Janindra Warusavitarne

St. Mark's Hospital · colorectal surgery

Background Crohn’s disease (CD) affecting the upper gastrointestinal (GI) tract is a rare condition, leading to a scarcity of information regarding its diagnosis, surgical treatment, and adjuvant therapy. The JUICE study aimed to conduct a surgical audit of duodeno-jejuno-ileal CD across 11 European IBD Referral Centres. Methods The study included...

Background Recent evidence challenges the current standard of offering surgery to patients with ileocecal Crohn’s disease only when they present complications of the disease. Methods A retrospective, multicenter comparative analysis was performed including patients operated for primary ileocecal CD at 12 referral centers. Patients were divided in...

Background: In the last decades, several surgical approaches have been proposed to treat hemorrhoids. Objective: This multicenter study aims to compare transanal hemorrhoidal artery ligation and conventional excisional hemorrhoidectomy for grade III hemorrhoidal disease. Design: Multicenter retrospective study. Settings: Any center belonging...

Background Management of spontaneous intra-abdominal abscess in patients with Crohn’s disease (IAA) with radiologically guided percutaneous drainage (PD) was debated. Method This is a secondary analysis from a multi-centre, retrospective cohort study of all the patients with CD who underwent PD followed by surgery at 19 international tertiary cent...

Background and aims: Inflammatory Bowel Disease colitis-associated dysplasia is managed with either enhanced surveillance and endoscopic resection or prophylactic surgery. The rate of progression to cancer after a dysplasia diagnosis remains uncertain in many cases and patients have high thresholds for accepting proctocolectomy. Individualised dis...

Aim Single-staged abdominal wall reconstruction (AWR) with simultaneous enterocutaneous fistula (ECF) repair is safe. This study aims to evaluate short-term outcomes from AWR with ECF repair and compare short-term outcomes between two commonly used acellular dermal matrices (ADM) as well as suture repair alone, with focus on ECF recurrence. Method...

Background: Robotic-assisted surgery (RAS) offers improved visualisation and dexterity compared to laparoscopy. As a result, RAS is considered an attractive option for performing rectopexy, particularly in the confines of the lower pelvis. The aim of this study was to explore the benefits of RAS in rectopexy by analysing the views of a group of su...

Purpose The likelihood of a stoma following ileocolic resection (ICR) for Crohn’s disease (CD) is an important consideration. This study aims to identify the factors associated with an increased likelihood of a stoma and develop a predictive scoring system (SS). Methods Patient data were collected from St. Marks Hospital, London, UK and Humanitas...

Background Diagnosing anal incontinence (AI) based on manometry results is challenging due to the variation of the normal values and overlap between patients with and without AI. This study aimed to perform a systematic review on the difference in sphincter fatigability between patients with and without AI. Methods MEDLINE, EMBASE, SCOPUS, and Goo...

Perianal fistulising Crohn's disease is an aggressive disease phenotype that can have a substantial detrimental impact on patients' quality of life. Current biological understanding of perianal fistulising Crohn's disease remains inadequate and previous classification systems have not provided clear guidance on therapy in clinical practice nor on d...

Background Perianal fistulising Crohn’s disease (CD) is an aggressive disease phenotype that can have a significant impact on patients’ quality of life. Current biological understanding of perianal fistulising CD remains inadequate and previous classification systems have not provided clear guidance on therapy in clinical practice nor on defining p...

Perianal fistulizing Crohn's disease (PFCD) represents a challenging and complex disease phenotype. Patients typically suffer a more severe disease course than those without perianal complications and are often managing debilitating symptoms. Etiology is understood to be multifactorial, with genetic predisposition, microbiological insult, aberrant...

Background and Aims Crohn’s Disease increases colorectal cancer risk, with high prevalence of synchronous and metachronous cancers. Current guidelines for colorectal cancer in Crohn’s Disease recommend pan-proctocolectomy. Aim of this study was to evaluate oncologic outcomes of a less invasive surgical approach. Methods Retrospective database anal...

Fistula laser closure (FiLaC) is a relatively new sphincter-sparing technique in fistula surgery that was initially reported in 2011. It involves the radial dissipation of laser energy in the fistula tract and, through a combination of coagulation and shrinkage of the tract, is proposed to result in progressive sealing of fistulas. Early studies ha...

