Toshihiro Bando

Risk factors for surgical site infection and association with infliximab administration during surgery for Crohn's disease.

BACKGROUND: Preoperative infliximab treatment may influence postoperative infectious complications in patients with Crohn’s disease. OBJECTIVE: The aim of this study was to identify predictors of surgical site infection after surgery for Crohn’s disease and evaluate the effects of preoperative infliximab administration. DESIGN: We performed a prospective surveillance and review of surgical site infections. SETTINGS: This study was conducted in the Surgical Department of Hyogo College of Medicine. PATIENTS: A total of 405 consecutive patients with Crohn’s disease who underwent abdominal surgery between January 2008 and December 2011 were included. MAIN OUTCOME MEASURES: Infection was diagnosed by the infection control team. The possible risk factors were analyzed by using logistic regression analyses to determine their predictive significance. RESULTS: Within the patient population, 20% of patients received infliximab, and 60% had penetrating disease. The median duration from the last infliximab infusion to surgery was 43 days (range, 4–80). The overall incidence of surgical site infection was 27%. The incidence of incisional surgical site infection was 18%, and the organ/space surgical site infection rate was 8%. In the multivariate analysis, proctectomy was the highest risk factor for all surgical site infection (OR, 3.4–11.8; p < 0.01). The administration of preoperative infliximab was not a risk factor for surgical site infection. By contrast, there was a significantly reduced risk of incisional surgical site infection in patients with penetrating disease who received infliximab (OR, 0.1; p < 0.01). LIMITATIONS: This study was a cohort study and not a randomized trial. The data analyses were performed for surgical site infections but not for other infectious complications. CONCLUSIONS: Proctectomy was a high-risk factor for surgical site infection in patients with Crohn’s disease. The administration of preoperative infliximab was not a risk factor for surgical site infection.

Long-term efficacy of infliximab maintenance therapy for perianal Crohn’s disease

AIM To assess the long-term efficacy of seton drainage with infliximab maintenance therapy in treatment of stricture for perianal Crohns disease (CD). METHODS Sixty-two patients with perianal CD who required surgical treatment with or without infliximab between September 2000 and April 2010 were identified from our clinics database. The activities of the perianal lesions were evaluated using the modified perianal CD activity index (mPDAI) score. The primary endpoint was a clinical response at 12-15 wk after surgery as a short-term efficacy. Secondary endpoints were recurrence as reflected in the mPDAI score, defined as increased points in every major element. The clinical responses were classified as completely healed (mPDAI = 0), partially improved (mPDAI score decreased more than 4 points), and failure or recurrence (mPDAI score increased or decreased less than 3 points). RESULTS There were 43 males and 19 females, of whom 26 were consecutively treated with infliximab after surgery as maintenance therapy. Complete healing was not seen. Failure was seen in 10/36 (27.8%) patients without infliximab and 4/26 (15.4%) patients with infliximab (P = 0.25). Partial improvement was seen in 26/36 (72.2%) patients without infliximab and 22/26 (88.5%) patients with infliximab (P = 0.25). Short-term improvement was achieved in 48/62 (77.4%) patients. Although the mPDAI score improved significantly with surgery regardless of infliximab, it decreased more from baseline in patients with infliximab (50.0%) than in those without infliximab (28.6%), (P = 0.003). In the long-term, recurrence rates were low regardless of infliximab in patients without anorectal stricture. In patients with anorectal stricture, cumulative recurrence incidences increased gradually and exceeded 40% at 5 years regardless of infliximab. No efficacy of infliximab treatment was found (P = 0.97). Although the cumulative rate of ostomy creation was also low in patients without stricture and high in patients with stricture, no protective efficacy was found with infliximab treatment (P = 0.6 without stricture, P = 0.22 with stricture). CONCLUSION Infliximab treatment was demonstrated to have short-term efficacy for perianal lesions. Long-term benefit with infliximab was not proven, at least in patients with anorectal stricture.

Topical tacrolimus therapy for antibiotic-refractory pouchitis.

BACKGROUND: Pouchitis is the most common complication after restorative proctocolectomy for ulcerative colitis, and it leads to pouch failure. The administration of oral antibiotics is the main treatment for pouchitis; however, in some cases, antibiotic-refractory pouchitis may develop, which requires further medical therapy. OBJECTIVE: We investigated the applicability of topical tacrolimus for refractory pouchitis. DESIGN: We performed a prospective pilot study. The study protocols were registered with the University Hospital Medical Information Network Clinical Trials Registry, 000006658. SETTING: This study was conducted in the Surgical Department of Hyogo College of Medicine. PATIENTS: Patients with antibiotic-refractory pouchitis were treated for 8 weeks with a tacrolimus enema. MAIN OUTCOME MEASURES: The efficacy was assessed by comparing Pouchitis Disease Activity Index scores. Safety was assessed by measuring whole blood tacrolimus trough levels. RESULTS: Ten patients with refractory pouchitis were enrolled. No severe adverse events occurred. The mean scores decreased from 15.9 ± 0.8 to 7.8 ± 0.8 during 8 weeks of treatment (p < 0.01). Specifically, the clinical symptom, endoscopic finding, and histological finding subscores decreased to 0.8 ± 0.6, 3.9 ± 0.2, and 2.9 ± 0.4. Nine patients recovered from their clinical symptoms, and 3 patients recovered from pouchitis. LIMITATIONS: This small study was neither blinded nor randomized. CONCLUSIONS: This study demonstrates that the use of topical tacrolimus for the treatment of refractory pouchitis is safe and effective in the short term for clinical symptoms. Although complete endoscopic healing was not achieved, this treatment may have early rescue efficacy in the treatment of antibiotic-refractory pouchitis.

