Jacek Paszkowski

The diameter of the ileal J-pouch-anal anastomosis as an important risk factor of pouchitis - clinical observations.

Summary Background Patients’ quality of life after restorative proctocolectomy depends on the potential complications. Stricture of the ileal pouch-anal anastomosis is one of the complications following restorative proctocolectomy. Material/Methods We analyzed the correlation between the diameter of the anastomosis and clinical parameters, including pouchitis disease activity index (PDAI), the activity of fecal M2-pyruvate kinase and maximum tolerable volume of the pouch. The study group consisted of 31 patients in whom covering ileostomy had been closed 72±50 months before enrolement to the study. Restorative proctocolectomy for ulcerative colitis or familial adenomatous polyposis coli had been performed in this group. Results The study did not show any correlation between the diameter of the anastomosis and primary indication for surgery, the time elapsed after restoration of the bowel continuity, the activity of fecal M2-pyruvate kinase, or maximum tolerable volume. However, meaningful correlations between the stricture of the anastomosis and the presence and activity of pouchitis, together with the ileal villi atrophy, were detected. Conclusions Stricture of the anastomosis appears to be an important factor increasing the incidence of pouchitis, and is independent of the underlying condition and time after the operation. Dilation of the anastomosis and prevention of stricture should constitute a permanent element of postoperative follow-up.

Surgical methods of treatment of intestinal passage disturbances with the characteristics of constipation in patients with intestinal stoma based on own experience.

UNLABELLED Stoma is an intestinal fistula created in emergency or by elective indications, and it is done to drain out the digestive tract content. In some patients there is a disturbance passage of gastric contents through the stoma, which may take the form of chronic constipation or even periodic subileus that will sooner or later require surgical treatment. The aim of the study was the assessment of the causes and method of treatment of constipation in patients with intestinal stoma. MATERIAL AND METHODS A total of 331 patients with stoma followed by Ostomy and Proctology Outpatient Clinic were included in the study in the years 2011-2014. The study included 146 women and 185 men and the average age was 61.3 ± 12.7 years. Within the entire froup, 273 patients had the end stoma performed whereas in 58 patients the loop stoma was created. The highest percentage of patients were the ones with diverticulosis and colorectal cancer, i.e. 132 and 114 patients respectively. A stoma was created in 35 patients due to inflammatory bowel disease (IBD), in 23 patients because of cancer, in 14 as a result of injuries and in 13 due to rectovaginal fistula. RESULTS Out of the entire group subject to study (331 patients) 93 patients (28.1%) suffered from constipation. 50 patients with constipation required surgical intervention. The most common indication for surgical treatment was the parastomal hernia (36 patients, 72%), other indications were the narrowing of the stoma (5 patients, 10%), its collapse (6 patients, 12%) or prolapse (3 patients, 6%). Parastomal hernia was responsible for 84% of constipation within the stoma and 86.1% were treated with laparotomy (31 out of 36 patients). Other causes of constipation were the stomal stenoses (5 patients), collapse of the stoma (6 patients) and stomal prolapse (3 patients). All patients were treated surgically with a good final result. CONCLUSIONS Constipation associated with dysfunction of the stoma in most cases should be treated surgically. Parastomal hernia is the most common cause of constipation in the stoma. Treatment should be performed in due time because of the possibility of developing complications, especially dangerous one is a strangulated parastomal hernia and ischemia of stoma.

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.

Perineal wound healing after abdominoperineal resection for rectal cancer: a systematic review and meta-analysis.

To the Editor—recently, Musters et al published a very interesting review on perineal wound healing after abdominoperineal resection (APr) for rectal cancer. the authors discussed various methods of perineal wound closure, as well as treatment options for potential complications of primary closure. We did not find any information in the article about the implementation of negative pressure wound therapy (NPWt). NPWt has been demonstrated to be an effective method for the management of complicated and chronic wounds. Perianal wounds, both postoperative and posttraumatic, remain a challenging problem. Because of an impaired healing process (radiation therapy), as well as difficulty in dressing and nursing, we strongly recommend implementing NPWt after an APr procedure. Based on our experience, we found NPWt to be a helpful method for management of this type of wound. the crucial aspect of NPWt is to apply the dressing in the appropriate manner, particularly in the anal and genital regions. Keeping the entire system sealed is challenging and usually requires the use of a stoma paste or silicone plate. our results are consistent with other publications that have reported good results when using NPWt after an APr procedure. NPWt has been used to support the healing process from complicated perineal wounds after APr procedures, as well as for gracilis muscle flap transposition and an omentoplasty technique after an APr procedure. Promising results were also demonstrated concerning incisional NPWt used postoperatively. Although the application of NPWt for a perineal wound is not considered a goldstandard procedure, in our opinion NPWt is an effective method for primary wound closure and a method of choice during impaired healing of perineal wounds after an APr procedure.

