Clinical relevance of endoscopic peri-appendiceal red patch in ulcerative colitis patients.

Background Increasing evidence is suggesting appendectomy as an alternative treatment for ulcerative colitis (UC), especially in case of histological appendiceal inflammation. Therefore, preoperative identification of appendiceal inflammation could be beneficial. This study aimed to assess the prevalence of peri-appendiceal red patch (PARP) on colonoscopy. In addition, prognostic relevance of PARP for disease course and its predictive value for histological appendiceal inflammation in patients undergoing appendectomy was assessed. Methods UC patients undergoing colonoscopy in 2014/2015 were included to determine PARP-prevalence in a cross-sectional study. Findings were correlated to patient and disease characteristics, upscaling of treatment and colectomy rates after cross-sectional colonoscopy. In patients undergoing appendiceal resection, histopathological inflammation was assessed using the Robarts Histopathology Index (RHI). Results In total, 249 patients were included of which 17.7% (44/249) had a PARP. Patients with PARP were significantly younger with a shorter disease course. The majority of patients with PARP (61.4%) was in endoscopic remission. Patients with PARP required more upscaling of medical therapy (81.8% vs. 58.0%, p < 0.01), and more PARP patients underwent colectomy (13.6% vs. 4.9%, p = 0.04). Patients with PARP had a higher median RHI in resection specimens (14 vs. 7, p < 0.01). Conclusion PARP was present during colonoscopy regardless disease activity and was predominantly found in UC patients with younger age and shorter disease duration. PARP patients had a more severe course of UC, and in case of appendectomy, more severe histopathological appendiceal inflammation. Appendectomy as an experimental therapy for UC has been suggested to be predominantly effective in UC patients with appendiceal inflammation. This study demonstrates that presence of a PARP on colonoscopy predicts appendiceal inflammation. After consensus has been reached on the therapeutic effect of appendectomy, assessing PARP presence during colonoscopy could therefore contribute to identifying patients most likely to respond

Unintentional Suture Fistula Between the Proximal and Distal Esophagus in a Preterm Neonate with Type C Esophageal Atresia

We present the case of a patient with gross type C esophageal atresia in a preterm neonate (gestational age of 31 weeks + 1 day) with a birth weight of 1,470 g. The fistula was released via a thoracotomy, but no primary anastomosis could be made, due to an unexpected long gap. The distal esophagus was closed and approximated to the blind pouch using traction sutures until an adjacent position was reached. A gastrostomy was created for enteral feeding. Although a second attempt to make an anastomosis was unsuccessful, the patient unexpectedly developed a suture fistula 6 weeks after the first procedure, enabling feeding via a nasogastric tube. Over time, six dilations were necessary. Full enteral feeding was achieved at the age of 6 months. Our case confirms sparse reports that deliberately creating a suture fistula may be a solution in esophageal atresia patients when an unexpected long gap prohibits a primary anastomosis

Ileal pouch-anal anastomosis complications and pouch failure: A systematic review and meta-analysis

Objective: This systematic review aims to assess the incidence of pouch failure and the correlation between ileal pouch-anal anastomosis (IPAA)-related complications and pouch failure. Background: Previous studies demonstrated wide variation in postoperative complication rates following IPAA. Methods: A systematic review was performed by searching the MEDLINE, EMBASE, and Cochrane Library databases for studies reporting on pouch failure published from January 1, 2010, to May 6, 2020. A meta-analysis was performed using a random-effects model, and the relationship between pouch-related complications and pouch failure was assessed using Spearman's correlations. Results: Thirty studies comprising 22,978 patients were included. Included studies contained heterogenic patient populations, different procedural stages, varying definitions for IPAA-related complications, and different follow-up periods. The pooled pouch failure rate was 7.7% (95% confidence intervals: 5.56-10.59) and 10.3% (95% confidence intervals: 7.24-14.30) for studies with a median follow-up of ≥5 and ≥10 years, respectively. Observed IPAA-related complications were anastomotic leakage (1-17%), pelvic sepsis (2-18%), fistula (1-30%), stricture (1-34%), pouchitis (11-61%), and Crohn's disease of the pouch (0-18%). Pelvic sepsis (r = 0.51, P < 0.05) and fistula (r = 0.63, P < 0.01) were correlated with pouch failure. A sensitivity analysis including studies with a median follow-up of ≥5 years indicated that only fistula was significantly correlated with pouch failure (r = 0.77, P < 0.01). Conclusions: The single long-term determinant of pouch failure was pouch fistula, which is a manifestation of a chronic leak. Therefore, all effort should be taken to prevent an acute leak from becoming a chronic leak by early diagnosis and proactive management of the leak

