Colectomy For Ulcerative Colitis Research Articles

Laparoscopic Emergency Colectomy for Ulcerative Colitis is Associated With Fewer Adhesions Compared to Open

Laparoscopic Emergency Colectomy for Ulcerative Colitis is Associated With Fewer Adhesions Compared to Open

Occurrence of Crohn’s Disease in Children After Total Colectomy for Ulcerative Colitis

Colectomy is the definitive treatment for ulcerative colitis (UC) to remove the inflammatory burden. Crohn's disease, however, can affect any portion of the bowel with a propensity to involve the terminal ileum. In some patients with fulminant colitis, distinction between the two is imperfect. Manifestations of Crohn's after colectomy can be devastating because the ileum is needed for restoration of continuity. There is currently little information in the pediatric literature addressing this concern. Therefore, we reviewed all of our patients who underwent colectomy for inflammatory bowel disease to evaluate the risk of subsequent Crohn's manifestations and to document the outcomes. A two-center retrospective review of children who underwent colectomy for IBD from January 2000 to July 2010 was performed. Demographic, diagnostic, management, and outcome variables were recorded. We identified 70 patients who underwent colectomy for UC. The mean age at diagnosis was 12 y ± 7 y, and 59% were female. Clinical diagnosis prior to colectomy was UC in 90%, and indeterminate colitis in 10%. There was discordance between clinical and pathologic diagnosis in five patients, two patients were clinically diagnosed with UC but had an indeterminate biopsy, and three patients were clinically diagnosed as indeterminate colitis with a biopsy confirming UC. Indications for colectomy were refractory bleeding in 63%, failure of medical treatment in 28%, toxic megacolon in 6%, and perforation in 3%. A restorative pouch was created after colectomy in 46% using a two-stage approach while, 53% were managed with an initial colectomy and three-stage approach. In one patient, Crohn's was intraoperatively diagnosed from the operative colectomy specimen. This patient had a clinical diagnosis of UC with concordant biopsy prior to surgery. After total abdominal colectomy, 68 patients went on to ileal pouch anal anastomosis by either a two-stage or three-stage approach. In these patients, nine (13%) had a change in their diagnosis to Crohn's after reconstruction. Crohn's complications requiring an operation consisted of two patients with anastomotic dilations, four patients with fistulotomies, and one patient with perianal abscess drainage procedures. In the children studied, 13% had a diagnostic change to Crohn's disease, and 13% were diagnosed with Crohn's after ileal pouch-anal anastomosis (IPAA). In patients with IPAA and Crohn's, there were more operative interventions for perianal disease.

Occurrence Of Crohn's Disease In Children After Total Colectomy For Ulcerative Colitis

Occurrence Of Crohn's Disease In Children After Total Colectomy For Ulcerative Colitis

Risk factors for complications after total colectomy in ulcerative colitis.

Risk factors for complications after total colectomy in ulcerative colitis.

Endobronchial Ultrasonography and Magnetic Resonance Imaging in Tracheobronchial Stenosis From Ulcerative Colitis

A 49-year-old woman presented with continuous cough, progressive dyspnea on exertion, and hoarseness. She had a total colectomy for ulcerative colitis 17 years earlier. Bronchoscopy showed circumferential mucosal erythema. The surface of the tracheal mucosa was irregular and bled easily on contact. Endobronchial ultrasonography and magnetic resonance imaging (MRI) showed characteristic findings that suggested that the lesion was located within the tracheal mucosa and submucosa. Endobronchial ultrasonography images showed circumferential thickening of the mucosa, but tracheobronchial cartilage was preserved intact. Moreover, the comparison between tracheal tissues from tracheostomy and colon tissues resected 17 years earlier showed similarities in pathologic findings. These findings suggested that inflammatory bowel disease can cause the tracheobronchial stenosis.

