The outlook after total colectomy in patients with Crohn's colitis and ulcerative colitis

The postoperative recurrence rates for Crohn's colitis (CC) and ulcerative colitis (UC) have varied markedly in different medical centers. We have reviewed the reasons for this variation and present our own series of patients in a manner which allows comparison with previous studies. In our study: 1) Patients with CC had an overall recurrence rate of 38% after total colectomy. By actuarial statistics, this recurrence rate computes to 48% by 12 years after operation. 2) Patients with ileal disease, even if totally removed at operation, had a recurrence rate of 48% whereas those with no obvious ileal involvement had a recurrence rate of 18%. 3) When nonspecific criteria are used for recurrence, which we call "complication," as has been the case in several previous studies of CC, even patients with UC had a complication rate of 33%. Such complications both in UC and CC represent postoperative occurrence rather than ileal recurrence of the inflammatory process. 4) Patients with CC develop more postoperative complications than patients with UC, but for most of the time they were asymptomatic. In this series there were no patients with disease originally or almost entirely limited to the colon who became "intestinal cripples" as a result of recurrent disease. 5) Patients with short preoperative intervals had the highest recurrence rate, whereas patients with disease of the terminal ileum had the highest postoperative complication rate. 6) Patients with "superficial" CC had a low recurrence rate, probably because of a shorter follow-up than the other patients. There were no true recurrences in patients with UC.     

Infliximab and complications after colectomy in patients with ulcerative colitis

BackgroundInfliximab treatment may increase the risk of subsequent postoperative complications in patients with ulcerative colitis. The main purpose of the present study therefore was to assess postoperative complications in patients who have undergone colectomy for ulcerative colitis with and without previous infliximab treatment.MethodsThrough a database search within a five-year period ulcerative colitis patients in a single highly specialized department, who had undergone colectomy, were identified. In total 71 ulcerative colitis patients were identified and analyzed according to pretreatment with infliximab or not. Twenty patients who had received infliximab within 12 weeks prior to colectomy were compared to 51 patients on standard treatment. Data on patient background, concomitant medication, endoscopic and the laboratory results, clinical activity, and complications within 30 days after colectomy were recorded.ResultsAt primary surgery, patient groups were similar with respect to distribution on gender, age, smoking behavior and concomitant medication. There were significant differences in partial Mayo-scores (7,95 (IFX) vs. 7,64, P = 0.032); preoperative CRP-levels (42,72 (IFX) vs. 63,2, P = 0.05); postoperative hospitalization time (10,9 (IFX) vs. 11,3 days, P = 0.039); and in number of patients who underwent elective surgery (10% vs. 37,3%, P = 0.015). There was no short-term mortality in either group and no significant difference in terms of postoperative complications between patients treated with IFX or not. However, the number of postoperative infectious complications was increased in corticosteroid-treated patients irrespective of IFX or not (45,8% in CS group vs. 13,0%, P = 0.028).ConclusionsThe use of infliximab does not seem to associate with an increased risk of short-term postoperative complications in ulcerative colitis.     

Cytomegalic colitis after total colectomy in ulcerative colitis

A 58-year-old man with ulcerative colitis underwent total colectomy and ileorectal anastomosis. Steroid suppositories were administered postoperatively, and he had had no exacerbation in the residual rectum for 12 years. He suddenly presented with frequent bloody stools and anal pain. An intensive intravenous regimen of prednisolone was ineffective. Cytomegalic inclusion bodies were identified in biopsy specimens. Administration of ganciclovir reduced the ulcers remarkably. The clinical course suggested that this deterioration was caused by cytomegalovirus infection from the beginning. Cytomegalovirus colitis should be recognized as an exacerbating factor, even in ulcerative colitis patients who have undergone surgery, especially when the residual bowel inflammation is resistant to steroid therapy.     

