Seminars in Colon & Rectal Surgery RSS feed: Current Issue. Seminars in Colon and Rectal Surgery offers a comprehensive and coordinated review of a single, timely topic related to the diagnosis and treatment of proctologic diseases. Each issue is an organized compendium of practical information that serves as a lasting reference for colorectal surgeons, general surgeons, surgeons in training and their colleagues in medicine with an interest in colorectal disorders. 2010 Topics March Pelvic Floor Evaluation Tracy Hull June Reducing Morbidity Warren Enker http://www.seminarscolonrectalsurgery.com/?rss=yesElsevier Inc.en © 2012 Elsevier Inc. All rights reserved. Seminars in Colon & Rectal Surgery1043-1489232June 2012 © 2012 Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.seminarscolonrectalsurgery.com/article/PIIS104314891200019X/abstract?rss=yesSurgeons remain the sole treating physicians competently able to manage acute appendicitis and gunshot wounds. Most abdominal conditions, however, are now treated not only by surgeons but also with a team of physicians including gastroenterologists and radiologists. The next two editions of Seminars in Colon and Rectal Surgery will fully demonstrate how the management of patients with inflammatory bowel disease is influenced by a variety of physicians, from surgeons to gastroenterologists to radiologists. Articles in the first volume are generally organized into areas of major concern in modern inflammatory bowel disease surgery, specifically how surgical outcomes are influenced by serologic markers, genetic factors and aggressive preoperative medical therapies, management of dysplasia, and appropriate therapy of the emerging issue of Clostridium difficile superinfection. The second volume will examine contrasting views of gastroenterologists and surgeons on the outcomes of surgery for Crohn's disease and ulcerative colitis. In addition, the controversy surrounding laparoscopic surgery and ileal pouch surgery for indeterminate colitis and Crohn's disease are addressed.IntroductionPhillip Fleshner10.1053/j.scrs.2012.02.001Seminars in Colon & Rectal Surgery 23, 2 (2012)2012-06-01Seminars in Colon & Rectal Surgery2012-06-01232S1043-1489(11)X0007-6Inflammatory Bowel Disease: Part 14343http://www.seminarscolonrectalsurgery.com/article/PIIS1043148912000206/abstract?rss=yes The relatively recent discoveries of >100 genes potentially involved with the etiology of inflammatory bowel disease (IBD) have stimulated intense research. The study of the pathophysiologic consequences of defects in these genes and the potential for a more careful classification of IBD patients based on genotype are two evolving benefits of this newfound knowledge. However, the use of such genetic information in the clinical care of IBD patients, especially in the surgical field, has lagged. There are many unresolved surgical issues in IBD management that hold hope for improvement through the use of genetic information in the individual patient. This includes, for example, identifying Crohn's disease patients at increased risk for recurrence after surgery to institute earlier prophylactic measures or maximize the use of bowel length preserving procedures. In the case of ulcerative colitis, genetics may help in preoperative patient selection by predicting which patients might suffer from severe pouchitis or pouch-threatening complications, such as fistuli or strictures. Similarly, the imperfect ability of colonoscopy to identify colitic patients who develop cancer may be solved by genetic markers that would predict malignant degeneration and so allow more effective prophylactic surgery. The Role of Genetics in the Surgical Management of Inflammatory Bowel DiseaseTara M. Connelly, Walter A. Koltun10.1053/j.scrs.2012.02.002Seminars in Colon & Rectal Surgery 23, 2 (2012)2012-06-01Seminars in Colon & Rectal Surgery2012-06-01232S1043-1489(11)X0007-6Inflammatory Bowel Disease: Part 14450http://www.seminarscolonrectalsurgery.com/article/PIIS1043148912000218/abstract?rss=yes Imaging studies play a critical role in the diagnosis and evaluation of patients with known or suspected inflammatory bowel disease. Historically, conventional barium small-bowel follow-through or enteroclysis was used in the evaluation of suspected or newly diagnosed IBD. However, they continue to have a declining role, supplanted by more revealing and sensitive cross-sectional imaging techniques. Computed tomography enterography and magnetic resonance