Complications after ileal pouch-anal anastomosis in Korean patients with ulcerative colitis

AIM:To investigate the outcomes of treatments for complications after ileal pouch-anal anastomosis(IPAA)in Korean patients with ulcerative colitis.METHODS:Between March 1998 and February 2013,72 patients(28 male and 44 female,median age 43.0years±14.0 years)underwent total proctocolectomy with IPAA.The study cohort was registered prospectively and analyzed retrospectively.Patient characteristics,medical management histories,operative findings,pathology reports and postoperative clinical courses,including early postoperative and late complications and their treatments,were reviewed from a medical record system.All of the ileal pouches were J-pouch and were performed with either the double-stapling technique(n=69)or a hand-sewn(n=3)technique.RESULTS:Thirty-one(43.1%)patients had early complications,with 12(16.7%)patients with complications related to the pouch.Pouch bleeding,pelvic abscesses and anastomosis ruptures were managed conservatively.Patients with pelvic abscesses were treated with surgical drainage.Twenty-seven(38.0%)patients had late complications during the follow-up period(82.5±50.8 mo),with 21(29.6%)patients with complications related to the pouch.Treatment for pouchitis included antibiotics or anti-inflammatory drugs.Pouch-vaginal fistulas,perianal abscesses or fistulas and anastomosis strictures were treated surgically.Pouch failure developed in two patients(2.8%).Analyses showed that an emergency operation was a significant risk factor for early pouch-related complications compared to elective procedures(55.6%vs 11.1%,P<0.05).Pouchitis was related to early(35.3%)and the other late pouch-related complications(41.2%)(P<0.05).The complications did not have an effect on pouch failure nor pouch function.CONCLUSION:The complications following IPAA can be treated successfully.Favorable long-term outcomes were achieved with a lower pouch failure rate than reported in Western patients.

Restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis:A narrative review

Restorative proctocolectomy with ileal pouch-anal anastomosis(RP-IPAA) is the gold standard surgical treatment for ulcerative colitis.However,despite the widespread use of RP-IPAA,many aspects of this treatment still remain controversial,such as the approach(open or laparoscopic),number of stages in the surgery,type of pouch,and construction type(hand-sewn or stapled ileal pouch-anal anastomosis).The present narrative review aims to discuss current evidence on the short-,mid-,and long-term results of each of these technical alternatives as well as their benefits and disadvantages.A review of the MEDLINE,EMBASE,and Ovid databases was performed to identify studies published through March 2016.Few large,randomized,controlled studies have been conducted,which limits the conclusions that can be drawn regarding controversial issues.The available data from retrospective studies suggest that laparoscopic surgery has no clear advantages compared with open surgery and that one-stage RP-IPAA may be indicated in selected cases.Regarding 2- and 3-stage RP-IPAA,patients who underwent these surgeries differed significantly with respect to clinical and laboratory variables,making any comparisons extremely difficult.The long-term results regarding the pouch type show that the W- and J-reservoirs do not differ significantly,although the J pouch is generally preferred by surgeons.Hand-sewn and stapled ileal pouch-anal anastomoses have their own advantages,and there is no clear benefit of one technique over the other.

Surgical treatment of ulcerative colitis:Ileorectal vs ileal pouch-anal anastomosis

Total proctocolectomy with ileal pouch-anal anastomosis(IPAA) is the current gold standard in the surgical treatment of ulcerative colitis(UC) refractory to medical management. A procedure of significant magnitude carries its own risks including anastomotic failure, pelvic sepsis and a low rate of neoplastic degeneration overtime. Recent studies have shown that total colectomy with ileorectal anastomosis(IRA) has been associated with good long-term functional results in a selected group of UC patients amenable to undergo a strict surveillance for the relatively high risk of cancer in the rectum. This manuscript will review and compare the most recent literature on IRA and IPAA as it pertains to postoperative morbidity and mortality, failure rates, functional outcomes and cancer risk.

