Impact of the body mass index on the retention of the anorectal mucosa after double-stapled ileal pouch-anal anastomosis for ulcerative colitis.

BACKGROUND: Double-stapled ileal pouch-anal anastomosis (DS-IPAA) is easy to construct and has a good functional outcome in patients with ulcerative colitis (UC). However, retention of the anorectal mucosa may lead to a subsequent risk of inflammation and neoplasia. This study aimed to identify factors associated with the retention of a large amount of anorectal mucosa after DS-IPAA. METHODS: The medical records of 163 patients who had undergone one-stage total proctocolectomy and DS-IPAA for UC between 2007 and 2020 were retrospectively reviewed. The patients were divided into two groups according to the length of the retained mucosa. The high anastomosis group was defined as having a retained mucosal length of ≥ 30 mm in the anterior or posterior wall. Clinical factors were compared between the high and low anastomosis groups. RESULTS: The high anastomosis group showed a significantly higher body mass index (BMI) (high vs. low: 23.2 vs. 19.0), longer operation time (304 vs. 263) and greater blood loss (357 vs. 240). In the multivariate analysis, high BMI was the only factor significantly associated with high anastomosis (odds ratio 1.32). There was a positive correlation between BMI and the length of the retained mucosa. CONCLUSIONS: In DS-IPAA, BMI showed the strongest association with the retention of a large amount of the anorectal mucosa. In high BMI patients, although the risk of inability of anastomosis is little than that of IPAA with mucosectomy, the possible retention of a large amount of mucosa should be considered.

Postoperative results and complications of fecal diversion for anorectal Crohn's disease.

PURPOSE: Fecal diversion is a less-invasive technique that can alleviate symptoms in patients with refractory anorectal Crohn's disease. However, complications, including recurrence of residual anorectal Crohn's disease, may develop. We aimed to evaluate the postoperative results and complications associated with fecal diversion in patients with refractory anorectal Crohn's disease. METHODS: We enrolled 1218 Crohn's disease patients who underwent laparotomy at our institute. We retrospectively analyzed the clinical features of 174 patients who underwent fecal diversion for refractory anorectal Crohn's disease, complications of the diverted colorectum, and the incidence and risk factors for proctectomy after fecal diversion. RESULTS: After fecal diversion, 74% of patients showed improved symptoms. However, bowel continuity restoration was successful in four patients (2.2%), and anorectal Crohn's disease recurred in all patients. Seventeen patients developed cancer with a poor prognosis. The rate of conversion to proctectomy after fecal diversion was 41.3%, and the risk factors included rectal involvement (p = 0.02), loop-type stoma (p < 0.01), and the absence of treatment with biologics after fecal diversion (p = 0.03). CONCLUSION: Fecal diversion for refractory anorectal Crohn's disease can improve clinical symptoms. Patients with rectal involvement or loop-type stoma have a greater risk of requiring proctectomy following fecal diversion. The administration of biologic may decrease the rate of proctectomy.

[Surgical treatment for ulcerative colitis in patients over 70 years of age].

The clinical course of 104 patients with ulcerative colitis who underwent primary surgery at ≥70 years was retrospectively examined. Pre- and postoperative patient conditions determined the choice of surgical procedure. Approximately half of the patients underwent restorative proctocolectomy, resulting in relatively good defecation function. In addition, the long-term outcomes of patients who underwent permanent ileostomy were favorable. However, the postoperative complication and mortality rates were high in all patients, including those with low preoperative performance status due to long-term hospitalization. In this patient population, surgery should be conducted before decreased performance status due to long-term hospitalization.

[A case of ulcerative colitis complicated by disseminated intravascular coagulation that improved markedly after surgery].

A 57-year-old man presenting with severe ulcerative colitis (UC) complicated by disseminated intravascular coagulation (DIC) was referred to our hospital. Since it was difficult to improve DIC immediately with any medical treatment, total proctocolectomy, ileoanal canal anastomosis, and ileostomy were performed on the patient. Soon after the surgery, his platelet count and coagulability improved, and he recovered from DIC. Thus, when the cause of DIC is probably UC itself, and medical treatment has limited efficacy in improving the DIC, surgery should be performed as soon as possible to eliminate the cause of DIC, considering the general condition of the patient.

Management of Pouch Neoplasia.

