Tim Eglinton

Patterns of recurrence in patients with acute diverticulitis.

The natural history of acute diverticulitis remains unclear, with the role of prophylactic surgery following conservatively managed diverticulitis increasingly controversial. This study investigated recurrence rates, patterns and complications after conservatively managed diverticulitis.

Impact of ileal pouch-anal anastomosis on female fertility: meta-analysis and systematic review.

PurposeThe aim of this review is to determine the effect of ileal pouch-anal anastomosis (IPAA) on female fertility in ulcerative colitis (UC) and familial adenomatous polyposis (FAP), the mechanisms of this effect, strategies for prevention and management of infertility post-IPAA.MethodsThis paper is a systematic literature review of all articles investigating IPAA and fertility from 1966 onwards that were found searching the Medline and Embase databases. Meta-analysis was performed on relevant studies.ResultsSeventeen relevant studies were identified. Six studies were excluded (duplicate data, one; predominantly not IPAA patients, one; no control group, four). The control groups of the remaining 11 studies were too varied for comparison, and so the meta-analysis was limited to six studies that provided data on infertility both pre- and post-IPAA. Five of these involved predominantly UC patients and one FAP. Average infertility rates were 20% pre-IPAA and 63% post-IPAA. The relative risk of infertility after IPAA is 3.91 ([2.06, 7.44] 95% CI). The possibility of publication bias suggests that the risk may be lower. Any increased risk is probably due to tubal dysfunction secondary to adhesions. Various methods have been proposed to reduce pelvic adhesions, but there is no evidence they have any effect in preventing infertility. Infertility treatment post-IPAA is associated with good success rates.ConclusionsInfertility is increased after IPAA in female patients in both UC and FAP. Both these disease processes affect patients during their reproductive years. This evidence emphasizes the need for careful consideration of fertility in the choice and timing of surgery.

Routine colonoscopy following acute uncomplicated diverticulitis

The evidence supporting current recommendations that the colon should be evaluated following an initial episode of acute diverticulitis is poor. The aim of this study was to clarify whether acute uncomplicated diverticulitis is a valid indication for subsequent colonoscopy/computed tomography (CT) colonography.

The spectrum of perianal Crohn's disease in a population-based cohort.

BACKGROUND: Perianal Crohn’s disease represents a phenotype distinct from luminal Crohn’s disease and may follow a different course. To date, the only detailed classifications of perianal Crohn’s disease arise from referral center cohorts that do not reflect the spectrum of disease in the population as a whole. OBJECTIVES: The aim of this study was to document the rate, classification, and time course of symptomatic perianal Crohn’s disease in a population-based cohort. DESIGN: This is a population-based cohort study. SETTING: This study was conducted in the Canterbury region of New Zealand. PATIENTS: All patients with IBD in Canterbury, New Zealand, were eligible for recruitment over a 3-year period. MAIN OUTCOME MEASURES: The clinical records of all patients with Crohn’s disease were reviewed, and all symptomatic perianal disease was classified according to the American Gastroenterological Society position statement. The rate of perianal involvement and timing of onset relative to Crohn’s diagnosis was determined. RESULTS: Ninety-one percent of IBD patients in the region were recruited. Seven hundred fifteen patients had Crohn’s disease, of which 190 (26.6%) patients had symptomatic perianal disease. The median age of patients with perianal disease was 37 years (range, 4–82 years) and 58.4% were female. Median follow-up was 9 years (range, 2 months to 45 years) from Crohn’s disease diagnosis. Onset of perianal disease ranged from 18 years pre-Crohn’s diagnosis to 33 years post-Crohn’s diagnosis. Fistulas were the most common lesion (50% of patients), followed by perianal abscesses (42.1%), fissures (32.6%), skin tags (11.1%), strictures (7.4%), and hemorrhoids (1.6%). The cumulative probability at 20 years of any perianal Crohn’s disease was 42.7% and of a perianal fistula 28.3%. LIMITATIONS: This study assumed all noted perianal lesions were related to Crohn’s disease and the retrospective classification may have been inaccurate in some cases. CONCLUSIONS: This study provides the first detailed classification of perianal Crohn’s disease in a population-based cohort.

