Browsing by Author "Warusavitarne, J."

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The benefit of tumor molecular profiling on predicting treatments for colorectal adenocarcinomas
(Impact Journals, 2018) Carter, P.; Alifrangis, C.; Chandrasinghe, P.; Cereser, B.; Del Bel Belluz, L.; Leo, C.A.; Moderau, N.; Tabassum, N.; Warusavitarne, J.; Krell, J.; Stebbing, J.
Correction: The benefit of tumor molecular profiling on predicting treatments for colorectal adenocarcinomas
(Impact Journals LLC, 2018) Carter, P.; Alifrangis, C.; Chandrasinghe, P.; Cereser, B.; Del Bel Belluz, L.; Leo, C.A.; Moderau, N.; Tabassum, N.; Warusavitarne, J.; Krell, J.; Stebbing, J.
This corrects the article DOI: 10.18632/oncotarget.24257. Erratum for The benefit of tumor molecular profiling on predicting treatments for colorectal adenocarcinomas [Oncotarget. 2018 ;9(13):11371-11376]
Development of a model of 3D imaging for the pre-operative planning of TaTME
(Oxford University Press, 2018) Sahnan, K.; Pellino, G.; Adegbola, S.O.; Tozer, P.J.; Chandrasinghe, P.; Misovik, D.; Hompes, R.; Hart, A.L.; Warusavitarne, J.; Lung, R.F.
BACKGROUND:Transanal TME (TaTME) is a new addition to the approaches in rectal surgery. TaTME requires advanced technical skills and, more importantly, knowledge of the pelvic structures, planes, and spaces as they are encountered moving cephalad from the perineum. We have developed a technique for producing 3D reconstructions of the anorectum and associated anatomy, to aid peri-operative planning and understanding of the anatomy crucial to TaTME surgery. METHODS: A patient was scheduled for single incision laparoscopy surgery (SILS) TaTME completion proctectomy and ileoanal pouch formation for ulcerative colitis. Standard axial T2-weighted Spectral Attenuated Inversion Recovery (SPAIR) and sagittal T2-weighted MRI sequences were obtained and digital imaging and communications in medicine (DICOM) images were imported into a validated open-source segmentation software.1 A specialist consultant gastrointestinal radiologist manually segmented the following structures: sphincter complex; rectosigmoid colon; levator plate, bladder, ureters, urethra and prostate. Each mesh was imported into another open-source system, MeshLab V1.3.3.1 as Stereolithography (STL) files for mesh smoothing to be applied. Individual labels were applied to each anatomical structure. RESULTS: Segmentation took approximately 15 min and an additional 10 min was required for smoothing and applying colour and transparency of the anatomical structures to emphasise surgically relevant anatomy. In Figure (A) provides an overview of the anatomy showing a relatively straight and posterior direction of the rectum as it descends into the pelvis; (B) provides insight into the relation between internal sphincter/rectum and the prostate/urethra. Distance between structures and relative proximity can be easily understood. Figure (C) shows the clearance between low rectum and both ureters, whilst (D) shows an anterior oblique view of the sphincter complex and the urethra. Conclusions :Surgeons currently use a combination of MRI scans, reports and discussion with radiologists to better understand anatomy. The use of these reconstructions in the MDT, in clinic and in the operating theatre could be useful to better communicate complex rectal anatomy, identify areas of difficulty and aid surgical planning. Our reconstructions present a present a cost-neutral solution to better visualise the anatomy they represent the first step towards innovation in TaTME surgery.
Development of a model of three-dimensional imaging for the preoperative planning of TaTME
(Springer, 2018) Sahnan, K.; Pellino, G.; Adegbola, S.O.; Tozer, P.J.; Chandrasinghe, P.; Miskovic, D.; Hompes, R.; Warusavitarne, J.; Lung, P.F.C.
Fistulizing Crohn's disease
(Mosby Inc., 2020) Lightner, A.L.; Ashburn, J.H.; Brar, M.S.; Carvello, M.; Chandrasinghe, P.; Van Overstraeten, A.D.B.; Fleshner, P.R.; Gallo, G.; Kotze, P.G.; Holubar, S.D.; Reza, L.M.; Spinelli, A.; Strong, S.A.; Tozer, P.J.; Truong, A.; Warusavitarne, J.; Yamamoto, T.; Zaghiyan, K.
