Faculty Bibliography

BACKGROUND:The epidemiology of inflammatory bowel disease (IBD) in developing countries may uncover etiopathogenic factors. We investigated IBD prevalence in Brazil by investigating its geographic, spatial, and temporal distribution, and attempted to identify factors associated with its recent increase. METHODS:A drug prescription database was queried longitudinally to identify patients and verify population distribution and density, race, urbanicity, sanitation, and Human Development Index. Prevalence was calculated using the number of IBD patients and the population estimated during the same decade. Data were matched to indices using linear regression analyses. RESULTS:We identified 162 894 IBD patients, 59% with ulcerative colitis (UC) and 41% with Crohn's disease (CD). The overall prevalence of IBD was 80 per 100 000, with 46 per 100 000 for UC and 36 per 100 000 for CD. Estimated rates adjusted to total population showed that IBD more than triplicated from 2008 to 2017. The distribution of IBD demonstrated a South-to-North gradient that generally followed population apportionment. However, marked regional differences and disease clusters were identified that did not fit with conventionally accepted IBD epidemiological associations, revealing that the rise of IBD was variable. In some areas, loss of biodiversity was associated with high IBD prevalence. CONCLUSIONS:When distribution is considered in the context of IBD prevalence, marked regional differences become evident. Despite a background of Westernization, hotspots of IBD are recognized that are not explained by population density, urbanicity, sanitation, or other indices but apparently are explained by biodiversity loss. Thus, the rise of IBD in developing countries is not uniform, but rather is one that varies depending on yet unexplored factors like geoecological conditions.

BACKGROUND:The data on management and outcomes of pelvic sepsis after re-do ileal pouch anal anastomosis are scarce. OBJECTIVE:The aim of this study is to report our management algorithm of pelvic sepsis in the setting of re-do ileal pouch anal anastomosis, and compare functional outcomes and quality of life after successful management of pelvic sepsis with a no-sepsis control group. DESIGN/METHODS:This is a retrospective cohort study. SETTINGS/METHODS:This investigation is based on a single-academic practice group experience on re-do IPAA. PATIENTS/METHODS:Patients who underwent re-do ileal pouch anal anastomosis for ileal pouch failure between 09/2016 - 09/2020 were included in the study. MAIN OUTCOME MEASURES/METHODS:Management of the pelvic sepsis was reported. Functional outcomes, restrictions and quality of life scores were compared between sepsis and no sepsis groups. RESULTS:One-hundred and ten patients were included to our study, of whom 25 (22.7) developed pelvic sepsis. Twenty-three patients presented with pelvic sepsis before ileostomy closure and 2 patients presented with pelvic sepsis after ileostomy closure. There were 6 pouch failures in the study period due to pelvic sepsis. Our management was successful in 79% of the patients with median follow-up of 26 months. Treatments included included IR abscess drainage (n=7), IV antibiotics alone (n=5), IR drainage and mushroom catheter placement (n=1), mushroom catheter placement (n=1), and endoluminal vacuum assisted closure (n=1). Average number of bowel movements, urgency, incontinence, pad use, seepage between were comparable between pelvic sepsis and no pelvic sepsis groups (p>0.05). Lifestyle alterations, Cleveland Global Quality of Life scores and happiness with the results of the surgery were similar (p>0.05). LIMITATIONS/CONCLUSIONS:This study is limited by its low study power and limited follow-up time. CONCLUSIONS:Pelvic sepsis is common after re-do ileal pouch anal anastomosis and management varies according to the location and size of the abscess/sinus. If detected early, our management strategy was associated with high pouch salvage rates. See Video Abstract at http://links.lww.com/DCR/B823.

