Sean T. Martin

Ileal pouch anal anastomosis: analysis of outcome and quality of life in 3707 patients.

Background:Ileal pouch anal anastomosis (IPAA) is the treatment of choice for chronic, medically refractory mucosal ulcerative colitis, indeterminate colitis, familial adenomatous polyposis (FAP), and a select group of patients with Crohns disease. Aim:We report outcomes, complications, and quality of life (QOL) in a cohort of 3707 patients treated at our institution from January 1984 to March 2010. Methods:Data were collected from a prospectively maintained database and chart review of 3707 consecutive primary IPAA cases. Patient demographics, postoperative complications, functional outcomes, and QOL data were available. Follow-up consisted of clinical examination with assessment of pouch function and QOL. Results:A total of 3707 patients underwent primary pouch and 328 underwent redo pouch surgery. Postoperative histopathological diagnoses were mucosal ulcerative colitis (n = 2953, 79.7%), indeterminate colitis (n = 63, 1.7%), FAP (n = 223, 6%), Crohns disease (n = 150, 4%), cancer/dysplasia (n = 97, 2.6%), and others (n = 221, 6.0%). Early perioperative complications were encountered in 33.5% of patients with a mortality rate of 0.1%. Excluding pouchitis, late complications were experienced by 29.1% of patients. Of those patients who had IPAA at our institution, pouch failure occurred in 197 patients (5.3%). During a median follow-up of 84 months, 119 patients (3.2%) required excision of the pouch, 32 (0.8%) had a nonfunctioning pouch, and 46 patients (1.2%) had redo IPAA. Functional outcomes and QOL were good or excellent in 95% of patients and similar in each histopathological subgroup. Conclusions:IPAA is an excellent option for patients with MUC, IC, FAP, and select patients with Crohns disease.

Systematic review and meta-analysis of outcomes following pathological complete response to neoadjuvant chemoradiotherapy for rectal cancer

Following neoadjuvant chemoradiotherapy (CRT) and interval proctectomy, 15–20 per cent of patients are found to have a pathological complete response (pCR) to combined multimodal therapy, but controversy persists about whether this yields a survival benefit. This systematic review evaluated current evidence regarding long‐term oncological outcomes in patients found to have a pCR to neoadjuvant CRT.

Systematic review of outcomes after intersphincteric resection for low rectal cancer

For a select group of patients proctectomy with intersphincteric resection (ISR) for low rectal cancer may be a viable alternative to abdominoperineal resection, with good oncological outcomes while preserving sphincter function. The purpose of this systematic review was to evaluate the current evidence regarding oncological outcomes, morbidity and mortality, and functional outcomes after ISR for low rectal cancer.

Omental pedicle flaps following proctectomy: a systematic review

Abdominoperineal excision (APR) for cancer carries significant morbidity of the perineal wound. An omental pedicle graft has been used to fill the pelvis and limit attendant complications after radical extirpation of the anorectum. A review of the literature was conducted to determine whether omentoplasty following APR reduces perineal wound complications.

Segmental vs extended colectomy in the management of hereditary nonpolyposis colorectal cancer: a systematic review and meta-analysis

The optimal surgical approach to the management of colorectal cancer in the setting of hereditary nonpolyposis colorectal cancer (HNPCC) is contentious. While some advocate total colectomy, others perform segmental resection followed by regular endoscopic surveillance. This systematic review evaluates the evidence for segmental colectomy (SC) and total (extended) colectomy (TC) in the management of HNPCC.

