Faculty Bibliography

BACKGROUND & AIMS: Pouchitis is the most common complication of ileal pouch anal anastomosis in patients with ulcerative colitis. In some cases the inflammation becomes chronic and requires long-term medical therapy. The clinical course and medical therapy are different between acute pouchitis and chronic pouchitis. The aim of this study was to determine if there are predictors of risk for acute vs. chronic pouchitis. METHODS: Patients with acute pouchitis (N = 40) and patients with chronic pouchitis (N = 40) were matched with a control group who never had pouchitis (N = 40). Data were collected for multiple pre-, peri-, and postoperative factors and follow-up telephone calls were performed. Case-control univariable analyses and multivariate logistic regression were used to measure the association between covariates and pouchitis. RESULTS: Multivariate logistic regression showed that extensive colonic disease (odds ratio [OR], 2.99; P = .045 for acute pouchitis; and OR, 4.61; P = .010 for chronic pouchitis) and extraintestinal manifestations (OR, 2.88; P = .037 for acute pouchitis; and OR, 2.69; P = .047 for chronic pouchitis) were associated with both acute and chronic pouchitis. Postoperative nonsteroidal anti-inflammatory drug (NSAID) use was associated with chronic pouchitis, but less so with acute pouchitis. Patients with fulminant colitis as an indication for surgery had a decreased risk for developing chronic pouchitis (OR, 0.22; P = .036), but no such association was seen for acute pouchitis. CONCLUSIONS: Extensive colonic disease and preoperative extraintestinal manifestations are associated with increased risk for both acute and chronic pouchitis. Fulminant colitis leading to colectomy is protective from development of chronic pouchitis. Postoperative use of NSAIDS is a risk factor for chronic pouchitis and possibly for acute pouchitis, and thus should be discouraged for patients who undergo ileal pouch anal anastomosis.

INTRODUCTION: Predictive models play a pivotal role in the provision of risk-adjusted, operative mortality rates. The purpose of the study was to describe the development of a dedicated prognostic index for quantifying operative risk in colorectal cancer surgery. METHODS: Data were collected from 5,034 consecutive patients undergoing major surgery in a single center from October 1976 to July 2002. Primary end point was 30-day operative mortality. A multilevel Bayesian logistic regression model was developed to adjust for case-mix and accommodate the variability of outcomes between surgeons. The model was internally validated (split-sample) and tested using measures of discrimination, calibration, and subgroup analysis. RESULTS: The patients' median age was 66 (range, 18-98) years. Operative mortality was 2.3 percent with no significant variability between surgeons or through time. Multivariate analysis identified the following independent risk factors: age (odds ratio = 1.5 per 10-year increase), American Society of Anesthesiologists grade (odds ratio for ASA II, III, IV-V vs. I = 2.6, 4.3, 6.8), TNM staging (odds ratio for Stage IV vs. I-III = 2.6), mode of surgery (odds ratio for urgent vs. nonurgent = 2.1) no-cancer resection vs. cancer resection (odds ratio = 4.5), and hematocrit level. The model offered adequate discrimination (area under receiver operator characteristic curve = 0.801) and excellent agreement between observed and model-predicted outcomes over ten major colorectal procedures (P = 0.191). CONCLUSIONS: The colorectal cancer model provided an accurate means of estimating risk for individual patients in the preoperative setting. It has important implications in everyday practice, because it may be used as an adjunct in the process of informed consent and for monitoring surgical performance through time.

