Functional Outcome After Restorative Proctocolectomy in Pigs: Comparing a Novel Transverse Ileal Pouch to the J-Pouch and Straight Ileoanal Anastomosis

Background  Restorative proctocolectomy followed by an ileoanal J-pouch procedure is the therapy of choice for patients with familial adenomatous polyposis and ulcerative colitis. After low anterior rectal resection, the authors have reported on a novel, less complex pouch configuration, a transverse coloplasty pouch. The aim of the present work was to apply this new design to the ileal pouch construction, to evaluate feasibility, and to measure functional results in comparison with the J-pouch and the straight ileoanal anastomosis using the pig as an animal model. Methods  Twenty-three pigs underwent restorative proctocolectomy followed by reconstruction with straight ileoanal anastomosis (IAA; n = 5), J-pouch (n = 7), and a transverse ileal pouch (TIP; n = 11). Pigs were followed for 6 days postoperatively. Peristaltic function was assessed by manometry proximal to the pouch, in the reservoir, and at the level of the ileoanal anastomosis. Functional outcome was monitored by semiquantitative assessment of the general condition of the animals, postoperative feeding habits, and stool frequency and consistency. A Fourier analysis was performed in order to compare peristalsis in the ileal reservoirs. The reservoir volume was measured in situ by triple contrast computed tomography scan with 3D reconstruction. Results  Seventeen animals survived for 1 week. There was no difference in the general condition or the feeding habits of the groups. A significant number of pigs with the TIP pouch (7/10) had semisolid or formed stools as opposed to liquid stools after J-pouch (6/6) and IAA (4/5; p = 0.01). TIP animals had a lower stool frequency (3.2 ± 1.14 per day) on day 6 after the operation than pigs with J-pouch, 5.33 ± 1,03, and IAA, 4.6 ± 1.82 (p = 0.0036). The in situ volume of the pouches did not differ significantly. The Fourier analysis demonstrated a disruption of peristalsis by the J-pouch and the TIP reconstruction but not after IAA. Conclusion  The function of ileoanal reservoirs after proctocolectomy may result from the disruption of properistaltic waves after pouch formation. The mechanism of peristalsis disruption is independent of the in situ volume of the pouch. This work was funded by Covidien Germany. F. H. Schmitz-Winnenthal and M. Kadmon contributed equally to this work.     

Should ileoanal pouch surgery be staged for patients with mucosal ulcerative colitis on immunosuppressives?

Introduction and objective Much debate has revolved around whether patients with mucosal ulcerative colitis (MUC) receiving immunosuppression should be weaned off immunosuppressives before undergoing ileal pouch surgery. Therefore, the aim of this study was to assess the affect of immunosuppressive drugs on postoperative complications after ileoanal pouch surgery. Materials and methods A retrospective medical record review of patients with MUC who underwent ileal pouch surgery while taking immunosuppressive drugs such as azathioprine, 6-mercaptopurine (6-MP), methotrexate, and cyclosporin A was performed. Postoperative complications in the study group were compared to three matched groups: patients with MUC who had ileoanal pouch surgery while taking systemic steroids, patients with MUC not receiving any immunosuppressive drugs, and patients with familial adenomatous polyposis. Results Twenty-two patients with MUC who underwent ileoanal pouch surgery while taking immunosuppressive drugs were identified from a prospectively entered database of patients who had this surgery between 1988 and 2005. All but two patients underwent temporary fecal diversion. Fifteen patients were taking 6-MP or azathioprine; six were on cyclosporine A, and one both on azathioprine and cyclosporine A. Fifteen patients were also taking steroids at the time of ileoanal pouch surgery. Early (within 30 days of surgery) and late complications occurred in 36 and 50% of the study group patients, respectively, but did not significantly differ from a matched group of patients with MUC who did not take immunosuppressive drugs. Patients with familial adenomatous polyposis had a significantly lower long-term complication rate. Conclusion This retrospective case-matched study suggests that the use of immunosuppressive drugs and cyclosporine A may not be associated with an increased rate of complications after ileoanal pouch surgery. This paper was presented at the annual meeting of the American Society of Colon and Rectal Surgeons, June 2–7, 2001, San Diego, CA and at the biennial meeting of the International Society of University Colon and Rectal Surgeons, April 10–14, 2002, Osaka, Japan.     