No abstract available
Improving quality of life after pouch surgery with a dedicated nurse led follow up programme
(Wiely-Blackwell, 2016) Chandrasinghe, P.; Leo, A.; Alison, L.; Perry-Woodford, Z.; Warusavitarne, J.
AIM:Bowel function after ileal pouch affects the quality of life (QOL). The aim of the study was to assess if objective evaluation and specialised supportive care improves QOL after pouch surgery.METHOD: Consecutive patients who had an ileoanal pouch were invited to participate in a systematic follow-up regime led by specialised pouch nurse practitioners. The Cleveland global Quality of Life (CGQOL) and specific pouch related symptoms were documented at 6, 12, 24 and 52 weeks after ileostomy reversal. Pearson's Rho coefficient was used to assess the correlation between symptoms and CGQOL. RESULTS: Thirty-nine consecutive patients who had ileoanal pouch surgery were evaluated. Thirty-four had more than two visits and improvement in CGQOL (mean-1.36 ± 0.95) was seen in 27 (79%). There was reduction in CGQOL in 5 patients (15%) and no change in 2 (6%). Daytime frequency (DTF) significantly correlated with mean CGQOL (R = −0.7, P < 0.01). Twenty (59%) of 34 had reduced DTF after intervention. Nocturnal frequency only showed correlation with CGQOL up to 3 months. Incontinence had no impact on the QOL in this cohort. CONCLUSION: DTF has the highest impact on QOL in this cohort. Regular systematic specialised pouch care follow up may achieve better QOL.
Incidence, prevalence and trends in IBD
(CRC Press, 2018) Chandrasinghe, P.; Spinelli, A.; Warusavitarne, J.
The inflammatory bowel diseases (IBD), Crohn’s disease and ulcerative colitis, are inflammatory conditions of unknown aetiology that affect the gastrointestinal tract. In Saudi Arabia, an increasing incidence of IBD has been registered, and a comparable disease progression has been recognised. Disease location is a significant factor associated with the long-term outcome in IBD. Extra-intestinal manifestations are pathologically and clinically important entities in IBD. Mortality due to IBD may be caused by complications of acute flares of the disease, long-term complication of the disease or surgical complications. Surgery is required in patients with IBD mainly for intestinal complications. The natural history of IBD is difficult to assess in today’s context, as a majority patients with symptoms will be undergoing some form of treatment. The downward trend may have been the result of more comprehensive surveillance programmes established in many high-volume IBD centres. IBDs are common chronic conditions, which place a significant burden on the individual and community.
Long-term function after transanal versus transabdominal ileal pouch-anal anastomosis for ulcerative colitis: a multicenter cohort study
(Wiely-Blackwell, 2019) Chandrasinghe, P.; Carvello, M.; Wasmann, K.; Tanis, P.; Warusavitarne, J.; Spinelli, A.; Bemelman, W.
AIM:The novel transanal approach to ileal pouch-anal anastomosis (ta-IPAA) provides better exposure with lower short-term morbidity in ulcerative colitis (UC). The aim of this study was to assess the long-term outcomes after ta-IPAA versus abdominal IPAA (abd-IPAA) in UC. METHOD:This is a multicentre cohort analysis between March 2002 and September 2017. Patient characteristics, surgical details and postoperative outcomes were compared. The primary end-point was CGQL (Cleveland Global Quality of Life) score at 12 months. RESULTS:374 patients (100 ta-IPAA vs 274 abd-IPAA) were included. Mean CGQL scores were comparable between the two groups (0.75 ± 0.11 vs 0.71 ± 0.14; respectively, P = 0.1). Quality of life (7.71 ± 1.17 vs 7.30 ± 1.46; P = 0.04) and energy level (7.16 ± 1.52 vs 6.66 ± 1.68; P = 0.03) were significantly better after ta-IPAA, while the quality of health item was comparable (7.68 ± 1.26 vs 7.64 ± 1.44; P = 0.9655). Stool frequencies (> 10/24 h:22% vs 21%; P = 1.0) and major incontinence rates (27% vs 26%; P = 0.89) were similar. Thirty-day morbidity rates (33% vs 41%; P = 0.2) and anastomotic leak rates were comparable (6% vs 13%; P = 0.09). CONCLUSION: This study, for the first time, provides evidence of comparable long-term functional outcome of ta-IPAA vs abd-IPAA for UC.