AIM/OBJECTIVE:Approximately 20-40% of the patients with re-do ileal pouch anal anastomosis (IPAA) experience pouch failure. Salvage surgery can be attempted in this patient group with severe aversion to permanent ileostomy. The literature regarding secondary IPAA revision after re-do IPAA failure is scarce. METHODS:All patients who underwent a secondary IPAA revision after re-do IPAA failure between 09/2016 - 07/2021 in a single center were included. Short- and long-term outcomes and quality of life in this patient group were reported. RESULTS:Ten patients who had secondary IPAA revision for re-do IPAA failure were included. All patients had ulcerative colitis. Nine of these patients had pelvic sepsis and one patient had a mechanical issue. Mucosectomy and handsewn anastomosis was performed in 9 patients. The existing pouch was salvaged in 6 patients and 4 patients had pouch excision and re-creation. Two patients had postoperative pelvic sepsis. Pouch retention rate was 78% in median 28 months. None of the patients had short gut syndrome. The procedure was associated with good quality of life (median CGQL=0.8). All patients would undergo the same surgery if needed. CONCLUSION/CONCLUSIONS:Secondary IPAA revision after a failed re-do IPAA can be an option in patients with severe aversion to permanent ileostomy if re-do IPAA fails and it is associated with good outcomes. This patient group should be carefully evaluated and referred to specialized centers if required.

BACKGROUND AND AIMS/OBJECTIVE:Crohn's disease (CD) can lead to work disability with social and economic impacts worldwide. In Brazil, where its prevalence is increasing, we assessed the indirect costs, prevalence, and risk factors for work disability in the state of Rio de Janeiro and in a tertiary care referral center of the state. METHODS:Data were retrieved from the database of the Single System of Social Security Benefits Information, with a cross-check for aid pension and disability retirement. A subanalysis was performed with CD patients followed up at the tertiary care referral center using a prospective CD database, including clinical variables assessed as possible risk factors for work disability. RESULTS:From 2010 to 2018, the estimated prevalence of CD was 26.05 per 100,000 inhabitants, while the associated work disability was 16.6%, with indirect costs of US$ 8,562,195.86. Permanent disability occurred more frequently in those aged 40 to 49 years. In the referral center, the prevalence of work disability was 16.7%, with a mean interval of 3 years between diagnosis and the first benefit. Risk factors for absence from work were predominantly abdominal surgery, anovaginal fistulas, disease duration, and the A2 profile of the Montreal classification. CONCLUSIONS:In Rio de Janeiro, work disability affects one-sixth of CD patients, and risk factors are associated with disease duration and complications. In the context of increasing prevalence, as this disability compromises young patients after a relatively short period of disease, the socioeconomic burden of CD is expected to increase in the future.

BACKGROUND:Perianal fistulizing Crohn's disease is one of the most severe phenotypes of inflammatory bowel diseases. Combined therapy with seton placement and anti-TNF therapy is the most common strategy for this condition. OBJECTIVES/OBJECTIVE:The aim of this study was to analyze the rates of complete perianal remission after combined therapy for perianal fistulizing Crohn's disease. METHODS:This was a retrospective observational study with perianal fistulizing Crohn's disease patients submitted to combined therapy from four inflammatory bowel diseases referral centers. We analyzed patients' demographic characteristics, Montreal classification, concomitant medication, classification of the fistulae, occurrence of perianal complete remission and recurrence after remission. Complete perianal remission was defined as absence of drainage from the fistulae associated with seton removal. DISCUSSION/CONCLUSIONS:A total of 78 patients were included, 44 (55.8%) females with a mean age of 33.8 (±15) years. Most patients were treated with Infliximab, 66.2%, than with Adalimumab, 33.8%. Complex fistulae were found in 52/78 patients (66.7%). After a medium follow-up of 48.2 months, 41/78 patients (52.6%) had complete perianal remission (95% CI: 43.5%-63.6%). Recurrence occurred in four (9.8%) patients (95% CI: 0.7%-18.8%) in an average period of 74.8 months. CONCLUSIONS:Combined therapy lead to favorable and durable results in perianal fistulizing Crohn's disease.

BACKGROUND:The aim of this study was to evaluate the clinical implications of pathologic complete response (pCR) (i.e., T0N0M0) after neoadjuvant chemoradiation and radical surgery in patients with locally advanced rectal cancer. MATERIALS AND METHODS/METHODS:A single-center, prospectively maintained colorectal cancer database was queried for patients with primary cII and cIII rectal cancer staged by CT and ERUS/MRI undergoing long-course neoadjuvant chemoradiation followed by proctectomy with curative intent between 1997 and 2007. Patients were stratified into pCR and no-pCR groups and compared with respect to demographics, tumor and treatment characteristics, and oncologic outcomes. Outcomes evaluated were 5-year overall survival, disease-free survival, disease-specific mortality, local recurrence, and distant recurrence. RESULTS:The query returned 238 patients (73% male), with a median age of 57 years and median follow-up of 54 months. Of these, 58 patients achieved pCR. Patients with pCR vs no-pCR were statistically comparable with respect to demographics, chemoradiation regimens, tumor distance from anal verge, clinical stage, surgical procedures performed, and follow-up time. No patient with pCR had local recurrence. Overall survival and distant recurrence were also significantly improved for patients achieving pCR. CONCLUSIONS:Achievement of pCR after neoadjuvant chemoradiation is associated with greatly improved cancer outcomes in locally advanced rectal cancer. Future studies should evaluate the relationship between increases in pCR rates and improvements in cancer outcomes in this population.

