Proctocolectomy For Ulcerative Colitis Research Articles

Risk Factors for Stoma Outlet Obstruction after Proctocolectomy for Ulcerative Colitis.

Stoma outlet obstruction (SOO) occurs with an incidence of approximately 40% after proctocolectomy for Ulcerative colitis (UC) with diverting ileostomy. This study aimed to identify the risk factors for SOO after proctocolectomy with diverting ileostomy for patients with UC. We reviewed the data of 68 patients with UC who underwent proctocolectomy and diverting ileostomy between April 2006 and September 2021. These cases were analyzed on the basis of clinicopathological and anatomical factors. SOO was defined as small bowel obstruction displaying symptoms of intestinal obstruction, such as abdominal distention, abdominal pain, insertion of a tube through the stoma. The study included 38 (56%) men and 30 (44%) women with a median age of 42 years (range, 21-80). SOO categorized as at least Clavien-Dindo grade II occurred in 11 (16%) patients. Six patients required earlier stoma closure than scheduled. Compared with patients without SOO, patients with SOO had a significantly higher total steroid dose from the onset of UC to surgery (p = 0.02), a small amount of intraabdominal fat (p = 0.04), and a higher rate of laparoscopic surgery (p < 0.01). A high preoperative steroid dose, a small amount of intraabdominal fat and laparoscopic surgery were identified as risk factors for SOO. Early detection and treatment for SOO are important for patients at risk.

Comprehensive systematic review and pooled analysis of real-world studies evaluating immunomodulator and biologic therapies for chronic pouchitis treatment.

Pouchitis is a common complication after restorative ileal pouch-anal anastomosis following proctocolectomy for ulcerative colitis. Antibiotic-dependent or antibiotic-refractory chronic pouchitis (CP), which is a common cause of pouch failure affecting 15-20% of patients, is challenging to treat. The efficacy of second-line immunomodulator and biologic therapy remains poorly defined. We present a pooled analysis of real-world efficacy data from peer-reviewed full-text manuscripts, focusing on immunomodulator and biologic therapies in CP. Embase and PubMed databases were searched for full-text articles describing the treatment of CP. We performed a systematic review and pooled analysis of published studies to assess the efficacy of immunomodulators, including thiopurines and methotrexate, and biologics including antitumor necrosis factor, anti-integrin, and interleukin-12/23 antagonists. Clinical and endoscopic response and remission rates were combined for pooled analyses. Rates of treatment discontinuation and safety were also assessed. Pooled analysis comprised 20 full-text articles (485 patients). Overall clinical response rate was 46% (95% CI: 35-59%) and clinical remission rate was 35% (95% CI: 21-52%). Overall endoscopic response and remission rates were 41% (95% CI: 18-68%) and 15% (95% CI: 5-39%), respectively. Individual agents' safety profile was reassuring, with vedolizumab being the most favorable. The real-world efficacy data of immunomodulators in the treatment of CP is insufficient. Vedolizumab and ustekinumab appeared effective and safe for CP, whereas anti-TNFs showed higher rates of adverse events. The high heterogeneity within the studies is attributed to the real-world study design, obfuscating drug efficacy comparisons across the studies. Further studies are required to define the comparative effectiveness of available treatments of CP.

Long-term behavior and functional outcomes of ileal-pouch anal anastomosis in inflammatory bowel disease with changing phenotype