Long-term function after transanal vs. transabdominal ileal pouch-anal anastomosis for ulcerative colitis: a multi-centre cohort study
(Oxford University Press, 2019) Chandrasinghe, P.; Carvello, M.; Wasmann, K.; Tanis, P.; Warusavitarne, J.; Spinelli, A.; Bemelman, W.
BACKGROUND:The transanal approach has been introduced in ileal pouch-anal (IPAA) surgery to gain better exposure for the rectal dissection. It has been shown to be safe with lower morbidity than the trans-abdominal approach. The aim of this study was to compare functional outcome of transanal ileal pouch-anal anastomosis (ta-IPAA) with transabdominal (abd-IPAA) approach for ulcerative colitis (UC) using the Cleveland Global Quality of Life (CGQL). METHODS: This is a multi-centre cohort of consecutive patients undergoing abd-IPAA or ta-IPAA for UC prospectively registered in the databases of three tertiary referral institutions between March 2002 to September 2017. Patient characteristics, surgical details and postoperative outcomes were retrieved. The primary end-point was pouch function determined by CGQL score. The questionnaire was administered to all patients with a functioning pouch for 12 months. RESULTS: Ninety-nine patients with ta-IPAA were compared with 274 patients with abd-IPAA. A defunctioning stoma was created at the time of pouch construction in 46 (46%) patients undergoing ta-IPAA and in 130 (47%) patients with abd-IPAA (p = 0.90). Thirty-day postoperative complications according to Clavien-Dindo classification (p = 0.22) as well as anastomotic leak rates (13% vs. 6%), abd-IPAA and ta-IPAA, respectively, were comparable (p = 0.09). Time to stoma closure did not differ between the two groups (abd-IPAA- 6 ± 7 vs. ta-IPAA- 5 ± 4 months; p = 0.72). Twelve months CGQL score was obtained for 251 patients in the abd-IPAA group and for 97 in ta-IPAA cohort. The CGQL index was comparable between the two groups (0.72 ± 0.15 vs. 0.75 ± 0.12; p = 0.07). Quality of health and energy level components were statistically higher for ta-IPAA (7.30 ± 1.53 vs. 7.73 ± 1.19, p = 0.01; 6.68 ± 1.74 vs. 7.17 ± 1.54, p = 0.01) while no difference was found for quality of life item (7.63 ± 1.52 vs. 7.62 ± 1.30, p = 0.73). Pouch failure (including defunction and excision) was reported in 40 of 298 (12%) patients undergoing abd-IPAA and in 1 patient (1%) having ta-IPAA during the follow-up period. CONCLUSIONS: ta-IPAA produces functional result comparable to transabdominal approach at 12 months after surgery.
The MACC1-SPON2 axis: a new biomarker and therapeutic target in colorectal cancer
(Nature Publishing Group, 2017) Chandrasinghe, P.; Stebbing, J.; Warusavitarne, J.
In this issue of the Journal, Schmid et al identify Spondin 2 (SPON2) as a prominent downstream signaling target of metastasis-associated in colon cancer 1 (MACC1) in colorectal cancer (CRC). It is shown that SPON2 mediates MACC1-induced CRC cell proliferation, invasion and metastasis in vitro and in vivo, while its high expression correlates with adverse disease free survival in clinical samples. Therefore, not only does this study shed further light into the complexity of colorectal carcinogenesis, but it also puts forward a potential novel prognostic biomarker to predict high-risk tumors before they metastasize. The MACC1/SPON2 axis may also have utility beyond an indicator of tumor aggressiveness and lends itself as a promising therapeutic target for colorectal and potentially other solid tumors.
Risk factors for locally advanced cancer associated with ulcerative colitis: Results of a retrospective multicentric study in the era of biologics
(Elsevier, 2020) Rottoli, M.; Tanzanu, M.; Di Candido, F.; Colombo, F.; Frontali, A.; Chandrasinghe, P.C.; Pellino, G.; Frasson, M.; Warusavitarne, J.; Panis, Y.; Sampietro, G.M.; Spinelli, A.; Poggioli, G.