Background In patients with active Crohn’s disease (CD), treatment of intra-abdominal abscess usually comprises antibiotics and radiologically guided percutaneous drainage (PD) preceding surgery. The aim of this study was to investigate the risk of postoperative complications and identify the optimal time interval for surgical intervention after PD...

Background Retrorectal masses are abnormalities located anatomically in the retrorectal space. A significant proportion are asymptomatic with no malignant potential while others cause symptoms due to mechanical pressure or malignant infiltration. We reviewed and categorised the retrorectal masses encountered over a thirty-year time period in a spec...

Background and aims: Few recent studies focus on the treatment of rectal cancer in patients with ulcerative colitis. We report treatment options and results for this subset of patients with a multimodal approach at two European referral centers. Methods: Ulcerative colitis patients diagnosed with rectal cancer arising at less than 15 cm from the...

Purpose The Ventral Hernia Working Group (VHWG) classification of ventral/incisional hernia (IH) was developed by expert consensus in 2010. Subsequently, Kanters et al. have demonstrated the validity of a modified version of the system for predicting short-term outcomes. This study aims to evaluate the modified system for predicting hernia recurren...

A correction to this paper has been published: https://doi.org/10.1007/s00384-021-03942-6

Aim Surgery is indicated in selected patients with inflammatory bowel disease (IBD). However, due to a negative perception, surgery may be delayed leading to possible unfavourable outcomes. We investigate patients’ perception of surgery and its impact on patients’ reported outcomes. Methods An international multilingual online survey queried IBD p...

Purpose: To define the change in Emergency Surgical Unit (ESU) workload during the COVID-19 pandemic. Methods: Patient data for a three-week period was prospectively collected for ESU patients during lockdown period and compared to the ESU workload for the same time period prior to lockdown. Results: Surgical emergencies admissions reduced by...

Aim The aim of this work was to determine the factors associated with poor wound healing in patients with perianal Crohn's disease (pCD) who had undergone proctectomy in the era of biologic therapies. Method Case record review was performed on 103 patients with pCD who underwent proctectomy at St Mark's Hospital, Harrow and the Western General H...

Objective Patients with ulcerative colitis (UC) diagnosed with low-grade dysplasia (LGD) have increased risk of developing advanced neoplasia (AN: high-grade dysplasia or colorectal cancer). We aimed to develop and validate a predictor of AN risk in patients with UC with LGD and create a visual web tool to effectively communicate the risk. Design...

Background Joint medical-surgical inflammatory bowel disease clinics allow simultaneous patient assessment by both a gastroenterologist and surgeon. However, patient perceptions of dual clinician presence have not been adequately assessed. Therefore, this study aimed to evaluate the patient's view of receiving multidisciplinary care in this clinic....

Background Literature regarding monoclonal antibodies and increased postoperative complications in inflammatory bowel disease remains controversial. No study has investigated tofacitinib. We sought to determine preoperative exposure to small molecule inhibitors, tofacitinib, and postoperative outcomes. Methods A retrospective review of all adult p...

Background Assessment of the entire small bowel is advocated during Crohn’s disease (CD) surgery, as intraoperative detection of new lesions may lead to change in the planned procedure. The aim of this study was to evaluate the inter-observer variability in the assessment of extent and severity of CD at the small bowel laparoscopic “walkthrough”.Me...

Introduction To explore the reported variability in the surgical management of ileocolonic Crohn’ s disease and identify areas of standard practice, we present this study which aims to assess how different colorectal surgeons with a subspecialty interest in inflammatory bowel disease (IBD) surgery may act in different clinical scenarios of ileocolo...

Aims: Many factors influence the postoperative length of stay (LOS) in Crohn's disease (CD). This study aims to identify the factors associated with a prolonged LOS after ileocolic resection (ICR) for CD and develop a scoring system (SS) to predict the post-operative LOS in CD. Methods: Patient data were collected from St. Marks Hospital, London...

Introduction Anti-TNF therapy is recommended as treatment for patients with Crohn´s perianal fistulas. However, a significant proportion of patients have a sub-optimal response to anti-TNF therapy. Higher serum levels of anti-TNF agents have been associated with improved outcomes in perianal Crohn’s disease. Currently, it is unknown whether anti-TN...

