Explore the vast range of titles available.

Background In order to improve a patient’s quality of life after total gastrectomy, jejunal pouch reconstruction has been employed. However, little information exists regarding the optimal size of the jejunal pouch after total gastrectomy. Methods The study was designed as a single-center randomized trial in which the results of double-tract reconstruction with pouches of two different sizes were compared, i.e., short and long pouch double tract (SPDT and LPDT, respectively). We conducted a clinical assessment with standard questionnaire after surgery. The amount of residual food in the jejunal pouch was determined by endoscopy. Results No demographic differences were noted between the two groups. The eating capacity per meal was higher in the SPDT group than in the LPDT group. The postoperative weight loss 24 months after surgery was lower in SPDT group than that in the LPDT group. Although the incidence of early dumping symptoms was higher in the SPDT group, no difference was noted in the other postprandial abdominal symptoms between the two groups. Conclusions We conclude that the optimal pouch should be relatively short, as a short pouch improves the eating capacity per meal and the weight loss ratio to the preoperative value.

Ileal pouch-anal anastomosis (IPAA) is the standard restorative procedure following proctocolectomy in patients with inflammatory bowel disease (IBD) who require colectomy. However, removal of the diseased colon does not eliminate the risk of pouch neoplasia. We aimed to assess the incidence of pouch neoplasia in IBD patients following IPAA. All patients at a large tertiary center with International Classification of Diseases-Ninth Revision/International Classification of Diseases-Tenth Revision codes for IBD who underwent IPAA and had subsequent pouchoscopy were identified using a clinical notes search from January 1981 to February 2020. Relevant demographic, clinical, endoscopic, and histologic data were abstracted. In total, 1319 patients were included (43.9% women). Most had ulcerative colitis (95.2%). Out of 1319 patients, 10 (0.8%) developed neoplasia following IPAA. Neoplasia of the pouch was seen in 4 cases with neoplasia of the cuff or rectum seen in 5 cases. One patient had neoplasia of the prepouch, pouch, and cuff. Types of neoplasia included low-grade dysplasia (n = 7), high-grade dysplasia (n = 1), colorectal cancer (n = 1), and mucosa-associated lymphoid tissue lymphoma (n = 1). Presence of extensive colitis, primary sclerosing cholangitis, backwash ileitis, and rectal dysplasia at the time of IPAA were significantly associated with increased risk of pouch neoplasia. The incidence of pouch neoplasia in IBD patients who have undergone IPAA is relatively low. Extensive colitis, primary sclerosing cholangitis, and backwash ileitis prior to IPAA and rectal dysplasia at the time of IPAA raise the risk of pouch neoplasia significantly. A limited surveillance program might be appropriate for patients with IPAA even with a history of colorectal neoplasia.

Background/aim In order to define future chemoprevention strategies for adenomas or carcinomas in the pouch of patients with familial adenomatous polyposis (FAP), a 4-weeks intervention with (1) sulindac, (2) inulin/VSL#3, and (3) sulindac/inulin/VSL#3 was performed on 17 patients with FAP in a single center intervention study. Primary endpoints were the risk parameters cell proliferation and glutathione S-transferase (GST) detoxification capacity in the pouch mucosa; secondary endpoints were the short chain fatty acid (SCFA) contents, pH, and cytotoxicity of fecal water. Methods Before the start and at the end of each 4-week intervention period, six biopsies of the pouch were taken and feces was collected during 24 h. Cell proliferation and GST enzyme activity was assessed in the biopsies and pH, SCFA contents, and cytotoxicity were assessed in the fecal water fraction. The three interventions (sulindac, inulin/VSL#3, sulindac/inulin/VSL#3) were compared with the Mann–Whitney U test. Results Cell proliferation was lower after sulindac or VSL#3/inulin, the combination treatment with sulindac/inulin/VSL#3 showed the opposite. GST enzyme activity was increased after sulindac or VSL#3/inulin, the combination treatment showed the opposite effect. However, no significance was reached in all these measures. Cytotoxicity, pH, and SCFA content of fecal water showed no differences at all among the three treatment groups. Conclusion Our study revealed non-significant decreased cell proliferation and increased detoxification capacity after treatment with sulindac or VSL#3/inulin; however, combining both regimens did not show an additional effect.