BACKGROUND: Pouch neoplasia occurs following ileal pouch-anal anastomosis, with or without mucosectomy in ulcerative colitis and familiar adenomatous polyposis. OBJECTIVES: This study aimed to review available literature and make recommendations regarding pouch neoplasia. DATA SOURCES: Data were collected from specialty hospitals, and a literature review was conducted due to the lack of published large-scale studies. Recommendations for treatment were made based on the literature review and expert opinions. STUDY SELECTION: Large-scale studies of pouch neoplasia were selected. INTERVENTION: The intervention was studies with details of pouch neoplasia. MAIN OUTCOME MEASURES: We aimed to identify the management modalities for pouch neoplasia based on the type. RESULTS: Pouch neoplasia can occur in each component of the pouch-afferent limb, pouch body, cuff, and anal transitional zone. In patients with ulcerative colitis, pouch neoplasia is treated because colitis-associated neoplasia comprises a multifocal lesion, which most commonly involves the cuff and anal transitional zone. Close surveillance or endoscopic complete resection is optimal for low-grade dysplasia. For adenocarcinoma, high-grade dysplasia, and low-grade dysplasia with difficult complete resection, pouch excision is recommended. In familiar adenomatous polyposis patients with adenomas of the afferent limb or pouch body, endoscopic resection is optimal. Endoscopic resection is feasible for discrete adenoma in the cuff and anal transitional zone, and surgical excision is optimal for laterally spreading, extensive, large, or flat adenoma. For adenocarcinomas involving any component, pouch excision is recommended. LIMITATIONS: Published large-scale studies were lacking because of disease rarity. CONCLUSION: Pouch neoplasia occurs in each pouch component. In patients with ulcerative colitis, pouch excision is recommended for adenocarcinomas and high-grade dysplasia, whereas endoscopic intervention may be preferable to low-grade dysplasia. In familiar adenomatous polyposis patients, pouch excision is necessary for adenocarcinoma, and endoscopic resection or excisional surgery is optimal for adenoma.

Postoperative complications, bowel function, and prognosis in restorative proctocolectomy for ulcerative colitis-a single-center observational study of 320 patients.

PURPOSE: To determine the selection criteria, postoperative complications, bowel function, and prognosis of stapled ileal pouch-anal anastomosis (IPAA) and hand-sewn IPAA for ulcerative colitis (UC). METHODS: We defined our surgical indications and strategy, and compared the postoperative complications, bowel function, and prognoses between patients who underwent stapled and hand-sewn IPAA for UC at the Yokohama City University Medical Center between 2004 and 2017. RESULTS: Among 320 patients enrolled, 298 patients underwent stapled IPAA while 22 underwent hand-sewn IPAA. There was no significant difference in the postoperative complications between the two groups. Regarding postoperative bowel function, stapled IPAA caused significantly less soiling (stapled vs hand-sewn: 9.1% vs 41.0%, odds ratio (OR) = 0.14, p < 0.0002), spotting (stapled vs hand-sewn: 23.2% vs 63.6%, OR = 0.17, p < 0.0001), and difficulty in distinguishing feces from flatus (stapled vs hand-sewn: 39.9% vs 63.6%, OR = 0.36, p < 0.026). No postoperative neoplasia was observed at the final follow-up in all patients. CONCLUSION: In this study, there was no clear difference in the postoperative complications between stapled and hand-sewn IPAA, but stapled IPAA resulted in better postoperative bowel function. Postoperative oncogenesis from the residual mucosa is rare. However, future cancer risk remains; thus, careful follow-up is required.

Clinicopathological and prognostic evaluations of anorectal cancer after fecal diversion for patients with Crohn's disease.

PURPOSE: Colorectum diversion with a proximal stoma is often the preferred surgical approach in patients with Crohn's disease-related anorectal lesions or refractory colitis. To date, few studies have assessed the incidence and prognosis of cancer in the diverted anorectal segments. This study aimed to evaluate the clinical characteristics and prognosis of anorectal cancer associated with Crohn's disease following fecal diversion. METHODS: This was a retrospective study based on medical records of patients diagnosed with Crohn's disease between 1999 and 2020. It was conducted at Yokohama Municipal Citizen's Hospital. Patients diagnosed with anorectal cancer following fecal diversion were identified, and their prognosis was the primary outcome measure. RESULTS: Among 1615 patients, 232 patients (14%) underwent colorectum diversion. Of those 232 patients, 11 were diagnosed with anorectal cancer following fecal diversion, ten were diagnosed with advanced cancer, 10 underwent abdominoperineal resection, and eight died. 1 could not undergo resection due to multiple lung metastasis and died. The overall five-year survival rate in patients diagnosed with anorectal cancer following fecal diversion was 20%. CONCLUSION: Crohn's disease-associated anorectal cancer following fecal diversion was challenging to diagnose early, and patients had a poor prognosis even after curative resection. Early abdominoperineal resection may be considered for patients with Crohn's disease who cannot benefit from cancer screening and surveillance due to difficulty accessing the anorectal stricture via endoscopy.