Clinical Features and Management of Parastomal Pyoderma Gangrenosum in Inflammatory Bowel Disease

Background: Pyoderma gangrenosum (PG) is often associated with inflammatory bowel disease even after bowel surgery, but it remains an extremely rare pathology. The purpose of this study was to investigate the clinical features and treatment of PG and to consider proper management for peristomal PG. Methods: Demographic data for patients who underwent colorectal surgery with ostomy creation at Hyogo College of Medicine between July 2007 and July 2011 were prospectively collected. The main outcome measures were postoperative occurrence of peristomal PG by type: explosive and rapidly spreading type (type R) and indolent and gradually spreading type (type G). Results: Overall prevalence was 11/738 (1.5%), with type R in 5 patients and type G in 6. Type R and type G were significantly more common in ulcerative colitis and Crohn’s disease, respectively (p = 0.01). Type R developed within 6 days after surgery. Type G developed a mean of 52 days after surgery. Complete healing required a long time in both types, with means of 69 days for type R and 48 days for type G. Conclusion: Although peristomal PG was a rare complication after surgery, differences in the development of PG were observed between ulcerative colitis and Crohn’s disease. Careful observation and knowledge of PG are needed.

Long-term outcomes and sex differences after restorative proctocolectomy in pediatric patients with ulcerative colitis

BACKGROUND Restorative proctocolectomy (RPC) for ulcerative colitis (UC) could result in a higher patient quality of life, avoiding frequent disease flares; however, pouch failures and pouch-related complications (PRCs) can develop. PURPOSE No cohort studies have examined pouch failure and the differences between adult and pediatric patients or the sex differences in pediatric UC. Therefore, the pouch failure rates were compared between adults and pediatric patients, and pouch failure and PRCs in pediatric UC were evaluated. METHODS UC patients who underwent RPC between January 1987 and June 2014 at Hyogo College of Medicine were included. Patient background characteristics, PRCs, and pouch failure were reviewed. RESULTS A total of 1347 adult UC patients and 90 (51 boys, 39 girls) pediatric UC patients were included in the study. The cumulative rate of pouch failure at 10years after RPC was significantly higher in pediatric UC (9.5%) than in adult UC (2.1%; p<0.01). In pediatric UC, the independent risk factors for pouch failure were pouchitis (hazard ratio (HR) 19.3) and anal fistula (HR 5.5). Although a sex difference was not seen in pouch failure, an independent risk factor for PRCs was being a girl (HR 2.5). CONCLUSIONS Pouch failure was more common in pediatric than in adult UC. PRCs after RPC were more common in girls in pediatric UC.

Clinical features and treatment of ulcerative colitis-related severe gastroduodenitis and enteritis with massive bleeding after colectomy

IntroductionUlcerative colitis (UC) has been recognised as a systemic immune disorder that is not as restricted as colitis. UC-related gastrointestinal lesions with bleeding can develop soon after colectomy and can progress rapidly. Therefore, we considered the clinical features and treatment of these UC-related lesions.MethodsWe reviewed the patient data in our UC surgery database to evaluate its prevalence and features.ResultsWe found 7/1,100 patients with UC-related lesions between January 2000 and April 2013. These lesions developed at a mean of 24 (range 8–480) days after colectomy. Six of the seven patients suffered from gastrointestinal bleeding as an initial symptom that rapidly developed into massive bleeding or perforations. All of the patients were diagnosed with pancolitis; at the time of colectomy, fulminant, severe, moderate, and mild colitis were presented by four, one, one, and one patients, respectively. All patients with enteritis had consecutively developed other infectious complications, including anastomotic leakage, pyoderma gangrenosum, wound infection, and pneumonia. Although patients with bleeding did not respond to treatment with corticosteroids, they responded well to infliximab soon after its administration. Although six of the seven patients showed cytomegalo virus re-activation in blood or pathological examinations, ganciclovir was not effective in its elimination.ConclusionAlthough UC-related lesions with an unknown aetiology can occur after colectomy, immediate examination and treatment are required if gastrointestinal bleeding is found after surgery. Because gastrointestinal bleeding from UC-related lesions can worsen rapidly and may be related to mortality, early potent immunosuppressive therapy should be considered.

Surgical procedure for sporadic colorectal cancer in patients with mild ulcerative colitis.

