Sigmoid diverticulitis is a common disease which carries both a significant morbidity and a societal economic burden.This review article analyzes the current data regarding management of sigmoid diverticulitis in its ...Sigmoid diverticulitis is a common disease which carries both a significant morbidity and a societal economic burden.This review article analyzes the current data regarding management of sigmoid diverticulitis in its variable clinical presentations.Wide-spectrum antibiotics are the standard of care for uncomplicated diverticulitis.Recently published data indicate that sigmoid diverticulitis does not mandate surgical management after the second episode of uncomplicated disease as previously recommended.Rather,a more individualized approach,taking into account frequency,severity of the attacks and their impact on quality of life,should guide the indication for surgery.On the other hand,complicated diverticular disease still requires surgical treatment in patients with acceptable comorbidity risk and remains a life-threatening condition in the case of free peritoneal perforation.Laparoscopic surgery is increasingly accepted as the surgical approach of choice for most presentations of the disease and has also been proposed in the treatment of generalized peritonitis.There is not sufficient evidence supporting any changes in the approach to management in younger patients.Conversely,the available evidence suggests that surgery should be indicated after one attack of uncomplicated disease in immunocompromised individuals.Uncommon clinical presentations of sigmoid diverticulitis and their possible association with inflammatory bowel disease are also discussed.展开更多
AIM: To report our experience on management of colorectal neoplasia during pregnancy and in the postpartum period.METHODS: Patients who were diagnosed with colorectal cancer during pregnancy or in the postpartum perio...AIM: To report our experience on management of colorectal neoplasia during pregnancy and in the postpartum period.METHODS: Patients who were diagnosed with colorectal cancer during pregnancy or in the postpartum period(< 6 mo), between 8/1997 and 4/2013, in our department were reviewed. Patient characteristics, operations, fetal health and follow-up during pregnancy, type of delivery and oncologic outcomes were analyzed.RESULTS: Eight patients met our study criteria. Median age at the time of diagnosis of colorectal cancer was 31 years. Median follow-up after surgery was 36 mo. Median duration of symptoms before diagnosis was 16 wk. Three patients were diagnosed with colorectal cancer during pregnancy and underwent surgery prior to delivery. None of the patients received adjuvant treatment during pregnancy. Five patients were diagnosed with colorectal cancer within a median of 2.1 mo after delivery and underwent surgery. No adverse neonatal outcomes were noted. All deliveries were at term(2 cesarean sections) except for one preterm delivery following low anterior resection on the 34 th week of pregnancy.CONCLUSION: There has been a significant delay in the diagnosis of colorectal cancer which is probably due to overlap of symptoms and signs between these tumors and a normal pregnancy. Surgery for colorectal cancer during pregnancy can be performed safely without compromisingmaternal and fetal outcomes.展开更多
Background:We have previously demonstrated that blood transfusion(BT)was associated with post-operative complications in patients undergoing surgery for Crohn’s disease(CD),based on our institutional data registry.Th...Background:We have previously demonstrated that blood transfusion(BT)was associated with post-operative complications in patients undergoing surgery for Crohn’s disease(CD),based on our institutional data registry.The aim of this study was to verify the association between perioperative BT and infectious complications in CD patients enrolled in the American College of Surgeons National Surgical Quality Improvement Program(ACS NSQIP)database.Methods:All CD patients undergoing surgery between 2005 and 2013 were identified from NSQIP.Variables were defined according to the ACS NSQIP guidelines.The primary outcome was infectious complications,including superficial,deep and organ/space surgical site infection,wound dehiscence,urinary tract infection,pneumonia,systemic sepsis and septic shock.Multivariate analyses were performed to assess the risk factors for post-operative infections.Results:All 10100 eligible patients were included and 611(6.0%)received perioperative BT.BT patients were older,lighter in weight and more likely to be functionally dependent.BT patients were more likely to have post-operative infectious complications than those without BT,including superficial surgical site infection(SSI)(10.8%vs 7.4%,p¼0.002),deep SSI(3.3%vs 1.6%,p¼0.003),organ/space SSI(14.2%vs 5.4%,p<0.001),pneumonia(3.8%vs 1.3%,p<0.001),urinary tract infection(3.9%vs 2.2%,p¼0.006),sepsis(11.5%vs 4.5%,p<0.001)and sepsis shock(3.1%vs 0.8%,p<0.001).Multivariate analysis showed that intra-and/or post-operative BT was an independent risk factor for post-operative infectious complications(odds ratio[OR]¼2.2;95%confidence interval[CI]:1.8–2.7;p<0.001)and the risk increased with each administered unit of red blood cell(OR¼1.3,95%CI:1.2–1.5).Other independent factors were history of smoking,chronic heart disease,diabetes,hypertension and the use of corticosteroids.Pre-operative BT,however,was not found to be a risk factor to post-operative infections.Conclusions:Intra-and/or post-operative,not pre-operative,BT was found to be associated with an increased risk for postoperative infectious complications in this CD cohort.Therefore,the timing and risks and benefits of BT should be carefully balanced.展开更多