enterography are currently the primary modalities for imaging luminal as well as extraluminal disease. Ultrasound with Doppler evaluation is widely used in some centers. Positron emission tomography scanning is currently an investigative tool in IBD. These modalities are of value in establishing the diagnosis, assessing the extent, activity, and severity of disease, monitoring therapeutic response, and identifying complications, which may require change in therapy or surgical intervention. This chapter will review examination techniques and diagnostic findings, performance and limitations of each modality, and highlight their utility in clinical practice. New Imaging Modalities in Inflammatory Bowel DiseaseDalia Artal, Cindy E. Kallman, Rola Saouaf10.1053/j.scrs.2012.02.003Seminars in Colon & Rectal Surgery 23, 2 (2012)2012-06-01Seminars in Colon & Rectal Surgery2012-06-01232S1043-1489(11)X0007-6Inflammatory Bowel Disease: Part 15164http://www.seminarscolonrectalsurgery.com/article/PIIS104314891200022X/abstract?rss=yes The incidence and severity of Clostridium difficile infection (CDI) have more than doubled over the past decade, leading to increased hospitalization rates and length of stay, with significant morbidity and mortality. It is estimated that the financial burden of CDI on the health care system in the United States costs billions of dollars. Recent studies have demonstrated that patients with inflammatory bowel disease (IBD; Crohn's disease, ulcerative colitis) are at an increased risk for developing CDI and experience increased morbidity and mortality, as well as an increased need for emergent colectomy. CDI may mimic an IBD flare, even in patients who have had a colectomy (C difficile enteritis); thus, a high suspicion should be maintained, as prompt diagnosis and treatment have been shown to improve outcomes. Currently, oral metronidazole is the treatment of choice for mild to moderate CDI, with oral vancomycin being reserved for patients with severe CDI. At this time, there are no clear guidelines for treatment of CDI in patients with IBD; prospective randomized control trials are needed. In this article, we summarize the epidemiology, pathogenesis, risk factors, clinical features, and treatment (both medical and surgical) of CDI in patients with IBD. Clostridium difficile in Inflammatory Bowel DiseaseHenry A. Horton, Gil Y. Melmed10.1053/j.scrs.2012.02.004Seminars in Colon & Rectal Surgery 23, 2 (2012)2012-06-01Seminars in Colon & Rectal Surgery2012-06-01232S1043-1489(11)X0007-6Inflammatory Bowel Disease: Part 16569http://www.seminarscolonrectalsurgery.com/article/PIIS1043148912000231/abstract?rss=yes Advances in research in the field of inflammatory bowel disease (IBD) have led to the identification of biological and genetic markers that can assess the natural history and perhaps predict the course of an individual's disease, including response to treatments over time and postoperative course. The ever-expanding genetic and immune discoveries have improved our understanding of the variability in presentation and course in all IBD patients. It will be important moving forward to be able to better classify patients so that appropriate decisions can be made regarding choosing the right treatment for the right patient at the right time. Surgical options also remain an integral part of IBD management, but like with medications, it is important to choose the right surgery for the right patient. Biomarkers in Inflammatory Bowel Disease: What Surgeons Need to KnowMarla C. Dubinsky10.1053/j.scrs.2012.02.005Seminars in Colon & Rectal Surgery 23, 2 (2012)2012-06-01Seminars in Colon & Rectal Surgery2012-06-01232S1043-1489(11)X0007-6Inflammatory Bowel Disease: Part 17074http://www.seminarscolonrectalsurgery.com/article/PIIS1043148912000243/abstract?rss=yes The “surgical” perspective of surveillance in ulcerative colitis can vary depending on whether the surgeon is the primary individual responsible for performing surveillance colonoscopy, or only consulted when dysplasia is identified, or consulted when there is uncertainty regarding the most appropriate clinical care for a given patient. In the former case, issues such as chemoprophylactic medication, timing and frequency of surveillance, choosing the type of colonoscopic imaging, and choosing the pathologist and number of biopsies are important. In the latter situation, it is important to determine the expertise of the referring endoscopist and reviewing pathologist