Faculty Bibliography

BACKGROUND:Crohn's disease (CD) often affects the terminal ileum, leading to complications such as stricture, fistula, and abscesses, necessitating surgery in up to 80% of patients. Early and effective treatment is crucial to prevent disease progression and improve outcomes, although timing between medical and surgical treatments is challenging. METHODS:This study reviewed patients who underwent ileocolic resection for CD at our quaternary inflammatory bowel disease center from September 2016 to September 2023. A novel classification system categorized the severity and complexity of ileocolic CD. Preoperative characteristics, operative variables, and postoperative outcomes were analyzed to assess the impact of disease complexity. RESULTS:Among the 301 patients (median age 33.3 years, 48.5% female), 56.8% had complex ileocolic CD. Complex disease was associated with greater blood loss, longer hospital stays, longer operative time, and greater rates of open surgery and conversion compared with noncomplex disease (P < .01). Diversion rates were significantly greater in complex cases (P < .01). Emergent operations were more common among complex cases (P < .01). Delayed referral and increased complexity correlated with inferior surgical outcomes and greater stoma rates. CONCLUSION/CONCLUSIONS:The proposed classification system stratifies patients on the basis of CD severity and complexity, facilitating better preoperative planning and communication among multidisciplinary teams. Early surgical intervention, when appropriate, may reduce morbidity and improve outcomes in patients with ileocolic CD. This system highlights the importance of timely referrals and standardizing the management approach for complex CD.

BACKGROUND:Long rectal cuff (>2 cm) and remnant mesorectum are known causes of pouch dysfunction because of obstructive defecation as well as pelvic sepsis after prolonged obstruction. OBJECTIVE:The aim of this study was to report the rates and management of patients who underwent redo IPAA because of pouch failure associated with a retained mesorectum and long rectal cuff. DESIGN/METHODS:This is a retrospective study. SETTINGS/METHODS:The investigation is based on data from a quaternary IBD center. PATIENTS/METHODS:Patients undergoing redo IPAA surgery with a long rectal cuff and/or remnant mesorectum between September 2016 and September 2023 were included in the study. MAIN OUTCOME MEASURES/METHODS:The main outcomes were functioning pouch rate and functional results. RESULTS:Of the 245 patients who underwent redo IPAA surgery, 98 patients (40%) had long rectal cuff and/or remnant mesorectum. Redo IPAA in this patient group was successful (92%) at a median follow-up of 28 (18-52) months. LIMITATIONS/CONCLUSIONS:The retrospective nature of the study and inclusion of a single specialized center. CONCLUSIONS:Long rectal cuff and remnant mesorectum are major causes of pouch failure, which can be successfully managed with redo IPAA surgery. Nearly half of pouch failure patients who had successful redo IPAA surgery initially received unnecessary biologic therapy before coming to our center. See Video Abstract . MUON RECTAL LARGO Y MESORRECTO REMANENTE SON LAS PRINCIPALES CAUSAS PREVENIBLES DE DISFUNCIN DE LA BOLSA ILEAL/UNASSIGNED:ANTECEDENTES:El muñon rectal largo (>2 cm) y el mesorrecto remanente son causas conocidas de disfunción de la bolsa debido a defecación obstructiva, así como de sepsis pélvica tras obstrucción prolongada.OBJETIVO:El objetivo de este estudio es informar las tasas y el tratamiento de los pacientes que se sometieron a una nueva anastomosis anal con bolsa ileal debido al fracaso de la bolsa asociado a mesorrecto remanente y el muñon rectal largo.DISEÑO:Se trata de un estudio retrospectivo.LUGAR:La investigación se basa en un centro cuaternario de enfermedad inflamatoria intestinal.PACIENTES:Se incluyeron en el estudio los pacientes sometidos a una nueva cirugía de anastomosis anal con bolsa ileal y que tenían muñon rectal largo y/o mesorrecto remanente entre septiembre de 2016 y septiembre de 2023.PRINCIPALES MEDIDAS DE VALORACIÓN:Los principales resultados fueron la tasa de funcionamiento de la bolsa y los resultados funcionales.RESULTADOS:De los 245 pacientes que se sometieron a una nueva cirugía de anastomosis anal con bolsa ileal, 98 (40%) pacientes tenían un muñon rectal largo y/o mesorrecto remanente. La repetición de la anastomosis anal con bolsa ileal en este grupo de pacientes fue exitosa (92%) en una mediana de seguimiento de 28 (18-52) meses.LIMITACIONES:La naturaleza retrospectiva del estudio y la experiencia de un solo centro especializado.CONCLUSIONES:El muñon rectal largo y el mesorrecto remanente son las principales causas de fracaso de la bolsa, que pueden tratarse con éxito mediante una nueva cirugía de anastomosis anal con bolsa ileal. Casi la mitad de los pacientes con fracaso de la bolsa que se sometieron con éxito a una nueva cirugía de anastomosis anal con bolsa ileal recibieron inicialmente un tratamiento biológico innecesario antes de acudir a nuestro centro. (Traducción-Ingrid Melo ).

