Jean Ashburn

Consequences of Anastomotic Leak After Restorative Proctectomy for Cancer: Effect on Long-term Function and Quality of Life

BACKGROUND: Long-term consequences of anastomotic leak after restorative proctectomy for rectal cancer, in terms of bowel function and quality of life, have been poorly delineated. OBJECTIVE: The purpose of this study is to evaluate the impact of anastomotic leak, when intestinal continuity can still be maintained, on bowel function and quality of life in patients undergoing rectal cancer resection with low colorectal or coloanal anastomoses. DESIGN: From 1980 to 2010, 864 patients undergoing restorative resection for rectal cancers were identified from a prospective cancer database. Anastomotic leak detected by a combination of clinical, radiographic, and operative means was diagnosed in 52 (6%) patients. MAIN OUTCOME MEASURES: Patients with anastomotic leak were compared with those without anastomotic leak for functional outcomes and quality of life at 1 year and most recent follow-up (mean 3.2 years) by using Short-Form 36 questionnaires (physical and mental component scales) and the Fecal Incontinence Severity Index. RESULTS: American Society of Anesthesiologists’ class (p = 0.48), cancer stage (p = 0.39), and the use of neoadjuvant therapy (p = 0.4) were similar in the 2 groups. Patients with anastomotic leak were younger (56 years vs 61 years; p = 0.007), more likely to be male (82% vs 64%; p = 0.008), and more likely to have undergone proximal diversion at proctectomy (51.9% vs 26.6%; p = 0.001). One year after proctectomy, patients with anastomotic leak had worse physical and mental component scores (p = 0.01), more frequent daytime (p = 0.001) and nighttime bowel movements (p = 0.03), and worse control of solid stool (p = 0.01) in comparison with those without an anastomotic leak. At most recent follow-up (leak, 3.3 years vs no leak, 2.4 years), patients with an anastomotic leak reported worse mental component scores and increased use of perineal pads. CONCLUSION: Anastomotic leak after restorative resection for rectal cancer leads to early adverse consequences on bowel function and quality of life even when anastomotic continuity can be maintained. These findings may help counsel patients and clinicians regarding anticipated outcomes over the long term.

Risk factors and management of refractory or recurrent clostridium difficile infection in ileal pouch patients.

Background:Clostridium difficile infection (CDI) is increasingly recognized in patients with ulcerative colitis with ileal pouch-anal anastomosis (IPAA). The aim of this study was to identify clinical risk factors for treatment-refractory or recurrent CDI in patients with IPAA. Methods:We identified patients with IPAA for underlying ulcerative colitis and a positive polymerase chain reaction stool test for C. difficile at the Center for Ileal Pouch Disorders during the period from October 2010 to November 2013. Demographic clinical variables were compared between the refractory or recurrent CDI and nonrecurrent CDI groups. Results:Patients with IPAA with refractory or recurrent symptoms (refractory/recurrent CDI, the study group, N = 19) were compared with patients with a single antibiotic-responsive episode of ileal pouch CDI (nonrecurrent CDI, the control group, N = 21). The frequency of pouchitis before the index CDI was similar in the study and control groups (63.2% versus 66.7%, P = 0.82). Postoperative mechanical abnormalities occurred in 16 patients (84.2%) in the study group versus 7 patients (33.3%) in the control group (P = 0.0008). There were no differences between the two groups regarding hospitalization, non-C. difficile antibiotic use, the use of gastric acid-reducing therapy, or immunosuppressives before or after the index CDI. Six of 15 patients (40.0%) in the study group versus 1 of 15 patients (7.1%) in the control group had a low serum level of IgG1 (P = 0.031). Conclusions:Refractory or recurrent disease is common in patients with ileal pouch with CDI. The presence of postsurgery mechanical intestinal complications or low serum immunoglobulin level may be risk factors for refractory or recurrent CDI in this patient population.

