Ileorectal Anastomosis Research Articles

Regular endoscopic surveillance and polypectomy is effective in managing rectal adenoma progression following colectomy and ileorectal anastomosis in patients with familial adenomatous polyposis.

Total colectomy with ileorectal anastomosis (TC-IRA) is a surgical option for patients with familial adenomatous polyposis (FAP). Regular endoscopic surveillance of the rectum is recommended to prevent rectal cancer. We aimed to document polyp progression in the rectum following TC-IRA and evaluate the role of polypectomy during surveillance. Patients with FAP who underwent TC-IRA between 1990 and 2017 were identified. Demographic, endoscopic and genetic data were retrieved. Cumulative rectal adenoma (polyp) counts were obtained, whilst accounting for any polypectomies during the study period. The rate of polyp progression and factors influencing secondary proctectomy were evaluated. One hundred and ninety-nine patients fulfilled our inclusion criteria, of which 44% were male. The median age at colectomy was 19 (range 11-70) years and median preoperative rectal polyp count was 7 (range 0-50). All patients had an APC pathogenic variant, of which 151 (79%) were 5' of the mutation cluster region (MCR), 19 (10%) in the MCR, six (3%) were 3' of the MCR and 15 (8%) had a gross deletion. After a median follow-up of 8.6 (range1-27) years and a median of 11 (range 2-37) flexible sigmoidoscopies per patient, the median rate of polyp progression was 5.5 polyps/year (range 0-70.2). There was no evidence of polyp regression. Eight (4%) patients underwent secondary proctectomy for neoplasia, of which one (0.5%) had rectal adenocarcinoma. A total of 13,527 polyps were removed, a median of 35 polyps/patient (range 0-829). The rate of polyp progression was not significantly associated with genotypic or phenotypic factors. Progression of rectal adenoma burden following TC-IRA appears to be slow and dependent on the length of follow-up. In the modern era of stringent endoscopic surveillance and therapeutic procedures such as cold snare polypectomy, the rate of secondary proctectomy and the risk of rectal cancer after TC-IRA are very low. These findings are important when counselling patients with regard to the choice of surgery for FAP and implementing endoscopic surveillance.

Primary Versus Staged Reconstruction and Risk of Surgical Failure in Patients With Ulcerative Colitis: a Nation-wide Cohort Study.

Restorative surgery after colectomy due to ulcerative colitis (UC) may be performed simultaneously with colectomy (primary) or as a staged procedure. Risk factors for failure after restorative surgery are not fully explored. This study aimed to compare the risk of failure after primary and staged reconstruction. This is a national register-based cohort study of all patients 15 to 69 years old in Sweden treated with colectomy due to UC and who received an ileorectal anastomosis (IRA) or ileal pouch-anal anastomosis (IPAA) between 1997 and 2017. Failure was defined as a reoperation with new ileostomy after restorative surgery or a remaining defunctioning ileostomy after 2 years. Risk of failure was calculated using the Kaplan-Meier method and Cox regression adjusted for sex, age, calendar period, primary sclerosing cholangitis, and duration of UC. Of 2172 included patients, 843 (38.8%) underwent primary reconstruction, and 1329 (61.2%) staged reconstruction. Staged reconstruction was associated with a decreased risk of failure compared with primary reconstruction (hazard ratio, 0.73; 95% CI, 0.58-0.91). The 10-year cumulative risk of failure was 15% vs 20% after staged and primary reconstruction, respectively. In all, 1141 patients (52.5%) received an IPAA and 1031 (47.5%) an IRA. In stratified multivariable models, staged reconstruction was more successful than primary reconstruction in both IRA (hazard ratio, 0.75; 95% CI, 0.54-1.04) and IPAA (hazard ratio, 0.73; 95% CI, 0.52-1.01), although risk estimates failed to attain statistical significance. In UC patients undergoing colectomy, postponing restorative surgery may decrease the risk of failure.

Preservation of the superior rectal artery in laparoscopic colectomy for slow transit constipation: Is it really associated with better outcomes?

Few patients with slow-transit constipation refractory to conservative treatment can benefit with a subtotal colectomy with ileorectal anastomosis with the preservation of the superior rectal artery. In this letter to the editor some important issues were discussed. First, the study did not include a comparison group. Second, they did not present the functional results in the short or long term related to the bowel function of these patients after surgery. Finally, the authors showed that this surgical procedure was safe, and no cases of leakage were found.