Long-term survival differences between sevoflurane and propofol use in general anesthesia for gynecologic cancer surgery.

BACKGROUND: This study aimed to evaluate the influence of anesthetic management with propofol or sevoflurane on the prognosis of patients undergoing gynecologic cancer surgery. METHODS: This retrospective cohort study included patients who underwent gynecologic cancer (cervical, endometrial, and ovarian cancer) surgery between 2006 and 2018 at the National Hospital Organization Osaka National Hospital. Patients were grouped according to anesthesia type for maintenance of anesthesia: propofol or sevoflurane. After propensity score matching, Kaplan-Meier survival curves were constructed for overall survival, cancer-specific survival, and recurrence-free survival. Univariate and multivariate cox regression models were used to compare hazard ratios for recurrence-free survival. RESULTS: A total of 193 patients with propofol and 94 with sevoflurane anesthesia were eligible for analysis. After propensity score matching, 94 patients remained in each group. The sevoflurane group showed significantly lower survival rates than the propofol group with respect to 10-year overall survival (89.3% vs. 71.6%; p = 0.007), 10-year cancer-specific survival (91.0% vs 80.2%; p = 0.039), and 10-year recurrence-free survival (85.6% vs. 67.7%; p = 0.008). Sevoflurane anesthesia was identified as an independent risk factor for recurrence-free survival. Furthermore, distant recurrence was significantly more frequent in the sevoflurane group than in the propofol group (p < 0.001). CONCLUSION: In patients undergoing gynecologic cancer surgery, sevoflurane anesthesia was associated with worse overall, cancer-specific, and recurrence-free survival than propofol anesthesia.

[A case of a patient with Crohn's disease who had vaginal delivery after abdominoperineal resection for severe anorectal complications].

We report the case of a young female patient with Crohn's disease case who had vaginal delivery after abdominoperineal resection for severe perianal disease. The patient had Crohn's disease with anorectal complications for 13 years and underwent abdominoperineal resection for anorectal stenosis, complex anal fistula, and rectovaginal fistula in her early twenties. Seven years later, she got pregnant and gave birth to a healthy boy by vaginal delivery. No recurrence of Crohn's disease was observed during the perinatal period. There is no curative treatment for severe anorectal complications, which may be necessary for young patients to undergo abdominoperineal resection. Further studies are needed to determine the effects of Crohn's disease with anorectal complications on pregnancy and childbirth in affected patients.

[Preoperative diagnosis of small intestinal cancer associated with Crohn's disease: a case report].

The patient was a 46-year-old woman with a history of Crohn's disease for several years. At 45 years of age, a colonoscopy was performed, and a protruding lesion in the terminal ileum was detected. Pathological analysis of a biopsy specimen noted high suspicion for a well differentiated adenocarcinoma. The patient underwent ileocecal resection, and histological examination of the specimen revealed that infiltration of the well differentiated adenocarcinoma was limited to the mucosa. To the best of our knowledge, this is the first known case of early small intestinal cancer associated with Crohn's disease in Japan. Both endoscopy and a biopsy of any protruding lesions may be useful for making a preoperative diagnosis of small intestinal cancer associated with Crohn's disease.

[Pregnancy and delivery in patients with Crohn's disease who had a history of abdominal surgery].

OBJECTIVE: A few studies have focused on pregnancy and childbirth in patients with Crohn's disease (CD) who had a history of abdominal surgery. The objective of this study is to analyze the problems of pregnant patients with CD with a history of abdominal surgery. METHODS: The rates of pregnancy-related complications and adverse birth outcomes were retrospectively analyzed in 29 patients with CD (45 pregnancies) with previous intestinal surgery. RESULTS: In this study, the following outcomes were observed:normal births occurred in 55.6% of the pregnancies, preterm births in 13.3%, and spontaneous abortions in 20.0%. The vaginal birth and cesarean section rates were 45.7% and 40.0%, respectively. The rate of low-birth weight infants was 14.3%. CONCLUSION: Overall, patients with CD with previous abdominal surgery can conceive and give birth. However, care needs to be taken to avoid preterm birth, spontaneous abortion, low birth weight, and cesarean delivery.