Clinical Features of Ileal Pouch Polyps in Patients with Underlying Ulcerative Colitis

Purpose Polypoid lesions rarely occur in the ileal pouch in ulcerative colitis patients after restorative proctocolectomy. Clinical features, malignant potential, and management of pouch polyps have not been characterized. Methods We identified 23 ulcerative colitis patients with large polyps (size≥1 cm) of the ileal pouch from our 2,512-case ulcerative colitis pouch database. Demographic, clinical, endoscopic, and histologic data were reviewed. The Pouchitis Disease Activity Index symptom score (range, 0–6) was used to quantify patients’ symptoms before and after polypectomy. Results Of the 23 patients, 95.7 percent (22 patients) had pouch endoscopy indicated for the evaluation of symptoms when polyps were detected, and 60.9 percent of patients had the polyps in the pouch, 26.1 percent in the anal transitional zone, and 21.7 percent in the afferent limb. The mean size of pouch polyps was 1.9 cm ± 1 cm. Twenty-one patients (91.3 percent) had concomitant pouchitis, cuffitis, or Crohn’s disease. On histology, 21 patients (91.3 percent) had inflammatory-type polyps, and 2 (8.7 percent) had dysplastic or malignant polyps. In 18 patients who had endoscopic polypectomy with concurrent medical therapy, the prepolypectomy and postpolypectomy mean symptom scores were 3.4 ± 1.7 and 1.1 ± 1.2 points, respectively (P = 0.015). Two patients (8.7 percent) had pouch excision for malignancy or for concomitant chronic refractory pouchitis. Conclusions The majority of patients with large ileal pouch polyps were symptomatic. These polyps were typically detected on the background of pouchitis, cuffitis, or Crohn’s disease. Although the majority of polyps were inflammatory type, polyps in two patients were dysplastic or malignant. Endoscopic polypectomy with concomitant medical therapy seemed to improve patients’ symptom scores. Supported in part by a NIH grant R03 DK 067275 and an American College of Gastroenterology Clinical Research Award (to B.S.). Poster presentation at meeting of the American College of Gastroenterology, Honolulu, Hawaii, October 30 to November 2, 2005. Reprints are not available.     

Laparoscopic-assisted proctocolectomy using complete intracorporeal dissection

Purpose Although many studies have demonstrated good results using laparoscopic proctocolectomy in patients with ulcerative colitis (UC), most surgical procedures require at least one additional incision larger than 5 cm to complete the surgery. The aim of this study was to evaluate the use of laparoscopic proctocolectomy with ileoanal J pouch, with a complete intracorporeal dissection using a 4–5 cm right lower quadrant (RLQ) incision. Methods Data were collected prospectively from all patients with UC that were subjected to a proctocolectomy with ileoanal J pouch between August 2003 and December 2006. The dissection was performed completely by laparoscopy using a medial–lateral approach for the colon and a total mesorectal excision for the rectum. Once the rectum was resected laparoscopically, a 4–5 cm incision in the RLQ was performed to resect the specimen and then an end or a loop ileostomy was implanted at the RLQ wound. The surgery was performed in two (proctocolectomy with ileoanal J pouch and loop ileostomy) or three steps (subtotal colectomy and end ileostomy with sigmoid fistula; proctectomy with ileoanal J pouch; and loop ileostomy). Results A total of 47 surgical procedures were performed in 32 patients with a mean age of 34.5 ± 15.7 years, of which 56% were male. The mean body mass index was 21 ± 16 kg/m²; 50% of patients underwent surgery in two steps and the other 50% in three steps. Surgery was converted in five (10.6%) cases due to megacolon in one case, narrow pelvis in two, and difficult rectal dissection in two; the overall morbidity rate was 14.9%. Two patients required reoperation and no mortality was registered. The mean operative time was 248 ± 62 min; proctocolectomy 292 ± 61 min, subtotal colectomy 203 ± 43 min, and proctectomy 248 ± 47 min. The mean hospital stay was 4.8 ± 1.9 days, and the mean interval time to close loop ileostomies was 64 ± 12 days. Conclusions A complete laparoscopic proctocolectomy dissection is feasible and safe for surgical treatment of UC.     

