Endoscopic management of ileal pouch strictures has not been systemically studied. The aim was to evaluate endoscopic balloon therapy of pouch strictures in inflammatory bowel disease (IBD) patients ...with ileal pouches and to identify risk factors for pouch failure for those patients.
Consecutive IBD patients with pouches from the Pouchitis Clinic who underwent nonfluoroscopy-guided outpatient endoscopic therapy were studied. The location, number, degree (range 0-3), and length of strictures and balloon size were documented. Efficacy and safety were evaluated with univariate and multivariate analyses.
A total of 150 patients with pouch strictures were studied. Stricture locations were at the pouch inlet (n = 96), outlet (n = 73), afferent limb (n = 33), and pouch body (n = 2). A cumulative of 646 strictures were endoscopically dilated, with a total of 406 pouchoscopies. The median stricture score was 1 (interquartile range IQR 1-2); the median stricture length was 1 (IQR 0.5-1.25) cm, and the median balloon size was 20 (IQR 18-20) mm. Of 406 therapeutic endoscopies performed, there were two perforations (0.46%) and four transfusion-required bleeding (0.98%). The 5-, 10-, and 25-year pouch retention rates were 97%, 90.6%, and 85.9%, respectively. In a median follow-up of 9.6 (IQR 6-17) years, 131 patients (87.3%) were able to retain their pouches. The number of strictures and underlying diagnosis were independent risk factors for pouch failure in the Cox regression model.
Endoscopic treatment of pouch stricture appears to be efficacious and generally safe to perform in experienced hands. Underlying diagnosis of Crohn's disease of the pouch and surgery-related strictures and multiple strictures were the risk factors for pouch failure.
Background
Laparoscopic sigmoidectomy for diverticulitis is widely accepted, using either endolinear staplers or traditional linear staplers under direct vision through the extraction site to ...transect the rectum. The aim of this study was to assess modifiable factors affecting perioperative morbidity after elective laparoscopic sigmoidectomy for diverticulitis.
Methods
Potential associations between perioperative morbidity and demographic, disease-related, and treatment-related factors were assessed on all consecutive patients included in a prospectively collected database undergoing elective laparoscopic sigmoidectomy for diverticulitis between 1992 and 2013. Rectal transection with a linear stapler under direct vision through the extraction site was considered compatible with laparoscopic technique.
Results
There were two deaths out of 1059 patients (0.19 %). Conversion rate was 13.1 %, overall morbidity 28 %, and anastomotic leak 3.7 %. Independent factors associated with morbidity in an intent-to-treat analysis were ASA 3 (OR 1.53,
p
= 0.006), conversion (OR 1.71,
p
= 0.015), and rectal transection without endolinear stapling (traditional linear stapler: OR 1.75,
p
= 0.003; surgical knife: OR 2.09,
p
= 0.002). The same factors along with complicated diverticulitis (OR 1.56,
p
= 0.013) were independently associated with overall morbidity among laparoscopically completed cases. BMI ≥ 35 (OR 2.3,
p
= 0.017), complicated diverticulitis (OR 2.37,
p
= 0.002), and rectal transection with a traditional linear stapler (OR 2.19,
p
= 0.018) were independently associated with abdomino-pelvic infections, both in an intent-to-treat analysis and among laparoscopically completed cases. The number of endolinear stapler firings was not associated with morbidity.
Conclusions
Most factors associated with morbidity of laparoscopic sigmoidectomy for diverticulitis cannot be easily modified. With the limitation of a retrospective analysis, modifiable factors to minimize morbidity are laparoscopic completion and endolinear stapling.
Pouchitis is the most common long-term complication of in patients with restorative proctocolectomy and ileal pouch-anal anastomosis. Patients often develop antibiotic-dependent form of pouchitis ...requiring long-term antibiotic therapy for remission maintenance. Rifaximin, an oral, non-systemic, broad-spectrum antibiotic with a favorable safety profile, may be a promising candidate agent for maintenance therapy. This historical cohort open-label study investigated the efficacy and tolerability of rifaximin in maintaining symptomatic and endoscopic remission in patients with antibiotic-dependent pouchitis.
Adult patients with antibiotic-dependent pouchitis received a 2-week course of various antibiotics for induction of remission. Patients in remission then began maintenance therapy with rifaximin 200 mg/day (to 1800 mg/day) for up to 24 months. Pouchitis Disease Activity Index symptom scores were assessed every 1-3 months to evaluate efficacy.
