Faculty Bibliography

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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Introduction: The aim of this study was to evaluate the impact of various factors on 30-day postoperative morbidity in patients with disseminated cancer who underwent appendectomy.
Method(s): Patients with disseminated cancer who underwent appendectomy, between 2016 and 2018, were identified from the American College of Surgeons National Surgical Quality Improvement Program database by using Current Procedural Terminology codes. Demographics, perioperative, and operative factors were assessed and compared between 2 groups classified according to the presence or absence of postoperative complications.
Result(s): A total of 354 patients met the inclusion criteria [female n=186 (52%)]. Eight-nine percent of the cases were performed laparoscopically, 46% (n=164) of cases were emergency surgery. Most common postoperative diagnosis was acute appendicitis (n=322, 90%). Operative time (73.9 vs 67.6 minutes) and length of stay (10.6 vs 3.3 days) were longer in patients with morbidity. Eighty-three patients (23.4%) had at least 1 postoperative complication. Most common complication was sepsis/septic shock followed by transfusion-requiring anemia. Patients who developed complications were more often male (p=0.003), dyspneic (p=0.001), with hypoalbuminemia (p=0.002), anemia (0.03), and preoperative diagnosis of sepsis/systemic inflammatory response syndrome (p<0.0001).
Conclusion(s): Morbidity for appendectomy in patients with disseminated cancer is high. Treatment decisions should be individualized based on preoperative comorbidities and disease extent.
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Background Dual-energy CT enterography (DECTE) has been shown to be useful in characterizing Crohn disease activity compared with clinical markers of inflammation but, to the knowledge of the authors, comparison has not been made with histopathologic specimens. Purpose To compare mucosal iodine density obtained at DECTE from Crohn disease-affected bowel with histopathologic specimens from surgically resected ileocolectomy bowel segments or terminal ileum colonoscopic biopsies in the same patients. Materials and Methods This was a retrospective study. Bowel segments in adults with Crohn disease who underwent DECTE from January 2017 to April 2019 within 90 days of ileocolectomy or colonoscopy were retrospectively evaluated with prototype software allowing the semiautomatic determination of inner hyperdense bowel wall (mucosal) mean iodine density, normalized to the aorta. Mean normalized iodine density and clinical activity indexes (Crohn Disease Activity Index [CDAI] and Harvey-Bradshaw Index [HBI]) were compared with histologic active inflammation grades by using two-tailed t tests. Receiver operating characteristic curves were generated for mean normalized iodine density, CDAI, and HBI to determine sensitivity, specificity, and accuracy. A P value less than .05 was considered to indicate statistical significance. Results The following 16 patients were evaluated (mean age, 41 years ± 14 [standard deviation]): 10 patients (five men, five women; mean age, 41 years ± 15) with 19 surgical resection specimens and six patients with terminal ileum colonoscopic mucosal biopsies (four men, two women; mean age, 43 years ± 14). Mean normalized iodine density was 16.5% ± 5.7 for bowel segments with no active inflammation (n = 8) and 34.7% ± 9.7 for segments with any active inflammation (n = 17; P < .001). A 20% mean normalized iodine density threshold had sensitivity, specificity, and accuracy of 17 of 17 (100%; 95% CI: 80.5, 100), six of eight (75%; 95% CI: 35, 97), and 23 of 25 (92%; 95% CI: 74, 99), respectively, for active inflammation. Clinical indexes were similar for patients with and without active inflammation at histopathologic analysis (CDAI score, 261 vs 251, respectively [P = .77]; HBI score, 7.8 vs 6.4, respectively [P = .36]). Conclusion Iodine density from dual-energy CT enterography may be used as a radiologic marker of Crohn disease activity as correlated with histopathologic analysis. © RSNA, 2021 See also the editorial by Ohliger in this issue.

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.

Pelvic sepsis is a dreadful complication after ileal pouch creation. It is mostly treated conservatively, and the ileal pouch can be salvaged if sepsis is detected and treated in a timely manner. Even under the best circumstances, pelvic sepsis is often associated with poor functional outcomes. If pelvic sepsis becomes chronic, it could lead to pouch failure. Redo ileal pouch-anal anastomosis (IPAA) is a viable option in the setting of chronic pelvic sepsis to preserve gastrointestinal continuity in motivated patients. It is associated with similar surgical morbidity, acceptable functional outcomes, and good quality of life. Patients should be involved in the decision-making process after ileal pouch failure. In the setting of ileal pouch failure, surgeons with limited experience may not be comfortable offering patients redo IPAA. Redo IPAA requires subspecialization and patients with ileal pouch failure should be treated at specialized high-volume centers.

BACKGROUND:A recent Norwegian moratorium challenged the status quo of transanal total mesorectal excision for rectal cancer reporting increased early multifocal local recurrences. OBJECTIVE:The aim of this systematic review and meta-analysis was to evaluate the local recurrence rates following transanal total mesorectal excision as well as to assess statistical, clinical, and methodological bias in reports published to date. DATA SOURCES/METHODS:The Pubmed and MEDLINE (via Ovid) databases were systematically searched. STUDY SELECTION/METHODS:Descriptive or comparative studies reporting rates of local recurrence at a median follow-up of 6 months (or more) after transanal total mesorectal excision were included. INTERVENTIONS/METHODS:Transanal total mesorectal excision. MAIN OUTCOME MEASURES/METHODS:Local recurrence was any recurrence located in the pelvic surgery site. Untransformed proportion method of one-arm meta-analysis was utilized. Untransformed percent proportion with 95% confidence interval was reported. Ad-hoc meta-regression with Omnibus test was utilized to assess risk factors for local recurrence. Among-study heterogeneity was evaluated: statistical by I2 and tau2, clinical by summary tables, and methodological by a 33-item questionnaire. RESULTS:Twenty-nine studies totaling 2,906 patients were included. The pooled rate of local recurrence was 3.4% (2.7%, 4.0%) at an average of 20.1 months with low statistical heterogeneity (I2=0%). Meta-regression yielded no correlation between complete total mesorectal excision quality (p=0.855), circumferential resection margin (p=0.268), distal margin (p=0.886), and local recurrence rates. Clinical heterogeneity was substantial. Methodological heterogeneity was linked to excitement of novelty, loss aversion, reactivity to criticism, indication for transanal total mesorectal excision, non-probability sampling, circular reasoning, misclassification, inadequate follow-up, reporting bias, conflict-of-interest, and self-licensing. LIMITATIONS/CONCLUSIONS:Included studies had observational design, limited sample and follow-up. CONCLUSION/CONCLUSIONS:This systematic review found a pooled rate of local recurrence of 3.4% at 20 months. However, given the substantial clinical and methodological heterogeneity across the studies, the evidence for or against transanal total mesorectal excision is inconclusive at this time.

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.

Ileal pouch anal anastomosis (IPAA) is gold standard surgical procedure for treatment of ulcerative colitis and majority of patients with familial adenomatous polyposis. This procedure allows preservation of fecal continence and gastrointestinal continuity. However, it is associated with a wide variety of complications, which often have nonspecific and overlapping clinical presentations, making imaging an important part of work up for pouch dysfunction. The purpose of this article is to propose structured reporting templates for Magnetic Resonance Imaging (MRI) and Water Soluble Contrast Enema (WSCE) in IPAA patients based on our referral pouch center's experience. Included will be a review of salient surgical technique, pouch anatomy and imaging protocols, with an emphasis on systematic search pattern for evaluation of ileal pouch complications using proposed structured reporting MRI and WSCE templates.