpha(2)-receptors on the enteric nervous system, whereas an intact vagal nerve is necessary for a GHRP-2-induced increase in food intake.

Ileal J-pouch perforation at the blind end: report of a case.

A 34-year-old woman presented with severe abdominal pain 8 years after undergoing ileal J-pouch anal anastomosis for ulcerative colitis (UC). Computed tomography (CT) showed free air and ascites in the abdomen, so she underwent laparotomy. A perforation was found at the ileal J-pouch blind end, which was remarkably enlarged. When we resected the blind end surgically, we observed a 3-mm perforation and some small ulcers. About 2 months after this operation, the patient complained of abdominal pain and an increased frequency of bowel movements. Based on our endoscopic observation of multiple ulcers, we diagnosed pouchitis. We report this case to show that the combination of an enlarged J-pouch blind end and pouchitis can result in perforation. To prevent such complications, we recommend avoiding the formation of a blind end during construction of a J-pouch.

The effect of a total colectomy on the motor inhibition of the upper gut induced by intraileal stimuli in conscious dogs.

PURPOSE: The administration of stimuli to the ileum inhibits upper gastrointestinal motility. The aim of this study was to determine whether a total colectomy can alter this motor inhibitory effect. METHODS: Beagle dogs were each equipped with four strain gauge force transducers on the upper gastrointestinal tract. The infusion of nutrients (saline as placebo control, oleate, butyrate, and glucose) began 90 min after feeding and continued for 30 min via a silicone catheter placed in the ileal lumen. Capsaicin (10 mg) was injected into the ileum as a bolus. All of the dogs underwent a relaparotomy and a total colectomy, and the same experiments were performed on all dogs. RESULTS: Before performing a colectomy, the oleate, the glucose, and the capsaicin were each found to inhibit the postprandial upper gastrointestinal motility in comparison to the placebo control (P < 0.05). The butyrate had no inhibitory effect. After a total colectomy, the inhibition of upper gastrointestinal motility was observed after the intraileal infusion of the oleate and the capsaicin (P < 0.05). The motor inhibitory response to the intraileal glucose was delayed after a total colectomy, and a reduction of the motility index was not observed in the gastric antrum and the duodenum because of this delay. However, a significant reduction in the motility index was observed in the jejunum. CONCLUSION: The intraileal stimuli-induced motor inhibition decreased after a total colectomy after the administration of glucose, but not after the administration of either oleate or capsaicin.

[An operative case of ulcerative colitis associated with hyperthyroidism].

We encountered a rare operative case of hyperthyroidism followed by ulcerative colitis (UC). A 26-year-old mam was referred to our department to undergo an operation. We suspected the possible complication of adrenal insufficiency, since he suffered from severe weight loss, a high fever and palpitation on admission. We diagnosed hyperthyroidism, however, based on the presence of high serum free T3 and T4 levels and a decreased TSH level. After improving the symptoms and the thyroid function by administering thiamazole, we then performed a total proctocolectomy. Although a high rate of association of autoimmune thyroid diseases with UC has been suggested, only 9 cases of hyperthyroidism coexisting with UC have so far been reported in Japan. A common immunological process has been suggested to be implicated in the pathogenesis of this association, however, the exact mechanism needs to be elucidated in the future.

Differential effects of two probiotic strains with different bacteriological properties on intestinal gene expression, with special reference to indigenous bacteria.

Probiotics are used for the improvement of gut disorders. To explore the potential of probiotics, a gnotobiotic study using BALB/c mice to analyze epithelial gene expression was performed. Microarray analysis of probiotic strain-monoassociated mice showed that Lactobacillus casei Shirota and Bifidobacterium breve Yakult noticeably affected gene expression in the ileal and colonic epithelial cells, respectively, although to a smaller extent than segmented filamentous bacteria (SFB). Lactobacillus casei Shirota enhanced the gene expression involving defense/immune functions and lipid metabolism more strongly than B. breve Yakult. In the colon, expression of a chloride transporter was slightly enhanced, although downregulation of many genes, such as guanine nucleotide-binding protein, was evident in mice with B. breve Yakult compared with the ones with L. casei Shirota. SFB affected gene expression more strongly than the probiotic strains. In particular, alpha(1-2) fucosyltransferase and pancreatitis-associated protein were significantly enhanced only in SFB-monoassociated mice but not probiotic strain-monoassociated mice. Gene expression of SFB-monoassociated mice was either stimulated or repressed in a manner similar to or opposite that of conventional colonized mice. Taken together, probiotic strains of L. casei Shirota and B. breve Yakult differentially affect epithelial gene expression in the small intestine and colon, respectively.

