Diagnosis andmanagement of floppy pouch complex

Restorative proctocolectomy with ileal pouch–anal anastomosis has become the surgical treatment of choice for patients with refractory ulcerative colitis,colitis-associated dysplasia or familial adenomatous polyposis.There are various pouch disorders and associated complications.Floppy pouch complex is defined as the presence of pouch prolapse,afferent limb syndrome,enterocele,redundant loop and folding pouch on pouchoscopy,gastrografin pouchogramor defecography.Common clinical presentation includes dyschezia,bloating,abdominal pain,straining or the sense of incomplete evacuation.Each disorder has its own unique endoscopic,radiographic and manometry findings.A range of therapeutic options are available for the management of the various causes of a pouch.

Vedolizumab in the treatment of Crohn’s disease of the pouch

Background:Our recent study showed the efficacy and safety of vedolizumab in the treatment of chronic antibioticrefractory pouchitis.However,there are no published studies on its efficacy and safety in Crohn’s disease(CD)of the pouch.The aim of this study was to assess the efficacy and safety of vedolizumab in those patients.Methods:This case series included all eligible patients with CD of the pouch from our prospectivelymaintained,IRB-approved Pouchitis Registry from 2015 to 2017.Disease activity in pouch patients can bemonitored using the modified Pouchitis Disease Activity Index(mPDAI).mPDAI is the 18-point pouchitis disease activity index consisting of three principal component scores:symptom(range,0–6 points),endoscopy,(range 0–6 points),and histology(range,2–6 points).Pre-and post-treatment(minimum 6 months)pouchoscopy and clinical visits were used to calculate mPDAI.Results:A total of 12 patients were included in this study,who had restorative proctocolectomy with ileal pouch anal anastomosis for medically refractory ulcerative colitis(UC).The mean age at the time of pre-colectomy diagnosis of UC was 25.0611.5 years.The mean current age was 41.0612.1 years,nine(75.0%)were female,three(25.0%)had smoked and eight(66.7%)had used anti-tumor necrosis factor agents prior to vedolizumab use.The mean duration of vedolizumab use was 1.066.4 years.There was a significant reduction in mPDAI symptom subscores after vedolizumab therapy(3.5061.93 vs 5.0860.79,P=0.015).The pre-and post-treatment mean endoscopy subscores were 1.2561.36 and 0.9161.50 in the afferent limb(P=0.583);2.5861.68 and 2.2762.05(P=0.701)in the pouch body;and 2.6761.93 and 2.0962.12(P=0.511)in the cuff,respectively.None of the patients experienced side effects throughout the vedolizumab therapy.Conclusion:The findings of our study suggests that vedolizumab appears to be effective and safe in reducing the symptoms in patients with CD of the pouch.

Vedolizumab for chronic antibiotic-refractory pouchitis

Background:Chronic antibiotic-refractory pouchitis(CARP)is a complication of ileal pouch-anal anastomosis(IPAA),which poses a therapeutic challenge.Vedolizumab,a gut-selective monoclonal antibody to the a4b7 of integrin,has been used in such patients,but data on its efficacy are limited.Our aim was to assess the efficacy and safety of vedolizumab as induction therapy in CARP patients.Methods:In this single-center,historic cohort,patients with CARP who received vedolizumab between January 2015 to June 2017 were identified and analysed.Patients were included if they had active pouchitis with a total of modified pouch disease activity index(mPDAI)score5 or if unavailable clinician diagnosis of active pouchitis.Pre-treatment and at 3-month posttherapy pouchoscopy and clinical visits were used to calculate mPDAI.Results:A total of 19 patients were included in the study.The mean age was 26.7612.8 years,with 10(53%)males.Nine(47%)patients had been treated with anti-tumor necrosis factor(TNF)agents before colectomy and 10(53%)had anti-TNFs after colectomy and IPAA.Six(32%)patients had improvement in the mPDAI symptom subscores(P=0.031)and 14(74%)had improvement in both endoscopic and total mPDAI scores with a median change of-2 units(both P=0.031).Adverse events were noted only in two(11%)patients and four(21%)required surgery for CARP.Conclusions:Our study suggests that vedolizumab has efficacy and can be safely used for CARP patients.Larger studies with a higher number of patients are required to confirm these findings.