Faculty Bibliography

BACKGROUND:Impact of the type of anastomosis on the outcomes of re-do ileal pouch anal anastomosis (IPAA) is unknown. OBJECTIVE:The aim of this study is to assess the indications, peri-operative and functional outcomes in patients undergoing stapled vs hand-sewn re-do IPAA. 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 IPAA for ileal pouch failure between 09/2016 - 05/2020 were included in the study. MAIN OUTCOME MEASURES/METHODS:Indications, perioperative, functional outcomes, restrictions and quality of life scores were compared between stapled and hand-sewn groups. RESULTS:A total of 105 patients underwent re-do IPAA for ileal pouch failure of whom 76 (72%) had hand-sewn and 29 (28%) had stapled re-anastomosis. The interval between the index and re-do IPAA was shorter in stapled re-do IPAA [median (IQR), Stapled: 3 years (1-4) vs hand-sewn: 7 years (3-17), p<0.001]. Hand-sewn anastomosis was more commonly used after pelvic sepsis [hand-sewn: n=57 (76%) vs stapled: n=13 (45%), p=0.002]. Overall postoperative morbidity was similar between the two groups [hand-sewn: n=38 (50%) vs stapled: n=16 (55%), p=0.635]. The number of bowel movements, pad use, daily restrictions and CGQL scores were similar between stapled and hand-sewn groups. While day-time seepage was more common after hand-sewn anastomosis [hand-sewn, n=20 (44%) vs stapled, n=3 (14%), p=0.013], night-time seepage was similar in both groups. Pouch survival rates were comparable and 88% vs 92% respectively (p>0.05). LIMITATIONS/CONCLUSIONS:This study is limited by its low study power and limited follow-up time. CONCLUSIONS:Patients who had pelvic sepsis after their index IPAA required hand-sewn anastomosis at higher rate than other re-do cases. Although hand-sewn anastomosis is a more complex procedure, it was associated with similar morbidity, functional outcomes and quality of life scores compared to stapled anastomosis for re-do IPAA. See Video Abstract at http://links.lww.com/DCR/B580.

Ileal pouch anal anastomosis (IPAA) is gold standard surgical procedure for treatment of ulcerative colitis and majority of patients with familial adenomatous polyposis. This procedure allows preservation of fecal continence and gastrointestinal continuity. However, it is associated with a wide variety of complications, which often have nonspecific and overlapping clinical presentations, making imaging an important part of work up for pouch dysfunction. The purpose of this article is to propose structured reporting templates for Magnetic Resonance Imaging (MRI) and Water Soluble Contrast Enema (WSCE) in IPAA patients based on our referral pouch center's experience. Included will be a review of salient surgical technique, pouch anatomy and imaging protocols, with an emphasis on systematic search pattern for evaluation of ileal pouch complications using proposed structured reporting MRI and WSCE templates.

BACKGROUND:Failed pouches may tend to be managed with only a loop ileostomy in obese patients due to some safety concerns. The effect of obesity on ileal pouch excision outcomes is poorly studied. In our study, we aimed to assess the short-term outcomes after ileal pouch excision in obese patients compared to their nonobese counterparts. METHODS:) groups. RESULTS:= .942]. CONCLUSION/CONCLUSIONS:Ileal pouch excision can be performed in obese patients with largely similar outcomes compared to their nonobese counterparts although obesity is associated with a higher rate of deep space infection.

Background: There is evidence from animal and in-vitro studies that THC can affect cannabinoid receptors (1 and2) in brain and periphery and influence immunological makers, and limited evidence from animal studies that it may affect epigenetic related methylation processes. THC ingestion has also been reported as a trigger for inducing schizophrenia in venerable individuals. This is less direct work on these effects in human cannabis smokers investigating these types of chemical biomarkers in peripheral blood cells. The present study further evaluated whether smoked cannabis in human subjects produced changes in cannabinoid receptors, biomarkers for DNA methylation cycle and immunorelated gene mRNA expression.
Method(s): 23 Subjects participated in an experiment in which they smoked cannabis cigarettes with one of two doses of marijuana (5.3% or 13.4% THC) or placebo (0.02%) and were evaluated driving abilities. Blood samples were drawn at baseline and several times after smoking. Plasma and WBC (PMCs) were separated and stored at -80degreeC until further analysis. Samples were analyzed for mRNA content for cannabinoid receptors 1(CBR1) and 2(CBR2), methylation and demethylating enzymes (DNMT, TET), glucocorticoid receptor (NRC3) and immunological markers (IL1B, TNFalpha) by qPCR using TaqMan probes. The results were correlated with THC whole blood levels and TCOOH baseline levels. Statistical analyzed used analysis of variance and covariance and t-test, or non-parametric equivalents for those values which were not normally distributed.
Result(s): There were no difference in background baseline characteristics of the subjects except that the higher dose THC group was older than the low dose and placebo groups, and the low dose THC group had higher baseline CBR2 mRNA levels. Both the 5.9 and 13.4 THC groups showed increased THC levels over the next 2 hours and then decreased toward baseline; the 13.4 THC dose still showed a higher THC levels than placebo at four hours. However, there were no significant differences between THC levels between the 5.9 and 13.4 doses at any time point. At the 4-hour time point after drug administration the 13.4% THC group had higher CBR2 (P = .021) and DNMT3A (P = .027) mRNA levels than the placebo group and DNMT1 mRNA levels showed a trend in the same direction (P = .056). The higher13.4 THC group had significantly higher CBR2 mRNA levels than the 5.9 dose group at several post drug administration time points, and showed trends for difference in effects for between 5.9 and 13.4 THC groups for other mRNAs. TET3 mRNA levels were higher in the 13.4 THC group at 55 minutes post-drug ingestion. When the high and lower dose THC groups were combined, none of the differences in mRNA levels from placebo remain statistically significant. Changes in THC plasma levels were not related to changes in mRNA levels.
Conclusion(s): Over the time course of this study CBR2 levels increased in human PMCs in the high dose THC group but where not accompanied by changes in immunological markers. The changes in DNMT and TET mRNAs suggest potential epigenetic effects of THC in human PMCs. Increases in DNMT metylating enzymes have been linked to some of the pathophysiological process in schizophrenia and, therefore, should be further explored as one of the potential mechanisms linking cannabism use as a trigger for schizophrenia