Single‐port access laparoscopic surgery for complex Crohn's disease

To the Editor: Single-port access or laparoendoscopic single site surgery is a fastgrowing advance in minimally invasive surgery. Conventional laparoscopy has advantages over open surgery in ileocolic Crohn’s disease (CD) resection. Single-port colonic resections have been performed for early neoplasia or diverticulosis; however, to the authors’ knowledge single-port access laparoscopy has not been performed for complicated CD. We report our initial experience with an umbilical single-port access to perform a laparoscopic ileocecal resection for CD complicated by an enterovesical fistula. The patient was a 39-year-old male with abdominal pain and weight loss for 3 months prior to a 2-week history of pneumaturia. He had no prior medical history and was a nonsmoker. The body mass index (BMI) was 27 and examination was normal other than a right iliac fossa mass. Preliminary investigations revealed markedly raised inflammatory markers with a C-reactive protein (CRP) of 227.5 mg/L and erythrocyte sedimentation rate (ESR) of 67 mm/h. The patient was referred to a gastroenterologist specializing in inflammatory bowel disease (IBD). Computed tomography showed thickened terminal ileum with peri-ileal fat inflammation and an evident ileovesical fistula. Endoscopic cecal and terminal ileal biopsies showed ulceration and chronic inflammation consistent with CD. The patient was referred for surgery. The patient was consented to laparoscopic ileocecal resection via a single port with additional access sites or conversion as necessary. Under general anesthesia with antibiotic prophylaxis the patient was positioned supine and prepared and draped as for a conventional laparoscopic right-sided colonic resection. A 2.5-cm vertical incision was made via the umbilicus to access the peritoneal cavity under direct vision and insert the triport (Fig. 1). Carbon dioxide was insufflated for pneumoperitoneum. A 5-mm 30 videolaparoscope was inserted (Olympus, Berlin, Germany). Operative findings were a grossly inflamed 20-cm segment of terminal ileum adherent to the bladder but no other abnormality. The ileal segment and fistula were sharply dissected from the bladder with electrocautery laparoscopic scissors before full mobilization of the cecum and ascending colon. Mesenteric vessel ligation was performed with a 5-mm laparoscopic Ligasure (Covidien, Valleylab, CT) The specimen was extracted via the sleeve of the pert at the umbilicus and an extracorporeal sideto-side ileocolic anastomosis constructed with a GIA 80 (Covidien) Following reduction of the anastomosed bowel to the peritoneum the triport sleeve was removed and the fascia closed with 0-Maxon (Covidien UK, S D G Suture). Subcuticular 4-0 monocryl (Ethicon, Johnson & Johnson, UK) suturing completed the closure. The operative time was 86 minutes with a blood loss of <100 mL. The patient had an uneventful postoperative course including normal cystogram and catheter removal on day 5. Histological examination of the specimen confirmed ileal CD with micro-abscess formation in the fat extending to the serosal surface consistent with a fistula. The patient has remained well on follow-up for 3 months. Conceptually, natural orifice transluminal endoscopic surgery (NOTES) offers ideal cosmetic outcomes but it has been proposed that combining single-port surgery with NOTES techniques could allow for adaptation into more widespread surgical practice. Using the umbilicus as the port site allows for essentially scarless surgery at a site intimately familiar to laparoscopic surgeons and also allows for use of conventional laparoscopic instruments. The umbilicus has been proposed as an embryonic natural orifice which would facilitate adaptation of embryonic (E)-NOTES) by surgeons experienced in laparoscopy. Umbilical single-port access surgery has been performed in appendectomy, cholecystectomy, and gastric FIGURE 1. TriPort boot and outer proximal ring lying flush to the skin. [Color figure can be viewed in the online issue, which is available at www.interscience.wiley.com.]

Heightened Expression of CD39 by Regulatory T Lymphocytes Is Associated with Therapeutic Remission in Inflammatory Bowel Disease

Background:To evaluate whether changes in expression of CD39 by regulatory T lymphocytes (Treg) impact treatment response in inflammatory bowel disease. To then define the biological role of expression of CD39 on Treg in an animal model of colitis. Methods:A prospective study of consecutive patients commencing anti-tumor necrosis factor therapy with infliximab (IFX) or adalimumab (ADA), who were then followed for 12 months. Treatment responses were defined both symptomatically and by endoscopy showing mucosal healing. Peripheral blood Tregs were quantified by flow cytometry. Functional importance of CD39 expression by Treg was determined in an adoptive T-cell transfer model of colitis. Results:Forty-seven patients (ulcerative colitis, n = 22; Crohns disease, n = 25) were recruited; 16 patients were complete responders and 13 nonresponders to anti-tumor necrosis factor. CD39 expression by Treg was lower in active inflammatory bowel disease and increased significantly after treatment in responders (CD39+Treg/total Treg; 8% at baseline to 22.5% at late time point, P < 0.001). Responders were more likely to have therapeutic drug levels and in multivariate analysis therapeutic drug levels were associated with higher expression of CD39 by FoxP3+ Treg and lower frequencies of interleukin 17A expressing cells. Tregs with genetic deletion of CD39 exhibit decrements in potential to suppress intestinal inflammation in a murine (CD45RBhi) T-cell transfer model of colitis in vivo, when compared with wild-type Treg. Conclusions:Increased expression of CD39 by peripheral blood Treg is observed in the setting of clinical and endoscopic remission in inflammatory bowel disease. Deficiency of CD39 expression by Treg can be linked to inability to suppress experimental colitis.