Surgery after colectomy for ulcerative colitis

The need for surgery after colectomy in patients with ulcerative colitis in Stockholm County over a 30-year period, 1955 to 1984, was investigated. During this time 483 patients were discharged from the hospital after colectomy. The mean period of observation from colectomy was 11.6 years. In 325 (67 percent) of the 483 patients there was need for further surgery (932 surgical procedures) during the period of observation. In 95 (20 percent) patients 115 small intestinal obstructions requiring surgery developed. The 2-year and 15-year cumulative probabilities of a first small intestinal obstruction were 11 percent (confidence intervals [CI] 8–14 percent) and 23 percent (CI 19–27 percent), respectively. In 42 (16 percent) of 255 patients treated by proctocolectomy and ileostomy there was need for 64 ileostomy revisions. The 2-year and 15-year cumulative probabilities of a first ileostomy revision were 9 percent (CI 6–12 percent) and 19 percent (CI 14–24 percent), respectively. Ninety-one Kock's pouches were constructed and a total of 125 revisions of Kock's pouch were performed. The 2-year and 15-year cumulative probabilities of a first Kock's pouch revision were 52 percent (CI 41–63 percent) and 57 percent (CI 46–68 percent), respectively. In 75 patients a pelvic pouch and ileoanal anastomosis was constructed. In 32 patients 73 surgical procedures due to pouch-related dysfunction were performed. Alterations in ileoanal pouch technique and increasing surgical experience has resulted in a markedly decreasing frequency of complications during the last years. There was no need for further surgery in 116 (45 percent) of the 255 patients treated by proctocolectomy and ileostomy, in 31 (34 percent) of the 91 patients with Kock's pouch, in 20 (39 percent) of the 51 patients with ileorectal anastomosis, and in 43 (57 percent) of the 75 patients with pelvic pouch and ileoanal anastomosis (closure of loop ileostomy excluded).Supported by grants from the Swedish Society of Medicine. Address reprint requests to Dr. Leijonmarck: Department of Surgery, St. Göran's Hospital, S-112 81 Stockholm, Sweden.     

溃疡性结肠炎患者肠道菌群变化与细胞因子、TLRs分子表达的相关性研究

目的探讨溃疡性结肠炎患者肠道菌群变化与细胞因子、TOLL样受体(Toll-like receptors,TLRs)分子表达的相关性。方法将2015年6月—2016年12月在山东省医学科学院第三附属医院确诊并接受治疗的溃疡性结肠炎患者78例作为试验组,同时选择未患溃疡性结肠炎的80例健康者作为对照组。分别对试验组和对照组进行肠道菌群检测,肠黏膜TLR2、TLR4、TLR5、TLR9分子表达检测和外周血IL-4、IL-6、IL-17、IL-23、TNF-α等炎性细胞因子表达检测,分析炎性细胞因子和TLRs表达与肠道菌群变化的关系。结果试验组双歧杆菌、乳杆菌含量明显低于对照组(P均0.05),拟杆菌、肠杆菌、肠球菌、梭杆菌含量明显高于对照组(P均0.05);试验组肠黏膜组织中TLR2、TLR4、TLR5、TLR9表达明显高于对照组(P均0.05);试验组外周血IL-4表达低于对照组,IL-6、IL-17、IL-23、TNF-α等炎性细胞因子表达高于对照组(P均0.05)。Pearson相关性分析显示,TLR2、TLR4、TLR5、TLR9表达与拟杆菌、肠杆菌、肠球菌含量呈正相关,与双歧杆菌、乳杆菌含量呈负相关;与IL-6、IL-17、IL-23、TNF-α表达呈正相关,与IL-4表达呈负相关。结论溃疡性结肠炎患者正常肠道菌群平衡被打破,促炎因子表达增加,抑炎因子表达减少,TLRs分子表达增加。肠道菌群紊乱可能通过增强TLRs分子表达来促进促炎因子的分泌,介导肠黏膜炎性反应。     