BACKGROUND & AIMS: Transmural inflammation, a distinguishing feature of Crohn's disease (CD), cannot be assessed by conventional colonoscopy with mucosal biopsy. Our previous ex vivo study of histology-correlated optical coherence tomography (OCT) imaging on colectomy specimens of CD and ulcerative colitis (UC) showed that disruption of the layered structure of colon wall on OCT is an accurate marker for transmural inflammation of CD. We performed an in vivo colonoscopic OCT in patients with a clinical diagnosis of CD or UC using the previously established, histology-correlated OCT imaging criterion. METHODS: OCT was performed in 40 patients with CD (309 images) and 30 patients with UC (292 images). Corresponding endoscopic features of mucosal inflammation were documented. Two gastroenterologists blinded to endoscopic and clinical data scored the OCT images independently to assess the feature of disrupted layered structure. RESULTS: Thirty-six CD patients (90.0%) had disrupted layered structure, whereas 5 UC patients (16.7%) had disrupted layered structure (P < .001). Using the clinical diagnosis of CD or UC as the gold standard, the disrupted layered structure on OCT indicative of transmural inflammation had a diagnostic sensitivity and specificity of 90.0% (95% CI: 78.0%, 96.5%) and 83.3% (95% CI: 67.3%, 93.3%) for CD, respectively. The kappa coefficient in the interpretation of OCT images was 0.80 (95% CI: 0.75, 0.86, P < .001). CONCLUSIONS: In vivo colonoscopic OCT is feasible and accurate to detect disrupted layered structure of the colon wall indicative of transmural inflammation, providing a valuable tool to distinguish CD from UC.

BACKGROUND: Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice in patients with ulcerative colitis. Strictures can occur at the inlet and outlet of the pouch. Endoscopic balloon dilation has been successfully used in patients with Crohn's strictures at the small intestine and colon. There are no published trials on endoscopic balloon therapy of ileal pouch strictures. AIM: To evaluate outpatient endoscopic balloon dilation of strictures in ileal pouches. METHODS: Patients underwent nonfluoroscopy-guided, nonsedated, outpatient endoscopic dilations with an 8.6-mm upper endoscope and through-the-scope balloons (size: 11-18 mm). Pre- and posttreatment Pouchitis Disease Activity Index symptom scores (range: 0-6), endoscopic stricture scores based on resistance in passing the endoscope (range: 0-4), and Cleveland Global Quality of Life were compared. RESULTS: Nineteen patients with pouch strictures who had concurrent Crohn's disease of the pouch (n = 11), cuffitis (n = 5), and pouchitis (n = 3), including 14 inlet and 14 outlet strictures, were enrolled. The mean number of strictures for each patient was 1.61 +/- 0.78. All strictures were successfully dilated with the through-the-scope balloon, with a mean of 1.74 +/- 1.19 (range: 1-5) sessions for each patient. Nine patients had a second endoscopy at 8 wk and five patients had a third pouch endoscopy at 16 wk after the initial endoscopic dilation. Endoscopic stricture scores immediately (0.30 +/- 0.47), 8 wk (0.40 +/- 0.51), and 16 wk (0.44 +/- 0.76) after the dilation were significantly improved compared to the predilation stricture scores (2.67 +/- 0.78). The symptom scores and quality-of-life (QOL) scores improved at week 8 and 16 following dilation, with a mean follow-up of 6.10 +/- 5.83 months (2-25 months). No complications were experienced with the procedure. One patient with CD who failed endoscopic and medical therapy underwent pouch resection. CONCLUSION: In conjunction with medical therapy, outpatient endoscopic balloon dilation appears safe and effective in treating pouch inlet and outlet strictures, by relieving symptoms, restoring pouch patency, and improving QOL in the majority of patients.

OBJECTIVE: Recent experience with surgery for enterocutaneous fistulae (ECF) at a specialist colorectal unit is reviewed to define factors relating to a successful surgical outcome. SUMMARY BACKGROUND DATA: ECF cause significant morbidity and mortality and need experienced surgical management. Previous publications have concentrated on mortality resulting from fistulae, while factors affecting recurrence have not previously been a focus of analysis. METHODS: Records were reviewed of patients who had ECF surgery (1994-2001). Management strategy involved early drainage of sepsis and nutritional support prior to elective ECF repair, with selective defunctioning proximal stoma formation. RESULTS: A total of 205 patients were available (89 males, 43%; median age, 51 years; range, 16-86) years). ECF were related to Crohn's disease in 95, ulcerative colitis in 18, diverticular disease in 17, carcinoma in 25 (16 after radiotherapy), mesh ventral hernia repair in 21, and other causes in 29. Forty-one (20%) had undergone attempted fistula repair at other institutions. Initial management included CT-guided drainage of an intra-abdominal abscess in 23 patients, and total parenteral nutrition in 74 (36%). A total of 203 patients had definitive ECF repair. Forty-four had oversewing or wedge resection of the fistula, and 159 had resection and reanastomosis of the involved small bowel segment or ileocolic anastomosis. Ninety-day operative mortality was 3.5%. A total of 42 (20.5%) patients developed ECF recurrence within 3 months. Multivariate analysis demonstrated that recurrence was more likely after oversewing (36%) than resection (16%, P = 0.006). CONCLUSIONS: A strategy of drainage of acute sepsis, maintenance of nutritional support prior to surgery, and selective use of PS allows for primary closure in 80% of complicated ECF. Resection should be performed when feasible.

