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Surgical management of patients with ulcerative colitis during pregnancy: maternal and fetal outcomes

Aytac, Erman; Ozuner, Gokhan; Isik, Ozgen; Gorgun, Emre; Remzi, Feza H
BACKGROUND AND AIMS: Ulcerative colitis can develop during the reproductive years, and there are limited data about perinatal care for patients with ulcerative colitis. In this study, we analyzed perinatal follow-up, complications, and maternal and fetal outcomes in pregnant patients undergoing surgery for ulcerative colitis. METHODS: Between January 1998 and July 2013, female patients who underwent surgery during pregnancy for abdominal complications of ulcerative colitis and followed up during their pregnancy in our institution were included in our study. Patient characteristics, complications, operations performed, maternal and fetal morbidity and mortality during the perinatal period, and type of delivery were analyzed. RESULTS: There were nine female patients with a median (range) age of 30 (21-33) years. Indications for surgery were fulminant/refractory colitis (n = 6) and bowel obstruction (n = 3). Operations performed were subtotal colectomy with an end ileostomy (n = 3), Turnbull blowhole procedure (n = 3), adhesiolysis with small bowel resection (n = 1), detorsion and decompression of bowel (n = 1) and adhesolysis (n = 1). Median (range) postoperative length of stay was 11 (5-28) days and median (range) duration of pregnancy was 36 (32-40) weeks. There were only two patients who had a transvaginal delivery, while a cesarean section was performed in seven patients. Indications for cesarean section were as follows: physician's preference (n = 4), planned small bowel surgery with cesarean section (n = 2), and metabolic disorders (n = 1). There were no perinatal maternal or fetal deaths. CONCLUSIONS: Surgery for ulcerative colitis complications can be performed safely if indicated during pregnancy under the care of a multidisciplinary team that includes gastroenterologists, obstetricians, and colorectal surgeons.
PMID: 25518046
ISSN: 1876-4479
CID: 2155162

Disease course and management strategy of pouch neoplasia in patients with underlying inflammatory bowel diseases

Wu, Xian-Rui; Remzi, Feza H; Liu, Xiu-Li; Lian, Lei; Stocchi, Luca; Ashburn, Jean; Shen, Bo
BACKGROUND: To evaluate the disease course and management strategy for pouch neoplasia. METHODS: Patients undergoing ileal pouch surgery for underlying ulcerative colitis who developed low-grade dysplasia (LGD), high-grade dysplasia, or adenocarcinoma in the pouch were identified. RESULTS: All eligible 44 patients were evaluated. Of the 22 patients with initial diagnosis of pouch LGD, 6 (27.3%) had persistence or progression after a median follow-up of 9.5 (4.1-17.6) years. Family history of colorectal cancer was shown to be a risk factor associated with persistence or progression of LGD (P = 0.03). Of the 12 patients with pouch high-grade dysplasia, 5 (41.7%) had a history of (n = 2, 16.7%) or synchronous (n = 4, 33.3%) pouch LGD. Pouch high-grade dysplasia either persisted or progressed in 3 patients (25.0%) after the initial management, during a median time interval of 5.4 (2.2-9.2) years. Of the 14 patients with pouch adenocarcinoma, 12 (85.7%) had a history of (n = 2, 14.3%) or synchronous dysplasia (n = 12, 85.7%). After a median follow-up of 2.1 (0.6-5.2) years, 6 patients with pouch cancer (42.9%) died. Comparison of patients with a final diagnosis of pouch adenocarcinoma (14, 32.6%), and those with dysplasia (29, 67.4%) showed that patients with adenocarcinoma were older (P = 0.04) and had a longer duration from IBD diagnosis or pouch construction to the detection of pouch neoplasia (P = 0.007 and P = 0.0013). CONCLUSIONS: The risk for progression of pouch dysplasia can be stratified. The presence of family history of colorectal cancer seemed to increase the risk for persistence or progression for patients with pouch LGD. The prognosis for pouch adenocarcinoma was poor.
PMID: 25137416
ISSN: 1536-4844
CID: 2155232

Twenty-year-old stapled pouches for ulcerative colitis without evidence of rectal cancer: implications for surveillance strategy?