Carcinoma in the retained rectum after colectomy for ulcerative colitis

A carcinoma arising in an excluded rectal stump 18 years after ileostomy and 14 years after subtotal colectomy has been described. Extent of involvement of the colon, age of the patient at onset of colitis, and duration of symptomatology are factors which have been shown to influence the incidence of carcinoma complicating ulcerative colitis. Fifty-eight similar cases of carcinoma developing in a retained rectum were collected from the literature. The incidence of this complication is approximately 3 per cent. Rectum-sparing operations do not appear to decrease the indicence of malignant transformation in ulcerative colitis. A decision to retain the rectum after colonic resection for ulcerative colitis must take into account both the significant incidence of malignant transformation associated with all rectum-sparing procedures and also the significant incidence of recurrent symptoms following this procedure.     

Acute cholecystitis after colectomy for ulcerative colitis.

OBJECTIVE: Many different hepatobiliary diseases have been related with ulcerative colitis. In this retrospective study we tried to determine whether colectomy involves a greater risk of postoperative cholecystitis in these patients than in other patients who undergo colectomy. METHODS: From 1990 to 1998 a total of 53 subtotal or total colectomies were carried out in our hospital. 35.8% of the operations were done for ulcerative colitis (group I), 58% for cancer, 1.8% for aganglionic megacolon, and 3.6% for volvular disorders (group II). RESULTS: In group I, 21% of the patients required reoperation because of postoperative acute cholecystitis. In group II there were no cases of acute cholecystitis. Neither parenteral nutrition nor diabetes were influential factors. 94.5% of the patients in group I had emergency surgery, while emergency surgery was necessary in only 38.2% of the patients in group II. CONCLUSIONS: Acute cholecystitis after colectomy for ulcerative colitis, especially when the latter arises in an emergency situation, is a common complication. Although the sample was small, the results show that in view of the mortality from cholecystitis, prophylactic cholecystectomy may be necessary.     

Rectal lymphoma after colectomy for ulcerative colitis.

Primary colonic lymphoma is an increasingly recognised complication of ulcerative colitis. We report the first known case of rectal lymphoma occurring after colectomy and ileorectal anastomosis in ulcerative colitis.     

Risk of colectomy in patients with ulcerative colitis under thiopurine treatment

Background and AimsLittle is known about the risk factors of colectomy in patients with ulcerative colitis (UC) under thiopurine treatment. The aim of the study was to determine the prevalence and the predictive risk factors of colectomy in an extensive cohort of patients with UC treated with thiopurines in Spain.MethodsAmong 5753 UC patients, we identified those diagnosed between 1980 and 2009 and treated with azathioprine or mercaptopurine (AZA/MP). We analyzed the age at diagnosis, familial history of IBD, extraintestinal manifestations (EIMs), disease extent, smoking status and treatment requirements (AZA/MP, cyclosporine (CsA) or anti-TNFα). Colectomies for dysplasia or cancer were excluded. Survival analysis and Cox proportional hazard regression were performed. Results were reported as hazard ratios (HR) with 95% CI.ResultsAmong the 1334 cases included, 119 patients (8.9%) required colectomy after a median time of 26 months (IQR 12–42) after AZA/MP initiation. Independent predictors of colectomy were: Extensive UC (HR 1.7, 95% CI: 1.1–2.6), EIMs (HR 1.5, 95% CI: 1.0–2.4), need for antiTNFα (HR 2.3, 95% CI: 1.5–3.4) and need for CsA (HR 2.4, 95% CI: 1.6–3.7). Patients requiring early introduction of AZA/MP had an increased risk of colectomy with a HR of 4.9 (95% CI: 3.2–7.8) when AZA/MP started in the first 33 months after UC diagnosis.ConclusionsNearly one-tenth of patients with UC under thiopurines require colectomy. Extensive UC, EIMs, need for CsA or anti-TNFα ever and an early need for AZA/MP treatment were associated with a higher risk of colectomy. These risk factors of colectomy could help to stratify risk in further controlled studies in UC.     