BACKGROUND: Patients affected by ulcerative colitis (UC) are more likely to develop colorectal cancer, and are often diagnosed with lymph node involvement (N+) at surgery. AIM: To identify the risk factors for N+ cancer in UC patients. METHODS: Patients undergoing surgery from 2001 to 2018 in six European tertiary centres were included. N+ patients were compared to the control group (N-) for clinical variables. The evaluation of risk factors for N+ was assessed using univariate and multivariable logistic regression analyses. RESULTS: A total of 130 patients were included. Median duration of disease was 21 years (1-52). Forty patients (30.8%) were N+ at surgery. Eighteen (13.8%) developed cancer within 10 years from the onset of UC. Younger age at surgery (Odds ratio -OR- 0.96, p = 0.042), left colon location (OR 2.44, p = 0.045) and the presence of stricture (OR 5.07, p = 0.002) were associated with N+. CONCLUSION: Location in the left colon, presence of strictures and younger age strongly correlated with a higher risk of N+ cancer, which could develop before the starting point of surveillance. Duration, extension and severity of disease were not associated with N+. These results should be considered in the evaluation of risk of advanced cancer in UC patients. KEYWORDS: Cancer; Lymph nodes; Ulcerative colitis.
Role of SMAD proteins in colitis-associated cancer: from known to the unknown
(MacMillan Press, 2018) Chandrasinghe, P.; Cereser, B.; Moorghen, M.; Al Bakir, I.; Tabassum, N.; Hart, A.; Stebbing, J.; Warusavitarne, J.
Small mothers against decapentaplegic (SMAD) proteins are a family of signal transduction molecules in transforming growth factor β (TGFβ) ligand pathways that have been found to have a key role in the pathogenesis of inflammatory bowel disease (IBD). Long standing IBD predisposes individuals to colitis-associated colorectal cancer (CAC), an entity that possess unique characteristics compared to hereditary and sporadic cancer. The ligands of the TGFβ super family along with SMADs have also been implicated in several aspects of colorectal cancer formation. SMAD proteins are shown to be involved in a number of potentially carcinogenic mechanisms such as altering gene transcription, controlling stem cell differentiation to causing epigenetic changes. Modulation of these proteins has emerged as a novel therapeutic intervention for IBD although its effect on carcinogenesis remains elusive. This account reviews available evidence linking SMAD proteins to CAC and explores the potential areas for future research in this area.
Single Incision Laparoscopic Surgery (SILS) as surgical option in Crohn's disease: our experience
(Oxford University Press, 2018) Leo, C.A.; Samaranayake, S.F.; Hodgkinson, J.D.; Santorelli, C.; Chandrasinghe, P.C.; Warusavitarne, J.
BACKGROUND:Transanal TME (TaTME) is a new addition to the approaches in rectal surgery. TaTME requires advanced technical skills and, more importantly, knowledge of the pelvic structures, planes, and spaces as they are encountered moving cephalad from the perineum. We have developed a technique for producing 3D reconstructions of the anorectum and associated anatomy, to aid peri-operative planning and understanding of the anatomy crucial to TaTME surgery. METHODS: A patient was scheduled for single incision laparoscopy surgery (SILS) TaTME completion proctectomy and ileoanal pouch formation for ulcerative colitis. Standard axial T2-weighted Spectral Attenuated Inversion Recovery (SPAIR) and sagittal T2-weighted MRI sequences were obtained and digital imaging and communications in medicine (DICOM) images were imported into a validated open-source segmentation software.1 A specialist consultant gastrointestinal radiologist manually segmented the following structures: sphincter complex; rectosigmoid colon; levator plate, bladder, ureters, urethra and prostate. Each mesh was imported into another open-source system, MeshLab V1.3.3.1 as Stereolithography (STL) files for mesh smoothing to be applied. Individual labels were applied to each anatomical structure. RESULTS: Segmentation took approximately 15 min and an additional 10 min was required for smoothing and applying colour and transparency of the anatomical structures to emphasise surgically relevant anatomy. In Figure (A) provides an overview of the anatomy showing a relatively straight and posterior direction of the rectum as it descends into the pelvis; (B) provides insight into the relation between internal sphincter/rectum and the prostate/urethra. Distance between structures and relative proximity can be easily understood. Figure (C) shows the clearance between low rectum and both ureters, whilst (D) shows an anterior oblique view of the sphincter complex and the urethra. Conclusions :Surgeons currently use a combination of MRI scans, reports and discussion with radiologists to better understand anatomy. The use of these reconstructions in the MDT, in clinic and in the operating theatre could be useful to better communicate complex rectal anatomy, identify areas of difficulty and aid surgical planning. Our reconstructions present a present a cost-neutral solution to better visualise the anatomy they represent the first step towards innovation in TaTME surgery.