Fifty-one patients began maintenance therapy with rifaximin (median dose 200 mg/day); 33 (65%) maintained remission through 3 months (primary endpoint). Of these 33 patients, 26 (79%) successfully continued maintenance for 6 months after beginning maintenance, 19 (58%) successfully continued for 12 months, and two (6%) successfully continued for 24 months. Only one patient reported an adverse event (transient facial rash).
Patients' response to rifaximin as a maintenance therapy appears to be favorable in this open-labeled trial of antibiotic-dependent pouchitis. Randomized, placebo-controlled trials with a longer follow-up are warranted.
In an effort to improve the quality of rectal cancer care in the US, the American College of Surgeons Commission on Cancer has developed the National Accreditation Program for Rectal Cancer (NAPRC). ...We aimed to describe the current status of rectal cancer care before implementation of the NAPRC.
The 2011-2014 National Cancer Database was queried for non-metastatic rectal cancer patients who underwent proctectomy. The NAPRC process measures evaluated included clinical staging completion, treatment starting fewer than 60 days from diagnosis, CEA level drawn before treatment, tumor regression grading, and margin assessment. The NAPRC performance measures included negative proximal, distal, and circumferential margins, and ≥12 lymph nodes harvested during resection.
There were 39,068 patients identified (mean age 62 years, 61.6% male sex). In >85% of patients, clinical staging was completed, treatment was started within 60 days, and all tumor margins were assessed. Pretreatment CEA level (64.6% complete) was the process measure most often omitted. However, completion of all included process measures occurred in only 28.1% of patients. All pathologic margins were negative in 79.8% of patients and 73.2% of specimens reported ≥12 lymph nodes. Overall, 56.3% of patients achieved all performance measures. Patients treated at high-volume centers (>30 cases/year) had higher odds of meeting all performance measures (odds ratio 1.42; p < 0.001).
Overall, very few patients achieved all of the proposed quality measures for rectal cancer care. It will be important to re-evaluate these data after the implementation of the NAPRC.
While current neoadjuvant protocols have proven benefits on local control for majority of patients with locally advanced rectal cancer, there are certain clinical conditions that require future ...advances for improving the outcomes. Total neoadjuvant therapy incorporates systemic chemotherapy planned within standard neoadjuvant protocols either before or after radiotherapy for locally advanced rectal cancer as a whole. Enhanced compliance with planned oncological therapy, tumour downstaging, administration of chemotherapy at the earliest time in the disease course to help assessing chemosensitivity are the proposed benefits of total neoadjuvant therapy in patients with locally advanced rectal cancer. Patient selection criteria for administration of total neoadjuvant therapy in the recent guidelines are unclear. Since current literature is inconclusive for the optimal sequence and type of radiotherapy and chemotherapy, premature incorporation of total neoadjuvant therapy for all locally advanced rectal cancers may result in overtreatment and subsequently toxicity. This article aims to discuss the current literature and to propose a future perspective by considering real‐life scenarios reflecting patients’ needs for treatment of locally advanced rectal cancer.
Objective
The objective of this study was to evaluate the efficacy of stricturoplasty and endoscopic balloon dilatation in the treatment for ileal pouch strictures.
Method
Consecutive inflammatory ...bowel disease patients with pouch strictures seen at our Pouch Center from 2002 to 2012 were studied. The efficacy and safety of stricturoplasty (vs. endoscopic balloon dilation) were evaluated with both univariate and multivariate analyses.
Results
A total of 167 patients met the inclusion criteria, including 16 (9.6 %) with surgical stricturoplasty and 151 (90.4 %) with endoscopic balloon dilation. Ninety-four patients (56.3 %) were male, with a mean age at the diagnosis of pouch stricture of 41.6 ± 13.2 years. Fifty-one patients (30.5 %) had multiple pouch strictures, while 100 (59.9 %) patients had strictures at the pouch inlet. The mean length of pouch strictures was 1.2 ± 0.6 cm. No difference was found between the stricturoplasty and endoscopic dilation groups in clinicopathological variables, except for the degree of strictures (
p
= 0.019). After a mean follow-up of 4.1 ± 2.6 years, pouch stricture recurred in 92 patients (55.1 %) and 21 (12.6 %) patients developed pouch failure. The time interval between the procedure and pouch stricture recurrence or pouch failure was longer in the stricturoplasty group than that in the endoscopic dilation group (
p
< 0.001). Patients in the two groups had similar overall pouch survival rates and stricture-free survival rates. In the multivariate analysis, stricturoplasty vs. endoscopic dilation was not significantly associated with either overall pouch survival or stricture-free survival. There was no difference in the procedure-associated complication rates between the two groups.
