Ileal Pouch Anal Research Articles

NSQIP 5-factor modified frailty index and complications after ileal anal pouch anastomosis for ulcerative colitis

BackgroundFrailty has been associated with worse postoperative outcomes. The 5-factor modified frailty index (mFI-5) is an objective measure although its validity in measuring frailty in patients undergoing ileal pouch-anal anastomosis (IPAA) for chronic ulcerative colitis (CUC) has not been reported. MethodsThis study used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted proctectomy database. The mFI-5 was calculated by five preoperative diagnoses: insulin-dependent or noninsulin-dependent diabetes, congestive heart failure, hypertension, chronic obstructive pulmonary disease, and dependent or partially dependent functional status. The impact of mFI-5 on minor and major postoperative morbidity in CUC patients undergoing IPAA was analyzed. ResultsThe cohort included 1454 patients (median age 38 years, median body mass index [BMI] 26 kg/m2) of which 87 % had a mFI-5 = 0, 11 % had a mFI-5 = 1, and 2.5 % a mFI-5 ≥ 2. In multivariable logistic regression, mFI-5 ≥ 2 was significantly associated with minor complications (OR = 2.29, 95 % CI [1.00–5.22], p = 0.049), but not with major complications (p = 0.860). ConclusionIPAA for CUC is associated with high postoperative morbidity, however, the mFI-5 alone has limited utility in determining which patients are at a higher risk of complications due to frailty. These observations suggest there is a need for more relevant instruments to measure frailty in this patient cohort.

Does an Ileoanal Anastomosis Decrease the Rate of Successful Pregnancy Compared With an Ileorectal Anastomosis? A National Study of 1491 Patients.

Report the rate of successful pregnancy in a national cohort of women with either an ileal pouch anal (IPAA) or ileorectal (IRA) anastomosis constructed after colectomy for inflammatory bowel disease (IBD) or polyposis. Fertility after IPAA is probably impaired. All available data are corroborated by only small sample size studies. It is not known whether construction of IPAA versus IRA influences the odds of subsequently achieving a successful pregnancy, especially with increased utilization of the laparoscopic approach. All women (age: 12-45y) undergoing IRA or IPAA in France for polyposis or IBD, between 2010-2020, were included. A control population was defined as women aged from 12 to 45 years undergoing laparoscopic appendicectomy during the same period. The odds of successful pregnancy were studied using an adjusted survival analysis. A total of 1491 women (IPAA=872, 58%; IRA=619, 42%) were included. A total of 220 deliveries (15%) occurred during the follow-up period of 71 months (39-100). After adjustment, the odds of successful pregnancy was not significantly associated with type of anastomosis (after IPAA: Hazard Ratio [HR]=0.79, 95% confidence interval=0.56-1.11, P =0.17). The laparoscopic approach increased the odds of achieving successful pregnancy (HR=1.79, 95% confidence interval=1.20-2.63, P =0.004). IRA and IPAA significantly impacted fertility when compared with the control population ( P <0.001). In this large cohort study, total colectomy for polyposis or IBD was associated with reduced fertility compared with the general population. No difference in odds of achieving successful pregnancy was found between IRA and IPAA after adjustment. This analysis suggests laparoscopic surgery may be associated with greater likelihood of pregnancy.

DIAGNOSTIC AND MANAGEMENT APPROACH TO POUCHITIS IN INFLAMMATORY BOWEL DISEASE.

In patients with ulcerative colitis refractory to medical therapy, total proctocolectomy and posterior ileal-anal pouch anastomosis is the standard surgical therapy. One of the possible complications is pouchitis. Depending on the duration of the symptoms, it can be classified as acute, recurrent, or chronic. The latter, according to the response to therapy, can be defined as antibiotic-dependent or refractory. The treatment of pouchitis is based on the use of antibiotics and probiotics. Thiopurine and biological therapy have been suggested in patients with refractory pouchitis. Special care should be taken in the endoscopic surveillance of these patients, especially if they present risk factors such as dysplasia or previous colorectal cancer, primary sclerosing cholangitis or ulcerative colitis for more than 10 years.

Anastomotic stenosis after coloanal, colorectal and ileoanal anastomosis: what is the best management?

