Faculty Bibliography

PURPOSE/OBJECTIVE:The safety and feasibility of minimally invasive surgery (MIS) in the setting of colorectal cancer emergencies have been debated. We sought to compare postoperative outcomes of MIS with open techniques in the setting of colorectal cancer emergencies from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. METHODS:We included patients undergoing colectomy for colorectal cancer emergency between 2012 and 2019 "2012-2019" from the ACS-NSQIP dataset. We compared short-term morbidity, mortality, short-term oncological outcomes, and secondary outcomes for MIS vs open colectomies using propensity score matching. We then evaluated the trends of MIS versus open colectomies using linear regression analysis. RESULTS:We examined a total of 5544 patients (open n = 4070; MIS n = 1474) and included 1352 patients for our postoperative outcome analyses after propensity score matching 1:1 (open n = 676; MIS n = 676). Within the matched cohort, mortality was significantly higher in the open group (open 6.95% vs MIS 3.99%, OR 1.8, p = 0.023). Anastomotic leak rates were comparable between the  two groups (open 4.46% vs MIS 4.02%, OR 1.12, p = 0.787). Pulmonary complications were significantly higher after open surgery (open 10.06% vs MIS 4.73%, OR 2.25, p < 0.001). Rates of ileus were significantly higher amongst open patients (open 29.08% vs MIS 19.94%, p < 0.001). Patients stayed on average 1 day longer in the hospital after open surgery (p < 0.001). Rates of MIS for early tumors (N0 and T1/T2, n = 289) did not significantly change over 7 years (p = 0.597, rate = - 0.065%/year); however, utilization of MIS for late tumors (N1 or T3/T4, n = 4359) increased by 2.06% per year (p < 0.001). CONCLUSIONS:This study demonstrates that MIS was associated with superior postoperative outcomes compared to open surgery without compromising oncological outcomes in patients undergoing emergency colectomy for colon cancer. Within the matched cohort, MIS was associated with lower rates of mortality, pulmonary complications, ileus, and shorter postoperative length of stay.

PURPOSE/OBJECTIVE:The aim of this study was to evaluate the diagnostic performance of preoperative cross-sectional imaging findings using the SAR-AGA definitions in Crohn's disease (CD) patients who underwent ileocolic resection (ICR) with and without surgically complex ileocolic CD (CIC-CD). METHODS:69 CD patients [38 men; mean (± SD) age: 40.6 (16.2) years] who underwent ICR were retrospectively classified by surgical complexity by a colorectal surgeon using operative findings. CIC-CD was defined as ileal CD, not confined to the distal ileum. Two radiologists retrospectively evaluated the preoperative imaging for the presence and type of penetrating disease, stricture, or probable stricture using the SAR-AGA consensus definitions. The diagnostic performance of preoperative imaging findings was compared for patients with and without CIC-CD. Estimated blood loss (EBL), operative time (OT), conversion to open surgery, diversion, and length of hospital stay (LOS) were compared. RESULTS:60.9% had CIC-CD and 79.7% underwent primary ICR. Penetrating disease was more common in patients with than without CIC-CD (76.2% vs. 40.7%, p = 0.0048) and similar among primary versus redo ICR (p = 0.12). Patients with CIC-CD had more complex fistulas (59.5% vs. 11.1%; p < 0.0001) and fewer simple fistulas (2.4% vs. 18.5%; p = 0.03) than those without. Mesenteric findings (abscess, inflammatory mass) were more frequent in patients with (35.7%) than without (0%) (p = 0.0002) CIC-CD. Stricture and probable stricture were similar (p = 0.59). CIC-CD patients had greater EBL (178 cc vs. 57 cc, p = 0.006), conversion rates (30% vs. 0%, p = 0.0026), and diversion (80% vs. 52%, p = 0.04). CONCLUSION/CONCLUSIONS:Complex fistula, mesenteric abscess, or inflammatory mass defined by the SAR-AGA guidelines suggests CIC-CD. ICR for CIC-CD had greater EBL, conversion to open surgery, and diversion.