Relationship between pouch microbiota and pouchitis following restorative proctocolectomy for ulcerative colitis

Restorative proctocolectomy with ileal pouch-anal anastomosis(IPAA)has become the surgical treatment of choice for many patients with medically refractory ulcerative colitis(UC)and familial adenomatous polyposis(FAP).UC patients with IPAA(UC-IPAA)are,nevertheless,susceptible to inflammatory and noninflammatory sequelae such as pouchitis,which is only rarely noted in FAP patients with IPAA.Pouchitis is the most frequent long-term complication of UC-IPAA patients,with a cumulative prevalence of up to 50%.Although the aetiology of pouchitis remains unclear,accumulating evidence suggests that a dysbiosis of the pouch microbiota and an abnormal mucosal immune response are implicated in its pathogenesis.Studies using culture and molecular techniques have detected a dysbiosis of the pouch microbiota in patients with pouchitis.Risk factors,genetic associations,and serological markers suggest that interactions between the host immune response and the pouch microbiota underlie the aetiology of this idiopathic inflammatory condition.This systematic review focuses on the dysbiosis of the microbiota that inhabit the pouch in UC and FAP patients and its interaction with the mucosal immune system.A metaanalysis was not attempted due to the highly heterogeneous microbiota composition and the different detection methods used by the various studies.Although no specific bacterial species,genus,or family has as yet been identified as pathogenic,there is evidence that a dysbiosis characterized by decreased gut microbiota diversity in UC-IPAA patients may,in genetically predisposed subjects,lead to aberrant mucosal immune regulation triggering an inflammatory process.

Ileal pouch surgery for ulcerative colitis

Ulcerative colitis (UC) is a relapsing and remitting disease characterised by chronic mucosal and submucosal inflammation of the colon and rectum. Treatment may vary depending upon the extent and severity of inflammation. Broadly speaking medical treatments aim to induce and then maintain remission. Surgery is indicated for inflammatory disease that is refractory to medical treatment or in cases of neoplastic transformation. Approximately 25% of patients with UC ultimately require colectomy. Ileal pouch-anal anastomosis (IPAA) has become the standard of care for patients with ulcerative colitis who ultimately require colectomy. This review will examine indications for IPAA, patient selection, technical aspects of surgery, management of complications and long term outcome following this procedure.

Fecal microbiota in pouchitis and ulcerative colitis

AIM To investigate the changes in microbiota in feces of patients with ulcerative colitis(UC) and pouchitis using genomic technology.METHODS Fecal samples were obtained from UC patients with or without an ileal pouch-anal anastomosis(IPAA) procedure, as well as healthy controls. The touchdown polymerase chain reaction technique was used to amplify the whole V3 region of the 16 S r RNA gene, which was transcribed from DNA extracted from fecal samples. Denaturing gradient gel electrophoresis was used to separate the amplicons. The band profiles and similarity indices were analyzed digitally. The predominant microbiota in different groups was confirmed by sequencing the 16 S rR NA gene. RESULTS Microbial biodiversity in the healthy controls was significantly higher compared with the UC groups(P < 0.001) and IPAA groups(P < 0.001). Compared with healthy controls, the UC patients in remission and those in the mildly active stage, the predominant species in patients with moderately and severely active UC changed obviously. In addition, the proportion of the dominant microbiota, which was negatively correlated with the disease activity of UC(r =-6.591, P < 0.01),was decreased in pouchitis patients. The numbers of two types of bacteria, Faecalibacterium prausnitzii and Eubacterium rectale, were reduced in UC. Patients with pouchitis had an altered microbiota composition compared with UC patients. The microbiota from pouchitis patients was less diverse than that from severely active UC patients. Sequencing results showed that similar microbiota, such as Clostridium perfringens, were shared in both UC and pouchitis.CONCLUSION Less diverse fecal microbiota was present in patients with UC and pouchitis. Increased C. perfringens in feces suggest its role in the exacerbation of UC and pouchitis.