S2941 Fecal Microbiota Transplant in Recurrent Clostridium difficile Enteritis Following Colectomy

Introduction: Fecal microbiota transplant (FMT) is well-known as treatment for recurrent Clostridium difficile infection (CDI). It is curative in 80% of severe or fulminant CDI cases. In this case, we explore the utility of FMT in a patient with recurrent C. diff enteritis (CDE) after colectomy with ileorectal anastomosis. Case Description/Methods: A 46 yr old woman underwent abdominal colectomy with ileostomy 05/2020 with ileorectal anastomosis 07/2020 for severe colonic inertia and h/o ligament release for Median Arcuate Ligament Syndrome in 2/2021. She initially presented with RUQ abdominal pain, nausea, vomiting and diarrhea during the 1st episode of CDI in 10/2020 which was treated with Vancomycin 125mg PO QID for 10 days. Symptoms recurred a month later, C. diff toxin (CDT)+, and this 2nd episode was treated with 3 weeks of Vancomycin 125mg PO QID. Symptoms resolved but recurred 5 months later with hospital admission, again CDT+. CBC and renal function were normal. CT abdomen/pelvis showed nonspecific prominent fluid-filled loops of proximal and mid small bowel consistent with focal ileus or enteritis. Patient was treated for the 3rd time on a prolonged Vancomycin taper (125mg QID x 10 days, 125mg TID x 7 days, 125mg BID x 7 days, 125mg QD x 7 days, 125mg QOD x 14 days) with plans for FMT. She was readmitted 2 months later for pain, nausea, vomiting and diarrhea, CDT-, and underwent planned FMT. FMT was performed via flexible sigmoidoscopy reaching 70cm proximal to the anus with 250cc of donor fecal material mixed with saline (Open Biome). Since FMT, patient has reported resolution of symptoms. Discussion: FMT for recurrent CDI in patients s/p colectomy is not well-documented. A small series of patients s/p colectomy over 20 years showed recurrent CDE does occur after colectomy, and results in severe disease in half of patients, requiring hospitalization in 81%. Risk factors for CDE were colectomy for IBD, colectomy for fulminant CDI, β-lactam use with enteral feeds, and acid suppression after colectomy. Cases of fulminant CDE with multiorgan failure and death have been reported (diagnosed post-mortem). A young man with UC s/p colectomy with IPAA with recurrent CDE was effectively treated with FMT. While rare, recurrent CDE is potentially fatal and warrants consideration of FMT as a treatment modality. Though our patient did not have IBD, was not immunosuppressed and underwent colectomy for reasons unrelated to IBD, the recurrent CDE was effectively treated with FMT.

Characterizing Pediatric Familial Adenomatous Polyposis in Patients Undergoing Colectomy in the United States

To characterize a multi-institutional cohort of pediatric patients who underwent colectomy for familial adenomatous polyposis (FAP). In this retrospective cohort study, diagnosis and procedure codes were used to identify patients who underwent colectomy for FAP within the Pediatric Health Information System (PHIS). The inclusion criteria were validated at 3 children's hospitals and applied to PHIS to generate a cohort of patients with FAP between 2 and 21years who had undergone colectomy between 2009 and 2019. Demographics, clinical and surgical characteristics, and endoscopic procedure trends as identified through PHIS are described. Descriptive and comparative statistics were used to analyze data. Within the PHIS, 428 pediatric patients with FAP who underwent colectomy were identified. Median age at colectomy was 14years (range 2-21years); 264 patients (62%) received an ileal pouch anal anastomosis and 13 (3%) underwent ileorectal anastomosis. Specific anastomotic surgical procedure codes were not reported for 151 patients (35%). Endoscopic assessment at the surgical institution occurred in 40% of the cohort before colectomy and in 22% of the cohort following colectomy. In this cohort, colectomy took place at an earlier age than suggested in published guidelines. Ileal pouch anal anastomosis is the predominant procedure for pediatric patients with FAP who underwent colectomy in US pediatric centers. Endoscopic assessment trends before and after surgery suggest that the surgical institution plays a limited role in the care of this population.

Double-scope rendezvous technique: a safe way to perform an endoscopic ultrasound-guided ileorectal anastomosis after complete stenosis.

Double-scope rendezvous technique: a safe way to perform an endoscopic ultrasound-guided ileorectal anastomosis after complete stenosis.

Ileorectal anastomosis in patients with Crohn's disease. Postoperative complications and functional outcome-a systematic review.

