Lightner, Amy L.

BACKGROUND: Revisional and reconstructive surgery for IPAA is rare given the high success of pouch surgery for chronic ulcerative colitis. Limited data exist on both surgical and functional outcomes in patients with chronic ulcerative colitis who undergo IPAA revision or reconstruction. OBJECTIVE: This study aimed to determine the surgical and functional outcome in patients with chronic ulcerative colitis who undergo IPAA revision or reconstruction. DESIGN: A prospectively collected surgical database was accessed for this study. SETTING: This study was conducted at an IBD referral center. PATIENTS: Patients with chronic ulcerative colitis who underwent IPAA revision or reconstruction were selected. MAIN OUTCOME MEASURES: The primary outcomes measured were 30-day postoperative outcomes and long-term pouch function. RESULTS: Eighty-one patients were identified. Original IPAA was performed for chronic ulcerative colitis (n = 71; 88%) and indeterminate colitis (n = 11; 12.%), and the most common configuration was a J-pouch (n = 69; 86%) with handsewn anastomosis (n = 41;68%). No independent predictors of 30-day postoperative complications following reconstructive/revisional surgery were identified. Pelvic abscesses and Crohn’s disease of the pouch were independently associated with ultimate pouch excision. Median follow-up following revision/reconstruction was 40 months (range, 1–292 months) during which 15 patients (23%) had pouch failure. The 5- and 10-year pouch survival rates following revision were 85 ± 5% and 65 ± 9% by Kaplan-Meier estimation; age <30 years was significantly associated with pouch survival. Long-term function (n = 30; 35%) compared with a matched control cohort of primary IPAA was characterized by significantly increased daytime bowel incontinence (p = 0.0119), liquid stool (p = 0.0062), and medication to thicken stools (p = 0.0452). LIMITATIONS: This was a single-center series, and response rate for functional data was 35%. CONCLUSIONS: In properly selected patients with a failing pouch, originally made for chronic ulcerative colitis or indeterminate colitis, revisional and reconstructive surgery is associated with low complication rates, high pouch salvage, and acceptable long-term pouch function. See Video Abstract at http://links.lww.com/DCR/A640.

Background: Vedolizumab (VDZ) is a gut-specific α4-β7 integrin antagonist that has demonstrated efficacy in Crohn’s disease (CD) and ulcerative colitis (UC). The safety of VDZ in the perioperative period remains unclear. The aim of this study was to evaluate postoperative complications and perioperative safety in VDZ-treated patients undergoing nonintestinal operations. Methods: A case-matched study was performed at two inflammatory bowel disease (IBD) referral centers. Adult patients with CD and UC who underwent a nonintestinal surgical procedure during treatment with VDZ were included. Patients who had their last VDZ infusion up to 12 weeks before the procedure were considered exposed and were matched in a 1:1 ratio to patients without VDZ therapy, according to type of surgical procedure, age, and sex. The primary outcome was overall risk of early postoperative infectious complications (up to 30 days after surgery), readmissions, reoperations, surgical site infections, and other infections. The VDZ and control groups were subsequently compared using the Pearson χ2 test and Wilcoxon rank sum. Results: We identified 34 patients treated with VDZ who underwent 36 nonintestinal surgical procedures. These patients were matched with 36 control procedures. Postoperative complications were not different between the VDZ-treated and control cohorts for all outcomes analyzed: infectious complications occurred in 14% versus 8% ( p = 0.45), superficial surgical site infections 6% versus 0% ( p = 0.15), reoperations 6% versus 3% ( p = 0.56) and readmissions 11% versus 6% ( p = 0.37). Conclusions: VDZ-treated patients with IBD undergoing nonintestinal procedures did not have an increased risk of overall postoperative infections or other complications compared with matched controls.

