Distal Pouch Research Articles

Transanal circumferential pouch advancement for treatment of pouch vaginal fistulae

BackgroundIleal pouch anal anastomosis (IPAA) circumferential pouch advancement (CPA) involves full-thickness transanal 180–360° dissection of the distal pouch, allowing the advancement of healthy bowel to cover the internal opening of a vaginal fistula. We aimed to describe the long-term outcomes of this rare procedure.MethodsPatients with IPAA who underwent transanal pouch advancement for any indication between 2009 and 2021 were included. Demographics, operative details, and outcomes were reviewed. An early fistula was defined as occurring within 1 year of IPAA construction. Clinical success was defined as resolution of symptoms necessitating CPA, pouch retention, and no stoma at the time of follow-up. Figures represent the median (interquartile range) or frequency (%).ResultsOver a 12-year period, nine patients were identified; the median age at CPA was 41 (36–44) years. Four patients developed early fistula after index IPAA, and five developed late fistulae. The median number of fistula repair procedures prior to CPA was 2 (1–2). All patients were diagnosed with ulcerative colitis at the time of IPAA and all late patients were re-diagnosed with Crohn’s disease. Four (44.4%) patients had ileostomies present at the time of surgery, three (33.3%) had one constructed during surgery, and two (22.2%) never had a stoma. The median follow-up time was 11 (6–24) months. Clinical success was achieved in four of the nine (44.4%) patients at the time of the last follow-up.ConclusionsTransanal circumferential pouch advancement was an effective treatment for refractory pouch vaginal fistulas and may be offered to patients who have had previous attempts at repair.

Unraveling Twisted Pouch Syndrome: A Narrative Review of Classification, Diagnosis, Treatment, and Prevention.

We recently described a cluster of symptoms known as twisted pouch syndrome that rarely affects patients with ileoanal pouches. Herein, we present a narrative review in which we describe the diagnosis, treatment, and preventionof twisted pouch syndrome, with a focus on a simple classification schema. Diagnostic signs from endoscopic and radiological examinations, treatment, and prevention strategies are presented. Patients with twisted pouch syndrome suffer from a triad of obstructive symptoms, erratic bowel habits, and pain which may besevere, debilitating visceral pain, all in the setting of a mechanical pouch abnormality. Diagnostic modalities include imaging, careful pouchoscopy, functional testing, diagnostic laparoscopy or laparotomy, and recently 3-dimensional pouchography. Classification of twisted pouch syndrome is based on the location and degree of rotation of the pouch and its mesentery. Outlet twists mayresult when the distal pouch rotates >90° to 360° clockwiseinadvertently during anastomosis; when only the distal most pouch is twisted, it results in an iris-like deformity of the pouch outlet, or when the distal half of the pouch is twisted, a mid-pouch stenosis and an hourglass-shaped pouchmayresult. Inlet twists are either a full 360° (mesentery posterior), unintentional 180° (mesentery anterior), or90° counterclockwise twists. Both inlet and outlet twists are fixed deformities and may only be reduced by disconnecting the entire pouch from the anus. If they result in twisted pouch syndrome, a redo pouch procedure or pouch excision is required to reduce the twist;90° counterclockwise twists may undergo pouch inlet transposition. Adhesive twists result when the pouch becomes fixed in the pelvis in an abnormal configuration, such as when the efferent limb becomes twisted underneath the afferent limb secondary to an occult tip of the J leak, and may be reduced by pelvic adhesiolysis with or without pouch revision. Pouches may rarely be inadvertently twisted during construction or twisted owing to adhesive disease or leaks. A high index of suspicion is needed to establish the diagnosis. We present a simple classification of twisted pouch syndrome that may aid in the prevention and recognition of these often difficult to diagnose postoperative complications.

Tubularization of the gastric pouch helps sustain weight loss after transoral outlet reduction for post-Roux-en-Y gastric bypass weight recurrence.

Background and study aims Traditional transoral outlet reduction (TORe) is a minimally invasive endoscopic approach focused on reducing the aperture of the gastrojejunal (GJ) anastomosis, while the tubular transoral outlet reduction (tTORe) consists of tabularization of the distal pouch utilizing an O-shape gastroplasty suturing pattern. The primary aim of this study was to compare short-term weight loss between TORe and tTORe. Patients and methods Retrospective analysis of a prospectively maintained database was conducted at a tertiary care bariatric center of excellence. The study included patients with history of Roux-en-Y gastric bypass (RYGB) who had an endoscopic revision by TORe or tTORe and had follow-up data in their electronic medical record. The primary outcome was percent total body weight loss (%TBWL). Results A total of 128 patients were included (tTORe=85, TORe=43). At 3 and 6 months, the tTORe and TORe cohorts presented similar %TBWL (3 months: 8.5±4.9 vs. 7.3±6.0, P = 0.27 and 6 months: 8.1±7.4 vs. 6.8±5.6, P = 0.44). At 9 months, there was a trend toward greater weight loss in the tTORe cohort (9.7±8.6% vs. 5.1±6.8%, P = 0.053). At 12 months, the %TBWL was significantly higher in the tubularization group compared to the standard group (8.2±10.8 vs. 2.3±7.3%, P = 0.01). Procedure time was significantly different between both groups (60.5 vs. 53.4 minutes, P = 0.03). The adverse events rate was similar between groups (8.2% vs. 7.0% for tTORe and TORe, respectively, P = 0.61). Conclusions The tTORe enhances efficacy and durability of the standard procedure without adding significant procedure-related risks.

