Rifaximin for maintenance therapy in antibiotic-dependent pouchitis

<p>Abstract</p> <p>Background</p> <p>Pouchitis is the most common long-term complication of in patients with restorative proctocolectomy and ileal pouch-anal anastomosis. Patients often develop antibiotic-dependent form of pouchitis requiring long-term antibiotic therapy for remission maintenance. Rifaximin, an oral, non-systemic, broad-spectrum antibiotic with a favorable safety profile, may be a promising candidate agent for maintenance therapy. This historical cohort open-label study investigated the efficacy and tolerability of rifaximin in maintaining symptomatic and endoscopic remission in patients with antibiotic-dependent pouchitis.</p> <p>Methods</p> <p>Adult patients with antibiotic-dependent pouchitis received a 2-week course of various antibiotics for induction of remission. Patients in remission then began maintenance therapy with rifaximin 200 mg/day (to 1800 mg/day) for up to 24 months. Pouchitis Disease Activity Index symptom scores were assessed every 1–3 months to evaluate efficacy.</p> <p>Results</p> <p>Fifty-one patients began maintenance therapy with rifaximin (median dose 200 mg/day); 33 (65%) maintained remission through 3 months (primary endpoint). Of these 33 patients, 26 (79%) successfully continued maintenance for 6 months after beginning maintenance, 19 (58%) successfully continued for 12 months, and two (6%) successfully continued for 24 months. Only one patient reported an adverse event (transient facial rash).</p> <p>Conclusion</p> <p>Patients' response to rifaximin as a maintenance therapy appears to be favorable in this open-labeled trial of antibiotic-dependent pouchitis. Randomized, placebo-controlled trials with a longer follow-up are warranted.</p

Laparoscopic surgery for complex and recurrent Crohn's disease

Crohn's disease (CD) is a chronic inflammatory disease of digestive tract. Approximately 70\% of patients with CD require surgical intervention within 10 years of their initial diagnosis, despite advanced medical treatment alternatives including biologics, immune suppressive drugs and steroids. Refractory to medical treatment in CD patients is the common indication for surgery. Unfortunately, surgery cannot cure the disease. Minimally invasive treatment modalities can be suitable for CD patients due to the benign nature of the disease especially at the time of index surgery. However, laparoscopic management in fistulizing or recurrent disease is controversial. Intractable fibrotic strictures with obstruction, fistulas with abscess formation and hemorrhage are the surgical indications of recurrent CD, which are also complicating laparoscopic treatments. Nevertheless, laparoscopy can be performed in selected CD patients with safety, and may provide better outcomes compared to open surgery. The common complication after laparoscopic intervention is postoperative ileus seems and this may strongly relate excessive manipulation of the bowel during dissection. But additionally, unsuccessful laparoscopic attempts requiring conversion to open surgery have been a major concern due to presumed risk of worse outcomes. However, recent data show that conversions do not to worsen the outcomes of colorectal surgery in experienced hands. In conclusion, laparoscopic treatment modalities in recurrent CD patients have promising outcomes when it is used selectively.4APR 16149-152

Fatores de risco para prolongamento do tempo de permanência após cirurgia colorretal