Missed Proximal Tracheoesophageal Fistula (TEF) in a Neonate with Type D Esophageal Atresia

We present the case of a patient with the rare type D esophageal atresia (EA), diagnosed after correction of an EA initially diagnosed as type C. Routine postoperative contrast esophagogram showed a missed proximal tracheoesophageal fistula. This case report illustrates the potential difficulties to diagnose type D EA

Intestinal ultrasound detects an increased diameter and submucosal layer thickness in the appendix of patients with ulcerative colitis compared to healthy controls – a prospective cohort study

Background: Increasing evidence suggests that appendicectomy as alternative treatment for ulcerative colitis (UC), especially in patients with histopathological appendiceal inflammation. Intestinal ultrasound (IUS) is a non-invasive diagnostic modality to characterise appendiceal inflammation. Aims: To assess appendiceal IUS characteristics in UC patients and compare findings to healthy controls (HC). Methods: In this prospective study, appendiceal IUS was performed in consecutive UC patients with active (A; n = 35) or quiescent (Q; n = 30) disease and in HC (n = 30). Transverse appendiceal diameter (TAD) and additional IUS parameters (bowel wall thickness, submucosal layer thickness and colour Doppler signal) were assessed. Results: The appendix was visualised in 41/65 UC patients (63.1%; A vs. Q: 23/35 vs. 18/30, p = 0.67) and 18/30 (60%) HC. UC patients had a higher TAD (A: 5.5 mm, Q: 5.0 mm, HC: 4.3 mm; A-HC p < 0.01; Q-HC p = 0.01, A-Q p = ns) and submucosal layer thickness (A: 1.0 mm, Q: 1.0 mm, HC: 0.7 mm; A-HC p < 0.01, Q-HC: p = 0.01, A-Q: p = ns) when compared to HC. A TAD ≥6 mm corresponding to an ultrasonographic suspicion of acute appendicitis was mainly reported in A-UC patients (A: 43%; Q: 6%; HC: 0%, p = 0.01) and occurred irrespective of disease extent. However, none of the patients had a clinical suspicion of acute appendicitis. Conclusion: A TAD ≥6 mm was predominantly seen in A-UC. TAD was higher in UC patients compared to HC irrespective of disease activity and was characterised by an increased submucosal layer thickness. IUS therefore has the potential to identify UC patients with appendiceal inflammation

Endo-sponge Assisted Early Surgical Closure of Ileal Pouch-anal Anastomotic Leakage Preserves Long-term Function: A Cohort Study

BACKGROUND AND AIMS: Endo-sponge [Braun Medical] assisted early surgical closure [ESC] is an effective treatment to control pelvic sepsis after ileal pouch-anal anastomosis [IPAA] leakage, and became standard treatment in our centre from 2010 onwards. The aim of this cohort study was to assess the long-term pouch function of ulcerative colitis [UC] patients treated with ESC or conventional management [CM] for anastomotic leakage after IPAA. METHODS: Consecutive patients who underwent an IPAA for UC between 2002 and 2017 were included. Patients treated with ESC [2010-2017] or CM [2002-2009] for anastomotic leakage were compared with control patients without anastomotic leakage of the corresponding time period. Main endpoints were long-term pouch function on a 3-point scale and pouch failure, as measured with the validated pouch dysfunction score questionnaire. RESULTS: Some 280 of 334 patients [84%] returned the pouch dysfunction questionnaire, of whom 18 were treated with ESC and 22 with CM for anastomotic leakage. Control cohorts included 133 [2010-2017] and 107 patients [2002-2009]. Between ESC-treated patients and control patients, pouch function [p = 0.647] and pouch failure rates [0/18 versus 5/133, p >0.99] were similar. CM resulted in worse pouch function [p = 0.016] and a higher pouch failure rate [5/22 versus 5/107, p = 0.013] compared with control patients. CONCLUSIONS: ESC, in contrast to CM, for IPAA leakage in UC patients is associated with preservation of pouch function and preclusion of pouch failure, probably due to early and effective treatment of pelvic sepsis

