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Second European evidence-based consensus on the diagnosis and management of ulcerative colitis Part 2: Current management

aDepartment of Pharmacology and Therapeutics, University of Porto; MedInUP, Centre for Drug Discovery and Innovative Medicines; Centro Hospitalar São João, Porto, Portugal bIBD Unit, DIMEC, University of Bologna, Bologna, Italy cDepartment of Gastroenterology and Hepatology, Chaim Sheba Medical Center, Tel Hashomer, Israel dGastrointestinal Unit ASST Fatebenefratelli Sacco—University of Milan—Milan, Italy eIBD Unit Complesso Integrato Columbus, Gastroenterological and Endocrino-Metabolical Sciences Department, Fondazione Policlinico Universitario Gemelli Universita’ Cattolica del Sacro Cuore, Rome, Italy fDepartment of Gastroenterology, IBD Unit, University Hospital Santiago De Compostela (CHUS), A Coruña, Spain gDepartment of Gastroenterology, North Zealand University Hospital, Frederikssund, Denmark hFirst Department of Medicine, Semmelweis University, Budapest, Hungary iIBD Unit, St Mark’s Hospital, Middlesex, UK jDepartment of Gastroenterology, University Hospital of Ghent, Ghent, Belgium kInstitute of Pathology, Medical University of Graz, Graz, Austria lDepartment of Gastroenterology, Pennine Acute Hospitals NHS Trust; Institute of Inflammation and Repair, University of Manchester, Manchester, UK mUnit of General Surgery, Second University of Naples, Napoli, Italy nMaria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, Department of Oncological Gastroenterology Warsaw; Medical Centre for Postgraduate Education, Department of Gastroenterology, Hepatology and Clinical Oncology, Warsaw, Poland oDepartment of Medicine, University of Cambridge, Cambridge, UK pImperial College London; Chelsea and Westminster Hospital, London, UK qDepartment of Pathobiology /NC22, Lerner Research Institute; Department of Gastroenterology, Hepatology and Nutrition/A3, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA

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Third European Evidence-based Consensus on Diagnosis and Management of Ulcerative Colitis. Part 1: Definitions, Diagnosis, Extra-intestinal Manifestations, Pregnancy, Cancer Surveillance, Surgery, and Ileo-anal Pouch Disorders.

Ulcerative colitis and Crohn’s disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn’s and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn’s disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn’s disease, including patients, their families and friends.

https://gut.bmj.com/content/gutjnl/68/Suppl_3/s1.full.pdf

British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults

,2,3Department of Medicine 1, Agaplesion Markus Hospital, Wilhelm-Epstein-Str. 4, D-60431 Frankfurt/Main, GermanyDivision of Gastroenterology, Department of Medicine, MtSinai Hospital and University Health Network;University of Toronto, 600 University Avenue, Toronto, ON, Canada M5G 1X5 and University of Leuven, BelgiumReceived 26 August 2012; accepted 3 September 2012KEYWORDS

Second European evidence-based Consensus on the diagnosis and management of ulcerative colitis: Current management

European Organization for Research and Treatment of Cancer

Background:Ileal pouch anal anastomosis (IPAA) is the treatment of choice for chronic, medically refractory mucosal ulcerative colitis, indeterminate colitis, familial adenomatous polyposis (FAP), and a select group of patients with Crohn's disease.Aim:We report outcomes, complications, and quality

Ileal pouch anal anastomosis: analysis of outcome and quality of life in 3707 patients.

Purpose Laparoscopy is the approach of choice for the majority of colorectal disorders that require a minimally invasive abdominal operation. As the emphasis on minimizing the technique continues, natural orifice surgery is quickly evolving. The authors utilized an embryologic natural orifice, the umbilicus, as sole access to the abdomen to perform a colorectal procedure. Herein, we present our initial experience of single-port laparoscopic colorectal surgery using a Uni-X™ Single-Port Access Laparoscopic System (Pnavel Systems, Morganville, New Jersey, USA) with a multi-channel cannula and specially designed curved laparoscopic instrumentation.