48. Serrated adenoma of an ileal stoma: a case report

Background and aim Serrated adenomas have gained recent recognition as having malignant potential and being part of an alternative pathway to colorectal carcinoma. Typically described in the proximal colon there have been rare case reports of serrated adenomas occurring in the stomach, duodenum and pancreas. Here we report a case of a serrated adenoma occurring at the ileostomy site of a patient with no previous history of carcinoma. The serrated adenoma arose in a zone of colonic metaplasia of the ileostomy. Case report A 74-year-old gentleman noticed a mass on his stoma which had been increasing in size over the previous 12 months. The stoma was formed in the 1960s secondary to a colectomy for ulcerative colitis (tissue of the colectomy for pathological review was not available to us). The stoma was functioning well and he had no symptoms. There was no reported family history of bowel cancer. Pathological findings There was a 25 × 15 × 10 mm exophytic growth on the external surface of the stoma. Histology showed a polypoid tumour with features of serrated adenoma. The adjacent mucosa of the terminal ileum showed histological features of colonic metaplasia. Conclusions Carcinomas arising in ileostomy sites are extremely rare. One study reports forty-four such cases since 1969. 1 Thirty-one of these cases occurred in patients with underlying ulcerative colitis. Our finding of a serrated adenoma in an ileostomy raises the possibility that carcinomas arising in ileostomy sites could, in some cases, arise via the serrated adenoma pathway. The role of adjacent colonic metaplasia in the development of neoplasia is yet to be determined. Although carcinomas can arise without adjacent metaplasia it is interesting to note that in the study by Quah et al., carcinoma development at the ileostomy site in patients with ulcerative colitis had associated adjacent colonic metaplasia in approximately one-third of cases.

Different clinical characteristics in hispanic and non-hispanic whites with ileal pouch–anal anastomosis: A case–control study

Inflammatory bowel disease (IBD) is increasingly diagnosed in ethnic and racial minorities. Ileal pouch-anal anastomosis (IPAA) has become the treatment of choice for ulcerative colitis (UC) patients requiring surgery. Few studies have characterized the natural history of IPAA and the pouch outcomes in the Hispanic American population. Ethnicity was designated by self-report and the Hispanics who had IPAA for UC were identified from a prospectively maintained database. Demographics, clinical characteristics, and pouch outcomes were compared between Hispanic and a sample of Non-Hispanic whites (1:4 ratio) randomly selected from the same database. Exclusion criteria were patients with a preoperative diagnosis of Crohn's disease or familial adenomatous polyposis, and patients of other ethnic groups. Thirty-six Hispanics with IPAA were identified. Hispanic patients were younger at UC diagnosis 23.1 ± 13.1 vs. 30.4 ± 12.6 yrs and at colectomy 31.9 ± 13.9 vs. 38.8 ± 13.8 yrs than controls. The interval between diagnosis and colectomy was comparable between the two groups. There were more uninsured in the Hispanic group than controls (13.9% vs. 2.8%). There were no significant differences in gender distribution, family history of IBD, smoking history, extent of UC, fulminant colitis, pouch configuration, stage of pouch, presence of extraintestinal manifestations, or concurrent autoimmune disorders. Pouch-related disorders and pouch failure were also similar. There appeared to be some difference in the preoperative characteristics of patients who underwent colectomy for UC between Hispanics and non-Hispanic whites, but outcomes after the restorative proctocolectomy with IPAA were comparable. Further studies are needed to characterize the natural history of UC and IPAA in the Hispanic population and the associated biosocioeconomic factors.

Early azathioprine/biological therapy is associated with decreased risk for first surgery and delays time to surgery but not reoperation in both smokers and nonsmokers with Crohnʼs disease, while smoking decreases the risk of colectomy in ulcerative colitis