BackgroundIleal-pouch-anal anastomosis is the operation of choice after proctocolectomy for ulcerative colitis; some patients will develop Crohn’s disease. We aim to determine long-term behavior and outcomes of inflammatory bowel disease–ileal-pouch-anal anastomosis after colectomy, where a specialist gastrointestinal pathologist re-evaluated the initial colectomy specimen. MethodsPatients with inflammatory bowel disease–ileal-pouch-anal anastomosis were identified from a single-surgeon prospective database containing 1,165 patients accrued from 1991 to 2017 and invited to complete pouch-function and quality-of-life assessments. Medical records were used to obtain clinical outcomes and subjective functional assessments for those unable to be contacted. Data were compared between patients with and without histological assessment disagreement and subsequent inflammatory bowel disease behavior subgroups. ResultsFor 138 patients included in the analysis, the median follow-up was 22.5 (range: 5–39) years. A total of 39.1% of patients had histologic diagnostic change after gastrointestinal pathologist review, and 19% and 39% developed Crohn’s disease-like disease behavior at 10- and 20-year follow-ups. Pouch function and quality-of-life scores were similar across diagnostic change subgroups. Pouch failure was higher in Crohn’s-like disease (31.1 vs 13.0%, P < .05). Intestinal continuity was maintained in 68.9% of Crohn’s disease-like patients, 57.9% required biologics. Gastrointestinal pathologist review did not alter the time to new diagnosis (P = .419) or time to pouch failure (P = .320), mean: 11.0 and 11.41 years, respectively. ConclusionWe describe equivocal patient-reported outcomes in patients with ileal-pouch-anal anastomosis and changing histologic and clinical diagnosis. Although pouch excision and biologic use rates are higher, many Crohn’s disease-like patients maintain their pouch. Diagnostic change and pouch failure often occur >10 years after ileal-pouch-anal anastomosis creation. This supports the consideration of ileal-pouch-anal anastomosis after colectomy in carefully selected patients with inflammatory bowel disease, even those with ambiguous histology and the need for close long-term follow-up.

P584 Efficacy, safety, and tolerability of AMT-101, a gut selective oral IL-10 fusion, in the Phase 2 FILLMORE trial of patients with chronic pouchitis

Abstract Background Chronic pouchitis can occur in up to half of patients within 10 years of ileal pouch-anal anastomosis (IPAA) after proctocolectomy for ulcerative colitis (UC). There is a large unmet need for medical treatments. Methods This was a phase 2, randomized double-blind, parallel-group, 2 active-arm trial of the combined phase 2/3 trial in adults (18-75 years) with a prior history of UC with proctocolectomy and subsequent IPAA, who presented with chronic or recurrent pouchitis. The trial was conducted in US, Canada, and Western Europe. Approximately 20 patients were planned to be randomized 1:1 to either 3 mg or 10 mg AMT-101 doses administered once daily, orally, for 12 weeks. The key efficacy endpoints were: 1) the proportion of patients with symptomatic improvement, as measured by stool frequency response, and 2) the proportion of patients with histologic healing, as measured by Geboes scores. Histology and endoscopy were centrally read. Results 22 patients were randomized to receive AMT-101 3 mg (n=10) or 10 mg (n=12). The mean (SD) baseline absolute stool frequency was 13.4 (4.5). Overall, 36.4% (8/22) of patients achieved stool frequency response, defined as either a reduction of ≥ 3 stools and a ≥ 30% reduction in number of stools from baseline, or a return to post-IPAA number of stools or lower, at Week 12. 40% (4/10) and 33% (4/12) of patients dosed with 3 mg or 10 mg, respectively, achieved stool frequency response at Week 12. Rapidity of stool frequency response was demonstrated as early as Week 2 in both arms and was substantially maintained through Week 12. Patients had a median (IQR) baseline Geboes score of 5.1 (3.2 to 5.2), representing severe pouchitis with ulceration and tissue destruction. Across both arms, 22.7% (5/22) [20.0% (3 mg) and 25.0% (10 mg)] of patients met the histologic healing response of Geboes score ≤ 3.1, an objective assessment of disease improvement. Endoscopic assessments (SES-CD, ≥50% reduction) were also performed, with modest improvements [10% (3 mg) and 8.3% (10 mg)] at Week 12. There was no systemic AMT-101 PK (by design) nor anti-drug antibodies detected. Translational analysis revealed IL-10 biological responses in both arms. In tissue, IHC results showed increases in anti-inflammatory FOXP3+ (Tregs) and CD163+ (M2-macrophages) cells in the lamina propria. Treatment emergent adverse events were mostly mild to moderate, with only one treatment-unrelated serious adverse event. Conclusion AMT-101 3 mg and 10 mg both appeared to be safe and generally well tolerated. PK and translational data confirmed AMT-101’s gut-restricted profile over the 12-week treatment with tissue-level PD effects and no systemic exposure. The AMT-101 3 mg dose is advancing into a Phase 3 trial for chronic pouchitis.