before proceeding. Never decide on surgery without a rereview of the pathology by a specialist gastrointestinal pathologist with experience in inflammatory bowel disease. Also, in choosing the best operation, ensure the adequate biopsies have been performed. For example, before deciding to perform a stapled ileal pouch-anal anastomosis, ensure the rectum has been adequately sampled to exclude the presence of dysplasia before proceeding. Decisions regarding management and surveillance of dysplasia should be weighed with patient age and other risk factors. Surveillance Colonoscopy in Ulcerative Colitis: A Surgical PerspectiveSusan Galandiuk10.1053/j.scrs.2012.02.006Seminars in Colon & Rectal Surgery 23, 2 (2012)2012-06-01Seminars in Colon & Rectal Surgery2012-06-01232S1043-1489(11)X0007-6Inflammatory Bowel Disease: Part 17580http://www.seminarscolonrectalsurgery.com/article/PIIS1043148912000255/abstract?rss=yes For inflammatory bowel diseases (IBD) that include Crohn's disease and ulcerative colitis, only limited therapeutic agents were available until the approval of infliximab in 1998. Since the introduction of the biological agents, which are antibodies to the cytokine tumor necrosis factor (TNF) alpha (anti-TNF), the therapeutic options have changed dramatically. Although side effects may occur, their clinical benefit is impressive and has changed the management and the expectations of treating IBD. Currently, 4 drugs have been approved by the Food and Drug Administration for the treatment of IBD, which include infliximab, adalimumab, certolizumab, and natalizumab. Their side effect profile seems to be safe when the physician follows recommended preventive pathways, including evaluation for hepatitis B and tuberculosis before treatment. There have been few reports about hepatosplenic T-cell lymphoma in young males on combination therapy with thiopurines and anti-TNFs. The risk for infection and malignancy does not seem to be increased. Natalizumab gained a negative reputation because of cases of progressive multifocal leukoencephalopathy. Tests for risk stratification including John Cunningham virus polymerase chain reaction in blood and antibody against John Cunningham virus may identify patients at higher risk for progressive multifocal leukoencephalopathy. Although, improvement of the patient's symptoms used to be the goal of therapy, this has shifted since the availability of anti-TNF therapy to mucosal healing as standard of care. In addition, as monitoring of drug levels and antibodies becomes more available, it will improve safety and efficacy of these agents. Biologic Therapy in Inflammatory Bowel Disease—A Gastrointestinal PerspectiveSebastian Strobel, Maria T. Abreu10.1053/j.scrs.2012.02.007Seminars in Colon & Rectal Surgery 23, 2 (2012)2012-06-01Seminars in Colon & Rectal Surgery2012-06-01232S1043-1489(11)X0007-6Inflammatory Bowel Disease: Part 18188http://www.seminarscolonrectalsurgery.com/article/PIIS1043148912000267/abstract?rss=yes The decision to proceed with surgery in an inflammatory bowel disease (IBD) patient is ideally a collaborative effort between the patient, gastroenterologist, and surgeon. Unlike emergency situations where surgery is required to address significant complications of the underlying disease, either ulcerative colitis (UC) or Crohn's disease (CD), elective cases often allow optimizing patient or disease factors in an attempt to improve surgical outcomes. Numerous factors contribute to success after IBD surgery. A detailed description of the pre-, intra-, and postoperative patient and procedure-specific risk factors associated with contributing to or reducing postoperative complications is beyond the scope of this monograph. However, a unique factor often encountered in IBD patients is their long-term immunosuppressive medication use in the perioperative period. They might be on a single agent. However, often they are on multiple medications with different modes of action. In this article, we will review the evidence regarding the impact of immunosuppressive medications commonly used in the treatment of IBD patients with an in-depth consideration of the newer antibody-based therapies. Surgical Outcomes in Inflammatory Bowel Disease Patients and the Potential Impact of Biologic TherapiesRobert R. Cima10.1053/j.scrs.2012.02.008Seminars in Colon & Rectal Surgery 23, 2 (2012)2012-06-01Seminars in Colon & Rectal Surgery2012-06-01232S1043-1489(11)X0007-6Inflammatory Bowel Disease: Part 18993