Intestinal Pouch Complications in Patients Who Underwent Restorative Proctocolectomy for Ulcerative Colitis and Familial Adenomatous Polyposis in 1985-2008

UNLABELLED Restorative proctocolectomy is considered a surgical treatment of choice in ulcerative colitis (UC) and familial adenomatous polyposis (FAP).The aim of the study was to evaluate postoperative complications in patients who underwent surgery for familial adenomatous polyposis and ulcerative colitis, on the basis of a retrospective data analysis. MATERIAL AND METHODS Data of 138 patients after restorative proctocolectomy performed between 1985 and 2008 were collected at routine follow-up visits in 2004-2008. We evaluated the presence of pouchitis, the degree of ileal pouch mucosa atrophy, the presence of ileal pouch mucosal metaplasia, the presence of ileal pouch malignancies, the necessity for diverting ileostomy, the necessity for pouch resection, and severe faecal incontinence. RESULTS Complications were observed in 45 (32.4%) patients. Thirty-seven patients developed pouchitis (26.6%). Low-degree dysplasia, severe dysplasia or malignancies were observed in total in 20 patients (14.4%). Six (4.3%) operated patients developed other analysed complications. CONCLUSIONS The most common complications of restorative proctocolectomy were dysplasia and pouchitis. The most common complication in patients operated for UC was pouchitis. The low observed incidence of intestinal pouchitis may be attributed to the implemented prophylaxis of inflammation. Dysplasia was the most common complication in patients undergoing proctocolectomy for FAP. Due to an increased risk of dysplastic lesions as compared with UC patients, careful endoscopic follow-up examinations are obligatory in this patient group. Other analysed complications were uncommon and were mostly a consequence of chronic pouchitis. Clinical symptoms of pouch-related problems were similar in both analysed groups.

A giant non-functioning pancreatic neuroendocrine carcinoma founded as an incidentaloma successfully treated with pancreatoduodenectomy

Pancreatic neuroendocrine tumours (PTENs) are a heterogeneous group of tumours that develop from neuroendocrine cells of the pancreas [1]. Pancreatic neuroendocrine tumours comprise a rare group of pancreatic tumours and represent about 1–2% of all tumours developing within this organ [2]. The potential of neuroendocrine cells to produce and secrete peptides and/or biogenic amines affecting the clinical presentation of the disease thus determines their division into functioning and non-functioning pancreatic neuroendocrine tumours (functioning, F-PTEN and non-functioning, NF-PTEN). General accessibility of cross-sectional imaging of the abdomen has caused a significantly increasing rate of incidentally revealed non-functioning pancreatic neuroendocrine tumours in recent years. The group of NF-PTEN represents the majority of neuroendocrine tumours of the pancreas and is estimated at 60–90% [3]. An asymptomatic pattern of the disease associated with a lack of the peptide and/or biogenic amine productions means that these tumours may present with considerable size at the time of clinical diagnosis.

A case of late breast cancer metastases to both suprarenal glands 28 years after mastectomy.

We present an extremely rare case of late metastases of breast cancer to both suprarenal glands 28 years after mastectomy. The patient originally underwent Patey’s radical mastectomy of the left breast. In the follow-up, metastases were detected in the skin of the thorax and labia majora and were subsequently resected. During the most recent hospitalization metastases to both adrenal glands were detected (PET-CT, MRI) and removed. In genetic examination the entire coding sequences of BRCA1 and BRCA2 gene were screened for mutation by direct PCR product sequencing as described before by Gorski et al. No BRCA1 and BRCA2 gene mutations were found. Histological examination revealed breast cancer metastasis to the adrenal glands. In our opinion our case can be the latest described metastases of breast cancer. The described case was an early stage of primary cancer (T1N0M0). Patients after breast cancer resection should still be followed up for late metastases. Late metastases including atypical sites should always be suspected regardless of time from initial presentation. The correlations between mutation and metastases of breast cancer needs to be discussed.