Conclusion
Surgical stricturoplasty and endoscopic dilation treatment are complimentary techniques for pouch strictures. Repeated endoscopic dilatations are often required, while surgical stricturoplasty appeared to yield a longer time interval to stricture recurrence or pouch failure.
Modality of index IPAA creation may affect the results after redo IPAA surgery for IPAA failure. To our knowledge, there is no study evaluating the effects of modality of index IPAA creation on redo ...IPAA outcomes.
This study aimed to compare short- and long-term outcomes of transabdominal redo IPAA surgery for failed minimally invasive IPAA and open IPAA.
This was a retrospective cohort study.
This investigation was based on a single-surgeon experience on redo IPAA.
Patients undergoing transabdominal redo IPAA for a failed minimally invasive IPAA and open IPAA between September 2007 and September 2017 were included.
Short-term complications and long-term outcomes were compared between 2 groups.
A total of 42 patients with failed index minimally invasive IPAA were case matched with 42 failed index open IPAA counterparts. The interval between index IPAA and redo IPAA operations was shorter in patients who had minimally invasive IPAA (median, 28.5 vs 56.0 mo; p = 0.03). A long rectal stump (>2 cm) was more common after minimally invasive IPAA (26% vs 10%; p = 0.046). Redo IPAAs were constructed more commonly with staplers in the laparoscopy group compared with open counterparts (26% vs 10%; p = 0.046), and other intraoperative details were comparable. Although short-term morbidity was similar between 2 groups, abscess formation (7% vs 24%; p = 0.035) was more frequent in patients who had index IPAA with open technique. Functional outcomes were comparable. Redo IPAA survival for failed minimally invasive IPAA and open IPAA was comparable.
This study was limited by its retrospective, nonrandomized nature and relatively low patient number.
A long rectal cuff after minimally invasive IPAA is a potential and preventable risk factor for failure. Due to its technical and patient-related complexity, handsewn anastomoses in redo IPAA are associated with increased risk of abscess formation. See Video Abstract at http://links.lww.com/DCR/B252. RESCATE DEL RESERVORIO ILEO-ANAL POR VIA TRANSABDOMINAL EN CASOS DE FUGA ANASTOMÓTICA ENTRE ABORDAGE MINIMAMENTE INVASIVO Y ABORDAJE ABIERTO: ESTUDIO DE EMPAREJAMIENTO DE MUESTRAS Y CASOS: La creación de modalidades e índices de Reservorios Ileo-Anales (RIA) pueden afectar los resultados después de rehacer la cirugía de RIAs por fallas en el reservorio. Hasta donde sabemos, no hay ningún estudio que evalúe los efectos de la modalidad de creación de índices RIA en los resultados para el rescate del reservorio.Este estudio tuvo como objetivo comparar los resultados a corto y largo plazo de la cirugía transabdominal redo RIA en casos de fracaso por via mínimamente invasiva (MI-RIA) o por la vía abierta (A-RIA).Estudio de cohortes tipo retrospectivo.Investigación basada en la experiencia de un solo cirujano en redo del Reservorio Ileo-Anal.Se incluyeron aquellos pacientes sometidos a re-operación transabdominal y re-confección de un RIA por fallas en el MI-RIA y en el A-RIA durante un lapso de tiempo entre septiembre 2007 y septiembre 2017.Las complicaciones a corto plazo y los resultados a largo plazo se compararon entre los dos grupos.Un total de 42 pacientes con índice fallido de MI-RIA fueron emparejados con 42 homólogos con índice fallido de A-RIA. El intervalo entre las operaciones de RIA y redo RIA fué más corto en pacientes que tenían MI-RIA (mediana, 28,5 meses frente a 56 meses, p = 0,03). Un muñón rectal largo (> 2 cm) fue más común después de MI-RIA (26% vs 10%, p = 0.046). Redo RIAs se construyeron más comúnmente con engrampadoras en el grupo Minimalmente Invasivo en comparación con la contraparte abiertas (26% vs 10%, p = 0.046). Aunque la morbilidad a corto plazo fue similar entre los dos grupos, la aparición de abscesos (7% frente a 24%, p = 0.035) fue más frecuente en pacientes que tenían RIA con técnica abierta. Los resultados funcionales fueron comparables. La sobrevida de las redo RIAs para MI-RIA y A-RIA fallidas, también fué comparable.Este estudio estuvo limitado por su naturaleza retrospectiva, no aleatoria y el número relativamente bajo de pacientes.Un muñon rectal largo después de MI-RIA es un factor de riesgo potencial y previsible para el fracaso. Debido a su complejidad técnica y relacionada con el paciente, las anastomosis suturadas a mano en redo RIA están asociadas con un mayor riesgo de formación de abscesos. Consulte Video Resumen en http://links.lww.com/DCR/B252.