BACKGROUND:Ileal pouch anal anastomosis is the preferred method for restoration of intestinal continuity after proctocolectomy. Successful ileal pouch anal anastomosis requires adequate reach of the ileal mesentery to the pelvis. Reach issues are a common cause for intraoperative pouch abandonment; however, data regarding contemporary abandonment rates are rare and nonexistent in the revisional setting. METHODS:A retrospective review was conducted of consecutive ileal pouch anal anastomosis surgery at a single referral center. Both initial or "primary" pouches and revisional pouch surgery were included. RESULTS:In total, 447 attempts at pouch anal anastomosis were made, with an 1.6% overall rate of intraoperative abandonment. Pouch abandonment was attributed to inadequate mesenteric reach during 3 surgeries, desmoid tumors in 2 surgeries, and insufficient remaining small bowel in 2 surgeries. Twelve patients required lengthening maneuvers including 6 S pouches (1%) and 6 H pouches (1%). One half (49%) of operations were revisional ileal pouch anal anastomosis surgery. Overall, reach issues led to intraoperative abandonment in only 0.4% of attempted primary pouches and 1.0% of revisional surgeries. A preoperative diagnosis of familial adenomatous polyposis was associated with pouch abandonment (P < .001). CONCLUSION/CONCLUSIONS:Extremely low pouch abandonment rates as a result of mesenteric reach can be achieved even in the revisional setting at a high-volume center with institutional expertise. In the revisional setting, intra-abdominal desmoids or the potential for short gut affects pouch abandonment rates as much as reach issues.

INTRODUCTION/BACKGROUND: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/CONCLUSIONS: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.

OBJECTIVE/UNASSIGNED:Analyze our long-term experience with a less-popularized but stalwart approach, the stapled end-to-side ileocolic anastomosis. BACKGROUND/UNASSIGNED:The choice of technical approach to ileocolic anastomosis after ileocecal resection for Crohn's disease affects surgical outcomes and recurrence. Yet, despite heterogeneous data from different anastomotic configurations, there remains no clear guidance as to the optimal technique. METHODS/UNASSIGNED:In a retrospective cohort design, patients undergoing ileocolic anastomosis in the setting of Crohn's disease between 2016 and 2021 at two institutions were identified. Patient characteristics and surgical outcomes in terms of recurrence (surgical, clinical, and endoscopic) were studied. RESULTS/UNASSIGNED:In total, 211 patients were included. Before surgery, 80% were exposed to at least 1 cycle of systemic steroids and 71% had at least 1 biologic agent; 60% exhibited penetrating disease and 38% developed an intra-abdominal abscess. After surgery, one anastomosis leaked (0.5%). Over 2.4 years of follow-up (IQR = 1.3-3.9), surgical recurrence was 0.9%. Two-year overall recurrence-free and endoscopic recurrence-free survivals were 74% and 85% (95% CI = 68-81 and 80-91), respectively. The adjusted hazard ratio of endoscopic recurrence was 3.0 (95% CI = 1.4-6.2) for males and 5.2 (1.2-22) for patients who received systemic steroids before the surgery. CONCLUSION/UNASSIGNED:The stapled end-to-side anastomosis is an efficient, reliable, and reproducible approach to maintain bowel continuity after ileocecal resection with durable outcomes. Our outcomes demonstrate low rates of disease recurrence and stand favorably in comparison to other more technically complex or protracted anastomotic approaches. This anastomosis is an ideal reconstructive approach after ileocecal resection for Crohn's disease.