Restorative proctocolectomy is recognized as the standard procedure for colitic cancer in patients with ulcerative colitis (UC). However, whether this represents the optimal procedure for UC patients with sporadic cancer remains questionable, as functional quality of life differs substantially between patients with proctocolectomy and partial resection. This study considered possible problems associated with sporadic cancer in UC. Case 1 is a 55-year-old man with a 3-year history of UC who was treated with endoscopic resection for sporadic adenocarcinoma in the rectum. Low anterior resection was subsequently performed due to deep invasion. The final diagnosis was pT3. Differentiating between histopathological diagnoses of sporadic and colitic cancer was difficult. Case 2 is a 71-year-old woman with a 6-year history of UC who was diagnosed with type 1 sporadic sigmoid colon cancer. Dementia and umbilical hernia were present as complications. Total colectomy was performed in consideration of the coexisting complications. Although partial resection for sporadic cancer could be favorable in mild colitis, further immunosuppressive treatments have the potential to elevate the risk of recurrence for advanced cancer. Restorative proctocolectomy may be safer to avoid further recurrent colitis and cancer except in elderly patients or those with other complications.

Randomized Controlled Trial of Prophylactic Negative-Pressure Wound Therapy at Ostomy Closure for the Prevention of Delayed Wound Healing and Surgical Site Infection in Patients with Ulcerative Colitis

Background/Aims: Although negative-pressure wound therapy (NPWT) is likely advantageous for wound healing, the efficacy and safety of its prophylactic use remain unclear for digestive surgery. We performed a prospective randomized controlled study to evaluate the efficacy and safety of this procedure during ileostomy closure. Methods: We conducted a prospective, randomized study between November 2014 and September 2015. Patients with ulcerative colitis scheduled to undergo ileostomy closure with purse-string suture (PSS) were randomly divided into groups with or without NPWT. The primary endpoint was complete wound healing. The secondary endpoints were incidences of wound complications. Results: A total of 31 patients with PSS alone and 28 patients with PSS + NPWT were enrolled. Wound infection was observed in 1 patient in the PSS-alone condition and 3 patients in the PSS + NPWT condition (p = 0.76). The mean duration of complete wound healing was 37.6 ± 11.7 days in the PSS-alone condition and 33.5 ± 10.0 days in the PSS + NPWT condition (p = 0.18). Conclusion: Although no adverse effects were observed in this series, the efficacy of PSS + NPWT was not confirmed. Further clarification of the indication of prophylactic NPWT and its efficacy must be obtained, and the efficacy and safety of NPWT in different dirty/infected surgeries should be evaluated.

Does Pre-Operative Multiple Immunosuppressive Therapy Associate with Surgical Site Infection in Surgery for Ulcerative Colitis.

Background: Almost all surgeries for ulcerative colitis (UC) are performed under immunosuppressive conditions. Immunomodulators or biologics, with the exception of corticosteroids, do not appear to be risk factors for post-operative infectious complications. However, many patients are on multiagent immunosuppressive therapy at the time of surgery. Therefore, we evaluated the influence of pre-operative multiple immunosuppressives on the occurrence of surgical site infection (SSI) in UC. Methods: We reviewed surveillance data from 181 patients who underwent restorative proctocolectomy between January 2012 and March 2014. The incidences of SSI and the possible risk factors among patients receiving different immunosuppressive therapies were compared and analyzed. Results: The incidence of incisional (INC) SSI was 13.3% and that of organ/space (O/S) SSI was 7.2%. The number of immunosuppressives did not significantly correlate with each incidence. Total prednisolone administration ≥12,000 mg (OR 2.6) and an American Society of Anesthesiologists score ≥3 (OR 2.8) were shown to be independent risk factors for overall SSI, whereas corticosteroid use in INC SSI (OR 17.4) and severe disease (OR 5.2) and a large amount of blood loss (OR 3.9) in O/S SSI were identified as risk factors. Conclusion: Although a correlation between multiple immunosuppressive therapy and SSIs was not found, it is not recommended that all patients be treated with multiple immunosuppressive therapy. Treatment strategy should be applied based on the patients condition.

Surgery for Severe Ulcerative Colitis during Pregnancy: Report of Two Cases

Refractory ulcerative colitis (UC) that does not respond to medical therapy often requires surgery even during pregnancy. Although surgical cases of UC during pregnancy were reported previously, the standard surgical strategy for both colitis and pregnancy was unclear. Herein, fetal and maternal safety as well as the strategy for this unusual surgical procedure during pregnancy in patients with UC are considered. A 28-year-old woman was diagnosed with left-sided moderate UC at 12 weeks of pregnancy; toxic megacolon was suspected, and surgery was required. Although the babys gestational age was 23 weeks and 3 days, a cesarean section was performed before the colectomy. In a next case, a 28-year-old woman had a 2-year history of left-sided UC. Her colitis flared up at 11 weeks of pregnancy. Colectomy was performed because her colitis was unresponsive to conservative therapy, and the pregnancy was continued, with a transvaginal delivery at 36 weeks. In patients with UC, the need for surgery should be determined promptly based on disease severity, whether or not the patient is pregnant. The need for surgery should not be affected by pregnancy. The pregnancy should be continued for as long as possible when there are no fetal and maternal complications. Both cesarean section and colectomy should be performed independently if necessary.