Background:There are no published studies on the impact of visceral adipose tissue(VAT)change on outcomes of restorative proctocolectomy and ileal pouch-anal anastomosis(IPAA).The aim of this historic cohort study was...Background:There are no published studies on the impact of visceral adipose tissue(VAT)change on outcomes of restorative proctocolectomy and ileal pouch-anal anastomosis(IPAA).The aim of this historic cohort study was to evaluate the impact of excessive VAT gain on the outcomes of inflammatory bowel disease(IBD)patients with IPAA.Methods:We evaluated all eligible patients with at least two sequential CT scans after pouch construction from our prospectively maintained Pouchitis Registry between 2002 and 2014.The visceral fat area(VFA)was measured on CT images.The study group comprised patients with a significant VAT gain(>15%),and the control group was those without.The adverse outcomes of the pouch were defined as the new development of chronic pouch inflammation(chronic pouchitis,chronic cuffitis or Crohn’s disease of the pouch),anastomotic sinus and the combination of above(the composite adverse outcome)or pouch failure,after the inception CT.Results:Of 1564 patients in the Registry,59(3.8%)with at least 2 CT scans after pouch surgery were included.Twenty-nine patients(49.2%)were in the study group,and 30(50.8%)were in the control group.The median duration from the inception to the latest CT was 552(range:31–2598)days for the entire cohort.We compared the frequency of new chronic pouch inflammation(13.8%vs 3.3%,P=0.195),new pouch sinus(10.3%vs 0%,P=0.112),composite adverse pouch outcome(24.1%vs 3.3%,P=0.026)or pouch failure(10.3%vs 6.7%,P=0.671)between the two groups.Kaplan-Meier plot for time-to-pouch failure between the pouch patients with or without excessive body mass index(BMI)gain(>10%)showed statistical difference(P=0.011).Limited stepwise multivariate analysis showed that excessive VAT gain(odds ratio=12.608,95%confidence interval:1.190–133.538,P=0.035)was an independent risk factor for the adverse pouch comes.Conclusions:In this cohort of ileal pouch patients,excessive VAT gain as well as gain in BMI after pouch construction was found to be associated with poor long-term outcomes.展开更多
Background and Aim:Inflammatory bowel disease(IBD)is associated with an increased risk of colorectal cancer(CRC).Studies have shown tumorigenetic and histomorphological differences between IBD-associated CRC and non-I...Background and Aim:Inflammatory bowel disease(IBD)is associated with an increased risk of colorectal cancer(CRC).Studies have shown tumorigenetic and histomorphological differences between IBD-associated CRC and non-IBD CRC,suggesting differences in tumor behavior and response to treatment.We aimed to compare tumor recurrence and survival rates following postoperative chemotherapy in CRC patients with and without IBD.Methods:Search of the Cleveland Clinic’s CRC database revealed 65 patients who had IBD-associated CRC and received postoperative adjuvant chemotherapy between 1994 and 2010.Twenty-one patients were excluded due to incomplete clinical data.Propensity score-matching based on age,surgery intent,CRC site,tumor grade,American Joint Committee on Cancer(AJCC)stage and T stage was used to match IBD and non-IBD patients(1:4).Competing risk and Cox regression models were used to analyze differences in disease-free survival and overall survival,respectively.Results:Forty-four patients with IBD-associated CRC were matched to 176 patients with non-IBD CRC.Among IBD patients,29(66%)had ulcerative colitis,14(32%)had Crohn’s disease,and one(2%)had indeterminate colitis.Mean IBD diagnosis age was 28.1±14.5 years,and mean IBD duration at time of CRC treatment was 21.5±12.6 years.Ten(23%)IBD patients had tumor recurrence compared with 34(19%)non-IBD patients(P=.074).There was no significant difference in disease-free survival(hazard ratio[HR]=0.60;95%CI:0.35–1.05;P=0.074)or overall survival(HR=0.87;95%CI:0.54–1.4;P=0.58)between IBD and non-IBD patients.Conclusion:Patients with IBD-associated CRC have comparable rates of tumor recurrence and survival following postoperative chemotherapy as CRC patients without IBD.Prospective studies are needed to confirm these findings and guide therapeutic decisions.展开更多
