The incidence of inflammatory bowel disease is increasing and despite advances in medical therapy, patients continue to require operations for complications of their disease. Minimally invasive ...surgical options have impacted postoperative morbidity dramatically with reduction of pain, length of stay and adhesion formation, but additionally, this population of patients are not only concerned with successful operative therapy but also the ability to return to their lifestyle and cosmetics. Laparoscopic and robotic surgery for Crohn's disease has proven to benefit patients with ileocolic or colonic disease, however complicated disease with phlegmon, abscess or fistulae is best served with a hybrid approach. Ulcerative colitis treatment has seen advancements with laparoscopic and robotic platforms, however the benefits of minimally invasive surgery must be balanced with producible and durable outcomes.
Total abdominal colectomy with ileorectal anastomosis for Crohn's colitis is acceptable in the presence of a suitable rectum. Intentional IPAA has been proposed for diffuse Crohn's proctocolitis ...without enteric or anoperineal disease.
The aim of this study was to evaluate the long-term outcomes of sphincter-saving procedures for large-bowel Crohn's disease.
Patients with preoperative Crohn's disease diagnosis undergoing intentional IPAA and ileorectal anastomosis were included.
The study was conducted at a tertiary care research center.
Ileorectal anastomosis was performed in 75 patients with Crohn's disease, whereas 32 patients underwent intentional IPAA.
Long-term functional results and permanent stoma requirement of sphincter-saving operations were assessed. Quality of life and postoperative medication use were also compared with a control group of patients undergoing total proctocolectomy and end ileostomy.
Patients undergoing ileorectal anastomosis were older and had longer disease duration, higher prevalence of perianal and penetrating disease, and history of small-bowel resection than those receiving IPAA. Indications for surgery, preoperative use of immunomodulators, and postoperative use of biologics were also significantly different. Although functional defecatory outcomes were comparable, reported quality of life 3 years after surgery was significantly better in patients who underwent IPAA than in patients with ileorectal anastomosis. Patients with IPAA were associated with significantly lower cumulative rates of surgical recurrence (HR = 0.28 (95% CI, 0.09-0.84); p = 0.017), indefinite stoma diversion (HR = 0.35 (95% CI, 0.13-0.99); p = 0.039), and proctectomy with end ileostomy (HR = 0.27 (95% CI, 0.07-0.96); p = 0.030) than those with ileorectal anastomosis.
The study was limited by its retrospective nature and small sample size.
Contemporary patients selected to have intentional IPAA for Crohn's colitis have disease characteristics very different from those selected to have ileorectal anastomosis. Long-term follow-up confirms intentional IPAA as an acceptable option in selected patients with Crohn's colitis.
Long-term consequences of anastomotic leak after restorative proctectomy for rectal cancer, in terms of bowel function and quality of life, have been poorly delineated.
The purpose of this study is ...to evaluate the impact of anastomotic leak, when intestinal continuity can still be maintained, on bowel function and quality of life in patients undergoing rectal cancer resection with low colorectal or coloanal anastomoses.
From 1980 to 2010, 864 patients undergoing restorative resection for rectal cancers were identified from a prospective cancer database. Anastomotic leak detected by a combination of clinical, radiographic, and operative means was diagnosed in 52 (6%) patients.
Patients with anastomotic leak were compared with those without anastomotic leak for functional outcomes and quality of life at 1 year and most recent follow-up (mean 3.2 years) by using Short-Form 36 questionnaires (physical and mental component scales) and the Fecal Incontinence Severity Index.
American Society of Anesthesiologists' class (p = 0.48), cancer stage (p = 0.39), and the use of neoadjuvant therapy (p = 0.4) were similar in the 2 groups. Patients with anastomotic leak were younger (56 years vs 61 years; p = 0.007), more likely to be male (82% vs 64%; p = 0.008), and more likely to have undergone proximal diversion at proctectomy (51.9% vs 26.6%; p = 0.001). One year after proctectomy, patients with anastomotic leak had worse physical and mental component scores (p = 0.01), more frequent daytime (p = 0.001) and nighttime bowel movements (p = 0.03), and worse control of solid stool (p = 0.01) in comparison with those without an anastomotic leak. At most recent follow-up (leak, 3.3 years vs no leak, 2.4 years), patients with an anastomotic leak reported worse mental component scores and increased use of perineal pads.
Anastomotic leak after restorative resection for rectal cancer leads to early adverse consequences on bowel function and quality of life even when anastomotic continuity can be maintained. These findings may help counsel patients and clinicians regarding anticipated outcomes over the long term.
Whether preoperative biological therapy increases postoperative complications after restorative proctocolectomy remains controversial.
This study aims to evaluate the influence of preoperative use of ...biologics on outcomes after restorative proctocolectomy and to assess whether a staged approach modifies any negative influence of these medications.
The study was conducted at a single tertiary institution.