Efficacy of Vedolizumab in Patients with Antibiotic and Anti-tumor Necrosis Alpha Refractory Pouchitis

Refractory pouchitis is a risk factor for pouch failure and surgical excision. While TNFa inhibitors have been reported to be effective as treatment for pouchitis there is no data regarding the use of vedolizumab in refractory pouchitis. In this study we evaluated the clinical and endoscopic response to vedolizumab in refractory pouchitis. This is an open label case series. Three patients were identified as having refractory pouchitis with loss or lack of response to antibiotics, corticosteroids, and at least one TNFa inhibitor along with a variety of other modalities of therapy. Each patient underwent pouch endoscopy before initiation of vedolizumab and repeat endoscopy within 4 months of initiation of treatment. Vedolizumab was administered as per standard dosing regimen. The Pouch Disease Activity Index (PDAI) endoscopic subscore was evaluated by the 2 investigators independently and reported as an average. The clinical record was reviewed to determine patient reported response to therapy. Patient 1, a 54 year old male, had undergone colectomy and IPAA in 2000 for medically refractory ulcerative colitis (UC). He suffered from ankylosing spondylitis and chronic pouchitis. He had been treated serially with antibiotics, budesonide, infliximab, methotrexate, adalimumab, in combination with hyperbaric oxygen therapy with severe diarrhea. His pouchoscopy prior to initiation revealed confluent ulceration with PDAI endoscopic subscore of 4. Endoscopy 4 months after the initiation of vedolizumab therapy revealed visual improvement, with few small ulcers noted, with PDAI endoscopic subscore of 3. He experienced improvement in clinical symptoms and has avoided surgical resection of his pouch but did require maintenance therapy with budesonide. Patient 2, a 54 year old female underwent colectomy and IPAA in 1991 for medically refractory UC. She developed recurrent stricturing at the pouch inlet and afferent limb and pouchitis, treated with surgical stricturoplasty, antibiotics, thiopurines, mesalamine, intravenous immunoglobulin therapy, fecal microbiota transplant, and adalimumab. She continued to have symptoms of diarrhea and pain. Pouch endoscopy revealed chronic pouchitis with edema and loss of vascular pattern consistent with a PDAI score of 5, along with cuffitis, and ulcerated strictures in the neo-terminal ileum. She underwent pouchoscopy 4 months after the therapy with vedolizumab which revealed improvement in pouchitis, normal appearing mucosa and PDAI endoscopic subscore 1, but ongoing ulceration at cuff and inlet. Patient 3, a 54 year old female post restorative proctocolectomy for refractory UC in 2012 had required pouch redo surgery in 2014 for severe pouch dysfunction. She suffered from diarrhea requiring intravenous hydration despite use of antibiotics, infliximab with azathioprine, and mesalamine. Her pouchoscopy revealed pouchitis and ileitis with a PDAI score of 3. Pouch endoscopy 4 months after initiation of vedolizumab which revealed improved mucosa of the pouch with PDAI score of 1. She noted improvement in symptoms of diarrhea. All 3 patients had improved endoscopic scores and reported clinical improvement in terms of diarrhea and pain. Vedolizumab in open label use for chronic antibiotic- and anti- TNFα-refractory, chronic pouchitis demonstrated improvement in both symptoms and endoscopy scores.

Disease course and management strategy of pouch neoplasia in patients with underlying inflammatory bowel diseases.

Background:To evaluate the disease course and management strategy for pouch neoplasia. Methods:Patients undergoing ileal pouch surgery for underlying ulcerative colitis who developed low-grade dysplasia (LGD), high-grade dysplasia, or adenocarcinoma in the pouch were identified. Results:All eligible 44 patients were evaluated. Of the 22 patients with initial diagnosis of pouch LGD, 6 (27.3%) had persistence or progression after a median follow-up of 9.5 (4.1–17.6) years. Family history of colorectal cancer was shown to be a risk factor associated with persistence or progression of LGD (P = 0.03). Of the 12 patients with pouch high-grade dysplasia, 5 (41.7%) had a history of (n = 2, 16.7%) or synchronous (n = 4, 33.3%) pouch LGD. Pouch high-grade dysplasia either persisted or progressed in 3 patients (25.0%) after the initial management, during a median time interval of 5.4 (2.2–9.2) years. Of the 14 patients with pouch adenocarcinoma, 12 (85.7%) had a history of (n = 2, 14.3%) or synchronous dysplasia (n = 12, 85.7%). After a median follow-up of 2.1 (0.6–5.2) years, 6 patients with pouch cancer (42.9%) died. Comparison of patients with a final diagnosis of pouch adenocarcinoma (14, 32.6%), and those with dysplasia (29, 67.4%) showed that patients with adenocarcinoma were older (P = 0.04) and had a longer duration from IBD diagnosis or pouch construction to the detection of pouch neoplasia (P = 0.007 and P = 0.0013). Conclusions:The risk for progression of pouch dysplasia can be stratified. The presence of family history of colorectal cancer seemed to increase the risk for persistence or progression for patients with pouch LGD. The prognosis for pouch adenocarcinoma was poor.