BACKGROUND:The data on management and outcomes of pelvic sepsis after re-do ileal pouch anal anastomosis are scarce. OBJECTIVE:The aim of this study is to report our management algorithm of pelvic sepsis in the setting of re-do ileal pouch anal anastomosis, and compare functional outcomes and quality of life after successful management of pelvic sepsis with a no-sepsis control group. DESIGN/METHODS:This is a retrospective cohort study. SETTINGS/METHODS:This investigation is based on a single-academic practice group experience on re-do IPAA. PATIENTS/METHODS:Patients who underwent re-do ileal pouch anal anastomosis for ileal pouch failure between 09/2016 - 09/2020 were included in the study. MAIN OUTCOME MEASURES/METHODS:Management of the pelvic sepsis was reported. Functional outcomes, restrictions and quality of life scores were compared between sepsis and no sepsis groups. RESULTS:One-hundred and ten patients were included to our study, of whom 25 (22.7) developed pelvic sepsis. Twenty-three patients presented with pelvic sepsis before ileostomy closure and 2 patients presented with pelvic sepsis after ileostomy closure. There were 6 pouch failures in the study period due to pelvic sepsis. Our management was successful in 79% of the patients with median follow-up of 26 months. Treatments included included IR abscess drainage (n=7), IV antibiotics alone (n=5), IR drainage and mushroom catheter placement (n=1), mushroom catheter placement (n=1), and endoluminal vacuum assisted closure (n=1). Average number of bowel movements, urgency, incontinence, pad use, seepage between were comparable between pelvic sepsis and no pelvic sepsis groups (p>0.05). Lifestyle alterations, Cleveland Global Quality of Life scores and happiness with the results of the surgery were similar (p>0.05). LIMITATIONS/CONCLUSIONS:This study is limited by its low study power and limited follow-up time. CONCLUSIONS:Pelvic sepsis is common after re-do ileal pouch anal anastomosis and management varies according to the location and size of the abscess/sinus. If detected early, our management strategy was associated with high pouch salvage rates. See Video Abstract at http://links.lww.com/DCR/B823.

AIM/OBJECTIVE:Approximately 20-40% of the patients with re-do ileal pouch anal anastomosis (IPAA) experience pouch failure. Salvage surgery can be attempted in this patient group with severe aversion to permanent ileostomy. The literature regarding secondary IPAA revision after re-do IPAA failure is scarce. METHODS:All patients who underwent a secondary IPAA revision after re-do IPAA failure between 09/2016 - 07/2021 in a single center were included. Short- and long-term outcomes and quality of life in this patient group were reported. RESULTS:Ten patients who had secondary IPAA revision for re-do IPAA failure were included. All patients had ulcerative colitis. Nine of these patients had pelvic sepsis and one patient had a mechanical issue. Mucosectomy and handsewn anastomosis was performed in 9 patients. The existing pouch was salvaged in 6 patients and 4 patients had pouch excision and re-creation. Two patients had postoperative pelvic sepsis. Pouch retention rate was 78% in median 28 months. None of the patients had short gut syndrome. The procedure was associated with good quality of life (median CGQL=0.8). All patients would undergo the same surgery if needed. CONCLUSION/CONCLUSIONS:Secondary IPAA revision after a failed re-do IPAA can be an option in patients with severe aversion to permanent ileostomy if re-do IPAA fails and it is associated with good outcomes. This patient group should be carefully evaluated and referred to specialized centers if required.

