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Clinics in Colon and Rectal Surgery Jul 2017When created properly, an ileostomy or colostomy can dramatically improve a patient's quality of life. Conversely, when a patient develops complications related to their... (Review)
Review
When created properly, an ileostomy or colostomy can dramatically improve a patient's quality of life. Conversely, when a patient develops complications related to their stoma, the impact on physical and mental health can be profound. Unfortunately, significant morbidity is associated with stoma creation conveying high rates of both early and late-term complications. Early complications include stomal ischemia/necrosis, retraction, mucocutaneous separation, and parastomal abscess. Late complications include parastomal hernia, prolapse, retraction, and varices. This review will discuss commonly occurring nondermatological stoma complications and detail management strategies for the ostomate and the surgeon.
PubMed: 28684937
DOI: 10.1055/s-0037-1598160 -
Clinics in Colon and Rectal Surgery May 2019Ileostomy or colostomy formation is an important component of many surgical procedures performed for a wide range of disorders of the gastrointestinal tract. Despite the... (Review)
Review
Ileostomy or colostomy formation is an important component of many surgical procedures performed for a wide range of disorders of the gastrointestinal tract. Despite the frequency with which intestinal stomas are created, stoma-related complications remain common and are associated with significant morbidity as well as cost. Some of the most prevalent complications of stoma formation which will be detailed in this article include peristomal skin complications, retraction, stomal necrosis, stomal stenosis, prolapse, bleeding, dehydration from high ostomy output, and parastomal hernia. The authors will review these common complications, detail means to avoid or prevent them, and outline recommendations for management.
PubMed: 31061647
DOI: 10.1055/s-0038-1676995 -
Gastroenterology Jun 2021The incidence and prevalence of Crohn's disease (CD) is rising globally. Patients with moderate to severe CD are at high risk for needing surgery and hospitalization and... (Review)
Review
The incidence and prevalence of Crohn's disease (CD) is rising globally. Patients with moderate to severe CD are at high risk for needing surgery and hospitalization and for developing disease-related complications, corticosteroid dependence, and serious infections. Optimal management of outpatients with moderate to severe luminal and/or fistulizing (including perianal) CD often requires the use of immunomodulator (thiopurines, methotrexate) and/or biologic therapies, including tumor necrosis factor-α antagonists, vedolizumab, or ustekinumab, either as monotherapy or in combination (with immunomodulators) to mitigate these risks. Decisions about optimal drug therapy in moderate to severe CD are complex, with limited guidance on comparative efficacy and safety of different treatments, leading to considerable practice variability. Since the last iteration of these guidelines published in 2013, significant advances have been made in the field, including the regulatory approval of 2 new biologic agents, vedolizumab and ustekinumab. Therefore, the American Gastroenterological Association prioritized updating clinical guidelines on this topic. To inform the clinical guidelines, this technical review was completed in accordance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. The review addressed the following focused questions (in adult outpatients with moderate to severe luminal CD): overall and comparative efficacy of different medications for induction and maintenance of remission in patients with or without prior exposure to tumor necrosis factor-α antagonists, comparative efficacy and safety of biologic monotherapy vs combination therapy with immunomodulators, comparative efficacy of a top-down (upfront use of biologics and/or immunomodulator therapy) vs step-up treatment strategy (acceleration to biologic and/or immunomodulator therapy only after failure of mesalamine), and the role of corticosteroids and mesalamine for induction and/or maintenance of remission. Finally, in adult outpatients with moderate to severe fistulizing CD, this review addressed the efficacy of pharmacologic interventions for achieving fistula and the role of adjunctive antibiotics without clear evidence of active infection.