Ileal pouch anal anastomosis with modified double-stapled mucosectomy-the experience in China

AIM:To investigate the feasibility and long-term functional outcome of ileal pouch-anal anastomosis with modified double-stapled mucosectomy.METHODS:From January 2002 to March 2011,fourtyfive patients underwent ileal pouch anal anastomosis with modified double-stapled mucosectomy technique and the clinical data obtained for these patients were reviewed.RESULTS:Patients with ulcerative colitis(n = 29) and familial adenomatous polyposis(n = 16) underwent ileal pouch-anal anastomosis with modified doublestapled mucosectomy.Twenty-eight patients underwent one-stage restorative proctocolectomy,ileal pouch anal anastomosis,protective ileostomy and the ileostomy was closed 4-12 mo postoperatively.Two-stage procedures were performed in seventeen urgent patients,proctectomy and ileal pouch anal anastomosis were completed after previous colectomy with ileostomy.Morbidity within the first 30 d of surgery occurred in 10(22.2%) patients,all of them could be treated conservatively.During the median follow-up of 65 mo,mild to moderate anastomotic narrowing was occurred in 4 patients,one patient developed persistent anastomotic stricture and need surgical intervention.Thirtyfive percent of patients developed at least 1 episode of pouchitis.There was no incontinence in our patients,the median functional Oresland score was 6,3 and 2 after 1 year,2.5 years and 5 years respectively.Nearly half patients(44.4%) reported "moderate functioning",37.7% reported "good functioning",whereas in 17.7% of patients "poor functioning" was observed after 1 year.Five years later,79.2% of patients with good function,16.7% with moderate function,only 4.2% of patients with poor function.CONCLUSION:The results of ileal pouch anal anastomosis with modified double-stapled mucosectomy technique are promising,with a low complication rate and good long-term functional results.

Update on medical and surgical options for patients with acute severe ulcerative colitis: what is new?

Acute severe ulcerative colitis(UC) is a highly morbid con dition that requires both medical and surgical managementhrough the collaboration of gastroenterologists and colorectal surgeons. First line treatment for patients presenting with acute severe UC consists of intravenous steroids, but those who do not respond require escalation of therapy or emergent colectomy. The mortality of emergent colectomy has declined significantly in recent decades, but due to the morbidity of this procedure, second line agents such as cyclosporine and infliximab have been used as salvage therapy in an attempt to avoid emergent surgery. Unfortunately, protracted medical therapy has led to patients presenting for surgery in a poorer state of health leading to poorer post-operative outcomes. In this era of multiple medical modalities available in the treatment of acute severe UC, physicians must consider the advantages and disadvantages of prolonged medical therapy in an attempt to avoid surgery. Colectomy remains a mainstay in the treatment of severe ulcerative colitis not responsive to corticosteroids and rescue therapy, and timely referral for surgery allows for improved post-operative outcomes with lower risk of sepsis and improved patient survival. Options for reconstructive surgery include three-stage ileal pouchanal anastomosis or a modified two-stage procedure that can be performed either open or laparoscopically. The numerous avenues of medical and surgical therapy have allowed for great advances in the treatment of patients with UC. In this era of options, it is important to maintain a global view, utilize biologic therapy when indicated, and then maintain an appropriate threshold for surgery. The purpose of this review is to summarize the growing number of medical and surgical options available in the treatment of acute, severe UC.

Secondary pouchitis in a post-operative patient with ulcerative colitis,successfully treated by salvage surgery

We report a case of secondary pouchitis, defined as a mucosal inflammatory lesion in the ileal reservoir provoked by pouch-related complication following total colectomy and pouch anal anastomosis, which was successfully treated by salvage surgery. A 20-year-old woman with ulcerative colitis developed acute severe bloody diarrhea following proctocolectomy, ileal pouchanal anastomosis and diverting ileostomy. She was diagnosed as having a secondary pouchitis mainly caused by a peripouch abscess and partly concerned with the abnormal pouch formation. The remnantrectum and ileal pouch were excised and ileal pouch-anal anastomosis and diverting ileostomy were constructed.The postoperative course was uneventful with no sign of pouchitis. Salvage surgery may be indicated to treat secondary pouchitis when caused by surgery-related complications.