The objective of this systematic review was to investigate the outcomes of ileorectal anastomosis (IRA) in Crohn's disease and to clarify whether there are any time-related trends in outcome measures. The primary outcomes are risk of anastomotic leakage, death, clinical recurrence and subsequent diverting or permanent stoma and/or proctectomy. Secondary end-points are quality of life and functional outcome. Systematic searches were conducted using the Cochrane Library, Embase and MEDLINE. The complete search strategy is uploaded online at http://www.crd.york.ac.uk/prospero/. Human studies in English with over five subjects were included and no limit was set regarding the date of publication. All relevant studies were screened by two reviewers. The web-based software platform www.covidence.org was used for primary screening of the title, abstract, full-text review and data extraction. The search identified 2231 unique articles. After the screening process, 37 remained. Key results were an overall anastomotic leak rate of 6.4%; cumulative rates of clinical recurrence of 43% and 67% at 5 and 10years, respectively; an overall rate of proctectomy of 18.9%; and subsequent ileostomy required in 18.8%. Only one study presented useful data on quality of life. Recurrence rates remained stable over time. A small decline in the anastomotic leak rate was found. Only minor improvements in the outcomes of IRA in patients with Crohn´s disease have occurred during the past 50years regarding anastomotic leakage and recurrence, except for a slight increase in the rate of a functioning IRA. These results call for implementation guidelines in patient selection for IRA and postoperative medical treatment and follow-up.

Risk of extracolonic malignancies and metachronous rectal cancer after colectomy and ileorectal anastomosis in familial adenomatous polyposis

BackgroundAnalysis of long-term clinical outcomes of patients with familial adenomatous polyposis is critical in reducing or preventing the incidence of extracolonic malignancies after initial surgery. The aim of the present study was to clarify the long-term outcomes, and establish a surveillance strategy for surgically treated familial adenomatous polyposis patients. MethodsBetween January 1967 and March 2020, retrospective data were collected from 37 patients with familial adenomatous polyposis treated or monitored in our department. Occurrence of metachronous cancers, including rectal cancers and extracolonic malignancies, and other diseases was analyzed. ResultsThe median follow-up duration after the first surgery was 13.8 years. Initially, 16 patients underwent total proctocolectomy with ileal pouch-anal anastomosis, 18 underwent total colectomy with ileorectal anastomosis, and three underwent other procedures. A secondary proctectomy was performed for 9 of the 18 patients who underwent ileorectal anastomosis. Rectal cancer was diagnosed in 6 patients who underwent ileorectal anastomosis. In addition, 5 gastric cancer, 2 duodenal cancer, 1 gallbladder cancer, and 1 thyroid cancer cases were diagnosed. The age at which the extracolonic malignancies were diagnosed was >50 years. 4 patients died due to metachronous rectal cancer, gastric cancer, or gallbladder cancer. ConclusionCareful consideration should be paid before choosing ileorectal anastomosis as the treatment procedure for familial adenomatous polyposis patients because completion proctectomy was eventually necessary for half of the patients. Long-term surveillance, with more frequent gastric surveillance for patients over 50 years, is important for the prevention and treatment of extracolonic malignancies in familial adenomatous polyposis patients.

Endoscopic Treatment of a Total Ileorectal Anastomosis Stenosis using Magnets.

Endoscopic Treatment of a Total Ileorectal Anastomosis Stenosis using Magnets.

PARCELAR GASTRIC RESECTION IN ASSOCIATION WITH BOWEL RESECTIONS AS PART OF DEBULKING SURGERY FOR ADVANCED STAGE OVARIAN CANCER – A CASE REPORT

Ovarian cancer represents one of the most aggressive gynecological malignancies affecting women worldwide, associated with significant rates of cancer related death within the first years after the initial diagnostic. The poor survival rates are usually explained by the presence of disseminated lesions even from the beginning. In such situations, the digestive tube is one of the most commonly involved territory, therefore necessitating extended resections in order to achieve complete cytoreduction. The aim of this paper is to report the case of a 53 year old patient who was diagnosed with peritoneal carcinomatosis from ovarian cancer, presenting multiple levels of digestive tract involvement due to the presence of disseminated tumoral masses. Therefore the patients was submitted to multiple digestive resections represented by parcelar gastrectomy, segmental ileal resection and subtotal colectomy. In order to minimize the risks of developing severe postoperative complications – due to the relatively high number of anastomoses – the continuity of the digestive tract was established by a terminal ileostomy, considering that creation of a ileorectal anastomosis would be too dangerous in the context of multiple digestive resections. The postoperative evolution was simple, the patient being further submitted to adjuvant treatment.