Three-Year Durability of Restorative Neurostimulation Effectiveness in Patients With Chronic Low Back Pain and Multifidus Muscle Dysfunction

BackgroundRestorative neurostimulation is a rehabilitative treatment for patients with refractory chronic low back pain (CLBP) associated with dysfunction of the lumbar multifidus muscle resulting in impaired neuromuscular control. The ReActiv8-B randomized, sham-controlled trial provided evidence of the effectiveness and safety of an implanted, restorative neurostimulator. The two-year analysis previously published in this journal demonstrated accrual of clinical benefits and long-term durability.ObjectiveEvaluation of three-year effectiveness and safety in patients with refractory, disabling CLBP secondary to multifidus muscle dysfunction and no indications for spine surgery.Materials and MethodsProspective, observational follow-up of the 204 implanted trial participants. Low back pain visual analog scale (VAS), Oswestry Disability Index (ODI), EuroQol quality of life survey, and opioid intake were assessed at baseline, six months, and one, two, and three years after activation. The mixed-effects model repeated measures approach was used to provide implicit imputations of missing data for continuous outcomes and multiple imputation for proportion estimates.ResultsData were collected from 133 participants, and 16 patients missed their three-year follow-up because of coronavirus disease restrictions but remain available for future follow-up. A total of 62% of participants had a ≥ 70% VAS reduction, and 67% reported CLBP resolution (VAS ≤ 2.5cm); 63% had a reduction in ODI of ≥ 20 points; 83% had improvements of ≥ 50% in VAS and/or ≥ 20 points in ODI, and 56% had these substantial improvements in both VAS and ODI. A total of 71% (36/51) participants on opioids at baseline had voluntarily discontinued (49%) or reduced (22%) opioid intake. The attenuation of effectiveness in the imputed (N = 204) analyses was relatively small and did not affect the statistical significance and clinical relevance of these results. The safety profile remains favorable, and no lead migrations have been observed to date.ConclusionAt three years, 83% of participants experienced clinically substantial improvements in pain, disability, or both. The results confirm the long-term effectiveness, durability, and safety of restorative neurostimulation in patients with disabling CLBP associated with multifidus muscle dysfunction.Clinical Trial RegistrationThe Clinicaltrials.gov registration number for the study is NCT02577354.     

Multi-faceted informatics system for digitising and streamlining the reablement care model

Reablement is new paradigm to increase independence in the home amongst the ageing population. And it remains a challenge to design an optimal electronic system to streamline and integrate reablement into current healthcare infrastructure. Furthermore, given reablement requires collaboration with a range of organisations (including national healthcare institutions and community/voluntary service providers), such a system needs to be co-created with all stakeholders involved. Thus, the purpose of this study is, (1) to bring together stakeholder groups to elicit a comprehensive set of requirements for a digital reablement system, (2) to utilise emerging technologies to implement a system and a data model based on the requirements gathered and (3) to involve user groups in a usability assessment of the system. In this study we employed a mixed qualitative approach that included a series of stakeholder-involved activities. Collectively, 73 subjects were recruited to participate in an ideation event, a quasi-hackathon and a usability study. The study unveiled stakeholder-led requirements, which resulted in a novel cloud-based system that was created using emerging web technologies. The system is driven by a unique data model and includes interactive features that are necessary for streamlining the reablement care model. In summary, this system allows community based interventions (or services) to be prescribed to occupants whilst also monitoring the occupant’s progress of independent living.     

Porosity of resin filling materials

Gjerdet, N.R. Hegdahl, T. Porosity of resin filling materials.

Four paste-paste types of resin filling materials and three capsulated products were tested with respect to porosity content and size distribution of the pores. The data were obtained by using an automatic image analyzer. The paste-paste products were inserted into the test cavities by a bulk-packing technique and an injection technique. The results showed that the use of a syringe reduced the porosity content, mainly by the elimination of big pores. The capsulated products were not less porous than the paste-paste materials.