F. Ugolini

Antibiotic combination therapy in patients with chronic, treatment-resistant pouchitis

: Pouchitis is the major long‐term complication after ileal pouch‐anal anastomosis for ulcerative colitis. About 15% of patients have a chronic, treatment‐resistant disease.

Local Injection of Infliximab for the Treatment of Perianal Crohn’s Disease

PURPOSEPerianal disease is a serious complication of Crohn’s disease and its surgical management is still controversial. It has been suggested that the local injection of infliximab has resulted in some potential benefit. This pilot study analyzed the feasibility and safety of such therapy in selected patients with severe perianal Crohn’s disease.METHODSThe study included 15 patients with complex perianal Crohn’s disease in which sepsis was not controllable using surgical and medical therapy. Among them, four had previously undergone intravenous infusion of infliximab with no significant response, nine had contraindications for intravenous infusion, and two had associated stenosing ileitis and severe coloproctitis. The injection of 15 to 21 mg of infliximab, associated with surgical treatment, was performed at the internal and external orifices and along the fistula tract. Efficacy was measured by a complete morphologic evaluation using a personal score.RESULTSNo major adverse effects were reported. Ten of 15 patients healed after 3 to 12 infusions.CONCLUSIONSLocal injection of infliximab adjacent to the fistula tract of perianal Crohn’s disease is safe and may help in fistula healing. A controlled, randomized trial is required to prove the value.

Adenocarcinoma below ileoanal anastomosis for ulcerative colitis. Report of a case and review of the literature

AbstractBACKGROUND: Restorative proctocolectomy with handsewn ileoanal anastomosis and mucosectomy is warranted in patients with dysplasia and/or cancer on ulcerative colitis to prevent subsequent neoplastic changes in the retained mucosa. However, complete excision of the colonic mucosa cannot be obtained reliably. We report a case of anal canal adenocarcinoma after handsewn anastomosis with mucosectomy. METHODS: A 47-year-old patient, previously submitted to ileorectal anastomosis for colonic cancer on ulcerative colitis, underwent completion proctectomy and handsewn ileoanal anastomosis with mucosectomy for recurrent anastomotic cancer. Two years later, we submitted the patient to pouch removal with permanent ileostomy for a mucinous adenocarcinoma of the anal canal (T2N2Mx) found at follow-up pouch endoscopy. CONCLUSIONS: Only four cases of adenocarcinoma after handsewn anastomosis have been reported in the literature. This new case we report confirms that the risk of malignancy after ileoanal anastomosis with mucosectomy, although small, is real, despite the surgeon taking care with this particular step of the procedure. Careful surveillance is needed in patients with surgical treatment for long-term ulcerative colitis or dysplasia.

Indication and type of surgery in Crohn's disease

The large majority of patients affected by Crohns disease require surgery during their clinical history. Radical resection originally advocated for Crohns disease does not decrease the recurrence rate, and repeated resections predispose patients to the development of short‐bowel syndrome. Over the last few years, conservative surgery has become accepted by many authors as a safe means of treating obstructive Crohns disease. In this review article we analyse the efficacy and safety of conservative techniques, in comparison with resective surgery. Indications, advantages and technical aspects of resective and conservative surgery are reported.

Conservative surgical management of perforating Crohn's disease: side- to-side enteroenteric neoileocolic anastomosis: Report of two cases

Conservative surgical management of jejunoileal Crohns disease is the first-choice treatment in plurioperated patients with high risk of small-bowel syndrome. Treatment is more controversial in patients with a limited disease and no previous surgery, especially in those with terminal ileitis. Even in those cases we advocate conservative surgical management because we have demonstrated regression of both symptoms and morphologic lesions. Contraindications to nonresectional surgery include the presence of abscesses and fistulas. Impending short-bowel syndrome represents a partial exception to this approach. In this article two cases of conservative surgery performed in plurioperated patients with perianastomotic perforating recurrent disease are presented. We have named this procedure “side-to-side enteroenteric neoileocolic anastomosis,” which is a combination of small resections and conservative procedure. This operative strategy leads us to believe that nonresectional surgery could be selectively performed even in patients with perforating Crohns disease.

Management of Pouchitis

Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) proposed for the first time by Parks in 1978 [1], represents nowadays the surgical treatment of choice for the management of patients with familial adenomatous polyposis (FAP) and ulcerative colitis (UC) [2, 3]. This procedure allows the removal of the whole diseased colorectal mucosal and has the great advantage of preserving the anal sphincter function. Most patients undergoing IPAA for severe colitis or for chronic continuous disease will achieve excellent functional results and physical well-being. In a prospective evaluation of health related quality of life (HRLQ) after IPAA, a significant improvement of HRQL has been shown, assessed with both generic and disease-specific measures, with many patients experiencing improvements as early as 1 month postoperatively [4]. However pouchitis, a non-specific (idiopathic) inflammation of the ileal reservoir, is the most common long-term complication after pouch surgery for UC [5].

Ileoanal Pouches and Indeterminate Colitis

Correct diagnosis of IC has become essential in the “pouch era” for the good outcome of patients submitted to IPAA.