[A case of ulcerative colitis complicated by internal fistula between the transverse colon and stomach].

A case of ulcerative colitis (UC) with an internal fistula was reported;the patient, a 42-year-old male, was admitted to the hospital with a diagnosis of refractory UC. The preoperative examination revealed an internal fistula between the transverse colon and the stomach. UC was diagnosed preoperatively with an internal fistula, but the possibility of Crohn's disease could not be ruled out at that time. The patient underwent subtotal colectomy with end ileostomy, sigmoid colon mucous fistula, and partial gastrectomy. UC was diagnosed histopathologically, and an ileal pouch-anal anastomosis was performed. An internal fistula can complicate UC;a split surgery is recommended with the possibility of Crohn's disease in the patient.

[Familial adenomatous polyposis with papillary thyroid cancer:a case report].

The patient is 36-year-old woman who complained of proptosis and was diagnosed as thyroid cancer. The pathologic diagnosis of her resected specimen was papillary thyroid cancer, cribriform morular variant (CMV). Subsequently, she was suspected of having familial adenomatous polyposis (FAP), although she had no family history of it. The diagnosis of FAP was confirmed following colonoscopy, which showed multiple polyps, and the biopsies that revealed multiple adenomas and cancers with APC gene mutation. She underwent restorative proctocolectomy, rectal mucosectomy with ileal pouch anal anastomosis, and ileostomy in our department. Cancer in the adenomas was found in four polyps on histopathological examination. CMV is known to be complicated with FAP. However, the number of reported cases remains few. This case was relatively rare, with an initial diagnosis of FAP because of the coexistence of CMV. In patients with papillary thyroid cancer (CMV type), colonoscopy should be considered because of the possibility of FAP.

[A case of ulcerative colitis in an 86-year-old woman undergoing restorative proctocolectomy with ileal pouch-anal canal anastomosis].

An 86-year-old woman was diagnosed with ulcerative colitis (UC) in the 1970s. A colonoscopy performed 40 years thereafter revealed a 0-Is lesion in the upper rectum, and pathological examination showed well-differentiated adenocarcinoma. The lesion was diagnosed as colitic cancer based on the pathological findings and the 40-year interval since the diagnosis of total colitis type of UC. The patient was in good overall health with good anal function, based on the clinical examination and manometric study;she wished to undergo sphincter-preserving operation. Restorative proctocolectomy with ileal pouch-anal canal anastomosis that preserved the anal canal mucosa was performed. The postoperative course was good, with a defecation frequency of 4-5 times/day without fecal incontinence, and the patient resumed her preoperative lifestyle with very few alterations. Even in elderly patients aged >80 years who have UC, restorative proctocolectomy is feasible for those in good general health and with relatively good anal function, determined based on the daily defecation activity and anal manometry.

Postoperative functional outcomes and complications of partially intraanal canal anastomosis in stapled ileal pouch anal anastomosis for ulcerative colitis.

AIM: For ulcerative colitis (UC), stapled ileal pouch anal anastomosis (IPAA) reportedly results in better bowel function than does IPAA with mucosectomy. However, a potential cancer risk in the remnant mucosa has been observed. The clinical results of IPAA by double stapling technique (DS-IPAA) in which the anastomotic line was on the dentate line at posterior wall and the top of anal canal at anterior wall ("Partially intraanal canal anastomosis": PICA) to reduce the remnant mucosa were evaluated. METHODS: Clinical results of PICA were retrospectively compared with those by DS-IPAA with anastomosis at above the anal canal on 1 year after open surgery. Of 211 UC cases that underwent DS-IPAA, 146 cases (69%) with PICA who were confirmed by the squamous epithelium on the posterior part of the distal donuts were included. Sixty-five cases with anastomosis above the anal canal were evaluated as the control. One stage surgery underwent in 95% of PICA and 93% of control. RESULTS: One year after surgery, each group had six bowel movements daily. Nighttime evacuation was found in 16% of PICA and in 20% of control. Soiling was found in 1% of PICA and 4.8% of control. After one stage operation, anastomotic leakage that needed ileostomy was observed in 0.7% of PICA and 3% of control. CONCLUSION: Partially intraanal canal anastomosis (PICA) can reduce anal canal mucosa with the same postoperative bowel function and complication rate as DS-IPAA above the anal canal. This procedure may be feasible for UC patients who can tolerate this procedure in terms of decreasing postoperative cancer risk.