Smoking may alter the natural course of Crohn's disease (CD). Smokers are more likely to develop complications, relapses and have a greater risk for surgery. In contrast, in ulcerative colitis (UC), smoking might improve the disease course. Our aim was to assess the combined effect of disease phenotype, smoking, and immunomodulator [azathioprine (AZA), AZA/biological] treatment on the risk of intestinal resection/reoperation in CD and colectomy in UC. Six hundred and eighty-one inflammatory bowel disease patients were analyzed (CD: 340, male/female: 155/185, duration: 9.4+/-7.5 years; UC: 341, male/female: 174/164, duration: 11.5+/-9.7 years). Patients were interviewed on their smoking habits at the time of diagnosis and during the regular follow-up visits. Medical records were retrospectively analyzed. Smoking was present in 45.5% in CD and 15.8% in UC. CD patients who underwent at least one bowel resection comprised 46.5%. In an univariate analysis, disease location, behavior, AZA, or AZA/biological use before surgery [odds ratio (OR): 0.26 and 0.22, P<0.001] and smoking (OR: 1.61, P = 0.03) were associated with risk for first surgery. Smoking, AZA, or AZA/biological (P<0.001) use before first surgery and disease behavior were independently associated with risk for surgery in a proportional Cox-regression analysis. Perianal disease (OR: 3.2, P = 0.001) and frequent relapses (OR: 4.8, P<0.001) but not smoking, AZA, or AZA/biological use after first surgery were predictive for reoperation. In UC, the rate of colectomy was 5.6%. Disease location (P = 0.001) and smoking status (P = 0.02) were independently associated with risk for colectomy in a proportional Cox-regression analysis. Our data suggest that early AZA/biological therapy reduces the risk for first operation but not reoperation in CD, in both smokers and nonsmokers. In contrast, smoking was associated with a decreased need for colectomy in UC.

Bruk av TNF-α-antistoff ved inflammatorisk tarmsykdom

TNFalpha-antibodies have been used increasingly in treatment of inflammatory bowel disease (IBD) during the last years. This article provides an overview of indications, contraindications, efficacy, and side effects of this so-called biological treatment of IBD. Based on the clinical experience of the authors, literature was selected through a non-systematic search in PubMed. TNFalpha-antibodies have a documented initial effect in 60-70 % of patients with moderate to severe luminal and/or fistulising IBD. Approximately 30 % of patients achieve remission after a relatively short treatment period. However, the effect seems to decrease during long-term treatment. It is still unsettled whether these drugs prevent colectomy in ulcerative colitis. The treatment seems to increase the risk of serious infections and there are also some indications of an increased risk of malignancy. Combination therapy with azathioprin is common and probably increases both the effect and the risk of side effects. TNFalpha-antibodies have become an important part of the treatment for moderate to severe IBD, but the effect decreases during long-term treatment and has to be evaluated in light of potential side effects. Further long-term studies are necessary.

Successful Long-Term Use of Infliximab in Refractory Pouchitis in an Adolescent

Pouchitis is a common complication that develops after an ileal pouch-anal anastomosis after colectomy for ulcerative colitis. In some cases, pouchitis becomes chronic and refractory to conventional therapies including antibiotics, corticosteroids, immunomodulators, probiotics, and anti-inflammatory drugs. We report a case of an adolescent with chronic pouchitis who not only improved with infliximab therapy but remains in long-term remission with maintenance therapy without any adverse effects. Infliximab is a safe and effective therapy for refractory pouchitis and may obviate the need for pouch removal and a permanent ileostomy.

Diffuse enteritis after colectomy for ulcerative colitis: two case reports and review of the literature

Ulcerative colitis (UC) is an inflammatory disease of the colon. Involvement of the small bowel is limited to backwash ileitis or pouch-related conditions. Here, we report two men with UC who presented with small bowel inflammation and even perforation, within 1 month after subtotal colectomy. Endoscopy showed diffuse enteritis. Histology showed marked apoptosis of epithelial cells in both cases. One patient responded to steroids and the other to a calcineurin inhibitor. Both patients had no evidence of Crohn's disease in the small intestine before this event. Several more cases of small intestinal lesions in patients with well-established UC have been reported. The majority typically presented shortly after colectomy and responded well to steroids. The pathogenesis of this enteritis is unknown, but seems to be distinct from Crohn's disease and may be associated with UC and colectomy.