Single Incision Laparoscopic Surgery (SILS) as surgical option in Crohn's disease: our experience
(Wiely-Blackwell, 2016) Leo, C.A.; Samaranayake, S.F.; Hodgkinson, J.D.; Santorelli, C.; Chandrasinghe, P.C.; Warusavitarne, J.
AIM :Single Incision Laparoscopic Surgery (SILS) is a newer technique which is increasing in popularity. The benefit of SILS in complex Crohn's disease (CCD), which includes a significant cohort of young patients sometimes needing multiple operations has not been comprehensively assessed. This study analyses our early experience with this technique. METHOD: Patients who underwent SILS for CCD were included. Data were collected prospectively from Januray 2013 to December 2015. Ileocolic resections, right hemicolectomy, small bowel stricturoplasties and resections were included in the CCD cohort. Primary and re-do surgeries were analysed separately. RESULTS: A total of 45 patients were included: 39 ileocolic resections, 6 small bowel stricturoplasty/resections. Of the total, 27 were primary resections and 18 were re-do resections. In overall, the median age was 41 years (Range – 14 years–72 years), the median hospital stay was 8 days (Range - 3 days–28 days). Three patients from primary (11%) and 2 from re-do group (11%) had to be converted to open surgery. Total complication rate was 35.5% including 31.1% Clavien Dindo 1 and 2. In term of operating time, average blood loss, conversion rates, complication rate and hospital stay, there was no significant difference between the groups. Six months follow-up showed no major complications. CONCLUSION:We have demonstrated the feasibility of SILS in patients with CCD undergoing both primary and re-do surgeries. There were no significant differences between the two groups. More robust data and longer follow-up is needed in future studies to evaluate this further.
Single incision laparoscopic surgery (SILS) for primary surgery in medically refectory ulcerative colitis: a case series
(Wiely-Blackwell, 2016) Chandrasinghe, P.C.; Leo, C.A.; Samaranayake, S.F.; Santorelliei, C.; Strouhal, R.; Warusavitarne, J.
INTRODUCTION: Medically refractive ulcerative colitis (UC) requires surgical intervention. Due to the ongoing inflammation in the colon this patient group is considered as high risk. Primary surgery includes subtotal colectomy (STC) as the first step of a staged restorative procedure, restorative proctocolectomy (RPC) or panproctocolectomy (PPC) with end ileostomy. Single incision surgery is gaining popularity in this group of patients. METHOD: Patients who underwent single incision surgery for medically refractory UC from 2013 January to 2015 December were prospectively followed up. Demographics, hospital stay and early complications were analyzed. Mann-Whitney U test was used to compare the medians. RESULTS: A total of 34 patients (male – 24, median age – 41.5 years; range 17–69 years) were included. There were 21 STCs, 9 PPCs and 4 RPCs done as primary surgery for medically refractory UC. The median hospital stay was 7 days (4–41 days). Four out of 34 patients had a complication with Clavien-Dindo score above 3; (2-re-operation for obstruction (5%), 2 required intensive care for sepsis (5%). Two procedures (5.8%) had to be converted strategically to open. Three patients had cancer in the resected specimen. The median age of those who had PPC was significantly higher compared to those who had restorative procedures (48 years: range 17–69 Vs 38 years: range 34–64; P < 0.005). CONCLUSION: Single incision surgery for medically refractory UC is safe with an acceptable complication profile in this group of medically unwell patients. The quality of life implications of this procedure require further evaluation.
Single incision laparoscopic surgery (SILS) for primary surgery in medically refectory ulcerative colitis: a case series
(Wiely-Blackwell, 2016) Chandrasinghe, P.C.; Leo, C.A.; Samaranayake, S.F.; Santorelli, C.; Strouhal, R.; Warusavitarne, J.