基于网络药理学的苦参-地榆治疗溃疡性结肠炎、肛门湿疹的“异病同治”机制分析

目的:预测苦参-地榆药对治疗溃疡性结肠炎(UC)和肛门湿疹“异病同治”的作用机制。方法:采用网络药理学方法,基于中药系统药理学分析平台(TCMSP)及检索相关文献,寻找苦参-地榆药对中活性成分及作用靶点,并以口服利用度(OB)≥30%,类药性(DL)≥0.18为条件进行筛选;利用OMIM、TTD、Drug Bank数据库检索UC和肛门湿疹疾病相关靶点;通过R语言将苦参-地榆药对与UC和肛门湿疹靶点做Venn图;采用Cytoscape软件绘制疾病-药对-成分-靶点网络;利用STRING数据库,构建蛋白互作网络模型(PPI),并通过Cytoscape软件进行优化;基于Matescape数据平台,对药对治疗UC和肛门湿疹的共同靶点进行基因本体(GO)生物功能和基因组百科全书(KEGG)通路富集分析。结果:筛选后得出,苦参-地榆药对活性成分57个、靶点179个,UC靶点561个,肛门湿疹靶点677个,药对与两疾病交集靶点49个,包括IL-6、JUN、TNF、AKT1等。GO生物过程分析主要涉及对脂多糖的反应、对有毒物质的反应、对活性氧的反应等生物过程;KEGG富集分析共得到15条信号通路,主要包括IL-17信号通路、癌症通路、细胞因子受体相互作用等。结论:苦参-地榆药对“异病同治”UC和肛门湿疹是通过其多成分、多靶点、多通路的特点实现的,为进一步临床拓展应用及实验验证提供参考依据。

奥沙拉秦钠联合全结直肠切除回肠储袋肛管吻合术治疗溃疡性结肠炎临床观察

目的 探讨奥沙拉秦钠联合全结直肠切除回肠储袋肛管吻合术(IPAA)治疗溃疡性结肠炎的疗效,以及对患者肠黏膜屏障功能、炎性因子水平的影响。方法 选取河北省保定市竞秀区医院2020年3月至2022年3月收治的溃疡性结肠炎患者120例,按随机数字表法分为对照组和观察组,各60例。对照组行IPAA,术后服用抗菌药物3 d;观察组行IPAA,术后7 d待肠功能恢复后服用奥沙拉秦钠4周。结果 与治疗前比较,两组患者治疗后的D-乳酸、内毒素、二胺氧化酶(DAO)水平均明显降低,且观察组下降更明显(P <0.05);白细胞介素1β(IL-1β)、肿瘤坏死因子-α(TNF-α)水平均明显降低,IL-10水平明显升高,且观察组变化更明显(P <0.05);超氧化物歧化酶(SOD)水平均明显升高,丙二醛(MDA)、脂质过氧化物(LPO)水平均明显降低,且观察组变化更明显(P <0.05);血红蛋白(Hb)、血清白蛋白(ALB)、红细胞比容(HCT)水平均明显升高,且观察组升高更明显(P <0.05)。观察组总有效率为95.00%,明显高于对照组的78.33%(P <0.05)。观察组并发症发生率为10.00%,明显低于对照组的25.00%(P <0.05)。结论 奥沙拉秦钠联合IPAA治疗溃疡性结肠炎疗效较好,有助于患者肠黏膜屏障功能的恢复,降低炎性因子水平,且安全性较好。

痔瘘熏洗颗粒对肛门溃疡的作用研究

目的观察痔瘘熏洗颗粒对动物实验性肛门溃疡愈合与抗炎、镇痛、抗菌的作用。方法在大鼠肛门外周粘膜注射冰醋酸制备大鼠肛门溃疡模型,采用小鼠耳肿胀、热板法和扭体法,外用给药观察药物促溃疡愈合、抗炎、镇痛作用,采用试管稀释法观察该药的体外抗菌作用。结果痔瘘熏洗颗粒外用能明显缩小大鼠肛门溃疡面积和缩短肛门溃疡平均愈合天数,此外还具有对抗二甲苯致小鼠耳肿胀、提高小鼠热痛阈值、减少冰醋酸致小鼠的扭体数及体外抗金黄色葡萄球菌的作用。结论痔瘘熏洗颗粒具有促进大鼠肛门溃疡愈合、抗炎、镇痛和抗菌作用。