Patients who were operated on for medically refractory ulcerative or indeterminate colitis were identified and classified by initial surgery, whether subtotal colectomy or total proctocolectomy, then categorized into biologics user and nonuser groups. Demographics, perioperative data, postoperative complications, pouch function, and quality of life were collected.
Cumulative 1-year complication rates were estimated by using the Kaplan-Meier curve, and independent predictors for infectious complications were identified by using Cox proportional hazards regression models.
From 2006 to 2010, 407 and 181 patients underwent initial subtotal colectomy with end ileostomy or total proctocolectomy with IPAA. For the 181 patients who underwent total proctocolectomy straightaway, pre- and perioperative data were comparable for biologics users (n = 25) and nonusers (n = 156). Cumulative 1-year pelvic sepsis rate was significantly greater in patients on biologics (32% vs 16%, p = 0.012). Multivariate analysis demonstrated that preoperative anti-tumor necrosis factor therapy (HR, 2.62; p = 0.027) was an independent risk factor for postoperative pelvic sepsis after total proctocolectomy. After subtotal colectomy, no differences occurred in both 30-day and cumulative 1-year postoperative complications between biologics users (n = 142) and nonusers (n = 265). Outcomes were also similar when biologics users (n = 88) and nonusers (n = 164) underwent subsequent completion proctectomy with ileal pouch creation after initial colectomy.
The retrospective nature of this study and physician's preference were limitations.
Preoperative exposure to biologics is associated with an increased risk of pelvic sepsis after total proctocolectomy with IPAA. This risk is mitigated by the performance of an initial subtotal colectomy.
Purpose
There is scant data assessing the consequences of staging restorative proctocolectomy for ulcerative colitis. The aim of the study is to compare outcomes of initial vs. staged restorative ...proctocolectomy.
Methods
Patients completing restorative proctocolectomy, including ileostomy reversal, during 2006–2012 were identified from an IRB-approved database. Demographics, treatment variables, and perioperative outcomes were assessed.
Results
Out of 521 patients, 322 (62%) underwent initial total abdominal colectomy before restorative proctectomy. This group was associated with more common preoperative anemia, leukocytosis, hypoalbuminemia, severe colitis, steroids and biologics use, decreased proximal ileostomy rate at the time of completion restorative proctectomy (92.5 vs 97.5%,
p
= 0.023), shorter hospital stay (6.6 vs 7.8,
p
< 0.001), and marginally decreased pelvic sepsis rate (6.2 vs 11.1%,
p
= 0.05) compared with patients having initial restorative proctocolectomy. However, they also required longer combined postoperative hospital stays (17 vs 12 days,
p
< 0.001) and treatment span (10.4 vs 5.7 months,
p
< 0.001) to complete all surgical stages and they were associated with increased overall postoperative surgical site infection, hemorrhage, and small bowel obstruction rates. Pouch function and QOL were comparable between the groups, except for increased nightly bowel movements in the initial abdominal colectomy group (2.5 ± 2.2 vs 2.1 ± 1.8,
p
= 0.012).
Conclusions
Patients undergoing initial total abdominal colectomy require longer treatment time and experience increased overall morbidity, but ultimately experience comparable ileal pouch outcomes when compared to patients undergoing initial restorative proctocolectomy.
Salvage of the existing ileal pouch is favored during re-do ileal pouch anal anastomosis if the pouch is not damaged after pelvic dissection and there are no other mechanical reasons that may ...necessitate construction of a new pouch. Excision of the existing pouch may be associated with some concerns for short-bowel syndrome and poor functional outcomes. This study aimed to report indications and compare functional and quality of life outcomes of new pouch creation versus salvage of the existing pouch during re-do ileal pouch anal anastomosis.
Patients who underwent re-do ileal pouch anal anastomosis between September 2016 and June 2020 were included. The reasons for pouch excision and new pouch creation were reported. Perioperative, functional outcomes and quality of life were compared between patients who had creation of a new pouch versus salvage of existing pouch.
A total of 105 patients with re-do ileal pouch anal anastomosis (new pouch, n = 63) were included. Most common indications for a new pouch creation were chronic pelvic infection that compromised the integrity and viability of the existing pouch (n = 32) and small pouch (n = 21). No patient developed short-bowel syndrome. The number of bowel movements, daily restrictions and Cleveland Global Quality of Life score scores were similar between 2 groups. Day-time seepage, day-time and night-time pad usage were more common after new pouch creation. Two-year pouch survival rates were comparable (new pouch: 92% versus existing pouch: 85%, P = .31).
New pouch creation can be safely performed at the time of re-do ileal pouch anal anastomosis. It provides acceptable functional and quality of life outcomes if existing pouch salvage is not feasible.
Introduction
Crohn’s disease can present with complex surgical pathologies, posing a significant risk of morbidity and mortality for patients. The implementation of a loop ileostomy for selected ...patients may help minimize associated risks.
