Faculty Bibliography

BACKGROUND: 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. OBJECTIVE: The aim of this study was to evaluate the long-term outcomes of sphincter-saving procedures for large-bowel Crohn's disease. DESIGN: Patients with preoperative Crohn's disease diagnosis undergoing intentional IPAA and ileorectal anastomosis were included. SETTINGS: The study was conducted at a tertiary care research center. PATIENTS: Ileorectal anastomosis was performed in 75 patients with Crohn's disease, whereas 32 patients underwent intentional IPAA. MAIN OUTCOME MEASURES: 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. RESULTS: 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. LIMITATIONS: The study was limited by its retrospective nature and small sample size. CONCLUSIONS: 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.

Revisional surgery in colorectal patients carries an increased risk, including wound infection and breakdown. Multiple modalities have been employed to decrease surgical site infection (SSI). Adjuvant therapies have evolved from packing to closed suction drains, to the use of vacuum-assisted wound devices, but many necessitate leaving the wound open, resulting in time-consuming dressing changes, increased cost, length of stay, patient discomfort and worse cosmesis

AIM: Obesity adds to the technical difficulty of laparoscopic colorectal surgery. The robotic approach has the potential to overcome this limitation because of its proposed technical advantages over laparoscopy. The aim of this retrospective study was to compare the short-term outcomes of robotic surgery (RS) versus conventional laparoscopy surgery (LS) in this patient population. METHOD: Patients with a body mass index >/= 30 kg/m2 undergoing RS or LS for rectal cancer between 01/2011 and 6/2014 were identified from an institutional database. Perioperative parameters, oncologic findings and postoperative 30-day short-term outcomes were compared between the RS and LS groups. RESULTS: The RS and LS groups included 29 and 27 patients, respectively. Groups were comparable in terms of patient demographics, body mass index (34.9+/-7.2 vs. 35.2+/-5.0 kg/m2 , p = 0.71), co-morbidities, surgical and tumour characteristics. Comparison of the intraoperative findings revealed no significant differences between the groups including operative time (329.0+/-102.2 vs. 294.6+/-81.1 min, p = 0.13), blood loss (434.0+/-612.4 vs. 339.4+/-271.9 ml, p = 0.68), resection margin involvement (6.9% vs. 7.4%, p = 0.99), conversions (3.4% vs. 18.5%, p = 0.09) and complications (6.9% vs. 0%, p = 0.49). Regarding postoperative outcomes, there were no significant differences in morbidity except that robotic surgery was associated with a quicker return of bowel function (median, 3 vs. 4 days, p = 0.01) and shorter hospital stay (median, 6 vs. 7 days, p = 0.02). CONCLUSION: Robotic surgery for rectal cancer in obese patients has short-term outcomes similar to laparoscopy, but accelerated postoperative recovery

PURPOSE: Data evaluating the risk of lymph node metastasis depending upon the location of the primary tumor are limited in patients with T1 colorectal cancer. We aimed to evaluate the impact of tumor location on lymph node metastasis in T1 colorectal cancer. METHODS: Patients who underwent an oncologic resection with curative intent for T1 adenocarcinoma of the colon and rectum between January 1997 and October 2014 were assessed. Exclusion criteria were distant organ metastases, previous or concurrent cancer, past history of surgical or medical cancer treatment, preoperative chemoradiation, and patients with inflammatory bowel disease or polyposis syndromes. RESULTS: Out of 232 (56 % male) patients fulfilling the study criteria, 24 (10 %) had lymph node metastasis. Age (65 vs 61 years, p = 0.1), gender (55 vs 63 % male, p = 0.5), tumor size (2 vs 2 cm, p = 0.49), and lymphovascular invasion (5 vs 8 %, p = 0.46) were not associated with lymph node metastasis. While there was no statistical significance (p = 0.2), lymph node positivity was higher in rectal cancer (14 %, n = 11/79) compared to colon cancer (9 %, n = 13/153). CONCLUSIONS: Although it was not statistically significant, lymph node positivity varies based on tumor location of T1 colorectal adenocarcinoma regardless of fundamental tumor characteristics including size, differentiation, and lymphovascular invasion.