113 The Use of Machine Learning of Carotid Web Angioarchitecture for Predicting Stroke Risk

INTRODUCTION: Carotid webs (CWs) are a known mechanism for stroke in young adults without other vascular risk factors. Altered hemodynamics distal to the web may cause flow stagnation with the potential for distal embolization of clots. Although there are some computational flow models studies of CW, currently there are no well-described CT angiographic features to predict stroke risk. METHODS: Anatomical data of the internal carotid artery (ICA), common carotid artery (CCA), the CW and its “distal pouch” angioarchitecture was gathered as part of a retrospective cohort study from symptomatic (stroke) and asymptomatic (non-stroke) patients. Principal component analysis was applied to anatomical and angioarchitectural features, and the two components were plotted to investigate whether the stroke and non-stroke patients were easily separable. We built a predictive model of stroke risk using these features with Firth regression to reduce bias related to small datasets. RESULTS: The first two principal components of the anatomical and angioarchitectural features clearly distinguish between stroke patients and non-stroke patients. The firth regression and 5-fold cross validation revealed that CCA web “pouch” angle (p=.014), ICA web “pouch” tip angle (p=.023), CCA web “pouch” tip angle (p = .017), and ICA web “pouch” angle (p = .016) are the most important features to model and assess stroke risk. Conversely, CCA and ICA anatomy (diameter and angle) on their own were not found to be risk factors for stroke. Overall, pouch angles in respect to flow trajectory in the CCA and in the ICA are significant risk factors as compared to vessel sizes and flow relationships between them. CONCLUSIONS: This study demonstrates that carotid web angioarchitecture and carotid anatomy data from diagnostic angiography may be used to assess stroke risk, allowing physicians to tailor care for each patient according to risk stratification.

S2699 Endoscopic Management of Obstructing Pouch Twist

Introduction: The twisted pouch is a rare complication of IPAA with few cases being reported in the literature. Most patients have been managed surgically with adhesiolysis and de-rotation with or without redo of the ileorectal anastomosis. Endoscopic management of a twisted pouch has not been previously reported and this report describes the first successful endoscopic treatment of the twisted pouch with septectomy. Case Description/Methods: A 35-year-old female underwent 3-stage restorative proctocolectomy with IPAA for medically refractory ulcerative colitis in 2017. She presented a year later with nausea, vomiting, diarrhoea and significant weight loss. CT revealed a dilated small bowel with obstruction at the anal anastomosis. At our institution she underwent a pouchoscopy which revealed a dilated pouch lumen, a twist in the distal pouch with a nearly completely blocked pouch outlet. The twist was treated with outpatient endoscopic needle-knife septectomy with electroincision of the twisted fold, followed by the placement of two endoclip spacers. The procedure was performed with the patient under conscious sedation, observed for 30 mins and discharged afterwards. This led to immediate resolution of her symptoms. 2-week repeat pouchoscopy revealed a mild outlet stricture, requiring further endoscopic septectomy. 6-month repeat pouchoscopy showed complete resolution of the obstruction. Yearly routine pouchoscopy showed that pouch twist remained to be revolved, but a severe circumferential anastomotic stricture. The latter was treated with endoscopic circumferential stricturotomy with the needle knife. Her last follow-up was in 2021 with the pouch twist remaining resolved on pouchoscopy. (Figure) Discussion: Pouch twist results from poor orientation of the mesentery at surgery or due to adhesions. Severe twisted pouch can lead to acute or chronic pouch obstruction. Acute pouch twist requires timely management to avoid bowel necrosis and obstipation. Twisted pouch commonly presents two to five years after surgery with pouchitis, ulceration, chronic abdominal pain, and incontinence. Diagnosis of this condition typically requires a high degree of suspicion, CT, and gastrografin enema. The patients traditionally are managed surgically with adhesiolysis and derotation and fixing the pouch with or without redo of the ileorectal anastomosis.This case report describes the successful endoscopic treatment of the twisted pouch with septectomy. We believe that endoscopic septectomy can be offered as a first-line therapy.Figure 1.: Left: Initial obstructed twisted pouch Right: Post-endoscopic septectomy.

