Colorectal Unit

Auckland, New Zealand

Colorectal Unit

Auckland, New Zealand

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Yanai H.,IBD Center | Ben-Shachar S.,Genetics Institute | Baram L.,IBD Center | Elad H.,IBD Center | And 6 more authors.
Gut | Year: 2014

Objectives To evaluate molecular profiles in the small bowel (SB) mucosa proximal to the pouch in ulcerative colitis (UC) patients after pouch surgery. Design Patients were prospectively recruited and stratified according to disease behaviour: normal pouch (NP), chronic pouchitis (CP), and Crohn's-like disease of the pouch (CLDP). Biopsies obtained from the pouch and the normal-appearing proximal SB (40 cm proximal to the anal verge) were compared to ileal biopsies from normal controls (NC). A histopathological score based on the degree of polymorphonuclear and mononuclear infiltrates was used to assess inflammation in the pouch and the proximal SB. Gene expression analysis was performed using microarrays, and validated by real-time PCR. Gene ontology and clustering were evaluated by bioinformatics. Results Thirty-six subjects were recruited (age 18-71 years, 16 males). Histopathology scores demonstrated minimal differences in the normal-appearing proximal SB of all groups. Nonetheless, significant (fold change ≥2, corrected p [FDR] ≤ 0.05) molecular alterations in the proximal SB were detected in all groups (NP n=9; CP n=80; and CLDP n=230) compared with NC. The magnitude of DUOX2 alteration in the proximal SB was highest. An increase of 6.0, 9.8 and 21.7 folds in DUOX2 expression in NP, CP, CLDP, respectively was observed. This was followed by alterations in MMP1, SLC6A14 and PGC. Gene alterations in the proximal SB overlapped with alterations within the pouch (76% and 97% overlap in CP and CLDP, respectively). Gene ontology analysis in the proximal SB and pouch were comparable. Conclusions Significant gene expression alterations exist in an apparently unaffected proximal SB. Alterations in the pouch and the proximal SB were comparable, suggesting that inflammation may not be limited to the pouch, but that it extends to the proximal SB. © 2014 BMJ Publishing Group Ltd & British Society of Gastroenterology.


Wexner S.D.,Cleveland Clinic | Coller J.A.,Lahey Clinic | Devroede G.,Université de Sherbrooke | Hull T.,Cleveland Clinic | And 15 more authors.
Annals of Surgery | Year: 2010

Background: Sacral nerve stimulation has been approved for use in treating urinary incontinence in the United States since 1997, and in Europe for both urinary and fecal incontinence (FI) since 1994. The purpose of this study was to determine the safety and efficacy of sacral nerve stimulation in a large population under the rigors of Food and Drug Administration-approved investigational protocol. Methods: Candidates for SNS who provided informed consent were enrolled in this Institutional Review Board-approved multicentered prospective trial. Patients showing ≥50% improvement during test stimulation received chronic implantation of the InterStim Therapy (Medtronic; Minneapolis, MN). The primary efficacy objective was to demonstrate that ≥50% of subjects would achieve therapeutic success, defined as ≥50% reduction of incontinent episodes per week at 12 months compared with baseline. Results: A total of 133 patients underwent test stimulation with a 90% success rate, and 120 (110 females) of a mean age of 60.5 years and a mean duration of FI of 6.8 years received chronic implantation. Mean follow-up was 28 (range, 2.2-69.5) months. At 12 months, 83% of subjects achieved therapeutic success (95% confidence interval: 74%-90%; P < 0.0001), and 41% achieved 100% continence. Therapeutic success was 85% at 24 months. Incontinent episodes decreased from a mean of 9.4 per week at baseline to 1.9 at 12 months and 2.9 at 2 years. There were no reported unanticipated adverse device effects associated with InterStim Therapy. Conclusion: Sacral nerve stimulation using InterStim Therapy is a safe and effective treatment for patients with FI. Copyright © 2010 by Lippincott Williams & Wilkins.