BACKGROUND: Restorative proctocolectomy and ileal pouch anal anastomosis (RP/IPAA) has become the gold standard surgical therapy for the majority of patients with mucosal ulcerative colitis and familial adenomatous polyposis. The aims of this study were to evaluate the fertility rates before and after RP/IPAA, to compare them with the reproductive data of the general United States population, and to determine surgical parameters that might influence subsequent fertility. METHODS: Three hundred women of reproductive age who underwent RP/IPAA between 1983 and 2001 completed a mailed questionnaire regarding their reproductive function before and after the procedure. Additional information was obtained from the pelvic pouch database. The reproductive information was compared to age-matched historical control subjects from the United States general population. The associations between changes in fertility and surgical parameters were also investigated. RESULTS: The median (25th, 75th percentile) age at surgery was 28 (24, 33) years. Out of 300 women, 206 attempted to conceive. Before operation, 48 (38%) of 127 patients were unsuccessful after 1 year of unprotected intercourse, whereas after operation, 76 (56%) of 135 patients were unsuccessful. This infertility rate was higher after operation than before (P <.001). For the subgroup of 56 women who tried to get pregnant both before and after operation, the infertility rate was higher after operation than before (69% vs 46%; P=.005). Also, a higher percentage of these patients who had an intraoperative transfusion were infertile after operation compared to patients who did not have an intraoperative transfusion (54% vs 21%; P=.023). CONCLUSIONS: There was an increase in the infertility rate after RP/IPAA. Intraoperative blood transfusion had a negative impact on the fertility rate after operation in patients who tried to conceive both before and after RP/IPAA.

BACKGROUND AND AIMS: Distinguishing Crohn's disease (CD) from ulcerative colitis (UC) can be difficult. Transmural inflammation, a key feature of CD, cannot be assessed by conventional colonoscopy with biopsy. Optical coherence tomography (OCT) provides high-resolution, cross-sectional images of the gut wall and might become a new diagnostic tool. The aims of this study were to perform histology-correlated OCT on surgical specimens of CD and UC and to determine its diagnostic accuracy. METHODS: Colectomy specimens from patients with a preoperative diagnosis of CD (N = 24) or UC (N = 24) were studied with OCT in the operating room. OCT and histopathology were assessed blindly, and diagnostic accuracy of OCT was assessed. RESULTS: Eight preoperatively identified UC patients (33%) with transmural inflammation on postoperative histology were diagnosed with CD, and all 8 had a disrupted layered structure on OCT, a characteristic feature of transmural disease. Sixteen UC patients (67%) had superficial inflammation on histology; of them, 13 (81%) had an intact layered structure on OCT. All 24 preoperative CD patients had transmural inflammation on histology, and 23 (96%) had a disrupted layered structure on OCT. Of 585 histology-OCT image sets from the 48 patients, 152 sets (26%) had transmural inflammation on histology. The sensitivity and specificity for OCT to detect transmural disease were 86% and 91%, respectively. CONCLUSIONS: Transmural inflammation, as characterized by disruption of the layered structure of colon wall on OCT, is an accurate marker for the diagnosis of CD. Ex vivo OCT predicted transmural inflammation on postoperative histopathology.