To assess the results of treatment for colorectal (CRA), coloanal (CAA) or ileal pouch-anal (IPAA) anastomotic stenosis (AS). All patients operated on for AS from 1995 to 2014 were included. Success was defined as the absence of an additional surgical procedure for AS during 12months after the last procedure and the absence of a stoma at the end of follow-up. Fifty consecutive patients presenting with AS after CRA (n=16, 32%), CAA (n=18, 36%) or IPAA (n=16, 32%), performed for colorectal cancer (n=28, 56%), familial adenomatous polyposis (n=5, 10%), inflammatory bowel disease (n=8, 16%), diverticulitis (n=4, 8%), benign colorectal neoplasia (n=3, 6%) or other (n=2, 4%) underwent a total of 99 procedures including digital (n=14, 14%), instrumental (n=38, 38%) or endoscopic dilatation (n=5, 5%), transanal AS stricturoplasty (n=9, 10%), transanal circular stapler resection (n=11, 11%) or transabdominal redo-anastomosis (n=22, 22%). Overall the per-procedure success rate was 53% (52/99). Success rates were 36% (5/14) for digital dilatation, 40% (15/38) for instrumental dilatation, 20% (1/5) for endoscopic dilatation, 64% (7/11) for circular stapler resection, 89% (8/9) for stricturoplasty and 73% (16/22) for transabdominal redo-anastomosis. After a mean follow-up of 46months, 42/50 (84%) patients had treatment that was considered successful. Multivariate analysis identified redo-anastomosis [OR=5.1 (95% CI: 1.4-18.7), P=0.003] as the only independent prognostic factor for success. AS should be managed according to a step-up strategy. Conservative procedures are associated with acceptable success rates. If these fail, transabdominal redo-anastomosis is associated with the highest probability of success.

The Kock pouch reconsidered: an alternative surgical technique.

The psychological impact stoma surgery can have on an individual is well documented within the literature (White and Hunt, 1997; Borwell, 2009; Williams, 2005; Brown, 2005). For many years, surgeons have explored and developed innovations in surgical techniques, in particular restorative procedures with a view of preventing permanent stoma formation; ileal anal pouch (IAP) now being the surgical procedure of choice for treatment of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). However, high morbidity rates are associated with pouch longevity (Castillo et al 2005; Nessar and Wu, 2012) and once removed can lead to a high-output ileostomy with risks of electrolyte imbalance and malabsorption. This then creates the dilemma of whether the Kock pouch (KP) should be offered as a surgical option. This article offers a historical perspective of the KP and its place in the surgical management of UC and FAP. This article also presents results from a recent audit funded by the Ileostomy Association (IA), highlighting how patients manage their KP and the importance of maintaining bowel control and being free of an incontinent stoma as a means of coming to terms with their condition.

O-019 YI Genetic Predictors of Quality of Life Post Ileal Anal Pouch Anastomosis for Ulcerative Colitis