Introduction Anti-TNF therapy is recommended as treatment for patients with Crohn´s perianal fistulas. However, a significant proportion of patients have a sub-optimal response to anti-TNF therapy. Higher serum levels of anti-TNF agents have been associated with improved outcomes in perianal Crohn’s disease. Currently, it is unknown whether anti-...

Background: Anal inserts and percutaneous tibial nerve stimulation may be offered to those with fecal incontinence who have failed other conservative treatments. Objective: We aimed to compare anal inserts and percutaneous tibial nerve stimulation. Design: This was an investigator blinded randomized pilot study. Settings: The study was condu...

Introduction Crohn’s perianal fistulas are challenging for patients and clinicians. Many do not respond to available treatments and despite recommendations by a global consensus, there are currently no specific patient-derived quality of life tools to measure response to treatment. We present a new validated patient-reported outcome measure (PROM)...

Aims In cases of prognostic uncertainty and equipoise as to the best management (prophylactic colectomy vs. surveillance) for dysplasia in inflammatory bowel disease (IBD), individualised discussion with the patient is required. Further understanding of patients’ preferences is needed. Methods A nationwide cross‐sectional survey was distributed...

Introduction: Few studies have investigated perianal fistula etiopathogenesis, and although the cryptoglandular theory is widely accepted in idiopathic cases, in Crohn's disease, it is thought to involve the interplay between microbiological, immunological and genetic factors. A pilot study was conducted to assess for metabolic variations in Crohn...

Crohn's disease is increasingly thought to encompass multiple possible phenotypes. Perianal manifestations account for one such phenotype and represent an independent disease modifier. In its more severe form, perianal Crohn's disease confers a higher risk of a severe and disabling disease course, relapses, hospital admissions and operations. This,...

Perianal manifestations of Crohn’s disease constitute a distinct disease phenotype commonly affecting patients and conferring an increased risk of disability and disease burden. Much research has gone into management of fistulising manifestations, with biological therapy changing the landscape of treatment. In this article, we discuss the up-to-dat...

Purpose: Restorative proctocolectomy (RPC) with ileal pouch anal anastomosis (IPAA) is the procedure of choice in patients with ulcerative colitis (UC) refractory to medical therapy. The aim of IPAA surgery in UC is to improve quality of life for patients but ‘good’ pouch function is not always achieved. This study will be the first to longitudinal...

Background Short-term outcomes for patients undergoing contaminated complex abdominal wall reconstruction (CCAWR), including risk stratification, have not been studied in sufficiently high numbers. This study aims to develop and validate risk-stratification models for Clavien–Dindo (CD) grade ≥ 3 complications in patients undergoing CCAWR.MethodsA...

Background and Aims Double balloon enteroscopy (DBE) has revolutionised the diagnosis and treatment of small bowel (SB) conditions. However, deep SB insertion can be challenging in patients with a history of abdominal surgery and a two-step procedure is required when findings are not amenable to endoscopic therapy. This case series reports the deve...

PurposeComplex abdominal wall repair (CAWR) in a contaminated operative field is a challenge. Available literature regarding long-term outcomes of CAWR comprises studies that often have small numbers and heterogeneous patient populations. This study aims to assess long-term outcomes of modified-ventral hernia working group (VHWG) grade 3 repairs. B...

Background The LIR!C trial showed that laparoscopic ileocaecal resection is a cost-effective treatment that has similar quality-of-life outcomes to treatment with infliximab, an anti-tumour necrosis factor (TNF) drug. We aimed to compare long-term outcomes of both interventions and identify baseline factors associated with the duration of treatment...

Aim To provide dynamic guidance from a rigorous and up‐to‐date consensus on the safe implementation and application of TaTME from an international panel of expert surgeons and educationalists supported by 14 international surgical societies. Method An adapted Delphi method and focus group discussion approach was implemented for this consensus proc...

Introduction The prognosis of dysplasia in patients with IBD is largely determined from observational studies from the pre‐videoendoscopic era (pre‐1990s) that does not reflect recent advances in endoscopic imaging and resection. Aims To better understand the risk of synchronous colorectal cancer and metachronous advanced neoplasia (ie high‐grade...