P449 Minimally invasive IPAA in UC: Preliminary results from a referral center

Abstract Background Minimally invasive approaches in performing restaurative total proctocolectomy in Ulcerative Colitis(UC) have been increasingly adopted. In particular, the robotic approach could be used with more benefits in proctectomy with ileal pouch anal anastomosis (IPAA). In fact, the robotic device seems to potentially overcome all the limitations found in laparoscopic and conventional open surgery. The aim of our study was to compare and evaluate early and late functional postoperative outcomes and complications after IPAA, performed with open, laparoscopic and robotic techniques in UC patients. Methods At our institution, 397 UC patients who underwent restorative proctocolectomy with IPAA during the period 1986-2022, consecutively treated either with open surgery, laparoscopic or robotic techniques were enrolled. The incidence of early (&amp;lt;30 days) and late (&amp;gt;30 days) postoperative complications (intestinal occlusion, haematoma/wound infection, anastomotic dehiscence), hospital stay and an assessment about continence, autonomic nerve damage, incidence of pouchitis and cuffitis was evaluated. Results About the 397 patients, 344 underwent conventional open IPAA, 31 laparoscopically and 22 robotically. Comparable early and late postoperative surgical complications were recorded among the different techniques [early and late complications respectively 24/53 (45,2%) and 146/344(42,4%)] in minimally invasive and open groups. Minimally invasive surgery showed a better outcome regarding wound infections [0/53 (0%)], anastomotic dehiscence and reduced length of stay but open surgery demonstrated a better result on early and late intestinal occlusion [8/53 (15%)vs 22/344 (6,39%)] and anastomotic stenosis [5/53 (9,43%) vs 15/344 (4,36%)]. Lastly, the rate of cuffitis was higher in open surgery than in the minimally invasive group [(3/53 (5,66%) vs 46/344(13,37%)] and within these, robotic approach seems to show better results compared to laparoscopy. Conclusion UC patients undergoing IPAA could benefit from a minimally invasive surgical approach. Our experience confirms that robotics seems to be related to hopeful outcomes both in the short and long term period, even if more studies are needed to refine the promising results.

Does surgical approach matter in the treatment of pediatric ulcerative colitis?

BackgroundThis study aims to compare the morbidity of open versus laparoscopic colectomy or proctocolectomy for pediatric patients with ulcerative colitis (UC) using national readmission outcomes. Materials and methodsThe 2010–2014 Nationwide Readmissions Database was used to identify patients < 18 years (excluding newborns) who underwent colectomy or proctocolectomy for UC. Patients with planned readmissions for staged procedures were excluded from readmission analysis. Demographics, hospital factors, and outcomes were compared by operative approach (open vs. laparoscopic) using standard statistical analysis. Results were weighted for national estimates. ResultsThere were 1922 patients (51% female, age 13 ± 3 years) with UC who underwent colectomy or proctocolectomy during index admission. Most cases were performed open (54%) and as elective admissions (64%). Compared to open approach, laparoscopy was associated with shorter index hospital length of stay (8 [5-17] days vs. 9 [6-18] days, p = 0.015), fewer surgical site infections (< 2% vs. 2%, p = 0.022), and less post-operative gastrointestinal dysfunction (5% vs. 8%, p = 0.008). After stratifying to control for elective and unplanned index admissions, laparoscopic approach was associated with fewer small bowel obstructions during index hospitalizations in both elective (9% vs. 15%, p = 0.003) and unplanned (5% vs. 16%, p<0.001) settings. Readmission for surgical site infection was also less common following laparoscopic approach in both elective (0% vs. 7%, p = 0.008) and unplanned (0% vs. < 7%, p = 0.017) settings. ConclusionsIn pediatric patients with ulcerative colitis, laparoscopic colectomy or proctocolectomy is associated with shorter hospital length of stay, less post-operative complications, and improved readmission outcomes.