Topics: Adult; Crohn Disease; Decision Support Systems, Clinical; Disease Management; Female; Gastroenterology; Humans; Male; Practice Guidelines as Topic; Rectal Fistula; Severity of Illness Index; Societies, Medical
PubMed: 34051985
DOI: 10.1053/j.gastro.2021.04.023 -
Nutrients Jun 2021Probiotics have been shown to benefit patients with constipation and depression, but whether they specifically alleviate constipation in patients with depression remains... (Randomized Controlled Trial)
Randomized Controlled Trial
Probiotics have been shown to benefit patients with constipation and depression, but whether they specifically alleviate constipation in patients with depression remains unclear. The aim of this study was to investigate the effect of strain Shirota (LcS), formerly strain Shirota, on constipation in patients with depression with specific etiology and gut microbiota and on depressive regimens. Eighty-two patients with constipation were recruited. The subjects consumed 100 mL of a LcS beverage (10 CFU/mL) or placebo every day for 9 weeks. After ingesting beverages for this period, we observed no significant differences in the total patient constipation-symptom (PAC-SYM) scores in the LcS group when compared with the placebo group. However, symptoms/scores in item 7 (rectal tearing or bleeding after a bowel movement) and items 8-12 (stool symptom subscale) were more alleviated in the LcS group than in the placebo group. The Beck Depression Index (BDI) and Hamilton Depression Rating Scale (HAMD) scores were all significantly decreased, and the degree of depression was significantly improved in both the placebo and LcS groups ( < 0.05), but there was no significant difference between the groups. The LcS intervention increased the beneficial , and levels and decreased the bacterial levels related to mental illness, such as , and Additionally, the interleukin (IL)-1β, IL-6, and tumor necrosis factor-α (TNF-α) levels were significantly decreased in both the placebo and LcS groups ( < 0.05). In particular, the IL-6 levels were significantly lower in the LcS group than the placebo group after the ingestion period ( < 0.05). In conclusion, the daily consumption of LcS for 9 weeks appeared to relieve constipation and improve the potentially depressive symptoms in patients with depression and significantly decrease the IL-6 levels. In addition, the LcS supplementation also appeared to regulate the intestinal microbiota related to mental illness.
Topics: Adult; Animals; Constipation; Cultured Milk Products; Depression; Double-Blind Method; Feces; Female; Gastrointestinal Microbiome; Humans; Lacticaseibacillus paracasei; Male; Middle Aged; Probiotics; Treatment Outcome
PubMed: 34209804
DOI: 10.3390/nu13072238 -
Expert Opinion on Pharmacotherapy Nov 2018Treatment of ulcerative colitis (UC) is constantly evolving. In the last two decades, new therapeutic strategies have been implemented by addressing specific disease... (Review)
Review
INTRODUCTION
Treatment of ulcerative colitis (UC) is constantly evolving. In the last two decades, new therapeutic strategies have been implemented by addressing specific disease mechanisms: biological agents against tumor necrosis factor-α and integrins are now widely used, and more agents targeting different pathological pathways are being marketed. Despite these novel therapies, nonbiological drugs are still the mainstay of treatment, especially in mild-to-moderate disease, since a proven safety and tolerability profile is observed. Excellent efficacy both in induction and maintenance of remission is obtained, with a lower cost compared to biological agents.
AREAS COVERED
The purpose of this review is to summarize the current knowledge and the latest clinical evidence regarding nonbiological therapies for UC.
EXPERT OPINION
Concomitant administration of oral and rectal 5-aminosalicylates acid is more effective in the treatment of UC in remission. Corticosteroids are the treatment of choice in patients with moderately severe or severe UC. The association of azathioprine with biological treatments is more effective than monotherapy. Cyclosporine is an effective drug in severe UC, but its poor management must be considered. Probiotics are very popular; however, evidence on their actual role in UC still must be demonstrated; cytapheresis plays only a niche role at this time.
