Ileal-anal pouches: A review of its history, indications, and complications.

The ileal pouch anal anastomosis (IPAA) has revolutionised the surgical management of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Despite refinement in surgical technique(s) and patient selection, IPAA can be associated with significant morbidity. As the IPAA celebrated its 40th anniversary in 2018, this review provides a timely outline of its history, indications, and complications. IPAA has undergone significant modification since 1978. For both UC and FAP, IPAA surgery aims to definitively cure disease and prevent malignant degeneration, while providing adequate continence and avoiding a permanent stoma. The majority of patients experience long-term success, but "early" and "late" complications are recognised. Pelvic sepsis is a common early complication with far-reaching consequences of long-term pouch dysfunction, but prompt intervention (either radiological or surgical) reduces the risk of pouch failure. Even in the absence of sepsis, pouch dysfunction is a long-term complication that may have a myriad of causes. Pouchitis is a common cause that remains incompletely understood and difficult to manage at times. 10% of patients succumb to the diagnosis of pouch failure, which is traditionally associated with the need for pouch excision. This review provides a timely outline of the history, indications, and complications associated with IPAA. Patient selection remains key, and contraindications exist for this surgery. A structured management plan is vital to the successful management of complications following pouch surgery.

Assessment of the efficacy of the rectovaginal button fistula plug for the treatment of ileal pouch-vaginal and rectovaginal fistulas.

BACKGROUND: The treatment of rectovaginal and ileal pouch-vaginal fistulas remains a challenging problem for the colorectal surgeon. The aim of this study was to assess the short-term efficacy of the new Surgisis Biodesign rectovaginal button fistula plug in patients with such fistulas. METHODS: Between May 2008 and September 2008, patients with confirmed rectovaginal and ileal pouch-vaginal fistulas with backgrounds of inflammatory bowel disease were treated with the button fistula plug. The fistulas were assessed by magnetic resonance imaging and/or examination under anesthesia before the procedure. RESULTS: Twelve patients with a median age of 36 (range, 29-42) years underwent a total of 20 plug insertions. Five patients had confirmed rectovaginal fistulas and seven patients had ileal pouch-vaginal fistulas. At a median follow-up of 15 (interquartile range, 10-21) weeks, 7 of 12 patients (58%) had been treated successfully. Seven of the 20 plugs that were inserted (35%) were successful. This equates to the successful treatment of three of five (60%) of the rectovaginal fistulas, and four of seven (57%) of the ileal pouch-vaginal fistulas. Of the six patients who initially failed, a repeat procedure was performed of which one was successful. Two patients underwent a third repeat procedure, which was again unsuccessful in both cases. The success rate of these eight repeat plug insertions was therefore 12.5%. All plug failures were the result of dislodgement of the plug. There was no morbidity in our series. CONCLUSIONS: The new button fistula plug successfully treated 7 of 12 (58%) rectovaginal and ileal pouch-vaginal fistulas.

Acute subarachnoid haemorrhage as a precipitant for takotsubo cardiomyopathy: a case report and discussion.

Takotsubo cardiomyopathy is a recently recognised acute cardiac entity. It involves transient left ventricular apical ballooning, which is usually preceded by an episode of physiological or emotional stress. Its presentation may mimic acute myocardial infarction but there is no evidence of obstructive disease at coronary angiography. The aetiology of this condition has not been clearly defined, though a number of hypotheses have been put forward. Precipitating factors vary widely, including acute medical conditions and emotional stressors. We present a case of takotsubo cardiomyopathy precipitated by acute subarachnoid haemorrhage, the first report of this association in a Caucasian patient, and discuss the implications for clinicians involved in the management of such a case.

The assessment of a rapid noninvasive immunochromatographic assay test for fecal lactoferrin in patients with suspected inflammation of the ileal pouch.

PURPOSE: Pouchitis is a common complication after ileal pouch-anal anastomosis. Diagnosis is based on the Pouch Disease Activity Index, which comprises clinical symptoms, endoscopic appearance, and histologic confirmation. A Pouch Disease Activity Index > or = 7 confirms pouchitis. Fecal lactoferrin is a marker of intestinal inflammation, which can aid in the diagnosis of pouchitis. The IBD EZ VUE test is a simple, rapid, noninvasive test for fecal lactoferrin. Our goal was to study the sensitivity and specificity of this test in the diagnosis of pouchitis. METHODS: Consecutive patients with pouch dysfunction were recruited from October 2005 to July 2006. A fecal sample was collected before calculation of the Pouch Disease Activity Index. An IBD EZ VUE test was performed on each fecal sample and the results correlated with the diagnosis of pouchitis to calculate sensitivity and specificity of the IBD EZ VUE test. RESULTS: There were 32 patients (21 healthy and 11 inflamed pouches). The IBD EZ VUE test was positive in 14 patients. It had a sensitivity of 100 percent and a specificity of 86 percent in diagnosing pouchitis. The positive predictive value was 76 percent. There were three false-positive results. CONCLUSIONS: The IBD EZ VUE test is a sensitive method that may remove the need for invasive pouch investigations and lead to greater confidence when antibiotic therapy is commenced. Further investigations may be reserved for those patients who have a positive lactoferrin test and fail to respond to antibiotic treatment.

Extrusion of metal radiological marker from a total ankle replacement insert: a case report.

Total ankle arthroplasty has become an increasingly performed procedure for the treatment of ankle arthritis. Failures related to polyethylene inserts can result from uncorrected deformities or malalignment of the components. We report a case of a 63-year-old man who underwent total ankle arthroplasty for osteoarthritis of the ankle. The talar component was placed in neutral alignment. Initial postoperative recovery and rehabilitation were unremarkable. At 9 months postoperatively, plain radiographs of the ankle showed worsening varus tilt when compared with radiographs taken earlier. There was also radiographic evidence of separation of the posterior metal marker, suggestive of a fracture of the polyethylene insert. Revision surgery to correct the varus tilt and replace the polyethylene insert was performed. At operation, the polyethylene insert was found to be intact with no evidence of fracture. The posterior metal marker of the polyethylene insert was found to be extruded from the insert. Small degrees of ankle prosthesis malalignment can lead to various degrees of polyethylene liner failure, such as metal marker extrusion. This article also shows that these metal markers may not be accurate indicators of the integrity of the polyethylene insert.