AIM:Medically refractive ulcerative colitis (UC) requires surgical intervention. Primary surgery includes subtotal colectomy (STC), restorative proctocolectomy (RPC) or panproctocolectomy (PPC) with end ileostomy. Single incision surgery is gaining popularity in this group of patients. METHOD: Patients who underwent single incision surgery for medically refractory UC from 2013 January to 2015 December were prospectively followed up. Demographics, hospital stay and early complications were analysed. RESULTS: A total of 34 patients were included. There were 21 STCs, 9 PPCs and 4 RPCs done as primary surgery for medically refractory UC. The median hospital stay was 7 days (range: 4–41 days). Four out of 34 patients had a complication with Clavien-Dindo score above 3; (2-re-operation for obstruction (5%), 2 required intensive care for sepsis (5%). Two procedures (5.8%) had to be converted strategically to open. Three patients had cancer in the resected specimen. The median age of those who had PPC was significantly higher compared to those who had restorative procedures (48 years: range 17–69 vs 38 years: range 34–64; P < 0.005). CONCLUSION: Single incision surgery for medically refractory UC is safe with an acceptable complication profile. The quality of life implications of this procedure require further evaluation.
SMAD7 shows a biphasic expression pattern during progression of ulcerative colitis-associated colorectal cancer
(Oxford University Press, 2019) Chandrasinghe, P.; Cereser, B.; Moorghen, M.; Spaggiari, P.; Maroli, A.; Del Bel Belluz, L.; Hart, A.; Spinelli, A.; Stebbing, J.; Warusavitarne, J.
BACKGROUND: Ulcerative colitis (UC) is an idiopathic inflammation of the intestine with an increased risk of developing colitis-associated cancer (CAC). Currently, clinical trials are underway aiming to inhibit SMAD7 to ameliorate inflammation. While the direct effect of depleting SMAD7, an inhibitory molecule in the transforming growth factor-β1 (TGFβ1) pathway, may be therapeutic in UC, its indirect effect on CAC development is largely unknown. TGFβ1 is known to enhance late stages of sporadic colorectal cancers (CRC), where SMAD7 is also elevated. Therefore, we hypothesise that removing inhibition of this pathway by depleting SMAD7 may also be detrimental for CAC. We therefore evaluated the expression of SMAD7 in the colonic epithelium during the inflammation associated neoplastic process to determine a possible role of SMAD7 in CAC. METHODS: The expression of SMAD7 protein and mRNA in colonic epithelia was assessed by immunohistochemistry (IHC) and in situ hybridisation (ISH),, respectively, in a cohort of 53 archival colon samples (17 CAC, 12 dysplastic, 12 inflammed, 12 non-neoplastic/non-inflammed) from patients who have undergone colectomies for UC and CAC. The expression within the epithelial cells was evaluated by both digital quantification and validated by blind scoring by a pathologist. Significant differences were tested with one-way ANOVA and Mann–Whitney U test. RESULTS: Cytoplasmic expression of SMAD7 protein is significantly higher in the inflammed epithelium compared with non-inflamed epithelium (p < 0.0001). Interestingly, a significant decrease of the same was detected in dysplasia (p = 0.01), although this group is characterised by a higher variability. SMAD7 levels are elevated in cancer compared with dysplasia, suggesting a biphasic expression (p = 0.009), which could be in part due to the different genetic composition. SMAD7 mRNA expression was not significantly different across different stages of CAC (p = 0.49). We hypothesise that the lack of correlation between mRNA and protein levels could be attributed to yet unknown post-transcriptional or post-translational regulations. CONCLUSIONS:In our cohort of UC affected colon tissues, SMAD7 demonstrated a biphasic expression pattern along the different stages of CAC with peaks during active inflammation and cancer. The increase in SMAD7 expression during neoplastic transformation, comparable to sporadic CRC, may be a protective response of the epithelium to inhibit the effect of TGFβ1. Although inhibiting SMAD7 as a therapy for UC may remit inflammation, we hypothesise it may exacerbate CAC due to further enhancement in TGFβ1 signalling. We envisage further mechanistic studies in vitro, in particular in organoids, could help in understanding the TGFβ superfamily pathway in CAC.
Technical tips and tricks of outpatient treatments for Hemorrhoids.
(Springer, 2018) Chandrasinghe, P.; Leo, C. A.; Hodgkinson, J. D.; Vaizey, C. J.; Warusavitarne, J.
