Faculty Bibliography

BACKGROUND:Salvage of the existing ileal pouch is favored during re-do ileal pouch anal anastomosis if the pouch is not damaged after pelvic dissection and there are no other mechanical reasons that may necessitate construction of a new pouch. Excision of the existing pouch may be associated with some concerns for short-bowel syndrome and poor functional outcomes. This study aimed to report indications and compare functional and quality of life outcomes of new pouch creation versus salvage of the existing pouch during re-do ileal pouch anal anastomosis. METHODS:Patients who underwent re-do ileal pouch anal anastomosis between September 2016 and June 2020 were included. The reasons for pouch excision and new pouch creation were reported. Perioperative, functional outcomes and quality of life were compared between patients who had creation of a new pouch versus salvage of existing pouch. RESULTS:A total of 105 patients with re-do ileal pouch anal anastomosis (new pouch, n = 63) were included. Most common indications for a new pouch creation were chronic pelvic infection that compromised the integrity and viability of the existing pouch (n = 32) and small pouch (n = 21). No patient developed short-bowel syndrome. The number of bowel movements, daily restrictions and Cleveland Global Quality of Life score scores were similar between 2 groups. Day-time seepage, day-time and night-time pad usage were more common after new pouch creation. Two-year pouch survival rates were comparable (new pouch: 92% versus existing pouch: 85%, P = .31). CONCLUSION/CONCLUSIONS:New pouch creation can be safely performed at the time of re-do ileal pouch anal anastomosis. It provides acceptable functional and quality of life outcomes if existing pouch salvage is not feasible.

Introduction: Strictures are reported in around 35%-40% of patients after primary ileal pouch anal anastomosis (IPAA). So far, there are no reports focusing on strictures after re-do IPAA. In our study, we evaluated the incidence, management, long-term functional outcomes, and quality of life scores of anastomotic strictures after re-do IPAA.
Method(s): Patients undergoing redo IPAA between 9/2016 and 9/2020 were included. Incidence and management strategy of re-do IPAA strictures were evaluated. Functional outcomes, lifestyle alterations, and quality of life scores were compared between stricture vs no-stricture groups.
Result(s): Ninety patients were included in the analysis after ileostomy closure. Twenty-two patients developed symptomatic strictures, all of which were at the pouch-anal anastomosis (first year: 25.3%;2 years: 31.8%) In 5 (23%) patients, the strictures were mild, and digital dilation was easily performed. Seventeen (77%) patients had tight strictures dilated with pilling dilators. Median number of dilations required to achieve permanent symptomatic relief was 1. None of the patients required pouch excision due to strictures. Incidence of pouch-anal anastomotic stricture was higher in the re-do IPAA compared with the primary IPAA. Lifestyle alterations were similar between the stricture and no stricture groups. Cleveland Global Quality of Life score was lower in patients with strictures. Strictures were associated with decreased patient happiness with their IPAA (p=0.005) (Table).
Conclusion(s): Stricture development after re-do IPAAs are common and have a higher incidence than primary IPAA, but it can be managed aggressively with a subsequent high pouch retention rate. Lower patient happiness after surgery and decreased QOL are associated with stricture development after re-do IPAAs. [Formula presented]
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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.