The "chicken-leg anastomosis": Low-cost tissue-realistic simulation model for esophageal atresia training in pediatric surgery.

IntroductionShifting the training from the operating room (OR) to simulation models has been proven effective in enhancing patient safety and reducing the learning time to achieve competency and increase the operative efficiency. Currently the field of pediatric surgery only offers few low-cost trainers for specialized training and these feature predominantly artificial and often unrealistic tissue. The aim of this study was to develop an easy access low-cost tissue-realistic simulation model for open training of esophageal atresia and to evaluate the acceptance in trainees and junior pediatric surgeons.Materials and methodsThe model is fashioned using reconfigured chicken skin from a chicken leg. To create a model of esophageal atresia, the chicken skin is dissected off the muscle and reconfigured around a foley catheter balloon to recreate the proximal pouch and a feeding tube to recreate the distal pouch. Surrounding structures such as the tracheo-esophageal fistula and the azygos vein can be easily added, obtaining a realistic esophageal atresia (Type C) prototype. Evaluation of model construction, usage and impact on user were performed by both a self-assessment questionnaire with pre- and post-training questions as well as observer-based variables and a revised Objective Structured Assessment of Technical Skills (OSATS) score.ResultsA total of 10 participants were constructing and using the model at two different timepoints. OSATS score for overall performance was significantly higher (p = 0.005, z = −2.78) during the second observational period [median (MD): 4,95% confidence interval CI: 3.4, 5.1] compared to the first (MD: 3, 95% CI 2.4, 4.1). Self-reported boost in confidence after model usage for performing future esophageal atresia (EA) repair and bowel anastomosis (BA) in general was significantly higher (EA: U = 1, z = −2.3, p = 0.021, BA: U = 1, z = −2.41, p = 0.016) in participants with more years in training/attending status (EA MD:5, BA MD: 5.5) compared to less experienced participants (EA MD: 1.5, BA: 1).ConclusionOur easy access low-cost simulation model represents a feasible and tissue realistic training option to increase surgical performance of pediatric surgical trainees outside the OR.

Gastric remnant shape following laparoscopic sleeve gastrectomy correlates with weight loss: A retrospective cohort study

Background: Laparoscopic sleeve gastrectomy (LSG) is a safe and effective bariatric surgical procedure. Sleeve configuration is believed to be an important outcome of good operative technique, yet the relationship of sleeve shape to clinical outcomes including weight loss and postoperative symptoms is not clearly defined. This study aims to identify whether gastric remnant anatomical shape is associated with short-term postoperative weight loss or symptoms of reflux, regurgitation, or dysphagia. Methods: 207 LSG patients were identified from a prospective, multicentre unit database who had surgery between June 2015 and June 2019. Routine postoperative upper gastrointestinal gastrograffin contrast studies were performed between postoperative days one to five and analyzed using a standardized protocol. Gastric remnant shape was classified as either tubular, proximal pouch or distal pouch consistent with previous studies. ANOVA Kruskal − Wallis and Mann − Whitney U-tests were performed to determine the effect of gastric remnant anatomy on weight loss. Descriptive statistics examined the symptoms of reflux, regurgitation, and dysphagia. Results: Gastric remnant anatomy was classified as tubular in 159/207 (78%), proximal pouch in 15/207 (7%), and distal pouch in 33/207 (16%). Patients with a tubular shape had a significantly greater reduction in median body mass index at 12 months postoperatively compared to those with a proximal pouch (11.3 kg/m2 vs. 10.2 kg/m2, P = 0.01). There was no relationship identified between gastric remnant shape and postoperative reflux, regurgitation, or dysphagia. Conclusion: A tubular-shaped gastric remnant is associated with increased weight loss. This suggests that tubular shape should be considered the desired LSG shape for greatest weight loss.

Technical Innovations to Reduce Complication Rates in Esophageal Atresia with Particular Reference to Long-term Outcomes: A Single Surgeon's Experience of 22 Years.

Following esophageal atresia/tracheoesophageal fistula (EA/TEF) repair, the standard leak rate reported in the literature is 5%-10%, and stricture rate is 40%-72%. There is a global quest for surgical innovations to drive down these complication rates which can cause considerable morbidity. A prospectively maintained database of the senior author's patients who had esophageal atresia repair from 1995 to 2016 was reviewed. Two distinct innovations were implemented: (1) adequate or generous mobilization of the lower esophageal pouch and (2) a 2-5 mm slit in distal esophagus to widen its circumference. Forty-three patients with EA/TEF were reviewed. Of those, 40 underwent primary repair. The median follow-up was 12.5 years (range 4-26 years). There were no anastomotic leaks and only 8 (20%) patients developed anastomotic strictures requiring dilations (1-5 dilations/patients). One patient (2.5%) had a recurrent fistula. One early mortality was recorded. At the latest follow-up, 35 (87.5%) patients had normal oral feeding, while 1 (2.5%) patient had occasional food sticking episodes. Four syndromic patients (10%) were on jejunal or gastrostomy feeding. An adequate or generous mobilization of the distal esophageal pouch, together with a 2-5 mm slit in the distal esophagus, achieves a tension-free and wide anastomosis. All anastomoses eventually narrow, sometimes just a little, and starting on a higher scale with a small slit, helps. These seemingly minor innovations, when used together, contributed to a substantially lower complication rate sustained over a 22-year period - no leaks and only 20% stricture rate.