慢性播散型组织胞浆菌病2例

目的提高临床医生对慢性播散性组织胞浆菌病的认识和诊治水平,以便减少误诊,改善预后。方法根据北京协和医院1980年至2012年诊断慢性组织胞浆菌病的2例临床和随诊资料,结合文献对该病的临床表现、组织病理学特点、诊断、治疗及预后进行分析。结果 2例患者均病程较长、首发症状缺乏特异性,多系统受累,无特殊疾病史。其中1例有消化道、肺和双肾上腺受累,另1例为肺和腹膜受累。早期均被误诊,确诊均依靠组织病理,抗真菌治疗效果好,未见复发。结论慢性组织胞浆菌病少见且临床表现不特异,确诊依赖于典型的病理形态和特殊染色,积极治疗预后好。

集束护理预防腹泻患者肛周皮炎的效果观察

目的探讨集束护理对预防ICU腹泻患者肛周皮炎的效果。方法将102例腹泻患者按照随机数字表分为2组,观察组52例,对照组50例。对照组采用呋喃林炉甘石洗剂外涂保护肛周皮肤的护理方法,观察组采用集束护理的方法。比较2组肛周皮炎发生率、严重程度和愈合时间。结果观察组肛周皮炎发生率为7.7%,对照组为23.1%,观察组肛周皮炎愈合时间少于对照组(p<0.05)。结论应用集束护理预防肛周皮炎比呋喃林炉甘石洗剂外涂肛周皮肤更有效,可作为预防ICU患者肛周皮炎的首要护理手段。

肛瘘的诊治专家共识(2020版)

肛瘘作为肛肠科的常见病及多发病,存在临床诊疗方案繁多、认知不统一等问题,缺乏业界公认的诊疗规范,多数研究仅限于理论探讨,临床指导意义较弱,导致肛瘘术后复发率较高。北京肛肠学会通过问卷调查的方式征询了国内肛肠领域30余位专家的意见,结合循证医学证据进行反复推敲,形成了《肛瘘的诊治专家共识(2020版)》。本共识提出了肛瘘的治疗原则,指出了传统挂线、肛瘘切开术、Lift术式、瘘管填塞术及近年兴起的视频辅助下肛瘘切除术(VAAFT)等多种术式的优缺点,以指导肛肠专业医生的临床实践,规范诊疗行为,提高肛瘘治愈率、减少复发率。

升丹临床应用研究述评

目的:探讨升丹的临床运用现状。方法:对近年来的相关文献进行整理、归纳、分析和总结。结果:升丹在临床上主要用于皮肤溃疡、乳痈、肛瘘、下肢慢性溃疡、病毒性皮肤感染等疾病。结论:升丹具有良好的提毒、祛腐、生肌功效。

双吻合器法回肠储袋肛管吻合治疗溃疡性结肠炎的临床效果分析

目的:分析双吻合器法回肠储袋肛管吻合治疗溃疡性结肠炎的临床效果。方法:本实验研究对象为2005-07～2012-06于我院治疗的121例溃疡性结肠炎病人。按照随机数字表法分为观察组(双吻合器法回肠储袋肛管吻合治疗组)60例,对照组(回肠储袋肛管吻合治疗组)61例,比较两组手术时间、术后并发症、术后排便功能、术中输血量、术后住院时间等。结果:观察组平均手术时间为3.7±11.3h、术中输血量平均为504.2±103.6mL、平均住院时间为14.8±8.4d、术后排便功能评分平均为2.3±3.1分、并发症发生率为10%,均明显低于对照组,差异明显,P<0.05。结论:双吻合器法应用于溃疡性结肠炎病人回肠储袋肛管吻合术中能够显著缩短手术时间及住院、降低术中输血量、减少并发症的发生、提高术后排便能力。