Prophylactic colectomy and rectal preservation in FAP: systematic endoscopic follow-up and adenoma destruction changes natural history of polyposis.

Background and study aims Prophylactic surgery of familial adenomatous polyposis (FAP) includes total colectomy with ileorectal anastomosis (IRA) to proctocolectomy with ileoanal anastomosis (IAA). Surgical guidelines rely on studies without systematic endoscopic follow-up and treatment. Our aim was to report our experience based on a different approach: therapeutic follow-up, comparing in this setting IRA and IAA in terms of oncological safety and quality of life. Patients and methods Between January 1965 and November 2015, all patients who underwent prophylactic surgery for FAP with therapeutic endoscopic follow-up in Lyon University hospital: systematic endoscopic treatment of adenomas, were retrospectively and prospectively (since 2011) included. Results A total of 296 patients were analyzed: 92 had proctocolectomy with IAA (31.1 %), 197 total colectomy with IRA (66.5 %), and seven abdominoperineal resections (2.4 %). Median follow-up was 17.1 years (range, 0–38.1). Incidence of secondary cancer (IR vs. IAA) was 6.1 % vs. 1.1 % ( P = 0.06; 95 %CI 0.001–0.36). The 15-year cancer-free and overall survival (IR vs. IAA) were 99.5 % vs 100 % ( P = 0.09) and 98.9 % vs. 98.8 % ( P = 0.82), respectively. Postoperative morbidity occurred in 44 patients: 29 (14.7 %) in the IRA and 15 (16.3 %) in the IAA group ( P = 0.72). The mean number of stools per day in the respective groups were 4.4 (2.5) vs. 5.5 (2.6) ( P = 0.001). Fecal incontinence occurred in 14 patients (7.1 %) in the IRA vs. 16 (17.4 %) in the IAA group ( P = 0.03). Conclusions A combination of therapeutic endoscopic treatment and extended rectal preservation appears to be a safe alternative to ileoanal J-pouch anastomosis.

Preservation of superior rectal artery in laparoscopically assisted subtotal colectomy with ileorectal anastomosis for slow transit constipation.

BACKGROUNDSlow transit constipation (STC) has traditionally been considered as a functional disorder. However, evidence is accumulating that suggests that most of the motility alterations in STC might be of a neuropathic etiology. If the patient does not meet the diagnosis of pelvic outlet obstruction and poorly response to conservative treatment, surgical intervention with subtotal colectomy may be effective. The most unwanted complication of the procedure is anastomotic leakage, however, preservation of the superior rectal artery (SRA) may reduce its incidence.AIMTo evaluate the preservation of the SRA in laparoscopically assisted subtotal colectomy with ileorectal anastomosis in STC patients.METHODSThis was a single-center retrospective observational study. STC was diagnosed after a series of examinations which included a colonic transit test, anal manometry, a balloon expulsion test, and a barium enema. Eligible patients underwent laparoscopically assisted total colectomy with ileorectal anastomosis and were examined between January 2016 and January 2018. The operation time, blood loss, time to first flatus, length of hospital days, and incidence of minor or major complications were recorded.RESULTSA total of 32 patients (mean age, 42.6 years) who had received laparoscopic assisted subtotal colectomy with ileorectal artery anastomosis and preservation of the SRA. All patients were diagnosed with STC after a series of examinations. The mean operative time was 151 min and the mean blood loss was 119 mL. The mean day of first time to flatus was 3.0 d, and the mean hospital stay was 10.6 d. There were no any patients conversions to laparotomy. Post-operative minor complications including 1 wound infection and 1 case of ileus. There was no surgical mortality. No anastomosis leakage was noted in any of the patients.CONCLUSIONLaparoscopically assisted subtotal colectomy with ileorectal anastomosis and preservation of the SRA can significantly improve bowel function with careful patient selection. Sparing the SRA may protect against anastomosis leakage.