Methods
In this retrospective cohort study, we investigated the utilization of temporary fecal diversion through the creation of a loop ileostomy in Crohn’s surgery. Closure of all ostomies involved a hand-sewn single-layer technique. We then conducted bivariate analysis on 30-day outcomes for closures, focusing on favorable recovery defined as the restoration of bowel continuity without the occurrence of two challenges in recovery: newly developed organ dysfunction or the necessity for reoperation.
Results
In total, 168 patients were included. The median age of the patients was 38 years (IQR 27–51). The most common indication for a loop ostomy was peritonitis (49%). After ileostomy closure, 163 patients (97%) achieved favorable recovery, while five encountered challenges; four (2.4%) underwent abdominal surgery, and one (0.6%) developed acute renal failure requiring dialysis. Two patients (1.2%) had a re-creation of ileostomy. Patients encountering challenges were older (56 IQR 41–61 vs. 37 IQR 27–50; p 0.039) and more often required secondary intention wound healing (40% vs. 6.7%; p 0.049) and postoperative parenteral nutrition following their index surgery (83% vs. 26%; p 0.006).
Conclusion
Selectively staging the Crohn’s disease operations with a loop ileostomy is a reliable practice with low morbidity and high restoration rates of bowel continuity. Our hand-sewn single-layer technique proves effective in achieving successful surgical recovery.
There are scant data on the presumed reduction of small-bowel obstruction and incisional hernia rates associated with laparoscopic IPAA.
The aim of this study was to compare long-term outcomes after ...open vs laparoscopic IPAA based on a previous study from our institution.
This was a retrospective cohort study (from January 1992 through December 2007).
The study was conducted in a high-volume, specialized colorectal surgery department.
Patients included those who were enrolled in a previous institutional case-matched (2:1) study that examined 238 open and 119 laparoscopic IPAAs.
Long-term complications, including incisional hernia clinically detected by physician, adhesive small-bowel obstruction requiring hospital admission and surgery, pouch excision, and pouchitis rates, were collected. Laparoscopic abdominal colectomy followed by rectal dissection under direct vision (lower midline or Pfannenstiel incision) and converted cases were analyzed within the laparoscopic group.
Groups were comparable with respect to age, sex, BMI, and extent of resection (completion proctectomy vs proctocolectomy), consistent with the original case matching. Mean follow-up was significantly longer in the open group (9.6 vs 8.1 years; p = 0.008). Open and laparoscopic operations were associated with similar incidences of incisional hernia (8.4% vs 5.9%; p = 0.40), small-bowel obstruction requiring hospital admission (26.1% vs 29.4%; p = 0.50), and small-bowel obstruction requiring surgery (8.4% vs 11.8%; p = 0.31). A subgroup analysis comparing 50 patients with laparoscopic rectal dissection versus 69 patients with rectal dissection under direct vision confirmed statistically similar incidences of incisional hernia, hospital admission, and surgery for small-bowel obstruction.
This study was limited by its retrospective nature.
Some of the anticipated long-term benefits of laparoscopic IPAA could not be demonstrated in this cohort. The lack of such long-term benefits should be discussed with patients when proposing a laparoscopic approach.
Pelvic sepsis after IPAA predisposes to pouch failure. There are limited data on long-term pouch function for patients with pelvic sepsis.
The aim of this study was to investigate functional outcomes ...and quality of life for patients undergoing IPAA who develop pelvic sepsis and preserve their pouch long-term.
This study is based on retrospective analysis of prospectively accrued data.
This study was conducted at a single-center institution.
All patients undergoing IPAA from 1983 to 2007 were included.
The primary outcomes measured were functional outcomes (urgency, incontinence, bowel movements) and quality-of-life (restrictions, energy, happiness) parameters.
Two hundred (6.2%) of 3234 patients developed pelvic septic complications within 3 months of IPAA. In the comparison of complications at the time of IPAA for the 2 groups, patients with pelvic sepsis had higher rates of postoperative hemorrhage (13.5% vs 3.7%, p < 0.001), anastomotic leak (35% vs 3.7%, p < 0.001), wound infection (14% vs 7.4%, p < 0.001), and fistula formation (37% vs 7.1%, p < 0.001). The overall median follow-up was 7 years. Pelvic sepsis was associated with greater pouch failure (19.5% vs 4%, p < 0.001). For patients with follow-up (pelvic sepsis = 144, nonpelvic sepsis = 2677) with a retained pouch, for whom we compared functional outcomes and quality of life, incontinence was worse (never/rare: 69.5% vs 77.8%, p = 0.03). Urgency scores were lower in pelvic sepsis but not statistically significant. The overall Cleveland Global Quality of Life score (and components) in the sepsis group were significantly worse than in the nonsepsis group (0.74 vs 0.79, p < 0.001). Patients who developed sepsis were also less likely to recommend IPAA to others than patients who did not develop pelvic sepsis.
This study was limited by the retrospective analysis and the use of questionnaires.
Pelvic sepsis after IPAA leads to worse functional outcomes and quality of life even when it does not lead to pouch failure. This finding argues for careful attention to preoperative and intraoperative planning and strategies aimed at reducing this complication after IPAA.