Total proctocolectomy and Ileal Pouch Anal Anastomosis (IPAA) for ulcerative colitis (UC) allows for the resection of diseased rectum and colon whilst preserving continence. Procedure outcomes and patient satisfaction are varied and difficult to predict preoperatively. This study aimed to determine demographic, operative and, most uniquely, genetic predictors of patient satisfaction with IPAA by evaluating 4 distinct categories: bowel symptoms, emotional wellbeing, social wellbeing and systemic symptoms using modified established quality of life questionnaires (the Modified Pouchitis Score and IBDQ (Inflammatory Bowel Disease Questionnaire)). Two hundred six IPAA patients identified from our IBD Biobank were mailed modified, pouch specific IBD questionnaires. Patient demographics and operative details were recorded. Genotyping using a custom designed microarray with 307 IBD and/or colorectal cancer (CRC) associated Single Nucleotide Polymorphisms (SNPs) was performed. Response variables were divided into high/low values based on their respective median values. Fisher's exact and Mann-Whitney U tests were used with the categorical and continuous explanatory variables respectively. Logistic regression with a Bonferroni correction was used for the SNP analysis. One hundred forty-two (86 male) patients responded (69%). Mean age at diagnosis was 31.8+/−.9 years. Average pouch duration was 10.1 +/−.5 years. One hundred four colectomies were performed electively with 13 resections for cancer/dysplasia. Covariates associated with symptom and wellbeing scores are listed in Table 1. A diagnosis of pouchitis, intermittent urgency and/or cramping and intermittent pyrexia were significantly associated with worse scores in every category. Smoking was associated with worse bowel and systemic symptoms and lower social wellbeing scores (P = 0.0029, 0.0062 and 0.02). More severe bowel symptoms and poorer emotional scores were reported by patients with less time between diagnosis and colectomy (6.6 versus 9.4 years, P = 0.04 and 0.05). Poorer emotional scores were seen in those diagnosed at a younger age (47.4+/− 12.4 versus 53.7 +/− 11.7) and in those with pouchitis of any degree (P = 0.04). The TNFSF14 associated SNP, rs2279627 was associated with poorer scores in overall quality of life and in each individual category. Significance was retained after correction in the overall quality of life, bowel symptom and emotional wellbeing categories (P = 0.033, 0.033 and 0.046). TNFSF14 plays a role in T cell differentiation and is associated with both UC and CD. Two SNPs, rs7837328 and rs7014346, associated with the POU5F1gene, were significantly associated with emotional wellbeing (P = 0.00002, 0.0066 corrected and P = 0.00014, 0.046 corrected). POU5F1 (also known as OCT4) plays a critical role in maintaining stem cell pluripotency, has a known role in CRC and has not previously been associated with IBD. 1) Pouchitis, urgency and/or cramps and intermittent fevers significantly impacted all aspects of quality of life in UC-IPAA patients 2). Smoking and pouchitis have the most significant impact, particularly on bowel and systemic symptoms respectively. 3) Potential genetic predictors of overall quality of life, bowel symptoms and, most interestingly, emotional wellbeing in this patient cohort were associated with the TNFSF14 and POU5F1B genes. 4) Patients diagnosed with IBD at an older age and who had a longer duration between diagnosis and colectomy were more likely to have a better emotional quality of life.

Multiphasic analysis of the temporal development of the distal gut microbiota in patients following ileal pouch anal anastomosis

BackgroundThe indigenous gut microbiota are thought to play a crucial role in the development and maintenance of the abnormal inflammatory responses that are the hallmark of inflammatory bowel disease. Direct tests of the role of the gut microbiome in these disorders are typically limited by the fact that sampling of the microbiota generally occurs once disease has become manifest. This limitation could potentially be circumvented by studying patients who undergo total proctocolectomy with ileal pouch anal anastomosis (IPAA) for the definitive treatment of ulcerative colitis. A subset of patients who undergo IPAA develops an inflammatory condition known as pouchitis, which is thought to mirror the pathogenesis of ulcerative colitis. Following the development of the microbiome of the pouch would allow characterization of the microbial community that predates the development of overt disease.ResultsWe monitored the development of the pouch microbiota in four patients who underwent IPAA. Mucosal and luminal samples were obtained prior to takedown of the diverting ileostomy and compared to samples obtained 2, 4 and 8 weeks after intestinal continuity had been restored. Through the combined analysis of 16S rRNA-encoding gene amplicons, targeted 16S amplification and microbial cultivation, we observed major changes in structure and function of the pouch microbiota following ileostomy. There is a relative increase in anaerobic microorganisms with the capacity for fermentation of complex carbohydrates, which corresponds to the physical stasis of intestinal contents in the ileal pouch. Compared to the microbiome structure encountered in the colonic mucosa of healthy individuals, the pouch microbial community in three of the four individuals was quite distinct. In the fourth patient, a community that was much like that seen in a healthy colon was established, and this patient also had the most benign clinical course of the four patients, without the development of pouchitis 2 years after IPAA.ConclusionsThe microbiota that inhabit the ileal-anal pouch of patients who undergo IPAA for treatment of ulcerative colitis demonstrate significant structural and functional changes related to the restoration of fecal flow. Our preliminary results suggest once the pouch has assumed the physiologic role previously played by the intact colon, the precise structure and function of the pouch microbiome, relative to a normal colonic microbiota, will determine if there is establishment of a stable, healthy mucosal environment or the reinitiation of the pathogenic cascade that results in intestinal inflammation.

