Surgical treatment of intestinal stricture in inflammatory bowel disease

Fibroblast infiltration and collagen deposition result in structural changes in the bowel wall, and lead to strictures in intestinal inflammatory disease. While strictures can also occur in other contexts, such as malignancy, this review focuses on the surgical treatment of stricture secondary to inflammatory bowel disease. Distinguishing between predominantly inflammation vs established fibrosis as the cause of a stricture can be challenging. While inflammatory strictures may be responsive to medication, predominantly fibrotic strictures usually need surgical intervention. Both endoluminal and extraluminal approaches are described in this review. Endoscopic dilatation of strictures is suitable for short‐segment isolated small bowel strictures. Other options are to divide the stricture surgically but preserve the length, performing a strictureplasty or resecting the strictured segment. The mesentery is increasingly recognized as playing a role in stricture recurrence. In a relapsing‐remitting disease such as Crohn's disease, the preservation of intestinal length is essential and balance is needed between this and a complete resection to reduce the risk of recurrence. Pre‐ and postoperative involvement of the multidisciplinary team is essential to improve outcomes in this challenging clinical scenario

Adipocyte-epithelial interactions and crohn's disease - an emerging drug target

Crohn's disease is hallmarked by mesenteric abnormalities including thickening, shortening and extension ofmesenteric fat over the intestinal surface (“fat wrapping” or “creeping fat”) (Coffey et al., 2016; Peyrin-Biroulet et al., 2007; Sheehan et al., 1992; Crohn et al., 1932). Mesenteric and submucosal mesenchymal abnormalities overlap in histological appearance and both inflammatory fronts meet to generate transmural inflammation (Coffey and O'leary, 2016)

Defining the mesentery as a new organ and what this means for understanding its roles in digestive disorders

Categorisation of structures into tissues, organs and systems is arbitrary but has considerable utility as it provides a structural hierarchy within which one can more easily investigate and better understand human biology and disease. Until recently, this process was greatly hampered by an erroneous anatomical appraisal of the mesentery. Advances in our understanding of the mesentery now present scientific and clinical communities with new opportunities. Based on these, it is suggested that the mesentery be re-designated as an organ.1 Herein we challenge this concept and explore whether there are clinical benefits to redesignation

Resectional surgery for malignant disease of abdominal digestive organs is not surgery of the organ itself, but also that of the mesenteric organ

Despite large strides in molecular oncology, surgery remains the bedrock in the management of visceral cancer. The primacy of surgery cannot be understated and a mesenteric (i.e. ontogenetic) approach is particularly beneficial to patients. Heald greatly advanced the management of rectal cancer with his description of the anatomical foundation of total mesorectal excision (TME), dramatically improving outcomes worldwide with this mesenteric-based approach. Moreover, complete mesocolic excision (CME) based on similar principles is becoming popular. Introduced by Hohenberger, CME resembles TME insofar as it emphasises strictly anatomical dissection along embryological planes to detach an intact (i.e. “complete”) mesentery with peritoneal envelope. CME also incorporates “central” vascular ligation (CVL) which broadly correlates with the “D3 lymphadenectomy” of Eastern literature. As many surgeons already practise anatomical and mesenteric-based surgery, it is unclear how the putative benefits of CME (including CVL) arise. Herein, we argue that these may relate to a more extensive resection of the mesentery, and thus mesenteric tumour deposits within the connective tissue lattice of the mesentery, and not necessarily the lymphadenectomy alone. We believe the connective tissue interface between the bowel wall and mesentery provides an alternative mode of spread of pathogenic elements. Whilst this remains a suggestion only, it would explain the histological independence of tumour deposits and why a greater mesenterectomy could be associated with benefits in survival. If this argument holds, it follows that resectional surgery for digestive organ malignancy is not surgery of the organ itself (or lymphatics only), but also that of the contiguous mesente

Length of stay following elective surgery can we improve efficiency?

Increasing emergency admissions place significant demands on limited hospital resources. We assessed national practices and resources for initiatives to reduce length of stay (LOS) and thereby improve efficiency of resource utilisation. Consultant members of the Irish Association of Coloproctology received a questionnaire seeking information about available initiatives aimed at reducing LOS. 20 out of 32 (62.5%) consultants responded to the questionnaire. Pre-assessment clinics for day surgery were available to 18(90%). Only 13 (65%) had access to pre-assessment clinics for patients requiring longer admissions. 11 (55%) could admit major cases on the day of surgery. Only 9 (45%) surgeons could guarantee immediate re-admission of patients discharged from hospital if needed. There was a divergence of opinion regarding the acceptable average LOS and percentage suitable for day surgery for a variety of common surgical procedures. This study highlights a number of key areas in which certain well-established initiatives could improve efficiency

Long-term outcome data for patients with HER2-positive early-stage breast cancer treated with adjuvant trastuzumab: benefit outside clinical trial setting