Topics: Colitis, Ulcerative; Humans; Immunologic Factors
PubMed: 30220228
DOI: 10.1080/14656566.2018.1525361 -
Abdominal Radiology (New York) Jun 2023For rectal cancer, MRI plays an important role in assessing extramural tumor spread and informs surgical planning. The contemporary standardized management of rectal... (Review)
Review
For rectal cancer, MRI plays an important role in assessing extramural tumor spread and informs surgical planning. The contemporary standardized management of rectal cancer with total mesorectal excision guided by imaging-based risk stratification has dramatically improved patient outcomes. Colonoscopy and CT are utilized in surveillance after surgery to detect intraluminal and extramural recurrence, respectively; however, local recurrence of rectal cancer remains a challenge because postoperative changes such as fat necrosis and fibrosis can resemble tumor recurrence; additionally, mucinous adenocarcinoma recurrence may mimic fluid collection or abscess on CT. MRI and F-FDG PET are problem-resolving modalities for equivocal imaging findings on CT. Treatment options for recurrent rectal cancer include pelvic exenteration to achieve radical (R0 resection) resection and intraoperative radiation therapy. After pathologic diagnosis of recurrence, imaging plays an essential role for evaluating the feasibility and approach of salvage surgery. Patterns of recurrence can be divided into axial/central, anterior, lateral, and posterior. Some lateral and posterior recurrence patterns especially in patients with neurogenic pain are associated with perineural invasion. Cross-sectional imaging, especially MRI and F-FDG PET, permit direct visualization of perineural spread, and contribute to determining the extent of resection. Multidisciplinary discussion is essential for treatment planning of locally recurrent rectal cancer. This review article illustrates surveillance strategy after initial surgery, imaging patterns of rectal cancer recurrence based on anatomic classification, highlights imaging findings of perineural spread on each modality, and discusses how resectability and contemporary surgical approaches are determined based on imaging findings.
Topics: Humans; Fluorodeoxyglucose F18; Neoplasm Recurrence, Local; Rectal Neoplasms; Rectum; Pelvis; Retrospective Studies; Neoplasm Staging
PubMed: 36737522
DOI: 10.1007/s00261-022-03746-4 -
Current Opinion in Gastroenterology Jul 2021Multiple new medications with novel mechanisms of action are now available to treat Crohn's disease (CD). However, they have varying effectiveness in the management of... (Review)
Review
PURPOSE OF REVIEW
Multiple new medications with novel mechanisms of action are now available to treat Crohn's disease (CD). However, they have varying effectiveness in the management of perianal CD. Identifying the most appropriate therapy and optimizing it is essential to maximize effectiveness of therapy. Additionally, the management of perianal CD requires imaging of the perianal area to identify the fistula anatomy and local complications such as abscesses that require surgical drainage. Initial surgical assessment is key to drain abscesses and allow fistula healing with medical therapy.
RECENT FINDINGS
Although anti-tumor necrosis factor (TNFs) remain the most effective medications to treat perianal CD, real-world data suggests that ustekinumab may be a 2nd-line option in patients nonresponsive to an anti-TNF or having contraindications. Mesenchymal stem cells are an emerging therapeutic approach that is currently in Phase 3 trials in the United States and poised to play a major role in the treatment algorithm.
SUMMARY
The management of perianal CD requires a multidisciplinary approach with a combination of initial imaging and surgical assessment to adequately control local sepsis, optimization of biological therapy with adjunct antibiotics or immunomodulators, and close clinical follow-up with imaging to evaluate response to therapy and guide further surgical management options.
Topics: Crohn Disease; Humans; Rectal Fistula; Treatment Outcome; Tumor Necrosis Factor Inhibitors; Tumor Necrosis Factor-alpha
PubMed: 33899777
DOI: 10.1097/MOG.0000000000000751 -
World Journal of Gastrointestinal... Jun 2016Sigmoid volvulus (SV) is extremely uncommon in children and is usually associated with a long-standing history of constipation or pseudo-obstruction. An early diagnosis... (Review)
Review
Sigmoid volvulus (SV) is extremely uncommon in children and is usually associated with a long-standing history of constipation or pseudo-obstruction. An early diagnosis and management are crucial in order to prevent the appearance of hemorrhagic infarction of the twisted loop, avoiding further complications such as necrosis, perforation and sepsis. In patients with no evidence of peritonitis or ischemic bowel, treatment starts with resuscitation and detorsion of the SV, accomplished by means of sigmoidoscopy and concomitant rectal tube placement. The bowel is then prepared and surgery is undertaken electively during the same hospitalization. We report a detailed review of the literature focusing on technical details, risks and benefits of endoscopic management of SV in childhood.