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.

Restorative proctocolectomy with ileal pouch-anal anastomosis (RP/IPAA) is the procedure of choice for patients with ulcerative colitis (UC), some patients with colonic Crohn’s disease (CD), and those with familial adenomatous polyposis (FAP); albeit, owing to its complexity, it should be performed by experienced professionals. RP/IPAA is the recommended surgical treatment for UC when the standard medical therapy is ineffective. This procedure has been demonstrated to provide patients with a good quality of life, such as in FAP patients with extensive disease in the rectum. The CD has been associated with higher rates of perianal involvement and disease recurrence, but some patients with CD limited to the large intestine and minimal perianal or ileal disease may also be considered for this operation. First, all patients undergo a detailed preoperative evaluation that includes a review of previous imaging, pathology, and colonoscopy findings, a perianal examination, an evaluation of the anorectal functions, mechanical bowel preparation, and prophylaxis against deep venous thrombosis and infectious complications. A staged approach is the most commonly preferred technique for RP/IPAA, which can be performed in 2 or 3 stages. The IPAA can be performed by laparoscopic, robotic, or open approach. The type of approach is determined based on the patient’s condition, medication used, elective or emergency setting, and the surgeon’s expertise level. A successful IPAA requires tension-free pouch anastomosis. The most common IPAA pouch types are the J or S pouches; alternatively, an H pouch may be created, which is mainly used in redo pouches. In experienced centers, > 95% of the patients become stoma-free in 10 years. IPAA is a complex procedure, and the complications after pouch surgery are pouchitis, pelvic sepsis, pouch failure, or anastomotic stricture. The majority of long-term complications can be prevented in such cases with a comprehensive preoperative evaluation and through the use of appropriate surgical techniques and postoperative care conducted at experienced centers. The techniques for performing RP/IPAA with their long-term outcomes have been reviewed in this article.

BACKGROUND/UNASSIGNED:The COVID-19 pandemic led to the urgent implementation of telehealth visits in inflammatory bowel disease (IBD) care; however, data assessing feasibility remain limited. OBJECTIVES/UNASSIGNED:We looked to determine the completion rate of telehealth appointments for adults with IBD, as well as to evaluate demographic, clinical, and social predictors of incomplete appointments. DESIGN/UNASSIGNED:We conducted a retrospective analysis of all patients with IBD who had at least one scheduled telehealth visit at the NYU IBD Center between 1 March 2020 and 31 August 2021, with only the first scheduled telehealth appointment considered. METHODS/UNASSIGNED:Medical records were parsed for relevant covariables, and multivariable logistic regression was used to estimate the adjusted association between demographic factors and an incomplete telehealth appointment. RESULTS/UNASSIGNED: = 0.22). After adjustment, patients with CD had higher odds of an incomplete appointment as compared to patients with UC [adjusted odds ratio (adjOR): 1.37, 95% confidence interval (CI): 1.10-1.69], as did females (adjOR: 1.26, 95% CI: 1.04-1.54), and patients who had a non-first-degree relative listed as an emergency contact (adjOR: 1.69, 95% CI: 1.16-2.44). While age ⩾60 years was not associated with appointment completion status, we did find that age >80 years was an independent predictor of missed telehealth appointments (adjOR: 2.92, 95% CI: 1.12-7.63) when compared to individuals aged 60-70 years. CONCLUSION/UNASSIGNED:telehealth, particularly those aged 60-80 years, may therefore provide an additional venue to complement in-person care.