Detail correction for Gross classification of esophageal atresia based on 434 cases in China.

Detail correction for Gross classification of esophageal atresia based on 434 cases in China.

Successful treatment of type III atresia ani and rectovaginal fistula in a kitten

A six-weeks-old, female kitten presented with dehydration, depression, atresia ani and a discharge of watery feces from the vulvar opening. On radiographic examination, the blind-end of the rectum was determined to be >1 cm cranial from the anal dimple, classifying it as type III atresia ani. Atresia ani combined with a rectovaginal fistula is an uncommon congenital defect of the terminal rectum and anus that can occur in kittens. After supportive medical treatment for three days, the patient was strong enough for surgical correction. The distal rectal pouch was connected to the unperforated anus and the rectovaginal fistula was closed. The kitten recovered uneventfully and was able to defecate normally at 38 weeks follow-up. In this case report, the importance of early surgical correction to avoid potential life-threatening complications from this congenital abnormality is demonstrated.

DOP29 The Normalization and Transition of J-Pouch Phenotype in the Chicago Classification of Pouchitis

Abstract Background Pouchitis can develop in up to 70% of patients with inflammatory bowel disease (IBD) treated by proctocolectomy with ileal pouch-anal anastomosis (IPAA). In our recent work, we proposed the “Chicago classification of pouchitis” describing 7 main pouch phenotypes with differing outcomes. In this study, we assessed the transition of pouch phenotypes in our classification. Methods This is a retrospective study of IBD patients with IPAA who subsequently underwent pouchoscopies at the University of Chicago between June 1997 and December 2019. We reviewed all available reports of pouchoscopies after ileostomy takedown and classified the pouches into 7 main phenotypes: (a) normal, (b) afferent limb (AL) involvement, (c) inlet (IL) involvement, (d) diffuse, (e) focal inflammation of the pouch body, (f) cuffitis, and (g) pouch fistulas (Figure 1). A normal pouch was defined as a pouch without any abnormal findings including fistulas. AL, IL involvement, and cuffitis were defined as any type of endoscopic inflammation in the AL, IL, and rectal cuff, respectively. Diffuse inflammation was defined as two or more endoscopic inflammatory findings in all anatomical locations of the pouch body (the tip, proximal, and distal pouch). Focal inflammation was defined as pouchitis that did not meet the criteria for diffuse inflammation. Pouch fistulas included pouches with any type of fistulas noted ≥6 months from ileostomy takedown. Using a Kaplan-Meier curve, event-free survival (EFS) was assessed from the scope date when a primary phenotype was first identified to the date when a subsequent phenotype was described. We excluded patients if a subsequent phenotype was identified before or at the scope date when a primary phenotype was initially noted. Logistic regression analysis was performed with variables with a P-value <0.05 in a Fisher’s exact test. Results We reviewed 1,359 pouchoscopies from 426 patients (90% preoperative diagnosis of ulcerative colitis). The most common subsequent inflammatory phenotype was focal inflammation (55%-88%), followed by IL involvement (31%-67%), cuffitis (33%-46%), diffuse inflammation (20%-38%), AL involvement (21%-32%), and pouch with fistulas (9%-20%). The rate of subsequent normal pouch was 6%-25% with pouch fistulas having the lowest normalization rate (6%, 5-year EFS 93%) (Table 1, Figure 2). On multivariable analysis, pouch fistulas were negatively associated with pouch normalization (OR 0.17, 95% CI 0.06–0.48) (Table 2). Conclusion We demonstrated that pouch phenotype can change over time and pouch normalization is possible. Further studies are needed to determine if pouch normalization should be a goal of treatment for IBD patients with IPAA.