S1165 Unexpected Follow-Up Surgeries Related to Failures in Colectomy for Ulcerative Colitis

S1165 Unexpected Follow-Up Surgeries Related to Failures in Colectomy for Ulcerative Colitis

155 Impact of Hospital Volume, Surgeon Volume, and Missed Quality Measures On Post-Operative Mortality Following Colectomy for Ulcerative Colitis

155 Impact of Hospital Volume, Surgeon Volume, and Missed Quality Measures On Post-Operative Mortality Following Colectomy for Ulcerative Colitis

Factors Predictive of Crohn Disease Following Colectomy in Medically Refractory Pediatric Colitis

Crohn disease (CD) has been diagnosed following colectomy for ulcerative colitis (UC). This study aims to determine the frequency of this occurrence, and to identify predictive factors leading to a CD diagnosis. A retrospective chart review was performed in patients who have undergone colectomy. From 1996 to 2006, colectomy was performed in 212 patients, 37 of whom were diagnosed preoperatively with UC. The mean ages at diagnosis and at colectomy were 10.6+/-4.3 years and 13.7+/-3.7 years, respectively. Inflammatory bowel disease serology at diagnosis in 29 patients showed that 26 (90%) were pANCA+. Serology was negative in 3. Ten (27%) had nonspecific inflammation of the upper digestive tract. Radiographs in 25 patients indicated no abnormalities in the small intestine. Before colectomy, patients (n=35) were treated with corticosteroid (97%), 5-ASA (69%), immunomodulator (66%), infliximab (29%), and cyclosporin (11%). The mean postoperative follow-up was 2.6+/-2 years. Six patients (16%) were found to have CD. All 6 patients were pANCA+ with elevated anti-OmpC (n=4), ASCA immunoglobulin A (n=2), and ASCA immunoglobulin G (n=1). The CD group had higher mean anti-OmpC compared with the UC group, 16.9+/-5.2 and 6.2+/-3.4, respectively (P<0.005). Weight z score at time of surgery was lower in the CD group (-1.38+/-0.79) than in the UC group (0.29+/-0.24), P<0.05. The possibility of CD remains in a small fraction of patients who undergo colectomy for medically refractory UC. A lower weight and a higher anti-OmpC titer may be predictive of CD.

8 - Azathioprine/biological therapy does prevent surgery but not reoperation in smokers with Crohn's disease

Background and Aim: Smoking may alter the natural course of Crohn’s disease (CD). Smokers are more likely to develop complications, relapses and have a greater risk for surgery. In contrast smoking might improve the disease course in ulcerative colitis (UC). Our aim was to assess the combined effect of smoking and immunomodulator (azathioprine, AZA/biological) treatment on the risk of intestinal resection and re-operation in CD and colectomy in UC. Patients and Methods: 504 IBD patients were analyzed (CD: 277, 46.2% males, age at diagnosis: 28.7 (SD 13.2) years, mean duration: 9.5(7.8) years; UC: 227, 48.5% males, age at diagnosis: 34.3 (SD 14.5) years, mean duration: 11.3 (10.4) years). Patients’ medical records have been analyzed retrospectively and patients were asked for smoking status at diagnosis and during follow-up by standardized questionnaires. Results: Smoking was present in 47.1% in CD and 13.2% in UC. 133 CD patients (48%) underwent at least one bowel resection, while at least one reoperation was necessary in 44 (15.9%). In univariate analysis disease location (p = 0.004), behavior (p < 0.0001), AZA or AZA/biological use prior to surgery (OR: 0.19 and 0.227, p < 0.0001 for both) and smoking (OR: 1.79, p = 0.018) were associated with the risk for surgery. Perianal disease (OR: 3.83, p = 0.001) and frequent relapses (OR: 5.85, p < 0.0001) but not smoking status or AZA or AZA/biological use after first surgery were predictive for reoperation. Smoking (OR: 1.91), AZA or AZA/IFX use prior to surgery (OR: 0.19) and disease behavior (OR: 3.13) were independently associated with risk for surgery in a logistic regression analysis. The deleterious effect of smoking was most striking in stenosing disease (pLogRank: 0.028) and females (p = 0.006) in a Kaplan Meier analysis. AZA use decreased the risk for first surgery (p < 0.0001 for both) but not re-operation in patients with and without smoking in the same analysis using LogRank/Breslow tests. In UC, 12 (5.3%) patients had colectomy. Disease location (p = 0.001) but not smoking status was associated with risk for colectomy. Of note, none of the patients with colectomy smoked compared to 14% of patients without colectomy (p =NS). Conclusion: Our data suggest that AZA/biological therapy reduces the risk for first operation but not reoperation in CD in both smokers and none-smokers. The deleterious effect of smoking was most pronounced in females and in patients with stenosing disease.