Machlenkin S.,Ben - Gurion University of the Negev | Pinsk I.,Ben - Gurion University of the Negev | Tulchinsky H.,Tel Aviv Sourasky Medical Center | Ziv Y.,Tel Aviv University | And 4 more authors.
Colorectal Disease | Year: 2011

Aim: The study aimed to characterize the pathological and clinical response of rectal gastrointestinal stromal tumours (GISTs) to neoadjuvant Imatinib. Method: The medical records of patients with rectal GISTs who were diagnosed and treated in five medical centres in Israel between January 2002 and January 2009 were retrospectively examined. Twelve patients who fulfilled the inclusion criteria of nonmetastatic rectal GIST for which preoperative neoadjuvant treatment with Imatinib was considered were suitable for enrollment. Results: Of the 12 patients, nine received neoadjuvant treatment with Imatinib. The three patients who had immediate surgery were excluded. There were five men and four women with a median age of 63years and a median follow up of 32months. All tumours were located in the lower two-thirds of the rectum. One patient had a complete clinical response, six had a partial response and two had stable disease. Seven patients subsequently underwent surgery; six had an R0 resection and one had an R1 resection. Three patients had recurrence. There was no disease-related mortality. The reduction in both tumour size and mitotic activity during preoperative Imatinib therapy was significant. Conclusion: Preoperative Imatinib therapy can shrink large rectal GISTs, improving the chances of successful radical surgery and decreasing the risk of considerable morbidity. © 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.


Vather R.,University of Auckland | Josephson R.,University of Auckland | Jaung R.,University of Auckland | Kahokehr A.,University of Auckland | And 3 more authors.
Annals of Surgery | Year: 2015

Objective: To investigate the therapeutic value of Gastrografin in shortening duration of prolonged postoperative ileus (PPOI) after elective colorectal surgery. Background: Gutwall edema is central to the pathogenesis of PPOI.Hyperosmotic, orally administered, water-soluble contrast media such as Gastrografin are theoretically capable of mitigating this edema. Methods: A double-blinded, placebo-controlled, randomized trial was conducted. Participants were allocated to receive 100 mL of Gastrografin (Exposure Group) or flavored distilled water (Control Group) administered enterally. Other aspects of management were standardized. Resolution of PPOI was assessed 12-hourly. Results: Eighty patients were randomized equally, with 5 in the Exposure Group and 4 in the Control Group excluded from analysis. Participants were evenly matched at baseline. Mean duration of PPOI did not differ between Exposure and Control Groups (83.7 vs 101.3 hours; P=0.191).When considering individual markers of PPOI resolution, Gastrografin did not affect time to resolution of nausea and vomiting (64.5 vs 74.3 hours; P = 0.404) or consumption of oral diet (75.8 vs 90.0 hours; P = 0.297). However, it accelerated time to flatus or stool (18.9 vs 32.7 hours; P = 0.047) and time to resolution of abdominal distension (52.8 vs 77.7 hours; P = 0.013). There were no significant differences between groups in nasogastric output; analgesia, antiemetic, or fluid requirement; complications; or length of stay. Conclusions: Gastrografin is not clinically useful in shortening an episode of PPOI characterized by upper and lower gastrointestinal symptoms. It may however be of therapeutic benefit in the subset of PPOI patients who display lower gastrointestinal symptoms exclusively after surgery. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.


Vather R.,University of Auckland | Josephson R.,University of Auckland | Jaung R.,University of Auckland | Robertson J.,University of Auckland | And 2 more authors.
Surgery (United States) | Year: 2015

Background Management strategies for prolonged postoperative ileus (PPOI) are principally conservative and it is therefore valuable to shift attention to prevention. This study aimed to identify prospectively the perioperative risk factors for the development of PPOI and create a tool to predict its occurrence. Methods Patients undergoing elective colorectal surgery at Auckland District Health Board between September 2012 and June 2014 were enrolled. In total, 92 variables were investigated prospectively with uniform application of a standardized definition of PPOI. Logistic regression and area under receiver operating characteristic curves (AUC) were used to generate risk stratification models. Results PPOI occurred in 88 of 327 patients (26.9%). Independent predictors of PPOI were male gender (odds ratio [OR], 3.01), decreasing preoperative albumin (OR, 1.11 per g/L unit), open or converted technique (OR, 6.37 [vs laparoscopic]), increasing wound size (OR, 1.09 [per cm]), operative difficulty (OR, 1.28 [per unit on 10-point Likert scale]), operative bowel handling (OR, 1.38 [per unit on 10-point Likert scale]), red cell transfusion (OR, 1.84 [per unit]), intravenous crystalloid administration (OR, 1.55 [per liter]), and delayed first mobilization (OR, 1.39 [per day]). The I-Score assimilated preoperative and intraoperative variables to generate a score out of 6 with a 7-fold increase in risk from low-risk to high-risk strata and fair predictive capacity (AUC, 0.742; 95% CI, 0.684-0.799). Conclusion Independent predictors for the development of PPOI have been identified prospectively and used to construct a novel risk stratification model. © 2015 Elsevier Inc. All rights reserved.