THE CLINICAL FEATURES AND PROGNOSTIC VALUE OF INFLAMMATORY POLYPS IN THE J POUCH OF PATIENTS WITH INFLAMMATORY BOWEL DISEASE TREATED BY PROCTOCOLECTOMY WITH ILEAL POUCH-ANAL ANASTOMOSIS

Abstract Background Patients with inflammatory bowel disease (IBD) sometimes require proctocolectomy with ileal pouch-anal anastomosis (IPAA) due to medically refractory colitis or neoplasia. However, pouchitis can develop in up to 80% of patients after the surgery. Given that previous studies demonstrated an association between chronic pouchitis and inflammatory polyps, we hypothesize that inflammatory polyps can be a predictor for pouch outcomes. This study assesses the frequency, risk factors, and prognosis of the J pouch with inflammatory polyps. Methods This is a retrospective single-center study of IBD patients treated by total proctocolectomy with IPAA and who subsequently underwent pouchoscopies at the University of Chicago between January 2007 and September 2019. We reviewed the endoscopic findings in different anatomic areas of the pouch: the pre-pouch ileum, inlet, “tip of the J”, proximal and distal pouch, anastomosis, rectal cuff, anal canal, and perianal area. Endoscopic findings included erythema/edema, erosions/friability, ulcerations, stenosis, granularity, loss of vascular pattern, and inflammatory polyps. To compare the J pouch with and without inflammatory polyps, we evaluated all available pouchoscopies and included any patient who had inflammatory polyps noted at least once. Demographic and clinical data were also assessed. Fisher’s test was used for a univariate analysis to assess factors contributing to inflammatory polyps in the J pouch. Logistic regression analysis was performed by including univariate variables with a P-value < 0.05. To assess the relevance between inflammatory polyps and pouch excision, log-rank test and Kaplan-Meier curve were used. Results We reviewed 1,195 pouchoscopies from 426 IBD patients who underwent proctocolectomy with IPAA and identified 61 patients (14.3%) with at least 1 inflammatory polyp in the J pouch. The most common anatomical location developing inflammatory polyps was the distal pouch (23, 38%), followed by the proximal pouch (21, 34%), afferent limb (13, 21%), rectal cuff (9, 15%), and inlet (7, 11%). Multivariable analysis showed that inflammatory polyps were significantly associated with male sex (OR = 2.8; 95% CI = 1.4–5.3; P = 0.002), postoperative anti-TNF drugs (OR = 2.9; 95% CI = 1.6–5.4; P < 0.001), and pouchitis (OR = 6.1; 95% CI = 1.4–25.9; P = 0.015) (Table). Kaplan-Meier curve showed that inflammatory polyps significantly increased the risk of pouch excision (P = 0.03) (Figure 1). Conclusion Our analysis found that more than 10% of IBD patients with a J pouch developed inflammatory polyps. Male patients had an increased risk of inflammatory polyps in the J pouch. Furthermore, our study suggested that inflammatory polyps can develop in patients with pouchitis requiring anti-TNF drugs and are an independent predictor of pouch excision. Table Figure 1

A New Approach to Tense End-to-End Anostomosis in Primary Surgical Repair of Esophageal Atresia: Vascularized Pleural Flap.

Background: Esophageal atresia (EA) is the most common congenital malformation of the esophagus. If the distance between the proximal and distal pouches is usually more than 2-3 cm, it is considered as long gap esophageal atresia (LGEA). In our study, it was planned to investigate the effect of the use of vascularized pleural flap (VPF) on postoperative recovery in cases with tense end-to-end anastomosis in the primary repair of LGEA. Methods: The postoperative recovery period data of patients who underwent tense end-to-end anastomosis due to LGEA between 01/01/2016 and 01/12/2020 in our clinic were analyzed retrospectively. Results: Between the specified dates, 37 patients were operated for EA. A tense end-to-end anastomosis was performed in 16 of 37 patients. In 5 of these patients, a VPF was placed on the anastomosis line. In the postoperative follow-up, no anastomotic leakage or anastomotic stenosis was observed in 5 patients who underwent tense anastomosis with VPF. In addition, it was observed that patients who underwent tense anastomosis with VPF were started oral nutrition earlier after surgery compared to patients without VPF. Conclusion: The success of the technique we performed in 5 patients without any complications suggested that this technique could be used as a method in tense anastomoses. It was thought that oral nutrition was initiated early in patients using VPF, since there was no anastomotic leak and the surgeon relied on the presence of the VPF.

P026 Assessment of Contributing Factors for Fistula Development in Patients with Inflammatory Bowel Disease Treated by Proctocolectomy with Ileal Pouch-Anal Anastomosis.