Colectomy subtypes, follow-up surgical procedures, postsurgical complications, and medical charges among ulcerative colitis patients with private health insurance in the United States

We describe colectomy subtypes, follow-up surgical and diagnostic procedures, complications, and direct medical charges occurring within 180 days of colectomy among privately insured patients with ulcerative colitis (UC). This was a retrospective analysis of an insurance claims database for 2001-2005. We identified patients with a diagnosis of UC and no concurrent diagnosis of Crohn's disease who underwent colectomy. Colectomy types were classified as: 1) total proctocolectomy (TPC) with ileal pouch-anal anastomosis (IPAA), 2) subtotal colectomy (SC) with ileostomy and Hartmann pouch or ileorectal anastomosis, 3) TPC with ileostomy, and 4) partial colectomy (PC). Follow-up surgical and diagnostic procedures and complications were collected. We developed estimates for UC-related charges for hospitalizations, outpatient visits, and medications for the time period 180 days before and after colectomy. A total of 55,934 UC patients were identified, of whom 540 had a colectomy and at least 180 days of pre- and postcolectomy follow-up. The colectomy distribution was: TPC-IPAA, 44%; SC-ileostomy, 22%; TPC-ileostomy, 17%; and PC, 17%. Within 180 days after colectomy, 54% of patients had a second colectomy-related surgery, and 27% had a follow-up diagnostic procedure. Complications following colectomy for UC included: abscesses (11.5% early / 14.6% late), sepsis/pneumonia/bacteremia (9.3% early / 10.0% late), and fistulas (3.9% early / 8.3% late). The mean UC-related direct medical charge for the 180 days following and including initial colectomy was $90,445. In this retrospective study of privately insured UC patients, we observed frequent follow-up surgical/diagnostic procedures, identified several complications postcolectomy, and estimated substantial charges 6 months pre- and postcolectomy.

Colostomy cancers: a report of two cases

Carcinomas on ileostomies have been reported in patients who have undergone colectomy for ulcerative colitis, familial adenomatous polyposis and Crohn′s disease. Colostomy carcinomas are relatively rare, with only ten cases reported worldwide. This article describes two cases that we have recently seen and highlights the challenges, such as diagnosis, extent of excision, closure of defects, and siting of further stoma. In both cases, the presentation was to a specialist nurse−led clinic. Lesions around a stoma are relatively common and specialist nurses need to be aware of the possibility of cancer on a colostomy or ileostomy.

Histologic Predictors of Future Ulcerative Colitis Disease Severity

Purpose: Accurate prediction of future disease severity course may optimize management of ulcerative colitis (UC) including tailoring “top-down” versus “step-up” approaches to therapy. We sought to determine if specific histologic variable could predict future clinical UC disease severity. Methods: The initial histopathology parameters from 19 patients with UC that later (≥ 6 months) underwent colectomy for severe disease (colectomy/severe course group) were compared to those from 25 patients who did not require colectomy (no colectomy/mild course group) from 1998–2007. The pathology variables assessed were cryptitis, cryptopenia, crypt branching, crypt abscesses, ulcerations and mucin depletion. The predictive value of disease extent, endoscopic severity, and initial serum albumin were also assessed. Groups were compared using Chi-square, Mann-Whitney or t-test with a significance level of 0.05. Patients with dysplasia were excluded. Results: Patients were followed for a median of 3 years. Median age was 39 years in no colectomy group versus 34 years in colectomy group (NS). Severe cryptitis occurred in 16/19 (84%) in colectomy group versus 13/25 (52%) in no colectomy group (P= 0.026). Cryptopenia was present in 11 (58%) colectomy group versus 10 (40%) no colectomy group (P= 0.239). In colectomy group, crypt abscesses were present in 16 (84%), crypt branching 16 (84%), mucin depletion 18 (96%), ulceration 6 (24%) at the initial histopathology. The prevalence of crypt abscess, crypt branching, cryptopenia, mucin depletion, ulceration were all not significantly different in the colectomy (severe course) versus no colectomy (mild course) group. A Mayo Score ≥2 on initial endoscopy was not significantly more common in colectomy group 13 (69%) versus no colectomy group 18 (75%) (P= 0.228). The initial albumin was significantly lower in the colectomy group 2.9 g/dL (SD ± 0.88) versus noncolectomy group 3.5 g/dL (SD ± 0.57) (P= 0.040). Pancolitis at initial endoscopy was not more prevalent in the colectomy group (32%) versus noncolectomy (32%). Immunosuppressant usage was not statistically different between groups: colectomy group (24%) versus no colectomy (32%). Conclusion: Cryptopenia, mucin depletion, crypt branching and crypt abscesses are common findings in UC but do not predict future clinical disease severity. The initial serum albumin and cryptitis were the only variables predictive of future progression to colectomy. Histopathology with extensive cryptitis was more predictive of future severe disease that eventually required colectomy than was the initial endoscopic severity or disease extent. Future prospective studies are required to confirm the prognostic value of diffuse cryptitis to predict a future colectomy in UC.