Background and aims: There is no consensus on the best management of the rectum after subtotal colectomy for refractory colitis complicating inflammatory bowel disease (IBD).The objective was to evaluate the impact of rectal stump management during laparoscopic subtotal colectomy (LSTC) for IBD. Methods: Patients who underwent LSTC with double-e...

Aim: Anorectal physiology tests provide a functional assessment of the anal canal. The aim of this study was to compare the results generated by the standard high-resolution water perfused manometry (WPM) with the newer THD® Anopress manometry system. Method: This was a prospective observational study. Conventional manometry was carried out usin...

Background The development of peri-anal fistula mucinous adenocarcinoma (MA) is a presumed rare but recognised event in patients with fistulating peri-anal Crohn’s disease. The true incidence is unknown, with a lack of robust registry data. Fistula mucinous cancers may evade early diagnosis, presenting with locally advanced intra-pelvic disease, ne...

Background Anti-TNF therapy is recommended as a treatment for patients with Crohn ́s perianal fistulas. However, a significant proportion of patients have a sub-optimal response to anti-TNF therapy. Higher serum levels of anti-TNF agents have been associated with improved outcomes in perianal Crohn’s disease. Currently, it is unknown whether anti-T...

Background The reasons why fistulas originate have been explained in idiopathic cases, with the cryptoglandular theory being widely accepted; however, in Crohn ́s disease, it is thought to involve interplay between microbiological, immunological and genetic factors. It remains unclear why fistulas persist. Novel investigative tools in systems biolo...

Background Current evidence demonstrates that anti-TNF therapies lead to clinical response rates >50% have been reported in the short-term. These remission rates decrease to about a third of patients who initially achieved remission, after three years. Options are limited in cases refractory to biologic therapy, and there is limited knowledge of di...

Background There is no consensus about the most appropriate management of rectal stump in laparoscopic subtotal colectomy (STC) performed for inflammatory bowel disease (IBD). The objective is to report our experience of laparoscopic STC with double-end ileosigmoidostomy in the right iliac fossa for IBD. Methods All patients undergoing laparoscopi...

This article is the second in a series of two publications relating to the European Crohn's and Colitis Organisation [ECCO] evidence-based consensus on the management of Crohn's disease. The first article covers medical management; the present article addresses surgical management, including preoperative aspects and drug management before surgery....

Aim: Temporary faecal diversion after ileocolic resection for Crohn's disease reduces postoperative anastomotic complications in high-risk patients. The aim of this study was to assess if this approach also reduces long-term surgical recurrence. Method: Multicentre retrospective review of prospectively maintained databases. Patient demographics,...

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 ana...

Objective: The aim of this study was to develop an objective and reliable surgical quality assurance system (SQA) for COLOR III, an international multicenter randomized controlled trial (RCT) comparing transanal total mesorectal excision (TaTME) with laparoscopic approach for rectal cancer. Background of summary data: SQA influences outcome meas...

Abstract 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+...

Background: The interest and adoption of transanal total mesorectal excision (TaTME) is growing worldwide, but evidence on nationwide implementation and short-term outcomes is scarce. This study aims to evaluate national results for this relatively new technique in the UK. Methods: All TaTME procedures performed in the UK and recorded on the int...

Introduction: This study aims to determine the prevalence of incisional hernia (IH) and enterocutaneous fistula (ECF) in patients with intestinal failure (IF) referred to a tertiary centre and attempt to identify factors associated with their development. Methods: A retrospective case note review was undertaken of a prospectively maintained data...

Introduction About 20% patients with perianal Crohn’s (pCD) undergo proctectomy with a significant number developing unhealed wounds. The purpose of this study was to determine factors which may be associated with poor wound healing in patients with pCD who had undergone proctectomy in the biologics era. Methods Case record review was carried out...

Sir Alan Parks in 1978 described the first case series of proctocolectomy with ileal-pouch creation [1]. The purpose of the procedure was to remove all disease-prone mucosa in ulcerative colitis (UC) while maintaining intestinal continuity [1]. Of the two main surgical methods of forming ileal pouches, the double-stapled (DS) method may have advant...

Fistulising perianal Crohn’s disease (pCD) is an aggressive phenotype and patients not only suffer with perianal manifestations but also a worsening course for their luminal disease. This article describes the 6 key steps clinicians need to consider when managing patients with pCD which include; (i) ensuring a prompt diagnosis, (ii) multi-disciplin...