BACKGROUND: In patients with inflammatory bowel disease (IBD), surgical intervention is sometimes required due to medically refractory colitis or the development of neoplasia, and restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the most common procedure for those with colitis. However, despite a preoperative diagnosis of ulcerative colitis (UC), a phenotype of the J pouch which has features similar to Crohn’s disease (CD) may develop after the surgery. This study aims to assess the frequency and risk factors of fistula development in IBD patients with a J pouch. METHODS: This is a retrospective single-center study of IBD patients treated by total proctocolectomy with IPAA and who subsequently underwent pouchoscopies at the University of Chicago between January 2007 and December 2019. We reviewed the endoscopic findings in different anatomic areas of the pouch (the afferent limb, inlet, “tip of the J”, proximal and distal pouch, anastomosis, rectal cuff, anal canal, and perianal area). Endoscopic phenotypes were classified into 5 main categories: (1) afferent limb, (2) inlet involvement, (3) diffuse inflammation of the pouch body, (4) cuffitis, and (5) J pouch with fistulas. This analysis included pouches with any type of fistulas that developed ≥6 months after ileostomy takedown. We assessed clinical data and pathological findings of the resected colon including deep, focal inflammation, and granulomas generally thought to be unique features of CD. Deep inflammation included ulcerations, fissures, and lymphoid aggregates observed below the level of the mucosa. Fisher’s test was used for univariate analysis to assess factors contributing to fistula development. Logistic regression analysis was performed as a multivariable analysis including variables with a P-value < 0.10 in the univariate analysis. RESULTS: We reviewed 1,359 pouchoscopies from 426 IBD patients who underwent proctocolectomy with IPAA and identified 18.8% of patients (78/414) with a J pouch and fistulas ≥ 6 months from ileostomy takedown. Ninety-one percent of patients were preoperatively diagnosed with UC. The most frequent type of fistula was perianal fistula (60.3%), followed by enterovaginal or rectovaginal fistula (24.4%), and fistula from the pouch (7.7%). Among 325 IBD patients with available pathological reports of resected colon, 86 patients (26.5%) showed deep inflammation and 88.4% (76/86) of patients were diagnosed with UC rather than CD by our pathologists. On univariate analysis, we did not find any significant clinical factors for fistula development in patients with a J pouch. As for pathological data, our univariate and multivariable analyses showed that deep inflammation of the resected colon was significantly associated with fistula development (OR = 3.52; 95%CI = 1.84-6.72; P < 0.001), but focal inflammation and granulomas were not. Notably, this association was not observed in patients with other endoscopic phenotypes of the J pouch. CONCLUSION: In this tertiary cohort of patients with a preoperative diagnosis of UC, we found that deep inflammation of the resected colon is a specific predictor for fistula formation in the J pouch. These findings suggest that in such patients a careful monitoring and early treatment strategy may be beneficial.

Accuracy Of Transperineal Sonography And Distal Loopogram In Determining Distal Rectal Pouch-Perineal Distance And Fistula On Anorectal Malformation Post Colostomy Patients At Dr. Mohammad Hoesin Palembang

Abstract&#x0D; Background : Imperforated anus is a congenital abnormality which is better known as anorectal malformation. The incidence of anorectal malformations is 1 in 4000 to 5000 live births. The incidence of anorectal malformations in Europe varies from 1.14 to 5.96 per 10,000 people and can change each year.1-3 The surgical approach in the management of anorectal malformations depends on the classification of anorectal malformations based on low, intermediate and high location. The distal loopogram or distal colostrography / colostrogram examination is an examination that is very important to determine the location of the distal rectum before definitive repair, but this examination has the disadvantage of using contrast and x-ray radiation. One alternative radiological examination that can be used for faster initial management is sonographic.7&#x0D; Method : This study was a diagnostic test study to assess the diagnostic accuracy of the distal loopogram / colostrography examination and sonographic examination with the transperineal approachon post-colostomy Anorectal Malformations patients at Mohammad Hoesin Hospital, Palembang in August 2019-October 20120 or until the number of research samples is met.&#x0D; Result : There were 21 samples in this study, 11 (52.4%) samples were dominated by clinical appearance without fistula. On the results of ultrasound examination, the majority of samples of rectouretral fistulas were 7 (33.3%). Loopogram examination found the majority of samples without fistulas as many as 10 (47.6%) samples. On intraoperative examination, 7 (33.3%) samples were obtained for rectouretral fistulas. The result of pouch-perineum measurement on ultrasound examination was 1.15 ± 0.6 cm, loopogram was 0.7 ± 1.5 cm, intra-operasionem was 1.8 ± 1.6 cm. In this study, USG has a very high accuracy value with a sensitivity of 100% and a specificity of 93.8% while the Loopogram has a sensitivity of 100% and a specificity of 68.8%.&#x0D; Conclusion : Transperineal ultrasound has a very high accuracy value with a sensitivity of 100% and a specificity of 93.8% while the Loopogram has a sensitivity of 100% and a specificity of 68.8%. Although there is a significant difference between the distal rectum -perineal distance calculation with a difference of -0.38 ± 0.70 cm, these two methods are equally accurate in assessing the distal rectal pouch -perineal distance and the location of the fistula.

Band neutrophil sign: A strong first-trimester ultrasound marker of combined duodenal and esophageal atresia.