Multidetector-Row Computed Tomography Enterographic Assessment of the Ileal-Anal Pouch

To describe the multidetector-row computed tomography enterographic (MD-CTE) features of the ileal-anal pouch after ileal pouch anal anastomosis (IPAA) surgery and correlate them with pouch endoscopy and histopathologic findings. All MD-CTE examinations performed on patients who underwent IPAA from July 1, 2005 to December 1, 2010 (n = 35; 16 [45.7%] men; mean age, 37.7 years; age range, 22-72 years) were retrospectively evaluated in consensus by 2 radiologists. All studies were evaluated for the presence of multiple imaging features. Two radiographic scores were then calculated: a total radiographic score and a radiographic active inflammation score. In patients who underwent MD-CTE, pouch endoscopy, and biopsy within 30 days (n = 13), both scores were correlated with findings on pouch endoscopy and histopathology. Of the 35 patients, 33 (94%) had at least one MD-CTE finding of active or chronic pouch inflammation and 27 patients (77%) had at least one MD-CTE finding of active pouch inflammation. Of the 13 patients who underwent endoscopy and biopsy, the total radiographic score demonstrated a strong positive correlation with endoscopic score (r = 0.81; P = 0.001) and a moderate positive correlation with histopathologic score (r = 0.56; P = 0.047). The radiographic active inflammation score demonstrated a strong positive correlation with endoscopic score (r = 0.83; P = 0.0004), but only a weak nonsignificant positive correlation with histopathologic score (r = 0.492, P = 0.087). In patients who had IPAA surgery, findings on MD-CTE correlate positively with findings on pouch endoscopy and histopathology and are sensitive measures for pouch inflammation with high positive predictive value. Thus, MD-CTE can be a useful noninvasive test in the early evaluation of symptomatic patients.

Incomplete ileal anal pouch emptying

Gastrointestinal NursingVol. 9, No. 7 Skills in PracticeIncomplete ileal anal pouch emptyingJulia WilliamsJulia WilliamsSearch for more papers by this authorJulia WilliamsPublished Online:16 Aug 2013https://doi.org/10.12968/gasn.2011.9.7.15AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Norton C et al. (2009) Oxford Handbook of Gastrointestinal Nursing. Oxford University Press, Oxford Google ScholarParks AG, Nicholls RJ (1978) Procolectomy without ileostomy for ulcerative colitis. BMJ 2(6130): 85–8 Crossref, Google ScholarWilliams J (2002) (ed) The Essentials of Pouch Care Nursing. Whurr Publications, London Google Scholar FiguresReferencesRelatedDetailsCited byNurse activity to prevent and support patients with a parastomal hernia17 December 2015 | Gastrointestinal Nursing, Vol. 13, No. 10Analysing the role of support wear, clothing and accessories in maintaining ostomates' quality of life21 September 2015 | Gastrointestinal Nursing, Vol. 13, No. 7Assessing support garments in the management of parastomal hernia16 May 2014 | Gastrointestinal Nursing, Vol. 12, No. 4 1 September 2011Volume 9Issue 7ISSN (print): 1479-5248ISSN (online): 2052-2835 Metrics History Published online 16 August 2013 Published in print 1 September 2011 Information© MA Healthcare LimitedPDF download

Thinking beyond the colon-small bowel Involvement in clostridium difficile infection

Small intestinal Clostridium difficile seems to be increasing in incidence. The spectrum of Clostridium difficile infection (CDI) has definitely expanded with small bowel involvement. They are more frequently reported in patients with inflammatory bowel disease (IBD) who have undergone total colectomy or patients with Ileal anal pouch anastomosis. The most common presentation is increased ileostomy output with associated dehydration. High clinical suspicion, early recognition and appropriate treatment are the keys to successful resolution. The increase in the number of these patients may actually reflect an increase in the rising incidence of CDI in general or increasing virulence of the organism. Heightened public awareness and initiation of prompt preventive measures are the keystones to control of this infection. This disease is no longer limited to the colon and physicians should be educated to think beyond the colon in patients with CDI.

Thirty years of the ileal-anal pouch and beyond

Still referred to as a new surgical procedure, the ileal-anal pouch or restorative proctocolectomy is now in its 30th year. Over this time the procedure has become the standard of care for patients with ulcerative colitis and familial adenomatous polyposis who require surgery. For many patients it not only eradicates disease, but also preserves the anal sphincter, therefore enabling the patient to defecate in the normal way. Much research over the years has explored optimum surgical techniques, pouch function/capacity, pouch failure and pouch satisfaction and its long-term follow-up. This article reviews literature relating to the ileal-anal pouch and traces its journey through the past three decades, providing an overview of how the pouch has evolved and considers its future development.