Abstract Background Patients with inflammatory bowel disease (IBD) who undergo proctocolectomy with ileal pouch–anal anastomosis may develop pouchitis. We previously proposed a novel endoscopic classification of pouchitis describing 7 phenotypes with differing outcomes. This study assessed phenotype transitions over time. Methods We classified pouch findings into 7 main phenotypes: (1) normal, (2) afferent limb (AL) involvement, (3) inlet (IL) involvement, (4) diffuse, (5) focal inflammation of the pouch body, (6) cuffitis, and (7) pouch-related fistulas noted more than 6 months after ileostomy takedown. Among 2 endoscopic phenotypes, the phenotype that was first identified was defined as the primary phenotype, and the phenotype observed later was defined as the subsequent phenotype. Results We retrospectively reviewed 1359 pouchoscopies from 426 patients (90% preoperative diagnosis of ulcerative colitis). The frequency of primary phenotype was 31% for AL involvement, 42% for IL involvement, 28% for diffuse inflammation, 72% for focal inflammation, 45% for cuffitis, 18% for pouch-related fistulas, and 28% for normal pouch. The most common subsequent phenotype was focal inflammation (64.8%), followed by IL involvement (38.6%), cuffitis (37.8%), AL involvement (25.6%), diffuse inflammation (23.8%), normal pouch (22.8%), and pouch-related fistulas (11.9%). Subsequent diffuse inflammation, pouch-related fistulas, and AL or IL stenoses significantly increased the pouch excision risk. Patients who achieved subsequent normal pouch were less likely to have pouch excision than those who did not (8.1% vs 15.7%; P = .15). Conclusions Pouch phenotype and the risk of pouch loss can change over time. In patients with pouch inflammation, subsequent pouch normalization is feasible and associated with favorable outcome. Lay Summary Endoscopic pouch phenotypes can change over time and subsequent development of diffuse inflammation, pouch-related fistulas, and afferent limb/inlet stenoses significantly worsen pouch outcomes. In patients with pouch inflammation, subsequent pouch normalization is feasible and associated with favorable outcomes.

Ileal pouch–anal anastomosis (IPAA) is the procedure of choice for refractory or complicated ulcerative colitis (UC). Since 1990, pouch-related adenocarcinomas have been described. The aim of this study was to review the literature to evaluate the burden of this complication, seeking for risk factors, prevention, and ideal management.MethodsWe performed a systematic review of the literature to identify all described pouch-related adenocarcinoma in patients operated on with IPAA for UC. Studies were thoroughly evaluated to select authentic de novo pouch carcinomas. Some authors were contacted for additional information. Data of patients were pooled. Meta-analyses of suitable studies were attempted to identify risk factors.ResultsThirty-four articles reported on 49 patients (2:1, male:female) who developed unequivocal pouch-related adenocarcinoma, 14 (28.6%) and 33 (67.3%) arising from the pouch and anorectal mucosa, respectively. Origin was not reported in 2 (4%). Pooled cumulative incidence of pouch-related adenocarcinoma was 0.33% (95% confidence interval [CI], 0.31–0.34) 50 years after the diagnosis and 0.35% (95% CI, 0.34–0.36) 20 years after IPAA. Primary pouch cancer incidence was below 0.02% 20 years after IPAA. Neoplasia on colectomy specimen was the strongest risk factor (odds ratio, 8.8; 95% CI, 4.61–16.80). Mucosectomy did not abolish the risk of subsequent cancer but avoiding it increased 8 times the risk of cancer arising from the residual anorectal mucosa (odds ratio, 8; 95% CI, 1.3–48.7; P = 0.02). Surveillance is currently performed yearly starting 10 years since diagnosis, but cancers escaping this pathway are reported. In patients receiving mucosectomy, a 5-year delay for surveillance could be proposed.ConclusionsPouch-related adenocarcinomas are rare. Diagnosis of Crohn's disease in the long term may further decrease the rates in UC. Presumed evolution from dysplasia might offer a time window for cancer prevention. Abdominoperineal excision should be recommended for pouch-related adenocarcinomas.