TAMIS for Recurrent Cancer of the High Rectum (25 cm from the Anal Verge) in a Patient with Serious Associated Disorders (Rescue Surgery)

INTRODUCTION Transanal Minimally invasive surgery (TAMIS) is indicated for benign lesions of the rectum distant up to 5 cm and not exceeding more than 1/3 of the rectal circumference; for early stage malignancies confined to the submucosa (T1 sm1 according to the Kikuchi classification); for cancers after complete response to neoadiuvant treatments or with T1 residue (due to a risk of mesorectal positive lymph node between 3-6%); for T2-T3 N0 in patients who cannot undergo major surgical resections due to a compromised general (rescue surgery). TAMIS is especially recommended for neoplasms located at a distance between 5 and 18 cm from the anal verge. CASE PRESENTATION We performed TAMIS on a 72-year-old patient diagnosed with diffuse polyposis syndrome (FAP), with multimorbidity and a history of recurrences, all treated with surgical resection, AND with a new recurrence on the ileo-rectal anastomosis at about 25 cm from the anal verge. A rectoscopy and a total body CT were performed (anastomotic level; size 2 cm; staging: cT1-2, N0, M0; histology: adenocarcinoma). The final decision after multidisciplinary meeting was for TAMIS, due to high intra- and post-operative risk contraindicating major surgery. Data regarding total operating time, blood losses, length of stay, surgical and general intra and post-operative complications, resumption of nutrition and therapies (antibiotics and pain relievers) were collected. The operation was successful, with a total operating time of 55 minutes, and an estimated blood loss of 20 ml. The patient was rapidly mobilized and nutrition promptly resumed. The length of stay was 3 days. We did not observe any complications. CONCLUSION We showed for this patient the feasibility and safety of TAMIS resections at greater distances than those normally recommended.

DOP33 Predictors of ileo-rectal anastomosis, permanent ileostomy and recurrence of disease after total colectomy for Crohn’s Colitis: Results over 20 years

Abstract Background Patients with surgical Crohn’s colitis (CC) might either undergo a total colectomy (TC) and ileo-rectal anastomosis (IRA), or TC and end ileostomy. Among the latter group, a second-stage IRA is not always performed. The predictors of the different outcomes after TC (including the recurrence of disease at the level of the anastomosis) are yet to be identified. Methods Retrospective study including 354 patients undergoing TC for CC (2000–2019), with a minimum preoperative follow-up of 2 years in our centre. The mean postoperative follow-up was 67.5+/-49.8 months (62 patients lost). The primary end-points were to identify the predictors for the following outcomes: a) IRA (87 cases, 24.6%) vs. end ileostomy (267 cases, 75.4%) at the primary colectomy. b) second-stage IRA (80 cases, 39%) vs. no IRA (125 cases, 61%) at the last follow-up. c) recurrence of the disease after IRA (167 patients). Considering the large number of regressors and the risk of over-fitting, the least absolute shrinkage and selection operator (LASSO) method was used. A multivariate analysis was carried out using the preselected covariates. The analysis was conducted using logistic regression and cox regression for dichotomus and time-dependent outcomes. A p-value<0.05 was considered significant. Results a) Predictors against the IRA at primary TC: preoperative biologic exposure (OR=1.96, CI 1.15–3.33, p=0.014), Crohn’s rectal location (OR=4.17, CI 2.0–8.33, p<0.0001), perianal disease (OR=3.33, CI 1.75–6.25, p<0.0001), and low hemoglobin concentration (OR=1.26, CI 1.01–1.58, p=0.037). b) Predictors of the risk of still having the ileostomy at the follow-up: age (OR: 1.02, CI 1.00–1.04, p=0.045), exposure to biologics before (OR 1.85, CI 1.11–3.03, p=0.017) and after (OR 1.79, CI 1.11–2.89, p=0.018) the TC; postoperative use of azathioprine was associated with a greater chance of a second-stage IRA (OR 2.66, CI 1.21–5.83, p=0.014). c) Risk of anastomotic recurrence was 8.7% and 30.8% at 5 and 10 years. Significant predictors were: female gender (OR 2.38, CI 1.11–5.55, p=0.046), use of more than one biologic (OR 5.65, CI 2.18–9.89, p<0.0001) and worsening of symptoms needing for drug escalation (OR 5.51, CI 2.06–8.59, p=0.001) during the follow-up. Conclusion The location and severity of the disease at diagnosis predict the long-term behavior of the disease. The exposure to biologics, especially if multiple drugs are required, does not represent a risk for worse outcomes per se, but rather identifies a population at higher risk of permanent ileostomy due to more severe disease. These predictors might be implemented in the assessment of patients affected by CC, in order to identify the population at risk of permanent ileostomy.

