Adam Studniarek

Management of enteroatmospheric fistula with negative pressure wound therapy in open abdomen treatment: a multicentre observational study.

The management of enteroatmospheric fistula (EAF) in open abdomen (OA) therapy is challenging and associated with a high mortality rate. The introduction of negative pressure wound therapy (NPWT) in open abdomen management significantly improved the healing process and increased spontaneous fistula closure. Retrospectively, we analysed 16 patients with a total of 31 enteroatmospheric fistulas in open abdomen management who were treated using NPWT in four referral centres between 2004 and 2014. EAFs were diagnosed based on clinical examination and confirmed with imaging studies and classified into low (<200 ml/day), moderate (200–500 ml/day) and high (>500 ml/day) output fistulas. The study group consisted of five women and 11 men with the mean age of 52·6 years [standard deviation (SD) 11·9]. Since open abdomen management was implemented, the mean number of re‐surgeries was 3·7 (SD 2·2). There were 24 EAFs located in the small bowel, while four were located in the colon. In three patients, EAF occurred at the anastomotic site. Thirteen fistulas were classified as low output (41·9%), two as moderate (6·5%) and 16 as high output fistulas (51·6%). The overall closure rate was 61·3%, with a mean time of 46·7 days (SD 43·4). In the remaining patients in whom fistula closure was not achieved (n = 12), a protruding mucosa was present. Analysing the cycle of negative pressure therapy, we surprisingly found that the spontaneous closure rate was 70% (7 of 10 EAFs) using intermittent setting of negative pressure, whereas in the group of patients treated with continuous pressure, 57% of EAFs closed spontaneously (12 of 21 EAFs). The mean number of NPWT dressing was 9 (SD 3·3; range 4–16). In two patients, we observed new fistulas that appeared during NPWT. Three patients died during therapy as a result of multi‐organ failure. NPWT is a safe and efficient method characterised by a high spontaneous closure rate. However, in patients with mucosal protrusion of the EAFs, spontaneous closure appears to be impossible to achieve.

Surgical Management of Complications with Peritoneal Dialysis

This report reviews the most common surgical interventions and complications of chronic peritoneal dialysis (PD) patients. Based on the current knowledge as well as our experience we detail the role of these surgical procedures. We supplement the reported knowledge in the field with our own experience in this area. The areas discussed include early complications such as surgical wound hemorrhage, bleeding from the catheter, intestinal perforation and urinary bladder perforation, dialysate leakage through the wound, as well as late complications including catheter kinking or occlusion, retention of fluid in the peritoneal recess, hernias and hydrothorax, and encapsulating peritoneal sclerosis. We also briefly cover the surgical aspects of exit‐site infection and peritonitis. An understanding by nephrologists of the role for surgical intervention in PD patients will improve their care and outcomes.

The diagnostic usefulness of fecal lactoferrin in the assessment of Crohn's disease activity

BACKGROUND Diagnosis and monitoring of Crohns disease (CD) is difficult and time-consuming. In recent years, diagnostic usefulness of fecal calprotectin has been proven. However, data on the utility of other fecal markers are scarce. AIMS To evaluate the usefulness of fecal lactoferrin (FL) in the assessment of CD activity. METHODS The group consisted of 101 CD patients (median age: 30 years, IQR: 24-37). FL was measured in a single stool sample by using the immunoenzymatic methods. The clinical activity of the disease was evaluated by using the Crohns Disease Activity Index (CDAI). Depending on the location of the disease, either a colonoscopy or magnetic resonance enterography was performed or both in order to evaluate the disease activity by using appropriate endoscopic and enterographic scores. RESULTS Median FL concentration was 84.14 (IQR: 36.4-302.9) μg/ml and it correlated with C-reactive protein concentration (p=0.0000001, r=0.5), CDAI (p=0.002, r=0.3) and colonic Simple Endoscopic Score for Crohns Disease (SES-CD) (p=0.000004, r=0.5). Assuming endoscopic remission in the large intestine with colonic SES-CD≤3 points, a ROC curve showed that FL concentration of 145.82 μg/ml had 84.6% sensitivity and 60.5% specificity in discriminating CD patients with endoscopically active and inactive disease [AUC: 0.676 (95% CI: 0.531-0.8), (p=0.0347)]. The positive predictive value for this concentration was 42% and negative predictive value -92%. CONCLUSIONS FL is a sensitive marker of CD activity and it reliably reflects the mucosal inflammatory lesions in large intestine. Thus, it can be helpful in diagnostics and monitoring of CD.