The present study reports an early institutional experience with robotic proctectomy (RP) and outcome comparison with laparoscopic proctectomy (LP) in patients with inflammatory bowel disease (IBD). Patients who underwent either RP or LP during proctocolectomy for IBD between January 2010 and June 2014 were matched (1:1) and reviewed. Twenty-one patients undergoing RP fulfilled the study criteria and were matched with an equal number of patients who had LP. Operative time was longer (304 vs. 213 min, P=0.008) and estimated blood loss was higher in the RP group (360 vs. 188 mL, P=0.002). Conversion rates (9.5% vs. 14.3%, P>0.99), time to first bowel movement(2.29+/-1.53 vs. 2.79+/-2.26, P=0.620), and hospital length stay(7.85+/-6.41 vs. 9.19+/-7.47 d, P=0.390) were similar in both groups. No difference was noted in postoperative complications, ileal pouch to anal canal anastomosis-related outcomes, Cleveland Global Quality of Life, and Short Form-12 health survey outcomes between RP and LP. Our good results with standard laparoscopy are unlikely to be improved with robotics in proctectomy cases. Potential benefits of robotic approach for completion proctectomy warrant further investigation as experience grows with robotics.

OBJECTIVE: There is no consensus on whether, when and how to surveil an ileal pouch. The aims of this study were to evaluate experts' opinions and practice patterns on pouch surveillance and to determine if they were associated with detection of neoplasia. METHODS: Eligible physicians were identified by searching the literature in MEDLINE and the physician list of the Crohn's and Colitis Foundation of America and surveying by questionnaire. RESULTS: Fifty-two eligible participants from 32 tertiary institutions were identified. Forty-one physicians (79%) felt that surveillance pouchoscopy was necessary, and 36 (69%) believed that pouchoscopy with biopsy was effective for the detection of neoplasia. Great variation exists with regard to the frequency of surveillance pouchoscopy. Eighteen physicians (35%) reported the detection of a total of 4 pouch dysplasias and 15 pouch cancers within the previous 5 years. The follow-up number of ileal pouches per year was significantly higher in the neoplasia detection group (50 vs 25, P = 0.041). Those who reported detecting neoplasia took even fewer biopsies from the ileal pouch body during the pouchoscopy examination (>3 biopsies per location, 44% vs 82%, P = 0.005). Multivariable analysis showed that the number of patients with ileal pouches followed up per year was the only independent factor associated with the detection of pouch neoplasia (odds ratio [OR]: 1.5; 95% confidence interval [CI]: 1.1-2.1; P = 0.005). CONCLUSION: Most experts agree with performing pouchoscopy and biopsy for surveillance of ileal pouch neoplasia, although the optimal interval varies greatly. The detection of pouch neoplasia appears to be related to patient volume and physician experience.