Silva-Velazco, Jorge; Stocchi, Luca; Wu, Xian-rui; Shen, Bo; Remzi, Feza H
BACKGROUND: The risk of anal transition zone dysplasia/cancer after stapled IPAA for ulcerative colitis might be cumulative over time. OBJECTIVE: The purpose of this work was to assess the long-term incidence and risk factors of anal transition zone dysplasia. DESIGN: This was a retrospective study from a prospectively maintained database. SETTINGS: The study was conducted at a tertiary referral center. PATIENTS: Participants included those in our surveillance program of serial anal transition zone biopsies after stapled IPAA from 1986 to 1992. MAIN OUTCOME MEASURES: Anal transition zone dysplasia was the main measured outcome. RESULTS: Of 532 patients, 285 had 2 or more anal transition zone surveillance biopsies, including 73 with >/=20 years of regular follow-up. No adenocarcinoma was detected, and 15 patients died of unrelated causes after a median follow-up of 13.4 years (range, 2.9-19.5 years) without dysplasia. The estimated survival rates at 10, 15, and 20 years were 99.6% (95% CI, 96.9-99.9), 98.9% (95% CI, 95.7-99.7), and 92.6% (95% CI, 86.5-96.0). The estimated rates of anal transition zone dysplasia based on the 9 patients were 2.9% (95% CI, 1.5-5.7) and 3.4% (95% CI, 1.8-6.4) at 10 and 15 years. No new-onset dysplasia was identified beyond 125 months. Postoperative anal transition zone dysplasia was significantly associated with both preoperative and pathology findings of colorectal dysplasia (p < 0.001 for each) or cancer (p = 0.025 and p <0.001) and was managed expectantly or with mucosectomy (5 and 4 patients), depending on the number of positive biopsies and degree of dysplasia. Continued surveillance after detection of anal transition zone dysplasia showed no evidence of recurrent dysplasia during a median follow-up of 125 months (range, 9-256 months). LIMITATIONS: Approximately half of the eligible patients were excluded from the analysis because of insufficient follow-up. CONCLUSIONS: Long-term follow-up data corroborate the use of stapled IPAA for ulcerative colitis. Future studies should assess whether a less intensive surveillance strategy is safe 10 years after surgery.
PMID: 25285694
ISSN: 1530-0358
CID: 2155182

Individualized decision making in treatment: in reply to Pellino and colleagues [Letter]

Aytac, Erman; Remzi, Feza H
PMID: 25440033
ISSN: 1879-1190
CID: 2155172

Outcomes associated with resident involvement in laparoscopic colorectal surgery suggest a need for earlier and more intensive resident training

Gorgun, Emre; Benlice, Cigdem; Corrao, Elizabeth; Hammel, Jeff; Isik, Ozgen; Hull, Tracy; Remzi, Feza H
PURPOSE: The aim of this study is to determine if resident involvement in a large cohort of laparoscopic colorectal surgery (LCS) cases negatively impacts outcomes and ultimately increases costs. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent LCS between 2005 and 2010. Patients were classified into two groups: postgraduate year (PGY; resident involvement) or Attending Only. A subgroup analysis was then conducted among the individual PGY levels (1-2, 3-5, >/=6) and Attending Only group. RESULTS: A total of 4,836 patients were included in the PGY group and 2,418 in the Attending Only group. Mean operative time (163.9 +/- 66.7 vs. 140.7 +/- 67.2 minutes, P < .001) and length of hospital stay (5.8 +/- 5.4 vs. 5.6 +/- 5.4 days, P = .015) were significantly longer in the PGY group. Surgical and nonsurgical complications and overall morbidity and mortality rates were similar between the two groups. Each individual PGY group was associated with longer operative time (P < .001), and PGY >/= 6 was associated with an increased length of stay (P < .001). CONCLUSION: Although resident participation in LCS does not affect overall mortality or morbidity, it may negatively impact hospital costs through increased operative time and length of hospital stay. Early and intensive laparoscopy training may be necessary for improving residents' laparoscopy skills before their involvement in LCS.
PMID: 25239327
ISSN: 1532-7361
CID: 2155192