Marinatou A.,Colorectal Unit | Theodoropoulos G.E.,Colorectal Unit | Karanika S.,Colorectal Unit | Karantanos T.,Colorectal Unit | And 4 more authors.
Diseases of the Colon and Rectum | Year: 2014

Background: Anastomotic leaks after colorectal resections for cancer are a leading cause of postoperative morbidity, mortality, and long hospital stay. Few data exist on the potentially deleterious effect of the anastomotic leaks after proctectomy for cancer on patient health-related quality of life. Objective: The aim of this study was to explore the effect of clinically evident anastomotic leaks on healthrelated quality of life after rectal cancer excision. Design: This is a case-matched study. Settings: This study was conducted in a Greek academic surgical department. Patients: Included were 25 patients undergoing low anterior resection complicated by an anastomotic leak (Clavien classification II, n = 14, and III, n = 11) and 50 patients undergoing low anterior resection with an uncomplicated course. Main Outcome Measures: Health-related quality-of-life data were prospectively collected at fixed assessment time points (baseline, 3, 6, and 12 months postoperatively) by the use of validated questionnaires (Medical Outcomes Study Short Form 36, Gastrointestinal Quality of Life Index, European Organization of Research and Treatment of Cancer Quality of Life Questionnaire-C30, and European Organization of Research and Treatment of Cancer Quality of Life Questionnaire-CR29). Results: "Leak" patients required a longer hospitalization. Although the numbers of initially constructed defunctioning loop ileostomies were not significantly different between cases and controls, "leak" patients were required to remain with a stoma significantly more often at all postoperative assessment time points. No differences were observed in the baseline scores between the 2 groups. Physical function of "leak" patients was significantly worse at all postoperative assessment time points. At 6 and 12 months, their emotional and social function and overall quality- oflife scores were significantly decreased in comparison with the patients with an uncomplicated course. "Leak" patients experienced significantly more "stoma-related problems" and "sore skin" around the stoma site. Limitations: Limited number of patients, restriction of follow-up to the end of the first year, and heterogeneity in terms of the presentation, severity, and management of anastomotic leaks were the limitations of this study. Conclusions: Anastomotic leaks have an adverse effect on postoperative health-related quality of life. © The ASCRS 2014.


Ryan J.,Colorectal Unit | Faragher I.,Colorectal Unit
Colorectal Disease | Year: 2014

Aim: It is recommended that patients with cancer should be managed in the context of a multidisciplinary team (MDT). Alternatively, proponents of the standard model of care propose that the well-informed treating doctor is able to make the appropriate plan for each patient, making the need for a MDT meeting redundant. We compared the management plans made within a colorectal cancer MDT with routine care. Method: Consecutive cases presenting to the colorectal MDT were prospectively assessed. Before the meeting management plans were made, based on routine care pathways. These were compared with plans made at the MDT meeting and discrepancies recorded. The number of patients who generated beneficial discussion was recorded. Results: There were 261 discussions regarding the care of 197 patients. In the 203 cases where the pathways were relevant, patient management was consistent with the pathway in 94% of the cases discussed. Discussion of routine cases of colon cancer rarely changed management (3.4%). Conversely, management changed after MDT discussion in 50% of complex cases (the preoperative management of rectal cancer, recurrence, metastatic disease and malignant polyps). The postoperative discussion of pathology findings rarely generated beneficial discussion. Conclusion: Discussion of routine cases of colon cancer in our MDT rarely changed management, but it did change the decisions regarding complex cases or in patients with unusual pathology. We propose a two-tiered approach to the MDT where all patients are listed for a MDT meeting but only patients with complex pathology are discussed in detail. © 2014 The Association of Coloproctology of Great Britain and Ireland.


Anastomotic leaks after colorectal resections for cancer are a leading cause of postoperative morbidity, mortality, and long hospital stay. Few data exist on the potentially deleterious effect of the anastomotic leaks after proctectomy for cancer on patient health-related quality of life. The aim of this study was to explore the effect of clinically evident anastomotic leaks on health-related quality of life after rectal cancer excision. This is a case-matched study. This study was conducted in a Greek academic surgical department. Included were 25 patients undergoing low anterior resection complicated by an anastomotic leak (Clavien classification II, n = 14, and III, n = 11) and 50 patients undergoing low anterior resection with an uncomplicated course. Health-related quality-of-life data were prospectively collected at fixed assessment time points (baseline, 3, 6, and 12 months postoperatively) by the use of validated questionnaires (Medical Outcomes Study Short Form 36, Gastrointestinal Quality of Life Index, European Organization of Research and Treatment of Cancer Quality of Life Questionnaire-C30, and European Organization of Research and Treatment of Cancer Quality of Life Questionnaire-CR29). "Leak" patients required a longer hospitalization. Although the numbers of initially constructed defunctioning loop ileostomies were not significantly different between cases and controls, "leak" patients were required to remain with a stoma significantly more often at all postoperative assessment time points. No differences were observed in the baseline scores between the 2 groups. Physical function of "leak" patients was significantly worse at all postoperative assessment time points. At 6 and 12 months, their emotional and social function and overall quality-of-life scores were significantly decreased in comparison with the patients with an uncomplicated course. "Leak" patients experienced significantly more "stoma-related problems" and "sore skin" around the stoma site. Limited number of patients, restriction of follow-up to the end of the first year, and heterogeneity in terms of the presentation, severity, and management of anastomotic leaks were the limitations of this study. Anastomotic leaks have an adverse effect on postoperative health-related quality of life.