Risk Factors and Consequences of Anastomotic Leakage After Esophagectomy for Cancer

Background: Identifying predictors of anastomotic leakage can contribute to prevention of this common complication after esophagectomy. This study identified predictors for anastomotic leakage and assessed the influence of anastomotic leakage on short-term outcomes and long-term survival. Methods: A retrospective cohort study was conducted of consecutive patients who underwent esophagectomy in the Amsterdam University Medical Centers, location Amsterdam Medical Center, between 1993 and 2019. Multilevel logistic and Cox regression models were used to assess predictors for anastomotic leakage and survival, and an operation year-level random effects was considered for the unmeasured characteristics at year of operation. Results: Included were 1539 patients, and anastomotic leakage developed in 288 (19%). Predictors for developing anastomotic leakage after a transthoracic esophagectomy were a higher body mass index and a cervical anastomosis. Diabetes mellitus type 2 and chronic obstructive pulmonary disease were predictors for anastomotic leakage after a transhiatal esophagectomy. Median intensive care unit and hospital stay was longer for patients with anastomotic leakage than for patients without anastomotic leakage (both P < .001 for transthoracic esophagectomy, P = .010 and P < .001, respectively, for transhiatal esophagectomy). A higher percentage of patients with anastomotic leakage died within 30 days (3.8% vs 1.9%, P = .050). However, anastomotic leakage did not significantly influence long-term survival (hazard ratio, 0.994; 95% CI, 0.849-1.176; P = .994). Conclusions: Higher body mass index, cervical anastomosis, diabetes mellitus, and chronic obstructive pulmonary disease are predictors for anastomotic leakage after esophagectomy. Anastomotic leakage is associated with worse short-term outcomes, but long-term survival was not influenced. Future studies should focus on patient optimization, accurate patient selection, and development of tools in risk assessment

Ileal Pouch-anal Anastomosis Complications and Pouch Failure

Objective:. This systematic review aims to assess the incidence of pouch failure and the correlation between ileal pouch-anal anastomosis (IPAA)-related complications and pouch failure. Background:. Previous studies demonstrated wide variation in postoperative complication rates following IPAA. Methods:. A systematic review was performed by searching the MEDLINE, EMBASE, and Cochrane Library databases for studies reporting on pouch failure published from January 1, 2010, to May 6, 2020. A meta-analysis was performed using a random-effects model, and the relationship between pouch-related complications and pouch failure was assessed using Spearman’s correlations. Results:. Thirty studies comprising 22,978 patients were included. Included studies contained heterogenic patient populations, different procedural stages, varying definitions for IPAA-related complications, and different follow-up periods. The pooled pouch failure rate was 7.7% (95% confidence intervals: 5.56–10.59) and 10.3% (95% confidence intervals: 7.24–14.30) for studies with a median follow-up of ≥5 and ≥10 years, respectively. Observed IPAA-related complications were anastomotic leakage (1–17%), pelvic sepsis (2–18%), fistula (1–30%), stricture (1–34%), pouchitis (11–61%), and Crohn’s disease of the pouch (0–18%). Pelvic sepsis (r = 0.51, P < 0.05) and fistula (r = 0.63, P < 0.01) were correlated with pouch failure. A sensitivity analysis including studies with a median follow-up of ≥5 years indicated that only fistula was significantly correlated with pouch failure (r = 0.77, P < 0.01). Conclusions:. The single long-term determinant of pouch failure was pouch fistula, which is a manifestation of a chronic leak. Therefore, all effort should be taken to prevent an acute leak from becoming a chronic leak by early diagnosis and proactive management of the leak. Mini abstract:. This systematic review aims to assess the incidence of pouch failure and the correlation between IPAA-related complications and pouch failure. Long-term pouch failure was correlated with fistula, suggesting that early septic complications may result in fistula formation during long-term follow-up, leading to an increased risk of pouch failure