Method  The abdomen was approached through a 3.5 cm incision via the umbilicus and a single-port access device was utilized to perform a right hemicolectomy on a patient with an unresectable caecal polyp and a body mass index of 35. Ligation of the ileocolic artery was done with a LigaSure Device™ (Covidien Ltd, Norwalk, Connecticut, USA), and was followed by colonic mobilization, extraction and extracorporeal ileocolic anastomosis.



Results  The total operative time was 115 min with minimal blood loss. Hospital stay was 4 days with no undue sequelae.



Conclusion  Single-port laparoscopic surgery may allow common colorectal laparoscopic operations to be performed entirely through the patient’s umbilicus and enable an essentially scarless procedure. Additional experience and continued investigation are warranted.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1463-1318.2008.01660.x

Single-port laparoscopy in colorectal surgery

Comparison of outcomes after hand-sewn versus stapled ileal pouch-anal anastomosis in 3,109 patients

Background:

The Turnbull–Cutait abdominoperineal pull-through procedure (T-C) is used as a last resort to avoid permanent diversion in patients with complex anorectal conditions. The aim was to evaluate short- and long-term outcomes after T-C.



Methods:

Patients undergoing T-C from 1996 to 2007 were reviewed retrospectively in terms of demographics, diagnosis, indications and postoperative complications. Patients were contacted to obtain functional outcomes using a standardized questionnaire. Functional outcomes were compared with those in a matched group of patients undergoing handsewn coloanal anastomosis (CAA) for rectal cancer.



Results:

Sixty-seven patients (40 men) underwent T-C. Postoperative complications included stricture in 11 patients (16 per cent), fistula in five (7 per cent), prolapse of the colon in five (7 per cent) and leak in two (3 per cent). Mean follow-up was 5·6 (s.d. 3·2) years. The operation failed in 17 patients (25 per cent). Among 44 patients (66 per cent) who completed questionnaires, faecal (P = 0·121) and urinary (P = 0·073) incontinence, and sexual function (P = 0·063) were comparable to those in patients who had CAA.



Conclusion:

T-C is an option for patients with complex anorectal conditions that might otherwise require permanent diversion. Functional outcomes are comparable to those of CAA. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Outcomes following Turnbull–Cutait abdominoperineal pull‐through compared with coloanal anastomosis

Single-port laparoscopic surgery can be performed via one incision hidden in the umbilicus. Herein, we report a patient with a sigmoid colon cancer undergoing single-port laparoscopic sigmoid colectomy. Laparoscopic single-port sigmoid colectomy through a 3-cm umbilical incision was performed on a patient with a diagnosis of sigmoid cancer. Patient was 54-year-old female with a body mass index of 25.8 kg/m2. Preoperatively, a CAT scan in the metastasis evaluation did not show any lesion. The total operative time was 198 min. Estimated blood loss was 300 ml. Length of hospital stay was 3 days. Patient had no intraoperative or postoperative complications. Examination of pathological specimen showed a specimen containing a circumferential lesion measuring 5 cm × 2.5 cm × 2.5 cm with adequate surgical margins (10 and 5.5 cm), and no regional lymph node metastases in 14 lymph nodes collected. Patient did not receive adjuvant chemotherapy after surgery. Colonoscopy performed 1 year after surgery showed no neoplasm or polyp identified. Abdomen and pelvis CT also found no evidence of recurrence or metastatic disease. Single-port laparoscopic surgery may allow common benign procedures via an incision in the umbilicus. It can also be performed with good surgical and oncologic results in selected patients with a colorectal cancer.

Hasan T. Kirat

Papers

Ileal pouch anal anastomosis: analysis of outcome and quality of life in 3707 patients.

Single-port laparoscopy in colorectal surgery

Comparison of outcomes after hand-sewn versus stapled ileal pouch-anal anastomosis in 3,109 patients

Outcomes following Turnbull–Cutait abdominoperineal pull‐through compared with coloanal anastomosis

Laparoscopic single-port colectomy for sigmoid cancer.