P090 Risk of Rectal Cancer after Colectomy in Patients with Inflammatory Bowel Disease – A Nationwide Population-based Danish Cohort Study 1978–2018

Abstract Background The risk of surgery remains high both among patients with ulcerative colitis (UC) and patients with Crohn’s disease (CD) with a cumulative risk of subtotal colectomy with ileostomy and diverted rectum of 7.5% after 5 years in UC and a similar risk in CD. Ileostomy with diverted rectum after colectomy may be permanent, or the patient can undergo restorative surgery with ileo-rectal anastomosis (IRA) or ileal pouch-anal anastomosis (IPAA). Risk of rectal cancer in this patient population remains uncertain. We performed a nationwide population-based Danish study of rectal cancer (RC) risk after subtotal colectomy. Methods Through the Danish Civil Registration System, a source population of all individuals 15 years or older living in Denmark between 1978 and 2018 was retrieved. By use of the unique personal identification number given to all citizens at birth, this source population was linked to the Danish National Patient Registry (NPR) in order to identify all patients with inflammatory bowel disease (IBD). Patients with a diverted rectum, IRA or IPPA after colectomy were also identified with NPR. Cases of RC were identified in the Danish Cancer Registry. Patients with IBD were followed from the date of surgery until cancer, emigration, death or end of the study. The risk of RC in patients with diverted rectum was assessed using Cox regression analyses, as compared to the background population as well as to subjects with IBD without subtotal colectomy. Results RC occurred in 42 (0.9%) of 4931 patients after subtotal colectomy with diverted rectum, compared to 209 (0.4%) of 49,251 in the matched IBD cohort with no colectomy and 941 (0.4%) of 246,550 in the matched background population. In the IBD and subtotal colectomy population 11 (26%) of the 42 cases were in patients diagnosed with CD and 31 (74%) were in patients with UC. The hazard ratio (HR) for RC in IBD patients with diverted rectum vs. matched IBD patients without colectomy (adjusted for IBD type and sex) was 0.80 (95% CI 0.29, 2.17) during the first 10 years of follow-up and 7.93 (95% CI 5.48, 11.48) 10 years or more after colectomy. Likewise, the HR for RC in IBD patients with diverted rectum compared to the matched background population was 0.85 (95% CI 0.32, 2.28) during the first 10 years of follow-up and 10.25 (95% CI 7.36, 14.28) 10 years or more after colectomy. Conclusion In our nationwide population-based cohort study covering years 1978–2018 we observed an 8 to 10-fold increased risk of RC of the diverted rectum 10 years after colectomy.These data suggest a need for developing a specific surveillance strategy for this group of IBD patients.

P293 Local Mesenchymal Stem Cells injection in Crohn’s disease strictures: a phase I-II, open-label clinical study

Abstract Background Intestinal fibrosis is a common complication of Crohn’s disease (CD) leading to progressive bowel stricture formation. Mesenchymal stem cells (MSCs), known for their immunomodulatory, anti-inflammatory and anti-fibrotic properties, could be a potential therapy in this frequently fibro-inflammatory condition. In this phase I–II open-label pilot trial, we aimed to assess safety and efficacy of local MSCs injection in CD strictures. Methods: CD patients with a non-passable stricture, length from 2 to 5 cm, accessible by ileocolonoscopy, but without intestinal obstruction, fistulas, or abscess, could be included. A total of 3X107 allogenic bone-marrow derived MSCs were equally injected in the 4 quadrants of the strictured bowel wall during an ileocolonoscopy. Adverse events and clinical scores (Crohn Disease Activity Index, Short Health Scale and Crohn Disease Obstructive Score) were evaluated at each follow-up visit (at week 4, 12, 24 and 48) while endoscopy was performed at baseline, W12 and W48. The main judgement criteria for efficacy was the complete (defined by the ability to pass the ileocolonoscope) or partial (defined by a diameter increase) resolution of the stricture at 12 weeks. Other efficacy criteria included complete or partial resolution of the stricture at 48 weeks as well as the evolution of clinical scores between weeks 0, 12 and 48. Results Between 2018 and 2020, we performed 11 local MSCs injections in 10 CD patients (6 female; aged to 38-65 years; median 45 years old; 70% were smoker). The strictures’ (3 primary, 7 anastomotic) location was as follows: 7 at an ileo-colonic or ileo-rectal anastomosis, 1 colonic and 2 of the ileocecal valve. MSCs injections were well tolerated but a total of 5 hospitalizations for occlusion were reported (2 secondary to a different stricture than the injected one) leading to a surgical resection for one patient and an endoscopic dilatation for another one. Neither intestinal perforation nor intra-abdominal fistula or abscess was reported. At 12 weeks, 5 patients (45%) presented a stricture improvement with a complete resolution for 2 and a partial resolution for 3. Of the 11 MSCs injections, 6 patients were re-evaluated at week 48 (2 patients still undergoing follow-up, 1 operated, 1 dilated, and 1 lost to follow-up), 4 patients had a complete resolution and 1 had a partial resolution. The evolution of clinical scores between weeks 0, 12 and 48 (Figure 1) was not statistically significant. Conclusion Local MSCs injection in non-passable CD stricture was well tolerated over the short term but several occlusions were reported in the follow-up. Combining the effects of MSCs with the proven effect of endoscopic balloon dilatation could possibly improve the outcome of CD stricture.