Adjuvant treatment options for HER2 positive Early-Stage Breast Cancer (EBC) have grown in recent years. The addition of adjuvant trastuzumab therapy for one-year to standard chemotherapy has been shown in several Randomized Controlled Trials (RCTs) to improve Disease-Free Survival (DFS) and Overall Survival (OS) in patients with high-risk HER2-positive EBC. This study aimed to review the long-term outcome data for patients with HER2-positive EBC who were treated with adjuvant trastuzumab therapy in a designated cancer centre. Methods: Data included all women diagnosed with HER2-positive EBC between 1st January 2001 and 31st January 2010 (N=147). Retrospective evaluation of healthcare records for clinical, demographic, and pathologic data was undertaken. Most had adjuvant trastuzumab following systemic chemotherapy (80/147; 54.4%). Kaplan-Meier estimates were used to evaluate whether one-year trastuzumab administration was associated with improved DFS and OS. Additionally, cohorts were generated by pathologic tumour size and lymph node involvement to stratify outcome measures (i.e. DFS and OS) by risk features

Colonisation of the colonic mucus gel layer with butyrogenic and hydrogenotropic bacteria in health and ulcerative colitis

Butyrate is the primary energy source for colonocytes and is essential for mucosal integrity and repair. Butyrate deficiency as a result of colonic dysbiosis is a putative factor in ulcerative colitis (UC). Commensal microbes are butyrogenic, while others may inhibit butyrate, through hydrogenotropic activity. The aim of this study was to quantify butyrogenic and hydrogenotropic species and determine their relationship with inflammation within the colonic mucus gel layer (MGL). Mucosal brushings were obtained from 20 healthy controls (HC), 20 patients with active colitis (AC) and 14 with quiescent colitis (QUC). Abundance of each species was determined by RT-PCR. Inflammatory scores were available for each patient. Statistical analyses were performed using Mann–Whitney-U and Kruskall-Wallis tests. Butyrogenic R. hominis was more abundant in health than UC (p< 0.005), prior to normalisation against total bacteria. Hydrogenotropic B. wadsworthia was reduced in AC compared to HC and QUC (p < 0.005). An inverse correlation existed between inflammation and R. hominis (ρ− 0.460, p < 0.005) and B. wadsworthia (ρ− 0.646, p < 0.005). Other hydrogenotropic species did not widely colonise the MGL. These data support a role for butyrogenic bacteria in UC. Butyrate deficiency in UC may be related to reduced microbial production, rather than inhibition by micrrobial by-products

The first robotic transanal minimally invasive surgery in Ireland: a case‑based review

Transanal minimally invasive surgery (TAMIS) has gained worldwide acceptance as a means of local excision of early rectal cancers and benign rectal lesions. However, it is technically challenging due to the limitations of rigid laparoscopic instruments in the narrow rectal lumen. Robotic platforms offer improved ergonomics that are valuable in operative fields with limited space. Robotic TAMIS represents an exciting new development that may be more versatile than traditional TAMIS. In this review, we describe the first case of robotic TAMIS performed in our country and a review of current literature on the technique

A comparison of the usage of anal verge and dentate line in measuring distances within the rectum

Introduction: The anal verge is key in determining measurement-based suitability for neoadjuvant radiotherapy in rectal cancer. The dentate line is a distinct anatomic landmark and may permit more accurate measurement for rectal lesions. This study aimed to establish measurative ranges for distances of the rectal valves from the dentate line and the anal verge and to compare variability between the two. Methods: Patients (n = 104) undergoing colonoscopy and sigmoidoscopy were prospectively accrued. The distances of rectal valves were measured from the anal verge and the dentate line respectively by using a vector subtraction-based approach. Distances were correlated with gender, age and body mass index. Standard deviation was the measure of variability. Results: The gross topography of the rectum was remarkably consistent with three valves identifiable in the majority (99 of 104) of patients. The median distance between the dentate line and the anal verge was 2.0 cm. The distances of each rectal valve (proximal to distal) to the anal verge and dentate line were 11.4 ± 2.0 cm, 8.6 ± 2.0 cm, 6.0 ± 1.7 cm and 9.1 ± 1.6 cm, 6.3 ± 1.6 cm, 3.7 ± 1.5 cm, respectively. Betweengroup variability was minimally reduced when using the dentate line as a reference point. Obesity was associated with an increased distance of the proximal rectal valve from the anal verge and the dentate line (p = 0.004 and 0.015 respectively). Conclusions: Rectal valve anatomy is remarkably consistent. Both dentate line and anal verge are reliable landmarks from which distances can be measured within the rectum

The abundance of Akkermansia muciniphila and its relationship with sulphated colonic mucins in health and ulcerative colitis

Akkermansia muciniphila utilises colonic mucin as its substrate. Abundance is reduced in ulcerative colitis (UC), as is the relative proportion of sulphated mucin in the mucus gel layer (MGL). It is unknown if these phenomena are related, however reduced sulphated mucins could contribute to reduced abundance, owing to a lack of substrate. The aim of this study was to quantify A. muciniphila within the MGL and to relate these findings with markers of inflammation and the relative proportion of sulphomucin present. Colonic biopsies and mucus brushings were obtained from 20 patients with active UC (AC), 14 with quiescent UC (QUC) and 20 healthy controls (HC). A. muciniphila abundance was determined by RT-PCR. High iron diamine alcian-blue staining was performed for histological analysis. Patients with AC had reduced abundance of A. muciniphila compared to HC and QUC. A positive association was found between A. muciniphila abundance and higher percentage of sulphated mucin (ρ 0.546, p = 0.000). Lower abundances of A. muciniphila correlated with higher inflammatory scores (ρ = 0.294 (p = 0.001)). This study confirms an inverse relationship between A. muciniphila and inflammation and a positive association between A. muciniphila abundance and percentage of sulfated mucin in the MGL