To reveal a first-trimester sonographic marker associated with combined duodenal and esophageal atresia (DA and EA). This retrospective study included four patients referred to our department in the first trimester due to fetal stomach anomaly. In the literature, we found 20 additional cases of combined DA and EA with four of them to be revealed at 12 weeks. We present the largest for to date case series of combined DA and pure EA diagnosed in the first trimester including one with additional visualization of the distal esophageal pouch and its communication with the stomach. All our cases and four previously published reports (including two cases of DA and EA with tracheoesophageal fistula [TEF]) were characterized by the presence of "band neutrophil" sign-a symmetrical C-shaped loop in the fetal abdomen, occupying a central position close to the anterior abdominal wall. Similar findings could be seen also later in pregnancy, but they lack the same prognostic value. Band neutrophil sign is a pathognomonic first-trimester ultrasound marker of combined DA and EA irrespective of the presence of TEF. Nevertheless, it should be further evaluated in prospective studies.

24 ENDOSCOPIC AND CLINICAL CHARACTERISTICS OF POUCHITIS INVOLVING THE RECTAL CUFF IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE TREATED BY PROCTOCOLECTOMY WITH ILEAL POUCH-ANAL ANASTOMOSIS

Abstract Background For patients with inflammatory bowel disease (IBD), surgical intervention is sometimes required due to medically refractory colitis or development of neoplasia. Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the most common procedure for patients with colitis. However, pouchitis can develop in up to 80% of patients after the surgery and significantly impairs quality of life. Despite the high prevalence of pouchitis, endoscopic phenotypes have not been clarified. This study assessed the frequency and characteristics of inflammation involving the rectal cuff. Methods This is a retrospective study from a tertiary IBD center of IBD patients treated by total proctocolectomy with IPAA and subsequently underwent pouchoscopies at the University of Chicago between January 2007 and September 2019. We reviewed the endoscopic findings in different areas of the pouch: the pre-pouch ileum, inlet, “tip of the J”, proximal and distal pouch, anastomosis, rectal cuff, anal canal, and perianal area. This analysis evaluated all available pouchoscopies per patient and included patients with normal cuff and those with cuffitis noted in every pouchoscopy. Demographic and endoscopic data were assessed to compare patients with normal cuff and those with cuffitis. Fisher’s test was used for a univariate analysis to assess factors contributing to cuffitis. Logistic regression analysis was performed as a multivariate analysis including univariate variables with a P-value &amp;lt; 0.15. Results We reviewed 1,081 pouchoscopies from 426 IBD patients who underwent proctocolectomy with IPAA and identified 184 patients (43%) with normal cuff and 107 (25%) with cuffitis. Of these 291 patients, 57% were men, 92% were Caucasian, the mean age at the diagnosis (SD) was 26 ± 12 years, and mean BMI 26 ± 5 kg/m2. The diagnosis before surgery for these patients were for ulcerative colitis (91%), indeterminate colitis (5.8%), and Crohn’s disease (1.7%). A significant difference (P = 0.003) was found in the frequency of pouchitis between patients with normal cuff (126/184, 69%) and those with cuffitis (90/107, 84%) (Table 1). Although not statistically significant, the frequency of pouch failure in patients with cuffitis (13/107, 12%) was higher than those with normal cuff (12/184, 6.5%). Multivariate analysis showed pouchitis was significantly associated with cuffitis (OR = 2.2; 95% CI = 1.2–4.2; P = 0.01) (Table 2). Endoscopic data showed that the pre-pouch ileum was significantly (P = 0.001) involved in patients with cuffitis (45/90, 50%) compared with those with normal cuff (36/126, 29%). Conclusion Our analysis of 291 patients suggested that cuff inflammation can be a significant risk factor of pouchitis and is significantly associated with the development of inflammation in the pre-pouch ileum. Cuffitis can be a therapeutic target to improve J pouch outcomes.

Histology of the terminal end of the distal rectal pouch and fistula region in varying the severity of anorectal malformations: Is it useful?