文摘Sigmoid diverticulitis is a common disease which carries both a significant morbidity and a societal economic burden.This review article analyzes the current data regarding management of sigmoid diverticulitis in its variable clinical presentations.Wide-spectrum antibiotics are the standard of care for uncomplicated diverticulitis.Recently published data indicate that sigmoid diverticulitis does not mandate surgical management after the second episode of uncomplicated disease as previously recommended.Rather,a more individualized approach,taking into account frequency,severity of the attacks and their impact on quality of life,should guide the indication for surgery.On the other hand,complicated diverticular disease still requires surgical treatment in patients with acceptable comorbidity risk and remains a life-threatening condition in the case of free peritoneal perforation.Laparoscopic surgery is increasingly accepted as the surgical approach of choice for most presentations of the disease and has also been proposed in the treatment of generalized peritonitis.There is not sufficient evidence supporting any changes in the approach to management in younger patients.Conversely,the available evidence suggests that surgery should be indicated after one attack of uncomplicated disease in immunocompromised individuals.Uncommon clinical presentations of sigmoid diverticulitis and their possible association with inflammatory bowel disease are also discussed.
文摘AIM: To report our experience on management of colorectal neoplasia during pregnancy and in the postpartum period.METHODS: Patients who were diagnosed with colorectal cancer during pregnancy or in the postpartum period(< 6 mo), between 8/1997 and 4/2013, in our department were reviewed. Patient characteristics, operations, fetal health and follow-up during pregnancy, type of delivery and oncologic outcomes were analyzed.RESULTS: Eight patients met our study criteria. Median age at the time of diagnosis of colorectal cancer was 31 years. Median follow-up after surgery was 36 mo. Median duration of symptoms before diagnosis was 16 wk. Three patients were diagnosed with colorectal cancer during pregnancy and underwent surgery prior to delivery. None of the patients received adjuvant treatment during pregnancy. Five patients were diagnosed with colorectal cancer within a median of 2.1 mo after delivery and underwent surgery. No adverse neonatal outcomes were noted. All deliveries were at term(2 cesarean sections) except for one preterm delivery following low anterior resection on the 34 th week of pregnancy.CONCLUSION: There has been a significant delay in the diagnosis of colorectal cancer which is probably due to overlap of symptoms and signs between these tumors and a normal pregnancy. Surgery for colorectal cancer during pregnancy can be performed safely without compromisingmaternal and fetal outcomes.
文摘Background:We have previously demonstrated that blood transfusion(BT)was associated with post-operative complications in patients undergoing surgery for Crohn’s disease(CD),based on our institutional data registry.The aim of this study was to verify the association between perioperative BT and infectious complications in CD patients enrolled in the American College of Surgeons National Surgical Quality Improvement Program(ACS NSQIP)database.Methods:All CD patients undergoing surgery between 2005 and 2013 were identified from NSQIP.Variables were defined according to the ACS NSQIP guidelines.The primary outcome was infectious complications,including superficial,deep and organ/space surgical site infection,wound dehiscence,urinary tract infection,pneumonia,systemic sepsis and septic shock.Multivariate analyses were performed to assess the risk factors for post-operative infections.Results:All 10100 eligible patients were included and 611(6.0%)received perioperative BT.BT patients were older,lighter in weight and more likely to be functionally dependent.BT patients were more likely to have post-operative infectious complications than those without BT,including superficial surgical site infection(SSI)(10.8%vs 7.4%,p¼0.002),deep SSI(3.3%vs 1.6%,p¼0.003),organ/space SSI(14.2%vs 5.4%,p<0.001),pneumonia(3.8%vs 1.3%,p<0.001),urinary tract infection(3.9%vs 2.2%,p¼0.006),sepsis(11.5%vs 4.5%,p<0.001)and sepsis shock(3.1%vs 0.8%,p<0.001).Multivariate analysis showed that intra-and/or post-operative BT was an independent risk factor for post-operative infectious complications(odds ratio[OR]¼2.2;95%confidence interval[CI]:1.8–2.7;p<0.001)and the risk increased with each administered unit of red blood cell(OR¼1.3,95%CI:1.2–1.5).Other independent factors were history of smoking,chronic heart disease,diabetes,hypertension and the use of corticosteroids.Pre-operative BT,however,was not found to be a risk factor to post-operative infections.Conclusions:Intra-and/or post-operative,not pre-operative,BT was found to be associated with an increased risk for postoperative infectious complications in this CD cohort.Therefore,the timing and risks and benefits of BT should be carefully balanced.