OP04 Vedolizumab intravenous is effective across multiple treatment targets in chronic pouchitis: Results of the randomised, double-blind, placebo-controlled EARNEST trial

Abstract Background Pouchitis is a common complication of ileal pouch-anal anastomosis (IPAA) after proctocolectomy in ulcerative colitis (UC). There are currently no approved therapies for chronic pouchitis. Here, we report a multicentre trial of intravenous (IV) vedolizumab (VDZ) for chronic pouchitis after IPAA in patients with UC. Methods EARNEST was a randomised, double-blind, placebo (PBO)-controlled, phase 4 study of VDZ in patients aged 18–80 years with chronic pouchitis after proctocolectomy with IPAA for UC (NCT02790138). Male and female patients with a history of IPAA for UC and chronic pouchitis were eligible. Patients were randomised (1:1) to receive VDZ IV (300 mg) or PBO on Day 1 and at Weeks (W) 2, 6, 14, 22 and 30, as well as ciprofloxacin for the first 4 weeks. The primary endpoint was modified Pouchitis Disease Activity Index (mPDAI) remission at W14; efficacy was also assessed through other mPDAI/PDAI secondary endpoints and endoscopic exploratory endpoints (assessed by a central reviewer) at W14 and W34. Safety (adverse events [AEs]) was monitored throughout the study. Results In total, 102 patients were treated (51 per group). Patients had a mean age of 40.8 years (VDZ) and 42.9 years (PBO). mPDAI remission rates (comprising clinical symptoms and endoscopy domains) were 31.4% (n=16/51) for VDZ vs 9.8% (n=5/51) for PBO at W14 (p=0.013; Figure 1). Significant differences in favour of VDZ over PBO were also seen in mPDAI remission at W34, mPDAI response at W14 and W34, and PDAI remission (comprising clinical symptoms, endoscopy and histology domains) at W14 and W34 (Figure 1). The rate of sustained remission (defined as remission at both W14 and W34) was higher for VDZ vs PBO on both the mPDAI (VDZ 27.5% [n=14/51] vs PBO 5.9% [n=3/51]; difference 21.6 percentage points [95% confidence interval (CI), 6.5–37.0]) and the PDAI (VDZ 31.4% [n=16/51] vs PBO 7.8% [4/51]; difference 23.5 percentage points [95% CI, 8.0–38.8]). Endoscopic ulceration analysis showed greater reductions in number of ulcers from baseline for VDZ over PBO at W14 and W34 (Figure 2). A higher proportion of patients in the VDZ vs PBO group had an improved SES-CD score and achieved SES-CD remission of pouchitis (Figure 2). AE rates were similar between groups and no new safety signals were identified (Table). Conclusion This is the first and largest randomised, double-blind PBO-controlled trial of biologic therapy to show significant benefits across multiple treatment outcomes in patients with chronic pouchitis after IPAA for UC. VDZ showed consistent treatment benefits over PBO across clinical, endoscopic and histologic endpoints, together with safety consistent with its established profile.

Prevalence of \u2018pouch failure\u2019 of the ileoanal pouch in ulcerative colitis: a systematic review and meta-analysis

Background and aimsThe ileoanal pouch (IPAA) provides patients with ulcerative colitis (UC) that have not responded to medical therapy an option to retain bowel continuity and defecate without the need for a long-term stoma. Despite good functional outcomes, some pouches fail, requiring permanent diversion, pouchectomy, or a redo pouch. The incidence of pouch failure ranges between 2 and 15% in the literature. We conducted a systematic review and meta-analysis aiming to define the prevalence of pouch failure in patients with UC who have undergone IPAA using population-based studies.MethodsWe searched Embase, Embase classic and PubMed from 1978 to 31st of May 2021 to identify cross-sectional studies that reported the prevalence of pouch failure in adults (≥ 18 years of age) who underwent IPAA for UC.ResultsTwenty-six studies comprising 23,389 patients were analysed. With < 5 years of follow-up, the prevalence of pouch failure was 5% (95%CI 3–10%). With ≥ 5 but < 10 years of follow-up, the prevalence was 5% (95%CI 4–7%). This increased to 9% (95%CI 7–16%) with ≥ 10 years of follow-up. The overall prevalence of pouch failure was 6% (95%CI 5–8%).ConclusionsThe overall prevalence of pouch failure in patients over the age of 18 who have undergone restorative proctocolectomy in UC is 6%. These data are important for counselling patients considering this operation. Importantly, for those patients with UC being considered for a pouch, their disease course has often resulted in both physical and psychological morbidity and hence providing accurate expectations for these patients is vital.