Adenocarcinoma of the anal transitional zone after double stapled ileal pouch‐anal anastomosis for ulcerative colitis

The development of adenocarcinoma in the anal transitional zone, after restorative proctocolectomy for ulcerative colitis, is rare. We report the first Asian and sixth known case. A 41-year-old Indian lady had a long standing history of ulcerative colitis. Restorative proctocolectomy and stapled ileal pouch-anal anastomosis without mucosectomy was performed. She remained asymptomatic until 3 years later when she complained of discomfort on defecation. A poorly differentiated adenocarcinoma in the anal transition zone was diagnosed and she subsequently underwent an abdomino-perineal resection. The previously reported cases in the literature are reviewed. We also discuss the suggested surveillance for high-risk patients who have undergone an ileal-anal pouch anastomosis.

Combination Treatment With Curcumin and Quercetin of Adenomas in Familial Adenomatous Polyposis

Familialadenomatous polyposis (FAP) is an autosomal-dominant disorder characterized by the development of hundreds of colorectal adenomas and eventual colorectal cancer. Regression of adenomas in this syndrome occurs with the administration of nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors, but these compounds can have considerable side effects. We evaluated the efficacy of the combination of diet-derived nonprescription supplements curcumin and quercetin to regress adenomas in patients with FAP. Five FAP patients with prior colectomy (4 with retained rectum and 1 with an ileal anal pouch) received curcumin 480 mg and quercetin 20 mg orally 3 times a day. The number and size of polyps were assessed at baseline and after therapy. The Wilcoxon signed-rank test was used to determine differences in the number and size of polyps. Treatment side effects and medication compliance also were evaluated. All 5 patients had a decreased polyp number and size from baseline after a mean of 6 months of treatment with curcumin and quercetin. The mean percent decrease in the number and size of polyps from baseline was 60.4% (P < .05) and 50.9% (P < .05), respectively. Minimal adverse side effects and no laboratory abnormalities were noted. The combination of curcumin and quercetin appears to reduce the number and size of ileal and rectal adenomas in patients with FAP without appreciable toxicity. Randomized controlled trials are needed to validate these findings.

Arthritis related to ileal pouchitis following total proctocolectomy for ulcerative colitis

Objective: To draw attention to arthritis that developed in patients who underwent total proctocolectomy with ileal pouch construction for ulcerative colitis (UC). Methods: The course of 4 patients who developed arthritis for the first time after ileal-anal pouch anastomosis is described. In addition, the relationship to the chronic inflammation of the pouch–pouchitis–is discussed. Results: The clinical manifestations were very similar to seronegative arthritis affecting mainly the joints of the lower extremities. It was accompanied by enthesopathy (2 patients) and by sacroiliitis (2 patients). All had active pouchitis. The abnormal laboratory test results were nonspecific, indicating chronic inflammation. All 4 patients tested negative for human leukocyte antigen (HLA) B27, and none had other concomitant extraintestinal manifestations. Steroids rapidly improved both the arthritis and pouchitis; however, disease-modifying antirheumatic drugs were required to maintain remission with minimal daily steroids. Flares of the arthritis were always associated with active pouchitis, but the opposite was not necessarily true. Conclusions: Arthritis related to ileal pouchitis after total colectomy for UC has many similarities to the arthritis associated with inflammatory bowel disease and should be added to the list of enteropathic arthropathies. Semin Arthritis Rheum 30:242-248. Copyright © 2001 by W.B. Saunders Company