Failure of evidence-based cancer care in the United States: the association between rectal cancer treatment, cancer center volume, and geography

Monson, John R T; Probst, Christian P; Wexner, Steven D; Remzi, Feza H; Fleshman, James W; Garcia-Aguilar, Julio; Chang, George J; Dietz, David W
OBJECTIVE: This study examines recent adherence to recommended neoadjuvant chemoradiotherapy guidelines for patients with rectal cancer across geographic regions and institution volume and assesses trends over time. BACKGROUND: A recent report by the Institute of Medicine described US cancer care as chaotic. Cited deficiencies included wide variation in adherence to evidence-based guidelines even where clear consensus exists. METHODS: Patients operated on for clinical stage II and III rectal cancer were selected from the 2006-2011 National Cancer Data Base. Multivariable logistic regressions were used to assess variation in chemotherapy and radiation use by cancer center type, geographical location, and hospital volume. The analysis controlled for patient age at diagnosis, sex, race/ethnicity, primary payer, average household income, average education, urban/rural classification of patient residence, comorbidity, and oncologic stage. RESULTS: There were 30,994 patients who met the inclusion criteria. Use of neoadjuvant radiation therapy and chemotherapy varied significantly by type of cancer center. The highest rates of adherence were observed in high-volume centers compared with low-volume centers (78% vs 69%; adjusted odds ratio = 1.46; P < 0.001). This variation is mirrored by hospital geographic location. Primary payer and year of diagnosis were not predictive of rates of neoadjuvant chemoradiotherapy. CONCLUSIONS: Adherence to evidence-based treatment guidelines in rectal cancer is suboptimal in the United States, with significant differences based on hospital volume and geographic regions. Little improvement has occurred in the last 5 years. These results support the implementation of standardized care pathways and a Centers of Excellence program for US patients with rectal cancer.
PMID: 25203879
ISSN: 1528-1140
CID: 2155202

Single-port laparoscopic colorectal resections in obese patients are as safe and effective as conventional laparoscopy

Aytac, Erman; Turina, Matthias; Gorgun, Emre; Stocchi, Luca; Remzi, Feza H; Costedio, Meagan M
BACKGROUND: Obese patients pose additional operative technical difficulties, and it is unclear if the outcomes of single-port colorectal surgery are equivalent to those of conventional laparoscopy in such patients. The aim of this study was to compare perioperative variables and short-term outcomes of single-port versus conventional laparoscopy in obese patients undergoing colorectal surgery. PATIENTS AND METHODS: Obese patients (BMI >/= 30 kg/m(2)) undergoing single-port laparoscopic colorectal resections between March 2009 and September 2012 were case matched 1:1 with obese counterparts undergoing conventional (multi-port) laparoscopic surgery based on diagnosis and operation type. RESULTS: Thirty-seven patients who underwent single-port surgery were matched with 37 conventional laparoscopic counterparts. Male gender predominated in the single-port group (26 vs 15, p = 0.02). The number of patients with a history of previous abdominal operations (17 vs 13, p = 0.48) and ASA score (3 vs 2, p = 0.6) were similar between the groups. No differences were observed with respect to conversion rate (2 vs 5, p = 0.43), operative time (146 vs 150 min, p = 0.48), estimated blood loss (159 vs 183 ml, p = 0.99), time to first flatus (3 vs 3 days, p = 0.91), time to first bowel movement (3 vs 4 days, p = 0.62), length of hospital stay (7 vs 6 days, p = 0.37), or reoperation (2 vs 1, p > 0.99), and readmission rates (2 vs 2, p > 0.99). There were no deaths. CONCLUSION: For obese patients undergoing colorectal resections, single-port laparoscopy appears to be as safe and effective as conventional laparoscopy.
PMID: 24853841
ISSN: 1432-2218
CID: 2155252

Single-port laparoscopic fecal diversion: more than cosmetic benefits?