BACKGROUND: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. METHODS: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. RESULTS: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). CONCLUSION/CONCLUSIONS: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: Strictures are reported in around 35%-40% of patients after primary ileal pouch anal anastomosis (IPAA). So far, there are no reports focusing on strictures after re-do IPAA. In our study, we evaluated the incidence, management, long-term functional outcomes, and quality of life scores of anastomotic strictures after re-do IPAA.
Method(s): Patients undergoing redo IPAA between 9/2016 and 9/2020 were included. Incidence and management strategy of re-do IPAA strictures were evaluated. Functional outcomes, lifestyle alterations, and quality of life scores were compared between stricture vs no-stricture groups.
Result(s): Ninety patients were included in the analysis after ileostomy closure. Twenty-two patients developed symptomatic strictures, all of which were at the pouch-anal anastomosis (first year: 25.3%;2 years: 31.8%) In 5 (23%) patients, the strictures were mild, and digital dilation was easily performed. Seventeen (77%) patients had tight strictures dilated with pilling dilators. Median number of dilations required to achieve permanent symptomatic relief was 1. None of the patients required pouch excision due to strictures. Incidence of pouch-anal anastomotic stricture was higher in the re-do IPAA compared with the primary IPAA. Lifestyle alterations were similar between the stricture and no stricture groups. Cleveland Global Quality of Life score was lower in patients with strictures. Strictures were associated with decreased patient happiness with their IPAA (p=0.005) (Table).
Conclusion(s): Stricture development after re-do IPAAs are common and have a higher incidence than primary IPAA, but it can be managed aggressively with a subsequent high pouch retention rate. Lower patient happiness after surgery and decreased QOL are associated with stricture development after re-do IPAAs. [Formula presented]
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BACKGROUND:Impact of the type of anastomosis on the outcomes of re-do ileal pouch anal anastomosis (IPAA) is unknown. OBJECTIVE:The aim of this study is to assess the indications, peri-operative and functional outcomes in patients undergoing stapled vs hand-sewn re-do IPAA. DESIGN/METHODS:This is a retrospective cohort study. SETTINGS/METHODS:This investigation is based on a single-academic practice group experience on re-do IPAA. PATIENTS/METHODS:Patients who underwent re-do IPAA for ileal pouch failure between 09/2016 - 05/2020 were included in the study. MAIN OUTCOME MEASURES/METHODS:Indications, perioperative, functional outcomes, restrictions and quality of life scores were compared between stapled and hand-sewn groups. RESULTS:A total of 105 patients underwent re-do IPAA for ileal pouch failure of whom 76 (72%) had hand-sewn and 29 (28%) had stapled re-anastomosis. The interval between the index and re-do IPAA was shorter in stapled re-do IPAA [median (IQR), Stapled: 3 years (1-4) vs hand-sewn: 7 years (3-17), p<0.001]. Hand-sewn anastomosis was more commonly used after pelvic sepsis [hand-sewn: n=57 (76%) vs stapled: n=13 (45%), p=0.002]. Overall postoperative morbidity was similar between the two groups [hand-sewn: n=38 (50%) vs stapled: n=16 (55%), p=0.635]. The number of bowel movements, pad use, daily restrictions and CGQL scores were similar between stapled and hand-sewn groups. While day-time seepage was more common after hand-sewn anastomosis [hand-sewn, n=20 (44%) vs stapled, n=3 (14%), p=0.013], night-time seepage was similar in both groups. Pouch survival rates were comparable and 88% vs 92% respectively (p>0.05). LIMITATIONS/CONCLUSIONS:This study is limited by its low study power and limited follow-up time. CONCLUSIONS:Patients who had pelvic sepsis after their index IPAA required hand-sewn anastomosis at higher rate than other re-do cases. Although hand-sewn anastomosis is a more complex procedure, it was associated with similar morbidity, functional outcomes and quality of life scores compared to stapled anastomosis for re-do IPAA. See Video Abstract at http://links.lww.com/DCR/B580.

BACKGROUND:Failed pouches may tend to be managed with only a loop ileostomy in obese patients due to some safety concerns. The effect of obesity on ileal pouch excision outcomes is poorly studied. In our study, we aimed to assess the short-term outcomes after ileal pouch excision in obese patients compared to their nonobese counterparts. METHODS:) groups. RESULTS:= .942]. CONCLUSION/CONCLUSIONS:Ileal pouch excision can be performed in obese patients with largely similar outcomes compared to their nonobese counterparts although obesity is associated with a higher rate of deep space infection.

INTRODUCTION/BACKGROUND:Opioid analgesia remains the mainstay of postoperative pain management strategies despite being associated with many adverse effects. A specific opioid-free protocol was designed to limit opioid usage. OBJECTIVE:The aim of the study was to audit the opioid-free rate within this protocol and to identify factors that might contribute to opioid-free surgery. METHODS:A retrospective study of all elective patients receiving abdominal colorectal surgery at the Center for Colon and Rectal Surgery at AdventHealth over 6 months was performed. Data on demographics, indications, perioperative management, outcomes, and inpatient and outpatient analgesic requirements were collected with subsequent analysis. RESULTS:A total of 303 consecutive patient records were analyzed. Approximately two-thirds (67.7%) of patients did not receive narcotics once they left the postanesthesia care unit as an inpatient. One-third of patients (32.0%) did not receive narcotic analgesia within 30 days of surgery as an outpatient. Patients in the opioid-free cohort were significantly older and had a malignant indication, less perioperative morbidity, and a shorter length of stay. CONCLUSIONS:Our study demonstrates that opioid-free analgesia is indeed possible in major colorectal surgery. Study limitations include its retrospective nature and that it is from a single institution. Despite these limitations, this study provides proof of concept that opioid-free colorectal surgery is possible within a specific protocol.