Systematic Review and Meta-analysis of the Role of Routine Colonic Evaluation After Radiologically Confirmed Acute Diverticulitis

Objective:To determine the yield of colorectal cancer at routine colonic evaluation after radiologically proven acute diverticulitis. Background:Acute diverticulitis accounts for 152,000 hospitalizations in the United States alone. Current guidelines recommend routine colonic evaluation after acute diverticulitis to confirm the diagnosis and exclude malignancy. However, research suggests that the yield of colorectal cancer after computed tomography–proven uncomplicated diverticulitis may be low. In the era of widespread computed tomographic scanning for diverticulitis, routine colonic evaluation after diverticulitis may represent a nonessential burden on health care resources. Methods:The PubMed (MEDLINE), EMBASE, BIREME, CINAHL, and the Cochrane Library databases were searched. Original studies of colonic evaluation after proven acute diverticulitis were included. Meta-analysis of data from included studies was performed using a DerSimonian Laird random effect proportion analysis. Results:Eleven studies from 7 countries were included in the analysis. Out of a pooled population of 1970 patients, cancer was found in 22. The pooled proportional estimate of malignancy was 1.6% (95% confidence interval [CI], 0.9%−2.8%). Of the 1497 patients with uncomplicated diverticulitis, cancer was found in 5 (proportional estimate of risk 0.7%; CI, 0.3%−1.4%). Of the 79 patients with complicated disease, cancer was found in 6 (proportion estimate of risk 10.8%; CI, 5.2%−21.0%). Conclusions:The risk of malignancy after a radiologically proven episode of acute uncomplicated diverticulitis is low. In the absence of other indications, routine colonoscopy may not be necessary. Patients with complicated diverticulitis still have a significant risk of colorectal cancer at subsequent colonic evaluation.

Clinical and genetic risk factors for perianal Crohn's disease in a population-based cohort.

OBJECTIVES:Perianal Crohns disease (CD) affects around one-quarter of CD patients and represents a distinct disease phenotype. The objective of this study was to investigate a large population-based cohort of inflammatory bowel disease (IBD) patients to identify clinical and genetic risk factors for perianal CD.METHODS:Data were collected in the Canterbury IBD database, estimated to include 91% of all patients with IBD in Canterbury, New Zealand. Genotyping was performed for selected loci previously demonstrated to be associated with CD. Patients with perianal disease were then compared with both CD patients without perianal disease and healthy controls to assess the presence of potential phenotypic, environmental, and genetic risk factors.RESULTS:Of the 715 CD patients in the database, 190 (26.5%) had perianal disease. In all, 507 patients with genotype data available were analyzed. Perianal disease was associated with younger age at diagnosis (P<0.0001), complicated intestinal disease (P<0.0001), and ileal disease location (P=0.002). There was no association with gender, ethnicity, smoking, or breast feeding. Genotype analysis revealed an association with the neutrophil cytosolic factor 4 (NCF4) gene compared with both non-perianal CD patients (odds ratio (OR): 1.47; 95% confidence interval (CI): 1.08–1.99) and healthy controls (OR: 1.47; 95% CI: 1.10–1.95). There was no association identified with other genes, including IBD5 (OR: 0.91; 95% CI: 0.69–1.20), tumor necrosis factor α (OR: 1.04; 95% CI: 0.56–1.85), and IRGM (immunity-related guanosine triphosphatase protein type M) (OR: 1.21; 95% CI: 0.80–1.82).CONCLUSIONS:This study suggests that younger age at diagnosis, complicated disease behavior, and ileal disease location are risk factors for perianal CD. In addition, this paper represents the first report of an association of the NCF4 gene with perianal disease.

Pulmonary staging in colorectal cancer: a review

Aim  Assessment of the chest in colorectal cancer (CRC) staging is variable. The aim of this review was to look at different chest staging strategies and determine which has the greatest efficacy.

DIAPHRAGMATIC HERNIAS COMPLICATING PREGNANCY

Background:  Diaphragmatic hernias complicating pregnancy are not a common problem but they can have catastrophic consequences. They can present to the surgeon as a life‐threatening emergency or pose a management dilemma when detected incidentally. In this paper, recommendations for the management of non‐hiatal maternal diaphragmatic hernias are made based on our experience and the available published reports.

Presacral tumours in adults

Presacral tumours represent a heterogeneous group of predominantly benign and occasionally malignant neoplasms. Due to the rarity of these tumours, their management is often performed in an ad hoc fashion and an algorithm for optimal treatment remains undefined. This review aims to present an overview of presacral tumours, focusing on their presentation, pathology, investigation and management.

Computed tomographic colonography in the diagnosis of colorectal cancer

This study aimed to determine the sensitivity of computed tomographic colonography (CTC) in diagnosing colorectal cancer and to explore the reasons why these cancers are missed on CTC.