The Usefulness of Preoperative Evaluation for Intractable Slow Transit Constipation by Computed Tomography.

Objectives: Total colectomy with ileorectal anastomosis is the gold standard surgical procedure for patients with slow transit constipation (STC). This operation's outcomes are highly variable; however, predictors of postoperative outcomes after surgical treatment of intractable STC remain unclear. This study aimed to clarify the usefulness of preoperative evaluation for intractable STC by computed tomography (CT) in predicting postoperative outcomes. Methods: From January 2011 to December 2018, 22 patients with intractable STC underwent laparoscopic total colectomy with ileorectal anastomosis at the Kashiwa Hospital, Jikei University. They were divided into two groups, eighteen patients in the colonic inertia type (CI) group, and four patients in the spastic constipation type (SC) group, by preoperative CT according to specific criteria. Results: There were no significant differences in the mean age, gender, mean operation time, or mean intraoperative blood loss. The SC group's postoperative hospital stay was significantly longer than that of the CI group. Postoperative gastric outlet obstruction occurred in two patients (11%) who underwent distal partial gastrectomy with R-Y reconstruction after the surgery in the CI group but no patients in the SC group. Postoperative pelvic outlet obstruction occurred in all four patients who underwent ileostomy within a year after surgery in the SC group but no patients in the CI group. Conclusions: The outcomes of total colectomy in the treatment of intractable STC are highly variable. Preoperative evaluation for intractable STC by CT seems to be a useful predictor of postoperative outcomes.

Anal Squamous Cell Carcinoma in Ulcerative Colitis: Can Pouches Withstand Traditional Treatment Protocols?

Anal squamous cell carcinoma has rarely been reported in the setting of ulcerative colitis. This study aimed to understand the prognosis of anal squamous cell carcinoma in the setting of ulcerative colitis. This is a retrospective review. This study was conducted at a referral center. Adult patients with both ulcerative colitis (556.9/K51.9) and anal squamous cell carcinoma (154.3/C44.520) between January 1, 2000 and August 1, 2019 were included. The primary outcomes measured are treatment and survival of anal squamous cell carcinoma. Of the 13,499 patients with ulcerative colitis treated, 17 adult patients with ulcerative colitis and anal dysplasia and/or anal squamous cell carcinoma were included in the study: 6 had a diagnosis of anal squamous cell carcinoma, 8 had high-grade squamous intraepithelial lesions, and 3 had low-grade squamous intraepithelial lesions. There were 4 men (23%) and a median age of 55 years (range, 32-69) years. At diagnosis, 6 had an IPAA, of which 5 had active pouchitis, 1 had an ileorectal anastomosis with active proctitis, 1 had a Hartmann stump with disuse proctitis, 5 had pancolitis, and 4 had left-sided colitis. Of the 6 with anal squamous cell carcinoma, all received 5-fluorouracil and mitomycin C with external beam radiation therapy. Four patients had an IPAA, all of whom required intestinal diversion or pouch excision because of treatment intolerance. At a median follow-up of 60 months, 3 patients died: one at 0 months (treatment-related myocardial infarction), one at 60 months (metastatic anal squamous cell carcinoma), and one at 129 months (malignant peripheral nerve sheath tumor); the remaining patients had no residual disease. This study was limited because of its retrospective nature and small number of patients. Anal squamous cell carcinoma in the setting of ulcerative colitis is extremely rare. In the setting of IPAA, diversion may be necessary to prevent radiation intolerance. Careful examination of the perianal region should be performed at the time of surveillance endoscopy. See Video Abstract at http://links.lww.com/DCR/B582. ANTECEDENTES:La incidencia de cáncer anal de células escamosas es muy baja en pacientes con colitis ulcerosa.OBJETIVO:Comprender el pronóstico del cáncer anal de células escamosas en el contexto de la colitis ulcerosa.DISEÑO:Revisión retrospectiva.AJUSTE:Centro de referencia.PACIENTES:Pacientes adultos con colitis ulcerosa (556.9 / K51.9) y cáncer anal de células escamosas (154.3 / C44.520) entre el 1 de enero de 2000 y el 1 de agosto de 2019.RESULTADOS PRINCIPALES:Tratamiento y sobrevida del cáncer anal de células escamosas.RESULTADOS:De 13.499 pacientes en tratamiento por colitis ulcerosa, diecisiete presentaron displasia y/o cáncer de células escamosas: 6 con cáncer, 8 con lesiones intraepiteliales escamosas con displasia de alto grado y 3 con displasia de bajo grado.Cuatro son hombres (23 %) con una mediana de 55 años (rango 32-69). Al realizar el diagnóstico 6 tenían pouch, 5 con pouchitis activa; 1 con ileorecto anastomosis con proctitis activa y 1 con operación de Hartman y muñón con colitis por desuso; además 5 tenían pancolitis y 4 tenían colitis izquierdaTodos los casos con cáncer anal de células escamosas (6 pacientes), fueron tratados con 5-FU mas Mitomicina y radioterapia externa. Cuatro pacientes tenían pouch, todos requirieron derivación intestinal o escisión del pouch por intolerancia al tratamiento.En la mediana de seguimiento de 60 meses, tres pacientes fallecieron: uno a los 0 meses (infarto de miocardio relacionado con el tratamiento), uno a los 60 meses (cáncer de células escamosas metastásico) y uno a los 129 meses (tumor maligno de la vaina del nervio periférico); el resto no presentaba enfermedad residual.LIMITACIONES:Revisión retrospectiva, número pequeño de pacientes.CONCLUSIÓN:El cáncer anal de células escamosas en el contexto de la colitis ulcerosa es extremadamente raro. En el contexto de IPAA, la derivación puede ser necesaria para prevenir la intolerancia a la radiación. Se debe realizar un examen cuidadoso de la región perianal en el momento de la endoscopia de control. Consulte Video Resumen en http://links.lww.com/DCR/B582.