Expression of MAdCAM-1 and Gut-homing T Cells in Inflamed Pouch Mucosa

Pouchitis is a common complication following formation of an ileal pouch-anal anastomosis [IPAA] after proctocolectomy for ulcerative colitis [UC]. Gut-specific lymphocyte trafficking mechanisms have been identified as players in the pathogenesis of UC. In the present study, we aimed to characterise the presence of lymphocyte subsets expressing gut-homing molecules in pouches and peripheral blood of UC patients with and without pouchitis. Biopsy samples and peripheral blood were collected from 29 patients with an IPAA [seven with active inflammation, 22 without inflammation]. Expression of adhesion molecule MAdCAM-1 was assessed using immunohistochemistry, and flow cytometry was used to characterise expression of integrin α4β7, C-chemokine receptor 9 [CCR9], and CD103 on T cell subsets. MAdCAM-1 expression was significantly increased in case of active inflammation in the pouch. T cells expressing integrin α4β7 were abundant in the pouch mucosa, but the frequency of integrin α4β7-expressing T cells was decreased on CD4+ lymphocytes during inflammation. Co-expression of gut-homing markers CCR9 and α4β7 was more pronounced in biopsies compared with peripheral blood, but was not enhanced upon active inflammation. Gut-homing T cells are abundant in pouch mucosa, but the classic hypothesis that the chronic inflammatory state is maintained by an accumulation of α4β7-expressing effector T cells is not supported by our data.

The pouch behaving badly: management of morbidity after ileal pouch–anal anastomosis

Ileal pouch-anal anastomosis (IPAA), or a 'pouch', allows restoration of intestinal continuity after proctocolectomy for ulcerative colitis or familial adenomatous polyposis. Most patients have a good long-term outcome after IPAA, but in a significant proportion the functional outcome and quality of life are unsatisfactory. We term this outcome 'the pouch behaving badly'. Managing this, especially one is when unfamiliar with the possible underlying pathologies, is a challenge for both patient and clinician. We aim to outline the clinical approach to the pouch behaving badly, highlighting key aspects of investigation and management. This is a narrative review of the literature covering the investigation and management of postoperative complications and morbidity after IPAA. Management of the pouch behaving badly requires a careful clinical assessment. The patient may present with multiple symptoms and a clear picture of the symptomatology and past history should be constructed before thorough examination and specialist investigation. We divide the pathology that underlies this clinical scenario into surgical, inflammatory, mechanical, functional and dysplastic causes and outline the investigation and management of each one. The pouch behaving badly is a challenging problem for both patient and clinician. A detailed clinical assessment with careful specialist investigation is key to diagnosing the underlying pathology. We stress the importance of patient-centred care - the aim is to improve quality of life.

Successful treatment of recurrent volvulus in the afferent limb of the pouch following proctocolectomy for ulcerative colitis: a case report