A Preliminary Study Examining the Binding Capacity of Akkermansia muciniphila and Desulfovibrio spp., to Colonic Mucin in Health and Ulcerative Colitis.

Background Akkermansia muciniphila and Desulfovibrio spp. are commensal microbes colonising the mucus gel layer of the colon. Both species have the capacity to utilise colonic mucin as a substrate. A. muciniphila degrades colonic mucin, while Desulfovibrio spp. metabolise the sulfate moiety of sulfated mucins. Altered abundances of these microorganisms have been reported in ulcerative colitis (UC). However their capacity to bind to human colonic mucin, and whether this binding capacity is affected by changes in mucin associated with UC, remain to be defined. Methods Mucin was isolated from resected colon from control patients undergoing resection for colonic cancer (n = 7) and patients undergoing resection for UC (n = 5). Isolated mucin was purified and printed onto mucin microarrays. Binding of reference strains and three clinical isolates of A. muciniphila and Desulfovibrio spp. to purified mucin was investigated. Results Both A. muciniphila and Desulfovibro spp. bound to mucin. The reference strain and all clinical isolates of A. muciniphila showed increased binding capacity for UC mucin (p < .005). The Desulfovibrio reference strain showed increased affinity for UC mucin. The mucin binding profiles of clinical isolates of Desulfovibrio spp. were specific to each isolate. Two isolates showed no difference in binding. One UC isolate bound with increased affinity to UC mucin (p < .005). Conclusion These preliminary data suggest that differences exist in the mucin binding capacity of isolates of A. muciniphila and Desulfovibrio spp. This study highlights the mucin microarray platform as a means of studying the ability of bacteria to interact with colonic mucin in health and disease.

Restorative Procedures in Colonic Crohn Disease

Surgical management for refractory Crohn colitis often involves creation of a temporary or permanent stoma. Traditionally, the procedure of choice has been a total proctocolectomy with permanent ileostomy. However, restorative procedures that help to avoid a permanent stoma are being used with more frequency. In this article, the authors will address these procedures, including colocolonic anastomosis, ileorectal anastomosis, ileal pouch rectal anastomosis, and ileal pouch anal anastomosis. Factors that may influence ones decision to perform these procedures, such as patient age and nutritional status, medical comorbidities, sphincter function, desire to avoid a permanent ostomy, and prior medical therapy, will be discussed. Functional outcomes regarding these procedures will also be described. One should keep in mind that surgery does not cure Crohn disease and that postoperative long-term management is essential in preventing progression or recurrence of disease.

Clostridium difficile enteritis: A new role for an old foe

BACKGROUND Small bowel involvement of Clostridium difficile is increasingly encountered. Data on many management aspects are lacking. AIM To synthesis existing reports and assess the frequency, pathophysiology, outcomes, risk factors, diagnosis and management of C. difficle enteritis. METHODS A systematic review of the literature was conducted to evaluate evidence regarding frequency, pathophysiology, risk factors, optimal diagnosis, management and outcomes for C. difficle enteritis. Three major databases (PubMed, MEDLINE and the Cochrane Library) were searched. The review included original articles reporting C. difficle enteritis from January 1950 to December 2012. RESULTS C. difficle enteritis is rare but increasingly encountered. Presentation is variable and distinct predisposing factors include emergency surgery, white race and increased age. Diagnosis generally involves a sensitive but often non specific screening test for C. difficile antigens. Oral metronidazole represents first line therapy and surgery may be required for complications. Outcomes are inconsistent but may be improving. CONCLUSIONS A high index of clinical suspicion, early diagnosis and treatment are vital. Further prospective studies are needed to determine the significance of asymptomatic small bowel C. difficile infections.