PURPOSE/OBJECTIVE:The aim of this study was to determine the effect of a longer interval between neoadjuvant chemoradiation and surgery on perioperative morbidity and oncologic outcomes. METHODS:A colorectal cancer database was queried for clinical stage II and III rectal cancer patients undergoing neoadjuvant chemoradiation followed by proctectomy between 1997 and 2007. The neoadjuvant regimen consisted of long course external beam radiation and 5-fluorouracil chemotherapy. Patients with inflammatory bowel disease, hereditary cancer, extracolonic malignancy, urgent surgery, or non-validated treatment dates were excluded. Patients were divided into two groups according to the interval between chemoradiation and surgery (<8 and ≥ 8 weeks). Perioperative complications and oncologic outcomes were compared. RESULTS:One hundred seventy-seven patients were included. Groups were comparable with respect to demographics, tumor, and treatment characteristics. Perioperative complications were not affected by the interval between chemoradiation and surgery. Patients undergoing surgery ≥ 8 weeks after chemoradiation experienced a significant improvement in pathologic complete response rate (30.8% vs. 16.5%, p = 0.03) and had decreased 3-year local recurrence rate (1.2% vs. 10.5%, p = 0.04). A Cox regression analysis was performed to assess the compounding effect of a complete pathologic response on oncologic outcome. A longer interval correlated with less local recurrence, although statistical significance was not reached (p = 0.07). CONCLUSION/CONCLUSIONS:An interval between chemoradiation and surgery ≥ 8 weeks is safe and is associated with a higher rate of pathologic complete response and decreased local recurrence.

INTRODUCTION: The field of laparoscopic rectal cancer surgery is expanding. We compare short-term and early oncological outcomes after laparoscopic versus open resection in carefully matched rectal cancer patients. METHODS: All consecutive patients undergoing elective laparoscopic resection for rectal cancer were reviewed. Laparoscopic resections were matched 1:1 to open resections by age, gender, American Society of Anesthesiologists class, body mass index, neoadjuvant chemoradiation, and type of surgery. Data were analyzed using Fisher's exact, chi-square, Wilcoxon rank-sum tests, and Kaplan-Meier estimates. P-value <0.05 was considered statistically significant. RESULTS: Ninety-one rectal cancer patients with laparoscopic resection were included, 59% were male, and median age was 62 years. Conversion rate was 18.7%. Laparoscopic and open surgery had similar 30-day morbidity and mortality except wound infection, which was lower for the laparoscopic group (p = 0.02). Laparoscopic surgery had similar 30-day readmissions but shorter total length of hospital stay (5 versus 7 days, p < 0.01), time to first flatus (3 versus 4.5 days, p = 0.001), and time to first bowel movement (4 versus 5 days, p = 0.05) when compared with open surgery. The 3-year disease-free survival, local recurrence, and distant recurrence rates were also similar between the two groups. CONCLUSION: Laparoscopic surgery can be safely performed for rectal cancer, with better postoperative recovery and acceptable early oncological outcomes. Results from large ongoing randomized trials with longer follow-up time are pending to better define oncologic outcomes.

Until the development of the ileal pouch-anal anastomosis in the early 1980s, proctocolectomy with end ileostomy was the only definitive surgery for ulcerative colitis and colectomy with ileorectal anastomosis was the procedure of choice for affected patients who were reluctant to have a permanent ileostomy. Currently, ileal pouch-anal anastomosis is the most common procedure for patients with ulcerative colitis requiring surgical treatment. However, there is still a role for ileorectal anastomosis and proctocolectomy with end ileostomy for a selected group of patients. In this review, the authors summarize the current indications for ileorectal anastomosis and proctocolectomy with end ileostomy in patients with ulcerative colitis.