OBJETIVO: Os cirurgiões proctologistas muitas vezes enfrentam dificuldades para explicar aos administradores/contribuintes as razões para o prolongamento do tempo de internação hospitalar (TIH). O objetivo deste estudo foi identificar os fatores associados ao aumento do TIH após cirurgia colorretal. MÉTODO: A população do estudo incluiu pacientes que constam do banco de dados do American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) no ano de 2007 e que foram submetidos à ressecção ileocólica, colectomia segmentar ou ressecção anterior. A população do estudo foi dividida em normal (abaixo do percentil 75) e TIH prolongado (acima do percentil 75). A análise multivariada foi realizada usando o TIH prolongado como variável dependente e as variáveis do ACS-NSQIP como preditivas. Um valor de p < 0,01 foi considerado significativo. RESULTADOS: No total, 12.269 pacientes com um TIH mediano de 6 dias (intervalo interquartil, 4-9) foram incluídos. Havia 2.617 pacientes (21,3%) com TIH prolongado (mediana, 15 dias; intervalo interquartil, 13-22). A idade média dos pacientes era de 69 anos (intervalo interquartil, 57-79) e 1.308 (50%) eram do sexo feminino. Os fatores de risco para TIH prolongado foram sexo masculino, insuficiência cardíaca congestiva, perda de peso, doença de Crohn, albumina < 3,5 g/dL e hematócrito < 47% no pré-operatório, sepse basal, classe ASA ≥ 3, cirurgia aberta, tempo cirúrgico ≥ 190 minutos, pneumonia no pós-operatório, falha no desmame da ventilação mecânica, trombose venosa profunda, infecção do trato urinário, sepse sistêmica, infecção do sítio cirúrgico e reoperação dentro de 30 dias da cirurgia primária. CONCLUSÃO: Vários fatores estão associados ao aumento do TIH após a cirurgia colorretal. Nossos resultados são úteis para que os cirurgiões possam explicar os TIH prolongados aos administradores/contribuintes que são críticos dessa métrica.OBJECTIVE: Colorectal surgeons often struggle to explain to administrators/payers reasons for prolonged length of stay (LOS). This study aim was to identify factors associated with increased LOS after colorectal surgery. DESIGN: The study population included patients from the 2007 American-College-of-Surgeons-National-Surgical-Quality-Improvement-Program (ACS-NSQIP) database undergoing ileocolic resection, segmental colectomy, or anterior resection. The study population was divided into normal (below 75th percentile) and prolonged LOS (above the 75th percentile). A multivariate analysis was performed using prolonged LOS as dependent variable and ACS-NSQIP variables as predictive variables. P-value < 0.01 was considered significant. RESULTS: 12,269 patients with a median LOS of 6 (inter-quartile range 4-9) days were included. There were 2,617 (21.3%) patients with prolonged LOS (median 15 days, inter-quartile range 13-22). 1,308 (50%) were female, and the median age was 69 (inter-quartile range 57-79) years. Risk factors for prolonged LOS were male gender, congestive heart failure, weight loss, Crohn's disease, preoperative albumin < 3.5 g/dL and hematocrit < 47%, baseline sepsis, ASA class ≥ 3, open surgery, surgical time ≥ 190 min, postoperative pneumonia, failure to wean from mechanical ventilation, deep venous thrombosis, urinary-tract infection, systemic sepsis, surgical site infection and reoperation within 30-days from the primary surgery. CONCLUSION: Multiple factors are associated with increased LOS after colorectal surgery. Our results are useful for surgeons to explain prolonged LOS to administrators/payers who are critical of this metric

Chronic Consptipation and Diet

Constipation presented a lof of sign-symptoms is not a single disease and a disorder that affect colonic and anorectal function. Constipation is defined as decreased of defecation number by physicians and all of problems relation with defecation by patients. But a accurate and correct defitinition giving base on patophyslogically by Rome III criteria. As patophyslogically, constipation is improved by decreased material that will be reached cecum, decreased motility of colon and multiple results improving defecation disorders. Constipation can be divided irratable bowel syndrome with constipation (normal transit), slow transit constipation and defecation disorders but there is no accurate border in this classification. Neurotransmitters, stress, medical therapies, sleep and meals are association with etiology of constipation. A high fiber diet can reach easily to cecum and prevent constipation. Therefore aim of this review is to stress effect of fiber diet in the first and second type of constipation. Slow transit constipation in 13-15% patients and irratable bowel sendrom with constipation (normal transit) in 59% patients has being diagnosed. Seconder causes of constipation can be found with a good history taking from patients. Accurate diagnosis can be find with colon transit time followed by abdominal and pelvic examinitian. Treatment should be begin after correction of seconder causes. It should be recommendation to patients a high fiber diet, exercise, appropriate fluid with medical therapy. Lubiprostone and Tegaserod are used to begin for treatment of slow transit constipation. Laparoscopic surgery is recommened to patients not recoveried by medical therapy. [TAF Prev Med Bull 2011; 10(1.000): 71-76

Complications of Ileoanal Pouches

Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical therapy of choice for patients with chronic ulcerative colitis and the majority of patients with familial adenomatous polyposis. It restores gastrointestinal continuity, re-establishes transanal defecation, and avoids a permanent stoma. Although this technically demanding procedure is associated with low mortality rates, it is frequently accompanied by early and late complications. This article will review these complications and discuss the interventions that are needed to provide appropriate treatment

Technical Aspects of Ileoanal Pouch Surgery in Patients with Ulcerative Colitis

Restorative proctocolectomy with ileal pouch-anal anastomosis is the procedure of choice for patients with ulcerative colitis requiring surgery. A J-pouch with a stapled anastomosis has been the preferred technique because it is quicker, safer, and associated with good functional outcomes. A diverting loop ileostomy is usually created at the time of ileal pouch-anal anastomosis. In patients with severe fulminant colitis or toxic megacolon, restorative proctocolectomy with ileal pouch-anal anastomosis is performed in multistages. The technical aspects of ileal pouch-anal anastomosis in patients with ulcerative colitis are reviewed in this article