BackgroundPouch volvulus after proctocolectomy for ulcerative colitis is a very rare postoperative complication. The common site of pouch volvulus has been reported to be the ileal pouch–anal anastomosis and the middle part of the pouch, but no reports on pouch volvulus in the afferent limb of the pouch have been observed. Here, we report the case of a patient with afferent limb volvulus who underwent afferent limbpexy, but required reoperation 7 months later.Case presentationA 38-year-old man with refractory ulcerative colitis had undergone open proctocolectomy 10 years ago at another hospital. He had been aware of lower abdominal pain and bowel movement difficulty for 2 years. After repeated bowel obstruction, he was referred to our hospital for surgery. Based on the radiographic findings, we diagnosed a pouch volvulus and performed an operation. Laparoscopically, counterclockwise rotation of the afferent limb of the pouch was recognized. Moreover, the ileal mesentery was adhered and fixed to the presacral space 20 cm from the oral side of the pouch. The antimesenteric side of the afferent limb was fixed using interrupted stiches on the left peritoneal wall of the pelvis. He was discharged uneventfully 18 days after surgery, and defecation improved immediately. However, he was readmitted 7 months after surgery with the same abdominal pain and defecation difficulty. A similar finding was found and diagnosed as recurrent volvulus. Therefore, we performed a laparoscopic surgery. The same volvulus as in the previous surgery was confirmed. The site fixed during the previous surgery showed scars, but the afferent limb was free. The dilated ileum that contained the volvulus was excised only on the oral side of the pouch and an intraluminal anastomosis was performed on the anterior wall of the pouch. He had a good postoperative course and was discharged.ConclusionProper diagnosis of volvulus based on the characteristic imaging findings is important. In principle, bilateral row fixation of the rotated ileum is the basic procedure for volvulus. However, fixation with this technique is sometimes difficult. Therefore, this procedure is one of the useful options for the fixation of difficult or recurrent cases.

Pouch failures following restorative proctocolectomy in ulcerative colitis

PurposeRestorative proctocolectomy (RPC) is the most common operation in ulcerative colitis. Nevertheless, permanent ileostomy will sometimes be unavoidable. The aim was to evaluate the reasons for pouch failure and early morbidity after pouch excision.MethodsThe number and the reasons for pouch failures were analysed in patients undergoing RPC 1985-2016.ResultsOut of 491 RPC patients, 53 experienced pouch failure (10 women, 43 men); 52 out of 53 underwent pouch excision. The cumulative risk for excision at 5, 10 and 20 years was 5.6, 9.4 and 15.5%, respectively. The reasons for failure included septic events such as fistula in 12 (23%), chronic pouchitis in 11 (21%) and leakage in 8 (15%) patients. Functional reasons for pouch failure were recorded as poor function in 16 (30%), incontinence in 12 (23%) and stricture in 12 (23%) patients. Multiple causes for pouch failure were recorded for individual patients. Seven cases of Crohn’s disease were found among the failure cases: two before pouch excision and five after. Altogether, 15 Crohn’s disease diagnoses were set in the RPC cohort, giving a percentage of 47% of pouch failure in this disorder. A complication occurred in 23 (44%) patients within 30 days after surgery; 16 were mild (Clavien-Dindo grades I–II).ConclusionsEleven percent of RPC patients suffered pouch failure: more men than women. The reasons were multiple. Crohn’s disease created a risk of failure, but a half of these patients maintained the pouch. Morbidity after pouch excision was moderate, but in most cases slight.

The Kock pouch in the 21st century (with videos)

In 1964, Dr Nils Kock first described the Kock pouch as a low-pressure orthotopic bladder substitute after total or partial cystectomy.1 Despite producing a large volume capacity with excellent function, the Kock bladder pouch never gained popularity as a bladder substitute. Using the same surgical technique, Dr Kock described the continent ileostomy in 1969 as a low-pressure intestinal reservoir and alternative to the end ileostomy after proctocolectomy for ulcerative colitis and familial adenomatous polyposis patients.

Restorative Proctocolectomy in Ulcerative Colitis: Effect of Preoperative Immunomodulatory Therapy on Postoperative Complications and Pouch Failure.

Patients with ulcerative colitis are often treated with multiple immunomodulative agents to achieve remission. In refractory disease, the next option is frequently proctocolectomy with ileal pouch-anal anastomosis. No consensus exists as to whether immunomodulatory therapy at the time of ileal pouch surgery leads to any increase in postoperative complications. Our aim was to assess, in ulcerative colitis patients with restorative proctocolectomy, the effect of preoperative anti-tumor necrosis factor therapy and corticosteroids on postoperative complications and pouch failure. A retrospective medical record review of 445 patients with ulcerative colitis who underwent proctocolectomy with ileal pouch-anal anastomosis in Helsinki University Hospital between January 2005 and June 2016. Anti-tumor necrosis factor agents were not associated with postoperative complications. Only high-dose corticosteroids (prednisolone ⩾20 mg or equivalent) were associated with higher incidence of anastomotic leak (12.6% vs 2.5%, P = 0.002) and wound dehiscence (4.2% vs 0%, P = 0.019), but pouch failure rate was no higher (2.1% vs 0%, P = 0.141) than in patients without corticosteroid treatment. A lower dosage of corticosteroids had no effect on early postoperative complications, but pouch failure rate was increased (4.4% vs 0%, P = 0.015). Corticosteroids, but not anti-tumor necrosis factor therapy, were associated with postoperative complications. Preoperative use of corticosteroids may increase pouch failure rate, but the risk is still minor in high-volume centers performing ileal pouch surgery.