Mutations spectrum in hereditary disorders predisposing to occurrence of intestine polyposis in Poland

The term polyp refers to any overgrowth of tissue from the surface of mucous membranes. Intestinal polyps grow out of the lining of the small and large bowels. The polyps that arise as a result of proliferative dysplasia are termed as adenomatous polyps or adenomas. They are true neoplastic lesions and are precursors of carcinoma. The hamartomatous polyps are formed as a result of abnormal mucosal maturation. They are non-neoplastic and do not have malignant potential. There are several hereditary diseases that produce large numbers of intestinal polyps. These disorders include: familial adenomatous polyposis of the colon (MIM 175100), familial adenomatous polyposis type 2(MIM 608456), Lynchs syndrome (MIM 120435), Peutz-Jeghers syndrome (MIM 175200), Juvenile polyposis syndrome (MIM 174900) PTEN Hamartoma Tumor Syndrome (PHTS) PHTS Includes: Bannayan-Riley-Ruvalcaba Syndrome (MIM 153480), Cowden Syndrome (MIM 153480), PTEN-Related Proteus Syndrome, Proteus-Like Syndrome. Here we present spectrum of mutation detected in over six hundred Polish families with intestinal polyposis. The studies have encompassed over 30 families with Juvenile polyposis syndrome and PHTS, over 40 families with Peutz-Jeghers syndrome and almost 600 families with familial adenomatous polyposis of the colon. The study was in part financed by the Ministry of Education and Science, Poland, grant number N402 481537, N401 331936.

Endoscopy-assisted minimally invasive loop ileostomy after previous restorative proctocolectomy.

BACKGROUND: Complications after proctocolectomy with ileal pouch-anal anastomosis may impair pouch function. Loop ileostomy can be performed to allow recovery of function before intestinal continuity is restored. To minimize operative trauma and to form the stoma with as little damage to the abdominal wall as possible, the invasiveness of the procedure should be minimized as far as possible. OBJECTIVE: To minimize the extent of surgical invasion, we developed a technical modification of loop ileostomy in which lower endoscopy is used to assist the procedure. PROCEDURE: The procedure requires only a single incision, which is made at the site of the ileostomy. While the surgeon incises the fascia and peritoneum, the endoscopist advances a flexible endoscope through the pouch to the distal part of the ileum up to approximately 40cm above the anal verge. The operation lamp is switched off, allowing the surgeon to see the lighted end of the endoscope in a loop of the ileum near the incision. This loop is drawn out through the incision and the stoma is created in a standard manner. LIMITATIONS: Clinical factors such as the presence of adhesions or obesity limit the use of the procedure in certain patients. CONCLUSIONS: We believe this technique of endoscopic-assisted loop ileostomy is a safe method for minimizing the invasiveness of surgery in patients who require ileostomy after restorative proctocolectomy.

PET/CT in recognition of a complicated case of adenocarcinoma within ileal pouch-anal anastomosis in a patient after restorative proctocolectomy for familial adenomatous polyposis

a patient who developed adenocarcinoma within the ileal “J” pouch-anal anastomosis (IPAA) after restorative proctocolectomy for familial adenomatous polyposis (FAP). Case report: The patient was treated for recurrent adenomatous polyps within the ileoanal anastomosis. Regular examination of the patient with endoscopic, histopathological and radiological measures such as ultrasonography (USG), computed tomography (CT) and magnetic resonance imaging (MRI) did not reveal malignant transformation in recurrent adenomatous polyps. Only positron emission tomography/computed tomography (PET/CT) showed a suspicious lesion. As a result abdominoperineal excision of the ileal pouch and anal canal was performed and diagnosis of cancer was confirmed on histopathological assessment. Conclusion: In our opinion PET/CT is recommended in each case of dysplasia in patients operated on for FAP.