The glucagon provocative test for the diagnosis and treatment of Zollinger-Ellison syndrome.

OBJECTIVE: Our aim was to determine whether the glucagon provocative test could be used in place of secretin test in patients with gastrinoma. METHODS: Three patients with gastrinoma underwent the following examinations: (1) preoperative intravenous glucagon test to enable a definitive diagnosis, (2) intra-arterial glucagon injection test to localize the tumor, and (3) intraoperative and postoperative intravenous glucagon test to confirm the completeness of the resection. RESULTS: Serum gastrin levels increased in response to intravenous glucagon in all three patients preoperatively. Computed tomography scans revealed a tumor in the lesser omentum, pancreatic head, and the pancreatic uncinate in cases 1, 2, and 3, respectively. Intra-arterial glucagon test revealed that the feeding artery for the tumor was the left gastric artery in case 1 and the superior mesenteric artery in case 3. Resection of the remnant stomach with tumor, pancreaticoduodenectomy with portal vein resection, and enucleation of the tumor were performed in cases 1, 2, and 3, respectively. Serum gastrin levels did not increase in response to intravenous glucagon intraoperatively and postoperatively in cases 1 and 3. Although intravenous glucagon caused a slight increase in serum gastrin in case 2, no recurrent tumors were evident. CONCLUSION: These results indicate that the glucagon provocative test is a suitable alternative to testing with secretin, which is not commercially available in Japan.

Stoma-related complications in inflammatory bowel disease.

BACKGROUND: This study was designed to evaluate the incidence and details of stoma-related complications in patients with ulcerative colitis and Crohn's disease who underwent permanent enterostomas, and to analyze the specific problems in these diseases. METHODS: Permanent enterostomas constructed for ulcerative colitis and Crohn's disease between 1984 and 2004 in our institution were included. The incidence and details of stoma-related complications were investigated retrospectively. The cumulative probability of complications and stoma reconstruction was also estimated by the Kaplan-Meier life-table analysis. RESULTS: 43 patients with ulcerative colitis and 59 patients with Crohn's disease underwent 46 and 76 stoma constructions, respectively. Stoma-related complications, including fistula, retraction and stenosis, were significantly more frequent in patients with Crohn's disease (36.8%) than ulcerative colitis (17.4%) (p < 0.05). The cumulative risk of complications and the necessity for stoma reconstruction was significantly higher in patients with Crohn's disease (p < 0.05). Among the patients with Crohn's disease, colostomies were likely to receive revisional surgery earlier than ileostomies (p < 0.05). CONCLUSION: In the surgical therapy of inflammatory bowel disease, special attention should be paid in the high incidence of stoma-related complications in patients with Crohn's disease, which needs revisional surgery more frequently.

Long-term outcomes following restorative proctocolectomy ileal pouch-anal anastomosis in pediatric ulcerative colitis patients: Multicenter national study in Japan.

BACKGROUND: Few studies have investigated surgical outcomes following a colectomy in pediatric patients with ulcerative colitis (UC). PURPOSE: This study aimed to determine long-term outcomes in a large cohort of pediatric patients who underwent proctocolectomy with ileal pouch-anal anastomosis (IPAA) for UC. METHODS: Pediatric patients (<17 years old) who underwent surgery at 12 different hospitals in Japan between May 1979 and March 2015 were included in this study. Information was obtained by the use of a questionnaire survey. RESULTS: There were 113 (53.3%) male and 99 (46.7%) female pediatric patients. The most common indication for elective surgery was failure of medical management, whereas emergency surgery was carried out for fulminant cases. A hand-sewn IPAA was used with a mucosectomy in 112 (52.8%), stapled anastomosis in 93 (43.9%), and not specified in 7 (3.3%) patients. Small bowel obstruction and surgical site infection were the most frequent early postoperative complications (POC), whereas pouchitis, small bowel obstruction, and perianal fistula were frequent late POC. The most common late POC was pouchitis, found in 38 (17.9%) of the patients, whereas pouch failure was noted in 11 patients at the latest follow-up examination. Cumulative pouch survival rate after 10 years was 91.7%. There were no significant differences regarding gender or anastomotic procedure in relation to cumulative pouch survival rate. CONCLUSION: To avoid pouch failure following an IPAA procedure, it is important to recognize that pouchitis or an anal fistula may lead to this condition in pediatric UC patients.