Is There Still a Role for Continent Ileostomy in the Surgical Treatment of Inflammatory Bowel Disease

Abstract:The continent ileostomy (CI) was first described in 1969 as an important advancement in the surgical treatment of patients with ulcerative colitis, providing an option for fecal continence to patients who would otherwise require a conventional ileostomy. The CI enjoyed a brief period of relative popularity during the 1970s before being displaced by todays gold standard for the surgical treatment of ulcerative colitis, the restorative proctocolectomy (ileal pouch–anal anastomosis [IPAA]). Although the CI is only rarely performed today, it still has a role to play in the treatment of patients with inflammatory bowel disease who have failed medical treatment. Current indications are patients with failed IPAAs who are not candidates for redo-IPAA, patients who require total proctocolectomy but cannot be reconstructed with IPAA, and patients with an existing conventional ileostomy that is adversely affecting their quality of life. CI, however, is a complex procedure that carries significant risk of both postoperative complications and the need for reoperation over the long term due to slippage of the nipple valve. Patients being considered for this procedure should undergo extensive preoperative counseling and must have a thorough understanding of the associated risks and a realistic vision of anticipated benefits. In well-selected and properly motivated patients, however, CI can be durable in the majority with long-term pouch survival rates approaching 80%. Published data suggest that these patients enjoy greater quality of life than their counterparts with a conventional ileostomy and that 95% would choose to undergo the procedure again or recommend it to another.

Restorative proctocolectomy: an example of how surgery evolves in response to paradigm shifts in care

Surgical technique constantly evolves in response to the pressure of progress. Ileal pouch anal anastomosis (IPAA) is a good example. We analysed the effect of changes in practice on the technique of IPAA and its outcomes.

Fecal microbiota transplantation for Clostridium difficile infection in patients with ileal pouches.

Abstract Background: Clostridium difficile infection (CDI) in patients with ileal pouch-anal anastomosis (IPAA) has been increasingly recognized. The aim of this study was to evaluate the outcome of fecal microbiota transplantation (FMT) in patients with pouch and CDI. Methods: All consecutive patients that underwent FMT for CDI from 2012 to 2016 were extracted from our IRB-approved, prospectively maintained Registry of Pouch Disorders. The primary outcome was negative stool tests for Clostridium difficile after FMT and the secondary outcomes were symptomatic and endoscopic responses. Results: A total of 13 patients were included in this study, with 10 being Caucasian males (76.9%). All patients had underlying ulcerative colitis for J pouch surgery. After a mean of 2.8±0.8 courses of antibiotic treatments was given and failed, 22 sessions of FMT were administered with an average of 1.7±1.1 sessions each. Within the 22 sessions, 16 were given via pouchoscopy, 4 via esophagogastroduodenoscopy and 2 via enemas. All patients tested negative on C. difficile polymerase chain reaction (PCR) after the initial FMT with a total of 7/12 (58.3%) documented patients showed symptomatic improvements and 3/11 (27.3%) patients showed endoscopic improvement according to the modified Pouchitis Disease Activity Index. During the follow-up of 1.2±1.1 years, there were a total of five patients (38.5%) that had recurrence after the successful initial treatment and four of them were successfully treated again with FMT. Conclusions: FMT appeared to be effective in eradication of CDI in patients with ileal pouches. However, FMT had a modest impact on endoscopic inflammation and recurrence after FMT and recurrence was common.

Impact of a restrictive vs liberal transfusion strategy on anastomotic leakage and infectious complications after restorative surgery for rectal cancer

The aim of this study was to investigate the impact of a restrictive vs liberal transfusion strategy on anastomotic leakage and infectious complications after rectal cancer surgery.

Frequency, manifestations and management of bezoars in ileal pouches

To evaluate the frequency, diagnosis and management of ileal pouch bezoars.

Radiation-Induced Problems in Colorectal Surgery.

Radiotherapy not only plays a pivotal role in the cancer care pathways of many patients with pelvic malignancies, but can also lead to significant injury of normal tissue in the radiation field (pelvic radiation disease) that is sometimes as challenging to treat as the neoplasms themselves. Acute symptoms are usually self-limited and respond to medical therapy. Chronic symptoms often require operative intervention that is made hazardous by hostile surgical planes and unforgiving tissues. Management of these challenging patients is best guided by the utmost caution and humility.