Importance: The use of narcotics among patients with Crohn disease (CD) is endemic. Objective: To evaluate the association between preoperative use of narcotics and postoperative outcomes in patients with CD. Design, Setting, and Participants: Patients undergoing abdominal surgery for CD at a tertiary referral center between January 1998 and June 2014 were identified from an institutional prospectively maintained CD database. Main Outcomes and Measures: Primary end points were overall morbidity, postoperative hospital length of stay, and readmission. Univariate and multivariate analyses were used to assess possible associations between postoperative outcomes and demographic and clinical variables, including preoperative narcotic use. Results: Of the 1331 patients included, the mean age for patients who had at least 1 pharmacy claim for narcotics within 1 month before surgery was 41.5 years and 41.1 years for patients without a pharmacy claim. Of 1461 abdominal operations for CD, 267 (18.3%) were performed on patients receiving preoperative narcotics. Patients receiving narcotics were more likely to have a current smoking habit (P < .001) with perianal disease (P = .046) and undergoing treatment with biologics (P = .04). Patients with preoperative narcotic use had a longer mean (SD) length of stay (11.2 [8.9] vs 7.7 [5.5]; P < .001) and were more likely to develop postoperative complications (52.8% vs 40.8%; P < .001). Multivariable analysis indicated that preoperative narcotic use was the only independent risk factor associated with both postoperative morbidity (odds ratio = 1.36; 95% CI = 1.02-1.82; P = .04) and prolonged hospital stay (estimate = 2.91; SE = 0.44; P < .001). Subgroup analysis indicated that outpatient narcotic users had increased incidence of adverse postoperative outcomes compared with inpatient-only narcotic users. Conclusions and Relevance: Preoperative use of narcotics in patients undergoing abdominal surgery for CD is associated with worse postoperative outcomes. Before starting regular narcotic use, patients with CD should be considered for surgical intervention.

BACKGROUND: This study was conducted to investigate the impact of different hemoglobin level-based transfusion practices on infectious complications after surgery for ulcerative colitis. METHODS: Patients who underwent ileal pouch-anal anastomosis for ulcerative colitis between January 2008 and December 2013 were identified and divided into four groups: group 1 with hemoglobin >/= 10 and group 2 with hemoglobin >/= 7 and <10 g/dL who did not receive transfusion and group 3 with hemoglobin >/= 7 and <10 and group 4 with hemoglobin < 7 g/dL who received transfusion. Clinical characteristics and septic complications within postoperative 30 days were compared. RESULTS: There were 237, 341, 40, and 20 patients in groups 1, 2, 3, and 4, respectively. All the groups were comparable regarding perioperative characteristics except for age, gender, preoperative albumin and hemoglobin levels, and operative blood loss. The rates of overall septic complications were 18.6, 26.7, 47.5, and 40 % in the groups 1, 2, 3 and 4, respectively. In multivariate analysis, compared to group 2, group 3 was associated with an increased likelihood of developing organ/space (odds ratio (OR) = 4.34, p = 0.004) and overall surgical site infections (SSIs) (OR = 2.81, p = 0.01). CONCLUSION: Blood transfusion decided based on a perioperative hemoglobin (Hgb) level above 7 mg/dL is associated with higher overall and organ/space SSIs.

PURPOSE: The location of locally recurrent rectal cancer (LRRC) may influence survival. This study examines factors affecting the location of LRRC, the effect of LRRC location on survival, and predictive factors for survival in patients with LRRC. METHODS: Patients undergoing initial proctectomy and subsequent management of LRRC at the Cleveland Clinic (1980-2011) were included. Data regarding index surgery, LRRC, and survival were obtained from a prospectively maintained database. RESULTS: One hundred and fifty-seven patients were identified with a mean follow-up 59.8 +/- 50.1 months and time to LRRC of 31.7 +/- 30.1 months. Sixty patients underwent surgery with curative intent. Anastomotic leak and retrieving less than 12 lymph nodes at index proctectomy were associated with posterior (P = 0.019) and lateral (P = 0.036) recurrences, respectively. Having an axial relative to an anterior, posterior, or lateral recurrence was associated with improved overall survival (P = 0.001). On multivariable analysis, undergoing primarily palliative treatment (OR, 5.2; 95 % confidence interval (CI), 3.2-8.4; P < 0.001), age at LRRC >60 years (OR, 1.9; 95 % CI, 1.3-2.7, P < 0.001), advanced primary tumour stage (OR, 1.5; 95 % CI, 1.1-2.1; P = 0.021), and anastomotic leak at index surgery (OR, 1.8; 95 % CI, 1.2-2.7; P = 0.008) were associated with reduced LRRC 5-year survival. CONCLUSIONS: The current study suggests that features of the primary tumour and technical factors at the time of index proctectomy influence both the location of LRRC and survival.