Aims: To Study the histology of the terminal end of distal rectal pouch and fistula region in cases of anorectal malformations (ARMs) and to get an insight on the usefulness of excising or preserving this region during its reconstruction. Materials and Methods: This was a prospective observational study of 20 consecutive cases of ARMs that underwent posterior sagittal anorectoplasty (PSARP) in our hospital over 6 months' period. The histopathological evaluation of the terminal end of the distal rectal pouch and fistula region in all cases with ARM was done. Complicated and redo cases were excluded from this study. Tissue specimen of about 0.5–1.0 cm from the most distal part of the rectal pouch and close to the fistula region was taken. Biopsy specimens were obtained from all patients undergoing a PSARP performed after a defunctioning colostomy or as a primary procedure without colostomy, and histopathological evaluation was done in all cases. Further, the internal sphincter and its morphology, hypoganglionosis or aganglionosis, anal glands and crypts, thickened nerve trunks, and other miscellaneous histopathological aberrations were studied. Based on these histological findings, conclusions were derived whether to preserve or excise this region during ARM reconstruction. Results: Out of the 20 ARM patients included, 12 patients (60%) were male and 8 (40%) were female. An internal sphincter was identified in all the patients. However, the smooth muscle bundles were disorganized in all the 20 patients (100%). While ganglion cells were absent in 90% cases, hypertrophic nerve bundles were a common histological finding (90% of patients). The abnormal mucosal finding was also noted in majority of the patients (75%). Conclusions: An atrophic or disorganized internal sphincter, absent ganglion cells, and abnormal anal mucosal findings in majority of these patients on histology would justify its excision during PSARP. However, further follow-up of these ARM patients in whom the terminal end of the distal rectal pouch and the fistula region is excised or retained is recommended.

Transhiatal isoperistaltic colon interposition without cervical oesophagostomy in long-gap oesophageal atresia.

Background:Oesophageal colonic interposition in oesophageal atresia (OA) patients is almost exclusively done as a staged operation with an initial oesophagostomy and gastrostomy followed by the definitive surgery months later. This study presents a series of patients in whom a cervical oesophagostomy was not performed before the substitution surgery.Patients and Methods:Records of EA patients were evaluated for those who underwent colon interposition without cervical oesophagostomy.Results:There were five patients: three with pure EA and two with proximal tracheo-oesophageal fistula. A delayed primary repair could not be performed because of intra-abdominally located distal pouch. The mean age at the time of definitive operation was 5.54 (±2.7) months and the mean weight was 6.24 (±1.3) kg. A right or a left colonic segment was used for interposition keeping the proximal anastomosis within the thorax. The post-operative results were quite satisfactory within a median follow-up period of 33.2 months.Conclusion:Avoiding cervical oesophagostomy and its inherent complications and drawbacks is possible in a subset of patients with long-gap EA who underwent colonic substitution surgery. This approach may be seen as an extension of the consensus that the native oesophagus should be preserved whenever possible, because it uses the native oesophagus in its entirety.

P002 Endoscopic Characteristics and Prognosis of Pouchitis Involving the Pouch Inlet in Patients With Inflammatory Bowel Disease

BACKGROUND: In patients with inflammatory bowel disease (IBD), surgical intervention is sometimes required due to medically refractory colitis or the development of neoplasia, and restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the most common procedure for those with colitis. However, pouchitis can develop in up to 80% of patients after the surgery and significantly impairs quality of life. Despite the high prevalence of pouchitis, endoscopic phenotypes have not been clarified. This study assessed the frequency of and risk factors for inflammation involving the pouch inlet. METHODS: This is a retrospective single-center study of IBD patients treated by total proctocolectomy with IPAA and who subsequently underwent pouchoscopies at the University of Chicago between January 2007 and September 2019. We reviewed the endoscopic findings in different anatomic areas of the pouch: the pre-pouch ileum, inlet, “tip of the J”, proximal and distal pouch, anastomosis, rectal cuff, anal canal, and perianal area. This analysis evaluated all available pouchoscopies and included any patient who had inlet inflammation noted at least once. Demographic and clinical data were also assessed. Log-rank test was used for a univariate analysis to assess factors contributing to pouch excision. Cox proportional hazard regression analysis was performed as a multivariate analysis including univariate variables with a p-value < 0.10. RESULTS: We reviewed 1,081 pouchoscopies from 426 IBD patients who underwent proctocolectomy with IPAA and identified 188 patients (44%) with pouchitis involving the inlet. Of these patients, 62% were men, 89% were Caucasian, mean age at diagnosis (SD) was 24 ± 11 years, and mean BMI 26 ± 5. The included patients had pre-pouch diagnoses of ulcerative colitis (165; 89%), indeterminate colitis (14; 7.5%), and Crohn’s disease (7; 3.8%) as the diagnosis before surgery. Twenty-five percent (47/188) had inlet stenosis and 33% (62/188) had pouch-anal anastomotic stenosis. Compared with the cuff, the rate of ulcerations was higher in the pre-pouch ileum and inlet (27.1% vs 42% and 66%, respectively). After a mean of 12 years of follow-up, the overall prevalence of pouch excision was 14% (25/188). Multivariate analysis identified that inlet stenosis significantly predicted pouch excision (HR = 2.92; 95% CI = 1.24-6.86; p = 0.014), whereas anastomotic stenosis was not a significant predictor (HR = 1.48; 0.64-3.42; p = 0.36). CONCLUSION(S): Inlet inflammation and stenosis is present in a significant number of IBD patients with pouchitis, and stenosis in particular is associated with pouch excision. There is a pressing need to understand the causes and develop treatments of this complication.