Purpose
Given that ileal pouch-anal anastomosis (IPAA) surgery is a technically challenging and high-morbidity procedure, there are numerous pertinent imaging findings that need to be clearly and ...efficiently communicated to the IBD surgeons for essential patient management and surgical planning. Structured reporting has been increasingly used over the past decade throughout various radiology subspecialties to improve reporting clarity and completeness. We compare structured versus non-structured reporting of pelvic MRI for ileal pouch to evaluate for clarity and effectiveness.
Methods
164 consecutive pelvic MRI’s for ileal pouch evaluation, excluding subsequent exams for the same patient, acquired between 1/1/2019 and 7/31/2021 at one institution were included, before and after implementation (11/15/2020) of a structured reporting template, which was created with institutional IBD surgeons. Reports were assessed for the presence of 18 key features required for complete ileal pouch assessment: anastomosis (IPAA, tip of J, pouch body), cuff (length, cuffitis), pouch body (size, pouchitis, stricture), pouch inlet/pre-pouch ileum (stricture, inflammation, sharp angulation), pouch outlet (stricture), peripouch mesentery (position, mesentery twist), pelvic abscess, peri-anal fistula, pelvic lymph nodes, and skeletal abnormalities. Subgroup analysis was performed based on reader experience and divided into three categories: experienced (
n
= 2), other intra-institutional (
n
= 20), or affiliate site (
n
= 6).
Results
57 (35%) structured and 107 (65%) non-structured pelvic MRI reports were reviewed. Structured reports contained 16.6 SD:4.0 key features whereas non-structured reports contained 6.3 SD:2.5 key features (
p
< .001). The largest improvement following template implementation was for reporting sharp angulation of the pouch inlet (91.2% vs. 0.9%,
p
< .001), tip of J suture line and pouch body anastomosis (both improved to 91.2% from 3.7%). Structured versus non-structured reports contained mean 17.7 versus 9.1 key features for experienced readers, 17.0 versus 5.9 for other intra-institutional readers, and 8.7 versus 5.3 for affiliate site readers.
Conclusion
Structured reporting of pelvic MRI guides a systematic search pattern and comprehensive evaluation of ileal pouches, and therefore facilitates surgical planning and clinical management. This standardized reporting template can serve as baseline at other institutions for adaptation based on specific radiology and surgery preferences, fostering a collaborative environment between radiology and surgery, and ultimately improving patient care.
Graphical abstract
Purpose
Risks and benefits of colorectal cancer resection in octogenarians are not clearly defined. This study aimed to assess the relationship between morbidity and mortality within 1 year after ...colorectal cancer resection in octogenarians compared with other age groups.
Methods
A single-institution, prospectively maintained database was queried to identify patients with sporadic, pathological stages I–III colorectal adenocarcinoma, electively undergoing radical resection with curative intent between 2000 and 2012. Patients were divided into three age groups: ‘octogenarians’ if ≥80 years of age; ‘intermediate’ if ≥65 and <80 years of age; and ‘younger’ if <65 years of age.
Results
Overall, 2485 patients fulfilled the inclusion criteria—326 in the octogenarian age group, 949 in the intermediate age group, and 1210 in the younger age group. Postoperative morbidity disproportionally increased 1-year mortality in octogenarians when compared with the younger age group (37 vs. 6.5 %;
p
< 0.001). Anastomotic leak, abdominopelvic abscess, reoperation, and readmission rates were comparable among different age groups, but were associated with a disproportionate risk of 1-year mortality in octogenarians (67, 43, 33, and 41 %, respectively). Multivariate analysis indicated that older age and postoperative complications were the only two independent variables associated with 30- and 90-day mortality. Besides these, American Society of Anesthesiologists (ASA) and pathological stage III were additional independent variables associated with 1-year mortality. An interaction test confirmed that age and postoperative complications were independent variables, with additive effect on 30-day, 90-day, and 1-year mortality.
Conclusions
Age plays an important and independent role in affecting mortality when complications occur following surgery for colorectal cancer. The full magnitude of postoperative risks should be taken into consideration when discussing colorectal cancer surgery in octogenarians.
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