Aytac, Erman; Stocchi, Luca; Williams, Ryan; Remzi, Feza H; Costedio, Meagan M
Single-port laparoscopic surgery is usually performed on patients with minor comorbidities. The aim of the study was to evaluate feasibility and efficacy of single-port fecal diversion in patients who had previous abdominal operations or comorbidities. Between October 2010 and March 2012, 14 patients with a median age of 57 years were diverted. The reasons for diversion were perianal infection/abscess (n=5), anal incontinence (n=3), radiation proctitis (n=2), colovesical fistula causing sepsis (n=1), outlet obstruction of ileal S pouch (n=1), perforation during pouchoscopy (n=1), and peritoneal carcinomatosis with enterocutaneus fistula (n=1). Median estimated blood loss was 20 mL, operative time was 52 minutes, and length of hospital stay was 4 days. Two patients had ileus postoperatively. One patient had a parastomal hernia 4 months after diversion. Single-port laparoscopic fecal diversion is a safe and feasible operation for patients with significant comorbidities and a history of multiple abdominal operations.
PMID: 24710240
ISSN: 1534-4908
CID: 2155272

Comparable pouch retention rate between pediatric and adult patients after restorative proctocolectomy and ileal pouches

Wu, Xian-rui; Mukewar, Saurabh; Hammel, Jeffrey P; Remzi, Feza H; Shen, Bo
BACKGROUND & AIMS: We compared long-term outcomes between adult and pediatric patients with inflammatory bowel disease (IBD) who underwent restorative proctocolectomy with ileal pouch-anal anastomosis. METHODS: We performed a retrospective study that analyzed data from consecutive patients with ileal pouches who presented to the subspecialty Pouch Center at the Cleveland Clinic from 2002-2011. Pouch outcomes of 104 pediatric patients (having pouch surgery at age <18 years; 53 male) were compared with those of 1135 adults (having pouch surgery at an age 18 years or older; 632 male). RESULTS: Pediatric patients had a shorter duration from time of IBD diagnosis to colectomy than adult patients. Fewer pediatric than adult patients had a history of smoking, concomitant extraintestinal manifestations, or dysplasia as the indication for colectomy. However, pediatric patients had higher rates of pouch procedure-related complications, postoperative pouch-associated hospitalization, and postoperative use of anti-tumor necrosis factor (TNF) agents. In multivariate analysis, risk factors for pouch failure included preoperative use of anti-TNF agents (hazard ratio [HR], 1.81; 95% confidence interval [CI], 1.05-3.13; P = .032), postoperative use of anti-TNF agents (HR, 2.07; 95% CI, 1.31-3.27; P = .002), Crohn's disease of the pouch (HR, 2.21; 95% CI, 1.28-3.82; P = .005), pouch procedure-related complications (HR, 2.68; 95% CI, 1.55-4.64; P < .001), and postoperative pouch-associated hospitalization (HR, 25.20; 95% CI, 14.44-43.97; P < .001). Being a pediatric patient was not significantly associated with pouch failure in univariate or multivariate analyses (HR, 0.6; 95% CI, 0.32-1.16; P = .13). CONCLUSIONS: On the basis of an analysis of patients with IBD who underwent restorative proctocolectomy and presented at a subspecialized Pouch Center, patients who had the surgery at a pediatric age tend to have a higher incidence of postoperative pouch complications than adults. However, long-term rates of pouch retention were comparable.
PMID: 24361418
ISSN: 1542-7714
CID: 2155312

The J-pouch for patients with Crohn's disease and indeterminate colitis: (when) is it an option?

Turina, Matthias; Remzi, Feza H
PMID: 24777433
ISSN: 1873-4626
CID: 2155262