Slow transit constipation

Slow transit constipation (STC) is arare condition almost exclusively encountered in middle-aged women. Pathophysiology and aetiology are poorly understood but amulti-factorial pathogenesis seems likely. With regard to differential diagnoses mechanical, drug induced, degenerative, metabolic, endocrinologic, neurologic, and psychiatric causes of constipation must be excluded by an interdisciplinary approach. Gastrointestinal physiologic investigations including colonic transit studies are mandatory. Furthermore, pangastrointestinal delay, pelvic floor dysfunction, and irritable bowel syndrome should be excluded. Initial treatment is strictly conservative. In cases of progression or persistence of symptoms surgical therapy should be discussed. Subtotal colectomy with ileorectal anastomosis is regarded as the standard operation for STC. Using strict selection criteria, overall success rates are reported in excess of 80%.

Safe Anastomoses without Ostomies in Cytoreductive Surgery with Heated Intraperitoneal Chemotherapy: Technical Considerations and Modifications.

Gastrointestinal complications, predominantly anastomotic leak (AL), are the most frequent source of severe morbidity after cytoreductive surgery (CRS). The aim of this study was to present the technical standards for colorectal anastomoses developed and systematically applied to all patients undergoing CRS in a high-volume tertiary center, and the associated AL rates. This was a descriptive study reporting the technical characteristics of a standardized protocol for three types of colorectal anastomoses (colorectal, ileorectal, and ileocolic) in CRS with heated intraperitoneal chemotherapy (HIPEC), and a retrospective analysis of prospectively collected data on anastomotic outcomes. All patients (1172) undergoing CRS with HIPEC from September 2006 to September 2020 were included. The anastomotic complications were classified according to the International Study Group of Rectal Cancer Surgery (ISGRCS) classification. Overall, 1172 patients underwent 1300 procedures and 1359 gastrointestinal anastomoses. An ileocolic anastomosis was performed in 408 patients, colorectal anastomosis in 469 patients, and ileorectal anastomosis in 16 patients, none with diverting ileostomy; 345 other gastrointestinal reconstructions and 82 urinary reconstructions were performed in these patients. The AL rate was 1% (4/408) for the ileocolic anastomosis, 0.85% (4/469) for the colorectal anastomosis, and 0% (0/16) for the ileorectal anastomosis. One patient died postoperatively due to AL. Systematic application of standardized techniques adapted to ensure optimal tissue healing (stapled anastomoses avoiding overlap, accurate staple deployment, and hand-sewn reinforcement) are associated with a very high level of anastomotic safety in a large cohort of patients undergoing CRS and HIPEC.