Short-term Results After Totally Robotic Restorative Total Proctocolectomy With Ileal Pouch Anal Anastomosis for Ulcerative Colitis

In this study, we aimed to present our initial experience on totally robotic total restorative proctocolectomy in ulcerative colitis (UC) patients. Patients undergoing a totally robotic restorative total proctocolectomy with ileal J-pouch anal anastomosis for UC between January 2015 and November 2017 were included. The da Vinci Xi was used for the operations. Patient demographics, perioperative and short-term operative outcomes were evaluated. Ten patients were included. The median operative time was 380 minutes(range, 300 to 480 min). The median blood loss was 65 mL (range, 5 to 400 mL). No conversion to open surgery was needed. The median time to flatus was 1 day (range, 1 to 2) and length of stay was 6 (4 to 12) days. Short-term complications (≤30 d) were superficial wound infection (n=3), anal bleeding (n=1), pouchitis (n=1). No mortality was observed during the study period. Our study, which is the largest series so far, reveals that totally robotic restorative proctocolectomy is a safe and feasible option for the surgical treatment of UC.

Time Does Not Heal All Wounds

Introduction: This is a case of pyoderma gangrenosum presenting 14 years after procto-colectomy for ulcerative colitis(UC). Response to oral steroids and wound therapy was suboptimal warranting use of anti-TNF therapy. Case presentation: A 61-year-old female with history of UC s/p procto-colectomy 14 years ago, and orthotopic liver transplant for primary sclerosing cholangitis (maintained on sirolimus) presented with a non-healing ulcerated wound on the left medial calf. The wound started as a blister and progressed to a 20x10x2cm ulcer with elevated violaceous borders.Despite initial concerns for infectious cellulitis, response to multiple prolonged courses of antibiotics was marginal. Given history of inflammatory bowel disease and wound characteristics, pyoderma gangrenosum was suspected. Wound biopsy showed vascular thrombosis with extensive necrobiotic changes and foci of acute inflammation was nonconclusive. Sirolimus was held to allow for wound to heal. Poor wound healing persisted despite three weeks on high dose prednisone. Patient was then started on infliximab, and the wound showed marked improvement after a few weeks of therapy. However thereafter, family decided to proceed with hospice care, mainly because of decline in mental status of unclear etiology. Discussion: Pyoderma gangrenosum(PG) is a rare cutaneous manifestation of UC and Crohn's disease. It has a course independent of the underlying disease activity. Traditionally treatment consisted largely of local wound care and topical and systemic steroids. Topical tacrolimus and oral cyclosporine have also been used as single agents or more commonly as combination therapy with steroids. Surgical debridement may actually worsen disease and is best avoided. Recently the role of biologics has been explored. PG is associated with the upregulation of several pro-inflammatory cytokines including IL-8, TNF, and interferon gamma, among many others, which may explain the response anti-TNF agents. Level of evidence supporting use of these agents is variable. Randomized controlled trials support the use of prednisolone, cyclosporine, and infliximab. Decision on using a particular agent will depend on wound extent, local expertise and associated comorbidities (for patients with concomitant active inflammatory bowel disease for example, anti-TNF agents may be an attractive option).2052 Figure 1. 20 x10 x 2cm non-healing ulcer on the left medial calf, with elevated violaceous borders.

Association between serum tumor necrosis factor-alpha level and the efficacy of infliximab for refractory pouchitis after restorative proctocolectomy in patients with ulcerative colitis.