[Diagnosis and treatment of six patients with Crohn's disease complicated by recto-perineal-urethral fistula].

Recto-perineal-urethral fistula caused by Crohn's disease is a rare, for which fundamental treatment has not been established yet. We analyzed the clinical characteristics, diagnosis, treatment, and prognosis of six male patients with anorectal lesions caused by Crohn's disease. Three patients were treated with abdominoperineal resection and the other three with rectal excision without anastomosis. Excluding one case, which presented worsening immediately after surgery, symptoms of urethral fistula improved without urethral stenosis, dysuria, or sexual dysfunction. Recto-perineal-urethral fistula is currently treated with various treatment modalities, including colostomy and drug therapy. Although the evaluation of these modalities is required, abdominoperineal resection or rectal excision without anastomosis may be a valuable treatment option because these approaches improve the urethral fistula while sparing the urethra without any significant complications.

Surgical treatment for Crohn's disease.

Surgery has important role in the management for Crohn's disease, although medical treatment had been developed in recent years. Surgical indications are as follows, massive bleeding, perforation, cancer, abscess, stenosis with obstruction, internal and external fistulas, severe anorectal disease, and medical failure. The principle of surgery is a minimal resection of intestine responsible for uncontrolled symptoms and repair of involved organs such as intestine, urinary bladder and abdominal wall. Strictureplasties are an effective alternative for stenosis which preserve the intestine. Seton treatment is often employed for complex perianal fistula. Surgery relieves the refractory symptoms well and should be employed at optimal time for the patients with severe symptoms which impaired their quality of lives.

Prolonged Medical Therapy Increases the Risk of Surgical Complications in Patients with Severe Ulcerative Colitis.

AIMS: To determine the risk factors of surgical complications and the optimal timing of surgery for patients with severe ulcerative colitis (UC). METHODS: One hundred one UC patients who had undergone surgery for a severe indication were retrospectively reviewed. Indications included severe disease unresponsive to medical therapy, massive bleeding, toxic megacolon, and colon perforation. Outcomes were compared based on the occurrence or absence of surgical complications. Patients with severe disease unresponsive to medical therapy were investigated separately to determine the optimal timing of surgery. RESULTS: There was no significant difference regarding the use of rescue therapy. The duration of all medical therapy for a severe attack was the only significant factor associated with a surgical complication (p = 0.032). In patients with severe disease unresponsive to medical therapy, the receiver operating characteristic curve analysis showed that 30.5 days was the length of medical therapy after which the risk of surgical complications significantly increased. CONCLUSIONS: In patients with severe UC, rescue therapy itself was not related to an increased risk of surgical complications. However, prolonged medical therapy increased the risk of surgical complications. Patients should undergo surgery within 30 days from the institution of medical therapy for a severe attack.

Has widespread use of biologic and immunosuppressant therapy for ulcerative colitis affected surgical trends? Results of a questionnaire survey of surgical institutions in Japan.

PURPOSE: The aim of the study is to assess the relationship between the introduction of biologic and immunosuppressant therapy and the number of patients undergoing surgery for ulcerative colitis (UC). METHODS: A questionnaire survey about patients undergoing surgery for UC was sent to 26 teaching hospitals throughout Japan. The questionnaire period spanned from 2008 to 2013, to account for the introduction of tacrolimus (2009) and infliximab (2010). RESULTS: The total number of patients who underwent surgery was 297, 291, 273, 255, 300, and 305 in 2008, 2009, 2010, 2011 2012, and 2013, respectively. The emergency surgery rate remained stable at 32-34 % each year. The proportion of patients who underwent surgery for cancer increased from 13.8 % in 2008 to 20 % in 2013. In 2013, 41, 38, and 6 % of patients who underwent surgery had received treatment with a biologic, tacrolimus, and cyclosporine, respectively. No institution reported an increase in postoperative complications among patients treated with immunosuppressive drugs. CONCLUSIONS: The number of patients undergoing surgery decreased temporarily soon after infliximab and tacrolimus first became widely available, but subsequently increased again. The emergency surgery rate remained unchanged throughout the study period. These data show that immunosuppressive drugs have had little effect on the risk of postoperative complications.