Despite significant advances in medical and surgical therapy for perianal fistulas in Crohn's disease (CD), treatment results are still modest, and a specific need for more effective therapies is a reality. Darvadstrocel is composed of expanded human allogeneic mesenchymal adult stem cells extracted from adipose tissue and constitutes the first ste...

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 (T...

Background Consensus guidelines emphasise the importance of multi-disciplinary team driven care for patients with complex Crohn’s disease (CD). There are, however, no clear definitions of complex ileocolonic CD beyond the presence or absence of preoperative intra-abdominal sepsis. This study aims to develop a staging instrument (The St Mark’s – Ams...

Background Uncertainty in inflammatory bowel disease (IBD) dysplasia prognosis makes management decision-making challenging. Further understanding of patient preferences is required to help clinicians support this process. Methods A web survey, evaluating views on dysplasia, was administered via IBD charity social media in November 2018, to UK IBD...

Background Transanal minimally invasive proctectomy (TaMIP) has some advantages particularly in relation to access to the deep pelvis. Key challenges faced with the TaMIP approach for proctectomy in Crohn’s disease are the diseased pelvis and inflamed, bulky mesorectum causing difficult planes. This study aims to assess the short-term outcomes and...

Background The purpose of this study was to determine factors which may be associated with poor wound healing in patients with perianal Crohn’s disease (pCD) who had undergone proctectomy in the biologics era. Methods Case record review was carried out of 79 patients with pCD who underwent proctectomy at St Mark’s Hospital, Harrow between 2005 and...

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 transabdomin...

Complex perianal fistulas can be difficult for surgeons and especially trainees to understand. For complex disease, MRI is the current gold standard facilitating identification of the primary tract/extensions and guiding the operative decision process. Conceptualisation of the images or even understanding the reports can be challenging.. 3D models...

Minimally invasive surgery for ileoanal pouch creation is associated with many advantages. Some of these are general to colorectal resections but some such as improved fecundity are unique to the ileoanal pouch. There is a learning curve attached to minimally invasive ileoanal pouch surgery and this chapter aims to discuss technical issues relating...

Follow-up and surveillance of the Kock pouch, also known as the Kock continent ileostomy, is determined by the initial indication for the pouch. Kock pouch formation is considered an option to improve a patient’s quality of life, and the indications for the pouch are usually similar to those for an ileoanal pouch. The frequency of Kock pouch creati...

This book gives a comprehensive overview of surgery that results in creating an ileoanal pouch or continent ileostomy. It deals with the entire journey of pouch surgery starting from patient selection and counselling to technical tips and tricks and ending in managing pouch function and failure. Containing a patient experience section this volume h...

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 i...

Background: THD® Anopress has been promoted as a new portable anal manometer providing measurements of whole anal canal pressures. This study aims to report the anorectal function of patients suffering from Faecal Incontinence (FI) using this new device and the associated patient comfort. Methods: We reviewed data from patients suffering from FI wh...

Aim There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. Methods Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections o...

Transanal minimally invasive surgery is a rapidly evolving platform surgery that is facilitating the transanal approach to colorectal surgery. Over the years since its initial description, the applications have widened and now include endoluminal and extraluminal approaches to rectal and pelvic surgery. This article discusses the various applicatio...

Background Consensus guidelines emphasise the importance of multidisciplinary team driven care for patients with complex Crohn's disease. There are, however, no clear definitions of complexity beyond the presence or absence of pre-operative intra-abdominal sepsis. This study aims to develop a staging instrument (The St Mark's-Amsterdam tool) for co...

Background: The characteristics of patients who develop a fistula-in-ano after an anorectal abscess are unclear. Objective: Our study explored this relationship and patient factors associated with fistula development. Design: International Classification of Diseases, 10 Revision, and Classification of Interventions and Procedures, version 4, c...

Introduction: The pathogenesis of perianal fistulas is poorly understood. The reasons why fistulas originate have been explained in idiopathic cases, with the cryptoglandular theory being widely accepted. However, in Crohn’s disease, it is thought to involve interplay between microbiological, immunological and genetic factors. It remains unclear wh...