Abstract Background Patients with medically refractory ulcerative colitis (UC) may undergo colectomy with ileal pouch-anal anastomosis (IPAA). Rectal cuff inflammation following surgery is common and may be associated with pouch failure, but the mechanisms underlying this association remain unclear. We assessed whether endoscopic cuff inflammation is associated with fistula and stricture development. Methods This cohort study included adults with UC who were grouped based on whether they had cuff inflammation with mucosal breaks on any endoscopy following IPAA. Endoscopic, clinical, and imaging data were reviewed for all patients to identify the development of strictures and/or fistulas. Multivariable Cox proportional hazard models were used to compare time to development of each outcome. Sub-analyses were conducted to determine whether persistent inflammation, new onset mucosal breaks, and resolution of mucosal breaks predicted the development of each outcome. Results A total of 324 patients met eligibility criteria with 96 (29.6%) patients with cuff inflammation and 228 (70.4%) of patients without inflammation. Patients with cuff inflammation had a higher risk of strictures of the pouch/pre-pouch ileum (adjusted hazard ratio [aHR] = 3.27; 95% CI, 1.70-6.33; P < .001) and fistulas of the pouch or rectal cuff (aHR = 4.24; 95% CI, 1.83-9.83; P = .001). Individuals with persistent, but not single-instance, inflammation were at higher risk of pouch strictures, fistulas, and pouch failure, and both durations were associated with a higher risk of anastomotic strictures. Conclusions Endoscopic cuff inflammation is associated with strictures and fistulas of the IPAA, and individuals with persistent inflammation appear to have the highest risk. Lay Summary Endoscopic rectal cuff inflammation is associated with a higher risk of strictures and fistulas in patients with ulcerative colitis who have undergone ileal pouch-anal anastomosis. Persistent inflammation conveys the highest risk, emphasizing the need for effective treatments.

Abstract Background and Aims Medically refractory ulcerative colitis may require colectomy with ileal pouch-anal anastomosis. Complications of the J-pouch include pouchitis, occurring in 50%-80% of patients, and Crohn’s disease (CD) of the pouch, occurring in 3%-17%. Our aim was to evaluate the efficacy and safety of ustekinumab (UST) and vedolizumab (VDZ) in patients with CD of the pouch. Methods This was a retrospective, multicenter cohort study of adults with CD of the pouch treated with UST or VDZ. The primary outcome was clinical response at 3 or 6 months. Secondary outcomes included clinical remission, endoscopic response, histologic response, pouch failure or surgery, and adverse effects of therapy. Multivariable logistic regression evaluated the efficacy and safety of UST versus VDZ, adjusted for age, smoking status, disease duration, corticosteroid use, and antibiotic use. Kaplan–Meier survival analysis evaluated the durability of UST versus VDZ for CD of the pouch. Results One hundred and four patients were included in this analysis. Seventy-seven patients were treated with UST and 57 patients were treated with VDZ between 2011 and 2021. A total of 64/77 (83%) UST-treated patients and 45/57 (79%) VDZ-treated patients had prior biologic exposure. Clinical response occurred in 62% UST-treated patients and 53% VDZ-treated patients at 3 months, and in 56% and 46% at 6 months, respectively. Clinical remission occurred in 32% UST-treated patients and 18% VDZ-treated patients at 3 months and 29% and 21% at 6 months, respectively. Among those treated with UST, 41% achieved endoscopic response, 10% achieved endoscopic remission, 46% achieved histologic response, and 7% achieved histologic remission. Among those treated with VDZ, 27% achieved endoscopic response, 16% achieved endoscopic remission, 26% achieved histologic response, and 8% achieved histologic remission. Over a follow-up period of 3 years, 5% UST-treated patients had inflammatory bowel disease (IBD)-related hospitalization, and 9% required pouch-failure surgery. In total, 3% VDZ-treated patients had IBD-related hospitalization and 5% required pouch-failure surgery. Reported adverse effects were uncommon, including arthralgias (1), hair loss (1), syncope (1), and upper respiratory infection (1) for UST and wrist edema (1) and elevated transaminases (1) for VDZ. In multivariable analyses, patients on UST were more likely to have a clinical response compared to VDZ at 3 months (OR 2.73, 95% [CI] 1.13-6.56, P = .025) and 6 months (OR 2.53, 95% CI: 1.01-6.29, P = .046). UST had significantly longer durability of treatment than VDZ (log-rank P < .005). Conclusions In one of the largest cohorts evaluating UST and VDZ for CD of the pouch thus far, these biologics were found to be safe and effective treatments for CD of the pouch. Lay Summary Medically refractory ulcerative colitis may require colectomy with ileal pouch-anal anastomosis. 3%-17% are found to have Crohn’s disease of the pouch. Clinical response at 3 and 6 months, as well as durability, was significantly greater for ustekinumab compared to vedolizumab.