Laparoscopic radiofrequency ablation (RFA) is gaining increasing acceptance as a treatment option for primary and secondary liver tumors with minimal morbidity. The purpose of this study is to see if adding a colorectal procedure to RFA increases the risk of hepatic abscess. Of the 310 patients with 1,080 primary and secondary liver tumors undergoing laparoscopic radiofrequency ablation (RFA), 16 patients underwent RFA in combination with various colorectal procedures. Data were collected prospectively. The concomitant procedures included loop ileostomy closures in 6 patients; laparoscopic-assisted right hemicolectomy in 3 patients; laparoscopic-assisted anterior resection in 2 patients; and open transverse colectomy, open anterior resection, open low anterior resection, open loop transverse colostomy formation, and anal stricture dilatation in 1 patient each. Mean +/- SD hospital stay was 2.9 +/- 1.7 days. There was no mortality, and the only complication was the development of a right flank abscess after laparoscopic-assisted right hemicolectomy that was treated with percutaneous drainage. Although patients undergoing laparoscopic RFA in combination with a clean-contaminated procedure could be at high risk for secondary infection of ablated foci, this was not observed. This approach is safe and does not impair recovery from either procedure. These data support the concept that RFA may be safely used with concomitant colon resections to treat liver metastases that may be resectable but are associated with increased morbidity if resected synchronously.

BACKGROUND: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice in the majority of patients with ulcerative colitis (UC) who require surgery. To ease the construction of the IPAA and improve functional outcome by minimizing sphincter related stretch injury, a stapling technique is being commonly used in the pouch-anal anastomosis. Despite its advantages, the procedure normally leaves a 1-2 cm of anal transitional zone or rectal cuff, which is susceptible to recurrence of residual UC or cuffitis. Cuffitis can cause symptoms mimicking pouchitis. AIM: To conduct an open-labeled trial of topical mesalamine in patients with cuffitis. METHODS: We treated 14 consecutive patients with cuffitis by giving mesalamine suppositories 500 mg b.i.d. (mean 3.2 months, range 1-9 months). The Cuffitis Activity Index (adapted from the Pouchitis Disease Activity Index) scores and improvement in symptoms of bloody bowel movements and arthralgias were measured as primary and secondary outcomes. RESULTS: All patients had surgery for medically refractory UC. There were significant reductions in the total Cuffitis Activity Index scores after the therapy (11.93 +/- 3.17 vs 6.21 +/- 3.19, p < 0.001). Symptom (3.24 +/- 1.28 vs 1.79 +/- 1.31), endoscopy (3.14 +/- 1.29 vs 1.00 +/- 1.52), and histology (4.93 +/- 1.77 vs 3.57 +/- 1.39) scores each were significantly reduced (p < 0.05). Ninety-two percent of patients with bloody bowel movements and 70% of patients with arthralgias improved after the therapy. No systemic or topical adverse effects were reported. CONCLUSION: Topical mesalamine appears well tolerated and effective in treating patients with cuffitis, with improvement in symptom as well as endoscopic and histologic inflammation.

BACKGROUND & AIMS: Some patients who undergo ileal pouch-anal anastomosis (IPAA) surgery for ulcerative colitis (UC) or indeterminate colitis are subsequently diagnosed with Crohn's disease (CD). Making the diagnosis of CD in patients with IPAA can be difficult, but it is important for prognostic and therapeutic purposes. The aim of this study was to identify diagnostic features of CD in patients with IPAA. METHODS: We evaluated 87 patients who had undergone IPAA for inflammatory bowel disease. Patients were classified as having UC (n = 28), CD (n = 27), or indeterminate colitis (n = 32) based on review of the original colectomy pathology and the postoperative clinical course. Each patient underwent a pouch endoscopy with biopsies of the pouch and afferent limb. Both the endoscopist and pathologist were blinded to the patient's diagnosis. RESULTS: Afferent limb ulcers (ALUs) were seen on endoscopy in 12 of 27 patients with CD (45%) and 4 of 28 patients with UC (14%) (P = 0.019). After excluding patients who had taken nonsteroidal anti-inflammatory drugs (NSAIDs) within the past month, ALUs were found in 7 of 18 patients with CD (39%) and 0 of 17 patients with UC (P = 0.010). Controlling for NSAID use and smoking, the odds ratio for ALUs indicating CD was 4.67 (P = 0.03). In the UC population, ALUs were seen in 4 of 11 patients (36%) who had taken NSAIDs in the past month and 0 of 17 patients who had not taken NSAIDs (P = 0.016). CONCLUSIONS: ALUs seen on endoscopy are suggestive of CD in patients with inflammatory bowel disease who are not taking NSAIDs.