Ulcerative colitis can be managed by surgical resection of the colon and rectum. The final reconstruction options of traditional end ileostomy, continent ileostomy, ileorectal anastomosis, or ileal pouch anal anastomosis (IPAA). We maintain that the IPAA is the gold standard management of ulcerative colitis and should be performed in stages. This article includes descriptions of technique, management alternatives, and intraoperative and postoperative management of pouch issues.

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the operation of choice for patients with ulcerative colitis (UC). The most common type of IPAA is a J-pouch. If despite all other mobilization maneuvers, inadequate mesenteric reach prevents a tension free anastomosis with J-pouch, a good alternative is S-pouch creation, which can provide an additional 2 to 4 cm of length (1). This article is protected by copyright. All rights reserved.

Background: Ileal pouch anal anastomosis (IPAA) is the preferred surgical option in patients with medically refractory ulcerative colitis (UC) to preserve gastrointestinal continuity. Tis study aimed to describe 30-day readmission rates, as well as predictive factors for it from a national dataset. METHODS: Patients who underwent IPAA surgery for UC between 2012 and 2015 were identifed from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database using current procedural terminology codes. Demographics, perioperative, and operative variables were collected. Patients were grouped according to the presence of 30-day readmission: (+)/(-). RESULTS: Query identifed 1882 patients, mean age was 40.8+/- 13.9 years, mean length of stay was 7.2+/- 5 days and postoperative 30-day morbidity rate was 28% (n=530). Most common complications in the study group were transfusion (7.5%), organ space surgical site infection (SSI) (3.3%), reoperation (3%) and superfcial SSI (2%). Twenty-two percent (n=416) were readmitted within 30 days of surgery. Reasons for readmission were: surgical site infection (n=88), dehydration (n=77), small bowel obstruction/ileus (n=38/18) and abdominal pain (n=28). Mean time for readmission was 14+/- 7 days, 39 patients had second readmission and 4 had a third readmission within 30-days of surgery. Multivariate analysis showed an ASA score of 4 [OR: 14.4 (2.3-89.7), P=0.004] and age<40 [OR: 1.3 (1.08-1.7), P=0.006] were associated with 30-day readmission. Preoperative albumin level of <3.5 was associated with a second readmission [OR:3 (1.1-8.2), P=0.02)]. CONCLUSION(S): IPAA surgery for UC has high morbidity. One ffh of patients were readmitted within 30 days from IPAA surgery for UC and one third of them had a second readmission. Tis study brings the possibility and consideration for national health care initiative in surgical management of patients with UC, undergoing IPAA surgery

Patients with inflammatory bowel disease (IBD) are well known to be at increased risk of venous thromboembolism. Systemic thrombotic events are rare, but likely more common among IBD patients as well. We describe a case of Crohn's colitis complicated by spontaneous pulmonary vein thrombosis eventually resulting in systemic embolism and acute mesenteric ischemia. A 25-year-old female with stricturing Crohn's colitis presented to the emergency department with one week of back pain and pleuritic chest pain. She was initially diagnosed with Crohn's disease three years prior, when she presented with large bowel obstruction requiring emergent transverse colostomy. Infliximab was begun after surgery, and she achieved complete clinical remission. She continued to feel well until the present illness. Upon hospital admission, a computed tomography (CT) scan revealed multiple right sided pulmonary emboli as well as a large pulmonary vein thrombus extending into the left atrium. Echocardiogram revealed no evidence of right heart strain. Anticoagulation was initiated with unfractionated heparin, and the patient was eventually transitioned to apixaban. On the evening prior to anticipated discharge, she developed sudden onset fever and epigastric pain. A CT scan of the abdomen revealed acute thrombosis of the superior mesenteric artery. The patient underwent emergent laparotomy with thrombectomy, initially without small bowel resection. Subsequent second-look laparotomy revealed 75cm of ischemic small bowel, which was resected. The patient continued to have fever and abdominal pain, however, and further exploration revealed necrosis of the entire remaining small bowel, which was resected leaving only a duodenal stump. The patient was eventually transferred to another center for consideration of intestinal transplant. Pulmonary vein thrombosis is an extremely rare condition usually precipitated by intrathoracic neoplasm or thoracic surgery, particularly lung transplantation. There is an associated risk of pulmonary hypertension as well as systemic arterial embolization. To our knowledge, this is the first reported case of spontaneous pulmonary vein thrombosis with IBD as the inciting factor. Due to the risk of catastrophic complications from systemic embolism, rapid diagnosis and treatment are essential. Anticoagulation alone may not be sufficient in all cases, and thrombectomy may be considered if the thrombus does not resolve with medical management