Objectives: Although the aetiology of pouchitis after restorative proctocolectomy in ulcerative colitis (UC) remains unknown, infliximab (IFX) is often effective for this condition. However, indicators and predictors of treatment efficacy remain unclear. In this study, the association between serum tumor necrosis factor-alpha (TNF-α) levels and refractory pouchitis was evaluated. Methods: We conducted a prospective study between January 2014 and April 2016. Patients with antibiotic-refractory pouchitis were treated with IFX. Serum TNF-α levels were measured before IFX induction. Diagnoses were confirmed using the modified Pouchitis Disease Activity Index (m-PDAI). Responders were defined as patients with an m-PDAI score lower than 5. Recurrence was defined as an m-PDAI score exceeding 5 during maintenance treatment or a need for additional treatments. Associations between serum TNF-α level and efficacy of IFX during 52 weeks of maintenance therapy were evaluated. Results: Thirteen patients were eligible for this study. The short-term efficacy was 8/13 (61.5%). Four patients could not be maintained with IFX alone. The cumulative maintenance ratio was 30.8%/52 weeks, and the cut-off value for serum TNF-α was 1.93 pg/mL for short-term response. Although there was no significant association between serum TNF-α and treatment response, IFX treatment was unsuccessful for all five patients with TNF-α levels below 1.93 pg/mL, including four short-term non-responders and one long-term non-responder. Conclusion: Serum TNF-α level was not an independent predictor of IFX efficacy for refractory pouchitis. However, IFX may be effective for patients with elevated serum TNF-α. Future studies should assess this possibility.

P540 Efficacy of granulocyte and monocyte apheresis for antibiotic-refractory pouchitis after proctocolectomy for ulcerative colitis: an open-label, prospective, multicentre study

P540 Efficacy of granulocyte and monocyte apheresis for antibiotic-refractory pouchitis after proctocolectomy for ulcerative colitis: an open-label, prospective, multicentre study

Efficacy of granulocyte and monocyte apheresis for antibiotic-refractory pouchitis after proctocolectomy for ulcerative colitis: an open-label, prospective, multicentre study.

Background:Granulocyte and monocyte apheresis (GMA) has shown therapeutic efficacy in active ulcerative colitis (UC). We thought that in patients with pouchitis after proctocolectomy for UC, GMA might produce immunological effects in the intestinal mucosa, and improve clinical symptoms. This prospective study was to evaluate the efficacy of GMA for antibiotic-refractory pouchitis after proctocolectomy for UC.Methods:A total of 13 patients with pouchitis disease activity index (PDAI) > 7 unresponsive to 2 weeks of antibiotic therapy were included. All patients received 10 GMA sessions at 2 sessions/week over 5 consecutive weeks. The primary endpoints were response (a decrease of ⩾3 points in the PDAI) and remission (PDAI < 4). Secondary endpoints included reduction of white blood cells (WBCs), C-reactive protein (CRP), faecal markers (calprotectin and lactoferrin), reduction of the PDAI endoscopic subscore, and GMA safety.Results:The median PDAI score was significantly decreased from 11 (range, 9–15) at entry to 9 (range, 6–13) after the GMA therapy (p = 0.02). A total of six patients (46%) responded to the treatment, but none achieved remission. The median endoscopic subscore (maximum: 6) was 5 (range, 4–6) at entry and 5 (range, 1–6) after the treatment (p = 0.10). None of the laboratory markers (WBCs, CRP, faecal calprotectin and lactoferrin) significantly changed during the treatment. Transient adverse events (AEs) were observed in two patients (15%), dyspnoea in one and headache in one. The AEs were not serious, and all patients completed the 10 GMA sessions.Conclusions:GMA has a good safety profile, but its efficacy appears to be limited in the management of chronic refractory pouchitis. However, a large controlled study should be conducted to evaluate the efficacy of GMA therapy in patients with pouchitis at an earlier clinical stage, before the disease has become refractory to conventional medical therapy.

潰瘍性大腸炎に対する全結腸切除術施行後に気管・気管支病変を呈した 1 症例

潰瘍性大腸炎に対する全結腸切除術施行後に気管・気管支病変を呈した 1 症例