文摘Background:There are no published studies on the impact of visceral adipose tissue(VAT)change on outcomes of restorative proctocolectomy and ileal pouch-anal anastomosis(IPAA).The aim of this historic cohort study was to evaluate the impact of excessive VAT gain on the outcomes of inflammatory bowel disease(IBD)patients with IPAA.Methods:We evaluated all eligible patients with at least two sequential CT scans after pouch construction from our prospectively maintained Pouchitis Registry between 2002 and 2014.The visceral fat area(VFA)was measured on CT images.The study group comprised patients with a significant VAT gain(>15%),and the control group was those without.The adverse outcomes of the pouch were defined as the new development of chronic pouch inflammation(chronic pouchitis,chronic cuffitis or Crohn’s disease of the pouch),anastomotic sinus and the combination of above(the composite adverse outcome)or pouch failure,after the inception CT.Results:Of 1564 patients in the Registry,59(3.8%)with at least 2 CT scans after pouch surgery were included.Twenty-nine patients(49.2%)were in the study group,and 30(50.8%)were in the control group.The median duration from the inception to the latest CT was 552(range:31–2598)days for the entire cohort.We compared the frequency of new chronic pouch inflammation(13.8%vs 3.3%,P=0.195),new pouch sinus(10.3%vs 0%,P=0.112),composite adverse pouch outcome(24.1%vs 3.3%,P=0.026)or pouch failure(10.3%vs 6.7%,P=0.671)between the two groups.Kaplan-Meier plot for time-to-pouch failure between the pouch patients with or without excessive body mass index(BMI)gain(>10%)showed statistical difference(P=0.011).Limited stepwise multivariate analysis showed that excessive VAT gain(odds ratio=12.608,95%confidence interval:1.190–133.538,P=0.035)was an independent risk factor for the adverse pouch comes.Conclusions:In this cohort of ileal pouch patients,excessive VAT gain as well as gain in BMI after pouch construction was found to be associated with poor long-term outcomes.
文摘Background and Aim:Inflammatory bowel disease(IBD)is associated with an increased risk of colorectal cancer(CRC).Studies have shown tumorigenetic and histomorphological differences between IBD-associated CRC and non-IBD CRC,suggesting differences in tumor behavior and response to treatment.We aimed to compare tumor recurrence and survival rates following postoperative chemotherapy in CRC patients with and without IBD.Methods:Search of the Cleveland Clinic’s CRC database revealed 65 patients who had IBD-associated CRC and received postoperative adjuvant chemotherapy between 1994 and 2010.Twenty-one patients were excluded due to incomplete clinical data.Propensity score-matching based on age,surgery intent,CRC site,tumor grade,American Joint Committee on Cancer(AJCC)stage and T stage was used to match IBD and non-IBD patients(1:4).Competing risk and Cox regression models were used to analyze differences in disease-free survival and overall survival,respectively.Results:Forty-four patients with IBD-associated CRC were matched to 176 patients with non-IBD CRC.Among IBD patients,29(66%)had ulcerative colitis,14(32%)had Crohn’s disease,and one(2%)had indeterminate colitis.Mean IBD diagnosis age was 28.1±14.5 years,and mean IBD duration at time of CRC treatment was 21.5±12.6 years.Ten(23%)IBD patients had tumor recurrence compared with 34(19%)non-IBD patients(P=.074).There was no significant difference in disease-free survival(hazard ratio[HR]=0.60;95%CI:0.35–1.05;P=0.074)or overall survival(HR=0.87;95%CI:0.54–1.4;P=0.58)between IBD and non-IBD patients.Conclusion:Patients with IBD-associated CRC have comparable rates of tumor recurrence and survival following postoperative chemotherapy as CRC patients without IBD.Prospective studies are needed to confirm these findings and guide therapeutic decisions.