Large bowel mucosal neoplasia in the original specimen may increase the risk of ileal pouch neoplasia in patients following restorative proctocolectomy for ulcerative colitis

PurposeRestorative proctocolectomy is a current gold standard procedure for patients who require a colectomy for ulcerative colitis. The incidence of ileal pouch neoplasia is low. The aims of this study were to assess the prevalence of neoplasia in ileal pouch and investigate the risk factors for ileal pouch neoplasia.MethodsA total of 276 patients who underwent restorative proctocolectomy for ulcerative colitis between 1984 and 2009 were analyzed. Results of histological examinations of both original specimen and biopsies from the J-pouch taken during routine pouch endoscopy were evaluated. Patients’ records were analyzed for ulcerative colitis duration, the time from pouch creation to pouch neoplasia, presence of pouchitis, as well as the concurrent primary sclerosing cholangitis.ResultsAnalyzing the original specimen of large bowel, fifty-six lesions of low-grade dysplasia, twenty-five high-grade dysplasia, and five adenocarcinoma were revealed. All patients with dysplasia (n = 8) or adenocarcinoma (n = 1) of the J-pouch were positive for dysplasia in the original specimen. Duration of ulcerative colitis before surgery and duration time following restorative proctocolectomy were found as risk factors for J-pouch neoplasia with a significant difference (p = 0.01 and p = 0.0003, respectively). Patients with pouch neoplasia developed significantly more severe pouchitis (p = 0.00001).ConclusionsNeoplasia of the J-pouch is rare. Patients with neoplasia in the original specimen are more susceptible to develop neoplasia in the J-pouch. Precise follow-up in patients with neoplasia lesions in the original specimen should be recommended. Moreover, in patients with risk factors, the exact surveillance pouch endoscopy should be recommended.

Conservative Measures for Managing Constipation in Patients Living With a Colostomy

PURPOSE: The purpose of this study was to determine the effect of a conservative regimen for the treatment of constipation in persons living with a colostomy. DESIGN: Prospective, noncontrolled, single-center study. SUBJECTS AND SETTING: The study sample comprised 35 patients with a colostomy who were diagnosed with constipation. Subjects with morphologic changes causing constipation such as stomal stenosis and neoplastic and inflammatory changes were excluded. The study was conducted in the Proctology and Stoma Outpatient Clinic at Poznan University of Medical Sciences. METHODS: Patients at our Stoma Outpatient Clinic underwent baseline evaluation, and those with symptoms of constipation (prolonged periods between bowel movements, passage of pasty or hardened fecal effluent, and associated symptoms such as abdominal discomfort or bloating, flatulence, and pain with passage of effluent into the stoma) received individualized dietary recommendations that typically included an increase in dietary fiber and fluid intake, along with increased fluid intake. The outcomes of dietary changes were evaluated during a follow-up visit 3 months later. If dietary changes alone did not improve constipation symptoms, we prescribed a psyllium-based bulk-forming agent, an osmotic stool softener, and a probiotic, with or without a prokinetic agent such as metoclopramide taken 3 times daily. RESULTS: Dietary interventions alone were deemed successful in 60% of study subjects (n = 21); the remaining 14 patients required additional treatment. CONCLUSIONS: Dietary modifications alone relieved constipation in more than half of a group of 35 patients with constipation. We therefore recommend a trial of dietary modifications prior to the initiation of pharmacotherapy in patients with a colostomy.

Diagnostic importance of faecal markers in long-term monitoring of anti-TNF- therapy in primary responders with Crohn’s disease

Introduction Monitoring the response to biological treatment in Crohn’s disease (CD) is a very important element of the therapeutic optimisation. Aim To evaluate the usefulness of measuring calprotectin, lactoferrin, and myeloperoxidase in stool as markers of long-term clinical and endoscopic response to anti-tumour necrosis factor α (anti-TNF) treatment in CD. Material and methods The studied group consisted of 35 CD patients treated with anti-TNF-α antibodies. Clinical activity was evaluated using Crohn’s Disease Activity Index (CDAI), and the exacerbation of endoscopic changes was evaluated using a Simple Endoscopic Score for Crohn’s Disease (SES-CD). The concentration of calprotectin, lactoferrin, and myeloperoxidase was measured using the ELISA method. All measurements were performed three times – before, after 3 months, and after a year of therapy. Results During anti-TNF treatment the concentrations of all measured faecal markers decreased significantly in relation to baseline values. We observed a significant correlation at all time-points: before the therapy, after 3 months, and 12 months after starting the therapy, between the concentration of calprotectin and SES-CD, calprotectin and CDAI, as well as between lactoferrin and SES-CD, and lactoferrin and CDAI. Myeloperoxidase correlated with both SES-CD and CDAI only after 1 year of treatment. Conclusions Faecal calprotectin and lactoferrin are valuable markers of clinical and endoscopic activity of CD in patients treated with anti-TNF antibodies. They are useful in monitoring the response to treatment. The usefulness of myeloperoxidase in this respect remains controversial.