Peitsidou K.,Colorectal Unit | Karantanos T.,Colorectal Unit | Theodoropoulos G.E.,Colorectal Unit
Digestive Surgery | Year: 2012

Background/Aims: Pro-/pre-/synbiotics supplementation seems to provide beneficial effects in various aspects of abdominal pathology. Skepticism exists with respect to their effects on colorectal cancer (CRC) patients. This review presents the potential clinical applications of pro-/pre-/synbiotics in CRC surgery. Methods: A literature search of electronic databases was conducted and all studies published on 'probiotics', 'prebiotics' and 'synbiotics' were collected. Among them, the ones referring to CRC and which had any clinical relevance offering information on perioperative parameters were used. Results: Incorporation of pre-/pro-/synbiotic formulations in the preoperative mechanical bowel preparation cannot be supported by the current evidence. Limited clinical studies may be promising in supporting their potentially protective role against postoperative infectious complications. Encouraging are the results on their protective role against adjuvant (chemo)radiation-induced diarrhea. Such supplementation may also hold promise to improve postcolectomy gastrointestinal related quality of life. Conclusions: Despite the positive results and plethora of agents, bacterial combinations and concentrations, the inconsistency in administration, the inhomogeneity of comparison groups and lack of stringent clinical endpoints remain obstacles in the effort to establish a definitive clinical strategy at this time. Further work is warranted to gain a keen understanding of their clinical value in CRC patients. © 2012 S. Karger AG, Basel.


Theodoropoulos G.E.,Colorectal Unit | Karantanos T.,Colorectal Unit | Stamopoulos P.,Colorectal Unit | Zografos G.,Colorectal Unit
Techniques in Coloproctology | Year: 2013

Background: The aim of the present study was to prospectively determine health-related quality of life (HRQoL) changes and affecting factors after elective laparoscopic colectomy for cancer. Methods: The SF-36, EORTC QLQ-C30 and QLQ-CR29, and Gastrointestinal Quality of life Index (GIQLI) were used to assess 85 patients preoperatively and at 1, 3, 6, and 12 months. Results: An initial drop form baseline values was observed in 3 of 8 SF-36 domains, 3 of 5 QLQ-C30 functional scales and 1 of 5 GIQLI subscales. Emotional functioning (EF) was better postoperatively even from the first month (p = 0.03). Most functional domains were improved compared to baseline. The statistically significant changes (p<0.05) were in the SF-36: general health (GH) (3 months), physical function (PF) (12 months) and role limitations due to emotional problems (12 months); in the QLQ-C30: EF (12 months); in the GIQLI: the global score and PF at 12 months and EF (3, 6, 12 months). From the first month after surgery, most QLQ-C30 "symptom" items were better than baseline. QLQ-CR29 "anxiety" and the "defecation problems" scales were significantly better than baseline at 1, 12 and at 6, 12 months (p<0.05). Advanced stage (III) and chemotherapy were linked to worse EF, social function (SF), GH and global quality of life (QOL) at 3 and 6 months (p<0.01). Males appeared to have a worse HRQoL than females at 3 and 6 months, and in 5 of 8 SF-36 domains and 3 of 5 GIQLI subscales at 12 months (p<0.05). According to the QLQ-CR29, rectal surgery was associated more often with "impotence," "stoma problems" and " incontinence" up to 6 months, and ostomies with "embarrassment" and "stoma problems" (p<0.05). Conclusions: HRQoL generally improved over the first year after laparoscopic colectomy reaching even better levels than before surgery. There was an early postoperative improvement in patients' emotional status. The main factors affecting HRQoL seem to be tumor stage, chemotherapy and male sex. © Springer-Verlag 2012.

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