PubMed: 27358669
DOI: 10.4253/wjge.v8.i12.439 -
Digestive Diseases (Basel, Switzerland) 2017The efficiency of the existing methods of treating inflammatory bowel disease (IBD) is limited. There are 2 ways to address this problem - either create new treatment... (Review)
Review
The efficiency of the existing methods of treating inflammatory bowel disease (IBD) is limited. There are 2 ways to address this problem - either create new treatment modalities or optimize current therapies. Optimisation may be accomplished by using combinations of established therapeutic strategies. With regard to topically acting compounds such as 5-aminosalicylic acid, combining oral and rectal preparations is a commonly used method. Another commonly used combination is anti-tumor necrosis factor (TNF)-α antibody modalities together with immunosuppressants (thiopurines, methotrexate). Several aspects favour those combinations such as increased effectivity, prevention of immunogenicity and perhaps less adverse events. Currently, discussion on directly additive therapeutic effects is in progress, which have been demonstrated in some clinical trials. As on date, the combination of infliximab with azathioprine is most likely the most effective treatment of Crohn's disease. On the other hand, a combination therapy with both compounds affecting the immune system has, of course, risks. For sure, the frequency with which serious infectious complications are arising is increasing. Furthermore, the number of patients experiencing malignancies such as hepato-splenic lymphoma or melanoma is strongly suspected to be on the rise. In summary, combinations of current treatments for IBD are widely established. Various strategies have been studied and significant improvements of therapeutic effects have been demonstrated. Unfortunately, some of those proven combinations increase therapeutic risks, for example, increase the frequency of serious infections and also of some malignancies. Therefore, great caution has to be exercised when applying combination therapies.
Topics: Aminosalicylic Acid; Antibodies; Azathioprine; Drug Therapy, Combination; Humans; Inflammatory Bowel Diseases; Tumor Necrosis Factor-alpha
PubMed: 28147380
DOI: 10.1159/000449084 -
International Journal of Gynecological... Dec 2023To evaluate the feasibility of uterine transposition as a method of preserving fertility and ovarian function after pelvic radiation. (Observational Study)
Observational Study
OBJECTIVE
To evaluate the feasibility of uterine transposition as a method of preserving fertility and ovarian function after pelvic radiation.
METHODS
This prospective multicenter observational study included patients with non-gynecologic pelvic cancers who underwent pelvic radiation as part of their cancer treatment between June 2017 and June 2019. For inclusion in the study, patients were required to have normal menstrual cycles and hormone levels (follicle-stimulating hormone, luteinizing hormone, and estrogen) before treatment. Uterine transposition to the upper abdomen was performed prior to irradiation. Clinical examinations and Doppler ultrasonography were used to evaluate the gonadal vasculature post-surgery. The uterus was repositioned into the pelvis 2-4 weeks after radiation therapy or at the time of rectosigmoid resection in patients with rectal cancer who had undergone neoadjuvant treatment. Cancer treatment and follow-up were performed according to standard guidelines.
RESULTS
Eight patients (seven with rectal cancer and one with pelvic liposarcoma) underwent uterine transposition at a median age of 30.5 years (range 19-37). The uterus was successfully preserved in six patients, accompanied by normal menses, hormonal levels, and vaginal intercourse after treatment. One patient with rectal cancer died of carcinomatosis 4 months after uterine transposition. One patient presented with uterine necrosis 4 days after uterine transposition, and the uterus was removed; however, one ovary was preserved. Cervical ischemia was the most common post-surgical complication in three (37.5%) patients. Three patients attempted to conceive, and two (66%) were spontaneously successful and delivered healthy babies at 36 and 38 weeks by cesarean section without complications.
CONCLUSIONS
Uterine transposition is a feasible procedure for preserving gonadal and uterine function in patients requiring pelvic radiotherapy for non-gynecological cancer, with the potential for achieving spontaneous pregnancy and successful delivery.
Topics: Adult; Female; Humans; Pregnancy; Young Adult; Cesarean Section; Fertility; Fertility Preservation; Prospective Studies; Rectal Neoplasms; Uterine Cervical Neoplasms; Uterus
PubMed: 37898483
DOI: 10.1136/ijgc-2023-004723