Hemorrhoids are a common condition affecting the anorectum. The clinician must accurately diagnose the condition and exclude more sinister causes responsible for the same symptoms. A focused history and thorough examination help in establishing a differential diagnosis. The treatment modality is guided by the degree of the hemorrhoids. Conservative measures should be employed, including dietary advice and toileting techniques, to treat acute inflammation and as a long-term method of reducing symptom recurrence and worsening disease. A wide range of out-patient therapies are available and all have been shown to be effective in experienced hands and when used in the correct clinical context. Here we present an approach to out-patient treatment methods including conservative treatments, medical therapies, and simple interventions.
Technical variations and feasibility of transanal ileal pouch-anal anastomosis for ulcerative colitis and inflammatory bowel disease unclassified across continents.
(Springer-Verlag, 2018) Zaghiyan, K.; Warusavitarne, J.; Spinelli, A.; Chandrasinghe, P.; Di Candido, F.; Fleshner, P.
PURPOSE: Initial reports of transanal ileal pouch-anal anastomosis (taIPAA) suggest safety and feasibility compared with transabdominal IPAA. The purpose of this study was to evaluate differences in technique and results of taIPAA in three centers performing taIPAA across two continents. METHODS: Prospective IPAA registries from three institutions in the US and Europe were queried for patients undergoing taIPAA. Demographic, preoperative, intraoperative, and postoperative data were compiled into a single database and evaluated. RESULTS: Sixty-two patients (median age 38 years; range 16-68 years, 43 (69%) male) underwent taIPAA in the three centers (USA 24, UK 23, Italy 15). Most patients had had a subtotal colectomy before taIPAA [n = 55 (89%)]. Median surgical time was 266 min (range 180-576 min) and blood loss 100 ml (range 10-500 ml). Technical variations across the three institutions included proctectomy plane of dissection (intramesorectal or total mesorectal excision plane), specimen extraction site (future ileostomy site vs. anus), ileo-anal anastomosis technique (stapled vs. hand sewn) and use of fluorescence angiography. Despite technical differences, anastomotic leak rates (5/62; 8%) and overall complications (18/62; 29%) were acceptable across the three centers. CONCLUSIONS: This is the first collaborative report showing safety and feasibility of taIPAA. Despite technical variations, outcomes are similar across centers. A large multi-institutional, international IPAA collaborative is needed to compare technical factors and outcomes.
Transanal ileal pouch-anal anastomosis for ulcerative colitis has comparable long-term functional outcomes to transabdominal approach: a multicentre comparative study
(Elsevier Science., 2020) Chandrasinghe, P.; Carvello, M.; Wasmann, K.; Foppa, C.; Tanis, P.; Perry-Woodford, Z.; Warusavitarne, J.; Spinelli, A.; Bemelman, W.
BACKGROUND:The transanal approach to ileal pouch-anal anastomosis (Ta-IPAA) provides better access to the lower pelvis with lower short-term morbidity in ulcerative colitis (UC). The aim of this study was to assess the long-term functional outcomes after Ta-IPAA versus transabdominal IPAA (Abd-IPAA) in UC.STUDY DESIGN:A multicentre cohort analysis was done between March 2002 and September 2017. Patient characteristics, surgical details and postoperative outcomes were compared. CGQL (Cleveland global quality of life) score at 12 months with a functioning pouch was considered the primary endpoint.RESULTS:A total of 374 patients (100 Ta-IPAA vs 274 Abd-IPAA) were included. Ta-IPAA demonstrated a comparable overall quality of life (CGQL score) to Abd-IPAA (0.75 ± 0.11 vs 0.71 ± 0.14; respectively, p=0.1). Quality of life (7.71 ± 1.17 vs 7.30 ± 1.46; p=0.04) and energy level items (7.16 ± 1.52 vs 6.66 ± 1.68; p=0.03) were significantly better after Ta-IPAA, while the quality of health item was comparable (7.68 ± 1.26 vs 7.64 ± 1.44; p=0.96). Analysis excluding anastomotic leaks did not change the overall CGQL scores. Stool frequencies (>10/ 24 hrs:22% vs 21%; p=1.0) and the rate of single episode of major incontinence during the 12-month period (27% vs 26%; p=0.89) were similar. The differences in thirty-day morbidity rates (33% vs 41%; p=0.2) and the anastomotic leak rates were not significant (6% vs 13%; p=0.09). CONCLUSION AND RELEVANCE:This study provides evidence of comparable long-term functional outcome and quality of life after Ta-IPAA and Abd-IPAA for UC.