Primary adenocarcinoma of the ileostomy after colectomy for ulcerative colitis

Summary A fifth case of adenocarcinoma arising at an ileostomy site many years after total colectomy for ulcerative colitis is reported with a review of the literature. The patient is a 79-year-old white man who presented with a bleeding, locally invasive exophytic mass at his ileostomy site 36 years after total colectomy for ulcerative colitis; he is the oldest patient, with the longest interval from creation of his ileostomy to diagnosis of adenocarcinoma. Careful gross and histopathologic examination of any mass arising at an ileostomy site is recommended. Early detection of such a slowly growing malignancy arising in a long-standing ileostomy may result in cure.     

The fate of the rectal stump after subtotal colectomy for ulcerative colitis

Objective To review the outcome of patients who had undergone subtotal colectomy for ulcerative colitis with formation of a rectal stump. To specifically look at the fate of the rectal stump, whether patients underwent emergency colectomy as opposed to urgent or elective resection. Patients and methods Between January 1990 and August 2000, a total of 31 patients underwent subtotal colectomy for ulcerative colitis. Patients were identified using the computerized coding system for the years 1995 to 2000, supplemented by pathology records, discharge letters, and operation notes. Postal and telephone surveys were undertaken using a standard questionnaire assessing social, physical, sexual, and bowel activities of patients. Results In 28 out of 31 patients, the follow-up was complete. Twenty-four of 28 patients (86%) underwent excision of rectal stump. Four patients (14%) preferred to undergo excision of rectum only, resulting in a permanent ileostomy; 20/28 (71%) had attempted ileal pouch–anal anastomosis, with success in 85%. In four patients (14%), the rectal stump remained in situ and was associated with a decrease in the quality of life. There were no perioperative deaths and morbidity was low for all procedures. Conclusion These data show that after subtotal colectomy, the majority of our ulcerative colitis patients undergo ileal pouch–anal anastomosis. Patients’ satisfaction is high with reasonable social and excellent sexual function on quality of life assessment. During its retention, the rectal stump causes considerable symptoms. When left in situ, it is associated with a decrease in the quality of life.     

The fate of the rectal stump after subtotal colectomy for ulcerative colitis

In a retrospective review of 311 patients having subtotal colectomy for ulcerative colitis, information on the fate of the rectal stump was obtained in 288. Proctectomy was performed in 159 patients (55 percent); for persistent proctitis in 118 (41 percent), cancer prophylaxis in 37 (13 percent), and cancer in four (1.4 percent). One hundred twenty-two patients (42 percent) had ileorectal anastomoses. Eighty-four of these (69 percent) retained a functioning ileorectal anastomosis at the time of follow-up or death, one to 22 years later, and an additional six patients (5 percent) had a satisfactory ileorectal anastomosis for five to 14 years before proctectomy. Cancer developed in the rectal stump in nine patients (3.1 percent), underscoring the need for either proctectomy (total or mucosal) or long-term surveillance of the retained rectum. However, subtotal colectomy, by permitting ileorectal anastomosis or other sphincter-preserving surgery at a later date, does have a definite place in many patients requiring surgery for ulcerative colitis. Read at the joint meeting of the American Society of Colon and Rectal Surgeons with the Section of Colo-Proctology, Royal Society of Medicine, and the Section of Colonic and Rectal Surgery, Royal Australasian College of Surgeons, New Orleans, Louisiana, May 6 to 11, 1984.     

Adenocarcinoma of the ileostomy occurring after colectomy for ulcerative colitis

Summary Apparently this is the first report of an adenocarcinoma of an ileal stoma. It occurred 19 years after partial colectomy performed for ulcerative colitis. The symptoms and radiographic findings were interpreted to indicate “ileitis.” The tumor continued to grow after limited excision, and the patient died ten months postoperatively. Ileoscopy will help in making a correct diagnosis. Radical excision of the abdominal wall and small bowel and reconstruction of the ileostomy in another quadrant of the abdominal wall is the appropriate treatment for this unusual condition.