Faculty Bibliography

BACKGROUND AND AIMS: To evaluate the impact of preoperative radiation on pouch outcomes in patients with colitis-associated cancer (CAC). METHODS: CAC patients who underwent restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) from 1984 to 2009 were identified from our registry. The impact of preoperative pelvic radiation for CAC or other pelvic cancer on pouch related outcomes was evaluated. RESULTS: Sixty-three pouch patients with confirmed CAC were included (37 male, 58.7%). The mean age at pouch construction was 46.9+/-10.6 years. Seven patients were excluded due to the presence of persistent diverting ileostomy (n=2) or no follow-up (n=5). The remaining 56 patients were analyzed, including 9 who received pelvic radiation prior to IPAA creation for CRC or other cancers. Preoperative pelvic radiation was significantly associated with chronic pouchitis (P=0.024). There was, however, no correlation between pelvic radiation and pouch/anal transitional zone neoplasia, pouch stricture, pelvic abscess and pouch fistula/sinus. Pouch failure occurred in 13 patients after a median follow-up of 66.4 (range: 2.7-322.2) months. Although a simple statistical analysis based on the number of patients with pouch failure did not achieve significance (4/9 vs. 9/47, P=0.19), Kaplan-Meier analysis showed a strong association between preoperative pelvic radiation and the risk for pouch failure (P<0.001). A subgroup analysis of rectal cancer patients revealed that 3/7 patients (42.9%) with radiation and 3/17 (17.6%) without had pouch failure (P=0.31). Again, the association between pelvic radiation and pouch failure was confirmed using Kaplan-Meier analysis (P=0.02). CONCLUSIONS: Pelvic radiation administered prior to IPAA creation appears to be associated with poor pouch outcomes. Oncological benefits and pouch functional outcomes should be carefully balanced before pelvic radiation is considered prior to restorative proctocolectomy.

The management of inflammatory bowel disease (IBD) in elderly patients provides added complexity for healthcare providers who need to take into account the high likelihood of co-morbid disease, the need for polypharmacy and, in many instances, greater patient fragility. While biologics are often considered first-line corticosteroid-sparing strategies for moderate to severe disease, the additional variables unique to an elderly patient warrant consideration when discussing IBD therapeutics. As chronic corticosteroid use, although relatively common among older IBD patients, is suboptimal, the efficacy and safety of biologics compared with immunomodulators among older IBD patients needs additional investigation.

OBJECTIVES: Activated granulocytes and monocytes may contribute to the pathogenesis of Crohn's disease (CD). In small, uncontrolled studies, granulocyte/monocyte apheresis (GMA) has shown promise in treating CD. We conducted a randomised, double-blind study to compare GMA with a sham procedure in patients with moderate to severe CD. DESIGN: Patients with active CD as defined by a Crohn's Disease Activity Index (CDAI) of 220-450 were randomly allocated in a 2:1 ratio to treatment with GMA using the Adacolumn Apheresis System (JIMRO, Takasaki, Japan) or sham apheresis. Ten apheresis sessions were scheduled over a 9-week period, and efficacy was evaluated at week 12. The primary end point was the proportion of patients achieving clinical remission (CDAI score /= 100-point decrease in CDAI) was achieved by 28.0% and 26.9% of patients in the GMA and sham groups, respectively (p = 1.000). The two treatments produced similar changes from baseline in CDAI and quality of life, as well as in disease severity assessed endoscopically. The incidence and types of adverse events did not differ between groups. CONCLUSIONS: GMA was well tolerated, but this study did not demonstrate its effectiveness over a sham procedure in inducing clinical remission or response in patients with moderate to severe CD.

: The aging U.S. population will approach 20% of the total population by 2030. The number of older patients with inflammatory bowel disease is anticipated to increase accordingly bringing the burden of multiple comorbidities, polypharmacy with drug interactions, the aging immune system, and extended social and financial issues to overall management of an already challenging management of these patients. Each of these concerns is measured by the metric of distinguishing the "fit versus frail" elderly and will be discussed in this review with an emphasis on a practical guide to therapy.

Ulcerative colitis diagnosis and management represent a challenge for clinicians. The disguises of ischemia and acute infectious colitis continue to confound the diagnosis. The therapeutic options have remarkably expanded in the way of immunomodulators, biologics, or ileoanal pouch surgery, yet all carry potential considerable risks. These risks can confuse and impair patient acceptance, particularly elderly patients and men younger than 30 years. Predictors of outcome of medical and surgical therapy have improved but are far from complete. Nevertheless, therapies focused on the specific patient's condition continue to offer hope.