Nutritional treatment for gastrointestinal illnesses: future directions

Throughout the world, departments of gastroenterology often include a division or section for nutritional care. This is a logical inclusion because of the inextricable nature of gastrointestinal illnesses and impaired nutrient utilization. Despite this intuitive rationale, patients are frequently prescribed the most avant-garde medications, such as the newest cholesterol-lowering drug, without explicit dietary recommendations regarding limiting the intake of cholesterol. This paradoxical approach to treatment is partly due to the lack of formal nutritional training among most physicians caring for patients with gastrointestinal illnesses. In addition, most nutritional scientists are unfamiliar with the pathophysiological effects of gastrointestinal illnesses that impair nutrient utilization. Advances in research are uniting pharmacological and nutritional therapies into a new treatment, termed ‘nutritional pharmacotherapy’. Evidence-based confirmation of this important therapy is included in this issue of Current Opinion in Clinical Nutrition and Metabolic Care. Nutritional pharmacotherapy is defined as the use of nutrients that function more like drugs, sometimes used in combination with drugs to enhance nutrient utilization. Historically, clinical nutritionists have been deeply imbued in the ‘more is better’ ideology. This therapeutic approach led to futile attempts to correct nutrient deficits during the catabolic phases of gastrointestinal illnesses. Controlled clinical trials have shown that it is impossible to reverse gastrointestinal-induced catabolism with the prescription of large amounts of nutrients; moreover, this approach may be harmful, often resulting in liver dysfunction. An improved understanding of the mechanisms of catabolism in gastrointestinal illnesses has shown that increased production of counter-regulatory hormones and upregulation of pro-inflammatory cytokines create a metabolic milieu which in turn inhibits the utilization of large (repletion) amounts of nutrients. Because of their unique properties, nutrients with pharmacological effects (pharmaconutrients) are prescribed in small amounts, and are metabolized efficiently in the patient with altered gut function. Examples of pharmaconutrients include the anti-oxidative effects of micronutrients such as vitamins A, C, and E, selenium and zinc; enterotrophic responses of glutamine in the small intestine and butyrate in the colon; stimulation of the immune response with the omega-3 fatty acids; vasodilatory effects of arginine; and amelioration of components of the stress response with the administration of growth factors such as growth hormone and insulin-like growth factor-1. Escalating costs and precipitous changes in the demographics of healthcare delivery will mandate the prescription of pharmaconutrients in the home setting. This will perhaps be most evident in patients in need of elective gastrointestinal endotherapeutic procedures and surgery. Future preoperative preparations will probably include combinations of enterotrophic nutrients, anti-oxidants and immune stimulants before elective surgery such as total proctocolectomy and ileal-anal pouch for refractory ulcerative colitis. ln summary, pharmaconutrients provide exciting new treatments for patients with gastrointestinal disorders. These nutrients may directly affect the gut or may enhance the response to medications. Alternatively, pharmacological agents may improve the absorption of nutrients. Preliminary work suggests that pharmaconutrients may be useful as singular agents or, more likely, in combination with other nutrients or drugs. Pharmaconutrients will be prescribed in the home setting, and may provide prophylactic benefits for depleted patients in need of major gastrointestinal procedures and surgery. These intriguing nutrient-pharmacological agents may revolutionize the nutritional treatment of selected patients with disorders of the gut. Further investigations are warranted in well-controlled clinical trials.

Surgical and nutritional treatment of inflammatory bowel disease

Patients with ulcerative colitis who undergo an Meal-anal pouch operation without ileostomy have increased morbidity. The quality of life after ileal-anal pouch procedure is comparable to patients with ulcerative colitis treated medically. The number of anastomoses is an important prognostic indicator for early symptomatic recurrence after Crohn's disease. Diversion of the fecal stream for patients with Crohn's disease of the colon produces a high incidence of sustained idsease remission, but the prospect of future restoration of intestinal continuity is limited. The energy requirements for patients with active Crohn's disease is similar (30 to 35 kcal/kg body weight/d) to other hospitalized patients. Polymeric diets are as effective as steroids in inducing short-term remission in patients with active Crohn's disease. Food sensitivities in patients with Crohn's disease are of insufficient importance to warrant routine trials of elimination diets.

Operative and perioperative treatment of patients with inflammatory bowel disease

The ileal–anal pouch continues to be the most significant advance in the operative treatment of patients with ulcerative colitis during the past decade. Reports no longer question the efficacy of this innovative operation and now focus on improvements in operative technique and postoperative management. The goal of operative management of patients with Crohn's disease continues to be a conservative one. Recent evidence demonstrates that histologic recurrence of disease at the anastomosis occurs very soon after resection. Transplantation of the small intestine is an operative treatment on the horizon for patients with short-bowel syndrome due to conditions such as Crohn's disease. Advances continue in perioperative nutritional-metabolic management of patients with inflammatory bowel disease. Use of perioperative total parenteral nutrition is becoming more restrictive in patients with ulcerative colitis. Because of its significant enterotrophic effect, reduced cost, and comparable outcome benefit when compared with total parenteral nutrition, perioperative enteral nutrition is being prescribed more frequently. Observations in experimental models of enterocolitis have demonstrated enhancement of gut growth and function due to the provision of intestinal nutrients such as glutamine for the small intestine and short-chain fatty acids for the colon.