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice for medically refractory inflammatory bowel disease (IBD). In this systematic review and meta-analysis, we assess outcomes and safety of endoscopic balloon dilatation (EBD) for IPAA strictures. A systematic search of numerous databases was performed through June 2023 to identify studies reporting on the outcomes of EBD in pouch-related strictures. Outcomes included technical success, clinical success at index dilation and in pouch retention, recurrence of symptoms post-EBD, and adverse events of EBD. Meta-analysis was performed using a random-effects model, and results were expressed in terms of pooled rates along with relevant 95% confidence intervals (CIs). Heterogeneity was assessed using Cochran Q statistical test with I2 statistics. Seven studies with 504 patients were included. The pooled rate of technical success and clinical success of index dilatation was 98.9% (95% CI, 94.8-99.8%; I20%) and 30.2% (95% CI, 7.1-71%; I20%), respectively. The pooled rate of clinical success in pouch retention without the need for additional surgery was 81.4% (95% CI, 69.6-89.3%; I272%). The pooled failure rate of EBD was 18.6% (95% CI, 10.7-30.4%, I272%). The pooled rate of recurrence of symptoms after index dilatation was 58.9% (95% CI, 33.3-80.5%; I213%). The pooled rate of serious adverse events was 1.8% (95% CI, 1-3.5%, I20%). No deaths related to EBD were reported. Endoscopic balloon dilatation is safe and highly effective for management of IPAA strictures. Additional studies are needed to compare its efficacy with surgical interventions.

Abstract Background The value of histologic assessment after ileal pouch-anal anastomosis (IPAA) has not been definitively determined. We evaluated the correlation between histology and endoscopic findings, as well as the proportion of patients with inflammation in areas beyond the pouch body on their initial pouchoscopy after IPAA. Methods In a retrospective cohort study, we evaluated patients who underwent IPAA for UC between 2012 and 2020 and subsequently underwent a pouchoscopy with routine biopsies of the pouch body, pre-pouch ileum, and rectal cuff. We compared endoscopic and histologic assessments in each location using χ2 testing and Spearman correlation, as well as the development of pouchitis and Crohn’s-like disease of the pouch (CLDP) in longitudinal follow-up. Results Among 126 patients, the median time to pouchoscopy after IPAA was 384 days, with 82 patients (65%) having inflammation of the pouch body. Significantly more patients with pouch body inflammation had histologic inflammation compared with patients without pouch body inflammation (96% vs 22%, P < .001, r = 0.769). Additionally, 16 patients (13%) were found to have endoscopic inflammation of the pre-pouch ileum with corresponding histologic inflammation in 88%; of these, 31% later developed CLDP. In contrast, 13% of patients with no endoscopic inflammation displayed histologic inflammation, with none later developing CLDP. Forty-six percent of patients had rectal cuff inflammation (correlation with histologic inflammation r = 0.580). Conclusions In our evaluation, the added benefit of histology in the presence of visible endoscopic inflammation for disease activity assessment scores is unclear. The prognostic value of histologic inflammation without endoscopic inflammation warrants a longitudinal study. Lay Summary Endoscopic evaluation after ileal pouch-anal anastomosis should include anatomic areas beyond the pouch body, including the rectal cuff and the pre-pouch ileum. The added benefit of histology in the presence of visible inflammation when assessing disease activity is unclear.

The impact of histologic inflammation on subsequent risk of acute pouchitis in patients with ulcerative colitis (UC) has not been robustly examined. We examined the association between histologic inflammation in endoscopically normal-appearing ileal pouches in patients with UC with subsequent risk of antibiotic-responsive acute pouchitis. Among 163 study patients, 53% had histologic inflammation in an endoscopically normal-appearing ileal pouch. Histologic inflammation in the pouch was associated with an increased risk of pouchitis (24.1% vs 6.8%, adjusted odds ratio 4.41, 95% confidence interval 1.48-13.20). Histologic inflammation in an endoscopically normal pouch was associated with an increased risk of acute pouchitis.