溃疡性结肠炎患者术后生活质量及远期肛门功能恢复的调查分析

目的探讨溃疡性结肠炎(UC)患者外科术后生活质量和远期肛门功能恢复情况。方法采用中文版SF-36量表对42例UC患者术后12个月生活质量和90例健康人群生活质量进行评估比较。同时观察患者术后12个月远期肛门功能恢复情况。结果 UC患者术后生活质量在生理机能、躯体疼痛、一般健康状况、精力、社会功能、情感职能、精神健康方面与健康人群比较差异无显著意义(P>0.05),在生理职能方面低于健康人群,差异有显著意义(P<0.05)。远期肛门功能恢复情况影响患者术后生活质量。便次少、肛门控便能力好的患者生活质量各维度得分均较高,并从生理机能、生理职能、躯体疼痛等方面影响术后生活质量。结论护理人员应采取有效的个体化健康教育和肛门功能恢复指导,提高UC患者术后生活质量。

以胃管代替肛管在溃疡性结肠炎保留灌肠中的应用

目的探索治疗溃疡性结肠炎中行保留灌肠的新方法。方法选取2014年1月至2015年4月份入住我院消化内科二区确诊为急性发作溃疡性结肠炎,病变部位在乙状结肠、降结肠、升结肠,均需采取保留灌肠治疗的患者63例,其中将2014年1~10月收治的31例患者设为对照组,2014年11月至2015年4月收治的32例患者设为观察组,对照组采用传统的肛管灌肠(肛管组),观察组使用14#胃管代替肛管灌肠(胃管组),观察两组患者在保留灌肠时的肛区疼痛反应,记录插管次数,统计一次性插管成功率和给药后溃疡性结肠炎急性发作缓解症状情况。结果胃管组一次性插管成功率为93.75%(30/32),肛管组为67.74%(21/31);插管时肛区疼痛不适发生率方面,胃管组为6.25%(2/32),肛管组为35.48%(11/31);从控制急性发作缓解症状的给药效果来看,胃管组的缓解率为96.88%(31/32),肛管组为70.97%(22/31),以上各项指标比较差异均有统计学意义(P<0.05)。结论保留灌肠可以使用胃管代替常规肛管,此方法给药效果更好,患者更易接受,临床护士更容易掌握操作技术要领。

不同幽门螺杆菌临床分离株的菌体蛋白

目的：了解不同幽门螺杆菌的菌体蛋白构成及其免疫印迹条带与胃十二指肠疾病的关系。方法：将６株幽门螺杆菌（Ｈｅｌｉｃｏｂａｃｔｅｒｐｙｌｏｒｉ，Ｈｐ）临床分离株的菌体蛋白进行十二烷基磺酸钠聚丙烯酰胺凝胶电泳（ＳＤＳＰＡＧＥ），以免疫印迹技术分析其免疫原性；以６株Ｈｐ菌体蛋白的等量混合物为抗原，检测了６２例胃十二指肠疾病患者血清抗ＨｐＩｇＧ的免疫印迹条带。结果：凝胶上６株Ｈｐ的菌体蛋白条带非常相似，均含６７．０ｕ、６５．０ｕ、５７．０ｕ３条主要蛋白条带，但各主要蛋白条带的含量在６株Ｈｐ中各不相同（薄层扫描法）；除共同含有６７．０ｕ、５７．０ｕ、５５．０ｕ、５２．０ｕ４条免疫反应条带外，６株Ｈｐ的其余免疫反应条带的检出率及颜色深浅有明显差异；２４．８ｕ免疫反应条带在胃癌组的检出比例（１１／１２）显著高于胃溃疡组（４／１３）、十二指肠溃疡组（７／１４）和慢性胃炎组（１／１２）。结论：不同Ｈｐ临床分离株的菌体蛋白结构相似，但其蛋白含量和免疫原性有差异；２４．８ｕ蛋白可能与胃癌有相关性。