Enterochromaffin Cell Hyperplasia in Irritable Pouch Syndrome

Irritable pouch syndrome (IPS) is a functional disease in patients with ileal pouch-anal anastomosis following colectomy for ulcerative colitis (UC). The pathophysiology of IPS is characterized by the presence of visceral hypersensitivity, similar to that seen in irritable bowel syndrome. However, the exact etiology and pathogenesis of IPS are not known. We hypothesized that serotonin-containing enteroendocrine cells or enterochromaffin (EC) cell hyperplasia and alterations in the mucosal immune cells may contribute to the patients' symptoms. The aim of the study was to assess EC cell hyperplasia and alterations in the mucosal immune cells in IPS. The Pouchitis Disease Activity Index (PDAI) was used to quantify symptoms and mucosal inflammation in 36 patients with IPS and 25 patients with normal pouches. The histology and immunohistochemistry of pouch mucosal biopsies were assessed by a blinded gastrointestinal pathologist for intraepithelial lymphocytes (IEL), CD3+ T cells, CD25- (interleukin [IL]-2 receptor), tryptase- (mast cells), and serotonin-expressing cells. The numbers of IEL and immune-stained cells were compared between the two groups. Both groups were compatible demographically in terms of age, gender, duration of UC, stage, indication, and duration of the pouch surgery. There were no differences in the number of IEL, CD3+ T cells, CD25+ cells, and mast cells between the IPS and normal control groups. However, there were a significantly larger number of EC cells in the IPS group than that in the control group (54.8 +/- 24.9 vs 36.7 +/- 17.5 per 4 200x epithelial cells, P < 0.005). The number of EC cells appeared to be correlated with the symptom score (r = 0.276, P= 0.032). There were no significant correlations between the PDAI endoscopy and histology scores and the number of EC cells or between the PDAI scores and the number of IEL or other immune-stained cells. A greater number of EC cells were found in the IPS group than the normal pouch group, and the number of EC cells appeared to be correlated with the clinical symptoms of IPS. EC cell hyperplasia may be a contributing mechanism of visceral hypersensitivity and symptoms in IPS.

Idiopathic Small-Intestinal Inflammation After Colectomy for Ulcerative Colitis

Severe ileostomy dysfunction with high ileostomy volumes or severe diarrhea after panproctocolectomy and restorative ileo-anal pouch formation are a rare but serious development after surgery for ulcerative colitis (UC). The incidence, severity, morbidity, and mortality are poorly documented in the literature. We describe the case of a patient who developed life-threatening diarrhea after surgery for UC and review the literature. Eight cases have now been described in the literature. Small-bowel disease has developed up to 17 months after colectomy. Most cases responded to corticosteroid therapy. A single case in which this treatment was delayed was fatal. This is a rare sequel to colectomy for UC, but one which is serious and can be fatal. If the diagnosis is made promptly, a full response to treatment can be expected and the long-term outlook is excellent.