INTRODUCTION: An IPAA is the preferred operative approach for restoration of intestinal continuity in patients with ulcerative colitis and familial adenomatous polyposis. As minimally invasive approaches have become more widely adopted, their use in IPAA has also become increasingly commonplace. Laparoscopy has the same limitations during the proctectomy portion as seen in operations for rectal cancer, including dissection in the mid-to-lower rectum attributed to angles created by bony confines of the deep pelvis and lack of visibility when constructing the anastomosis. Robotic surgery provides improved 3-dimensional and high-definition visualization of the pelvis and multiple degrees of freedom, which greatly enhance performance during the proctectomy and construction of the anastomosis. TECHNIQUE: In the setting of a previous subtotal colectomy, the ileostomy site is taken down and stapled across. A 15-mm balloon trocar is placed in the site to achieve insufflation, and the robotic ports are placed horizontally just above the umbilicus. The lateral mesenteric attachments are mobilized laparoscopically, then the J-pouch is constructed through the ostomy site. The J-pouch is placed back into the abdomen with the anvil in place, and the proctectomy is performed after docking the robot. The rectum is stapled with the robotic stapler and exteriorized from the ileostomy site, and the anastomosis is constructed under direct robotic visualization. RESULTS: In addition to the potential ergonomic advantages, the maneuverability and visualization in the pelvis during the proctectomy and construction of the anastomosis are reported by many surgeons to be improved as compared with laparoscopy, especially in male or obese patients. CONCLUSIONS: A robotic approach during the proctectomy and IPAA offers significant advantages to a laparoscopic approach, expanding our armamentarium of minimally invasive surgical techniques to IPAA.

SummaryBackgroundPrimary sclerosing cholangitis (PSC) is a chronic, progressive cholestatic biliary disease associated with inflammatory bowel disease (IBD) with no known cure.AimTo evaluate the effect of biological therapies on PSC progression in IBD patients.MethodsWe performed a retrospective cohort study of 88 cases (75 unique patients with 12 patients treated >1 biologics) of IBD (48 ulcerative colitis, 24 Crohn's disease and 3 indeterminate colitis) with concomitant PSC who received biological therapy (42 infliximab, 19 adalimumab, 27 vedolizumab) between June 2002 and October 2017. Hepatic biochemistries were compared using the paired t‐test (patients served as their own controls) ≤3 months before and 6‐8 and 12‐14 months after biological initiation. Radiographic information of biliary stenosis and liver fibrosis were obtained via abdominal ultrasound, abdominal magnetic resonance imaging and magnetic resonance elastography.ResultsUse of adalimumab was associated with a significant decrease in alkaline phosphatase (ALP) after 6‐8 months (P = 0.03; mean change −70 U/L, standard deviation [SD] 88 U/L) compared to vedolizumab (mean change +50 U/L, SD 142 U/L) or infliximab (mean change +37 U/L, SD 183 U/L) but the change was not significant after 12‐14 months (P = 0.24). No significant decreases were observed with AST, ALT, total or direct bilirubin, elastography score or radiographic imaging of biliary tree dilation/strictures with any biological therapy after 6‐8 or 12‐14 months.ConclusionsCurrent evidence suggests that biological therapies used for the treatment of IBD are not effective treatments for PSC. Further study is needed to elucidate any potential beneficial effect of adalimumab on PSC.

BACKGROUND: There has been a surge in clinical trials studying the safety and efficacy of mesenchymal stem cells for the treatment of perianal Crohn’s disease. OBJECTIVE: The purpose of this work was to systematically review the literature to determine safety and efficacy of mesenchymal stem cells for the treatment of refractory perianal Crohn’s disease. DATA SOURCES: Sources included PubMed, Cochrane Library Central Register of Controlled Trials, and Embase. STUDY SELECTION: Studies that reported safety and/or efficacy of mesenchymal stem cells for the treatment of perianal Crohn’s disease were included. Two independent assessors reviewed eligible articles. INTERVENTION: The study intervention was delivery of mesenchymal stem cells to treat perianal Crohn’s disease. MAIN OUTCOMES MEASURES: Safety and efficacy of mesenchymal stem cells used to treat perianal Crohn’s disease were measured. RESULTS: Eleven studies met the inclusion criteria and were included in the systematic review. Three trials with a comparison arm were included in the meta-analysis. There were no significant increases in adverse events (OR = 1.07 (95% CI, 0.61–1.89); p = 0.81) or serious adverse events (OR = 0.53 (95% CI, 0.28–0.98); p = 0.04) in patients treated with mesenchymal stem cells. Mesenchymal stem cells were associated with improved healing as compared with control subjects at primary end points of 6 to 24 weeks (OR = 3.06 (95% CI, 1.05–8.90); p = 0.04) and 24 to 52 weeks (OR = 2.37 (95% CI, 0.90–6.25); p = 0.08). LIMITATIONS: The study was limited by its multiple centers and heterogeneity in the study inclusion criteria, mesenchymal stem cell origin, dose and frequency of delivery, use of scaffolding, and definition and time point of fistula healing. CONCLUSIONS: Although there have been only 3 trials conducted with control arms, existing data demonstrate improved efficacy and no increase in adverse or serious adverse events with mesenchymal stem cells as compared with control subjects for the treatment of perianal Crohn’s disease.