Faculty Bibliography

BACKGROUND: The optimal management of the closed defunctionalized large-bowel stump after laparoscopic total abdominal colectomy with end ileostomy for ulcerative colitis remains controversial. OBJECTIVE: The aim of this study is to compare postoperative outcomes after different techniques of management of the defunctionalized (colo)rectal stump. DESIGN AND PATIENTS: Patients undergoing laparoscopic total abdominal colectomy for ulcerative colitis during 1998 to 2010 were assigned to an intraperitoneal group (creation of Hartmann rectal stump) or a subcutaneous group (subcutaneous placement of rectosigmoid stump). OUTCOME MEASURE: Postoperative morbidity was defined as complications occurred within 30 days after the operation or during the same hospital stay. RESULTS: Of 204 patients, 99 were in the intraperitoneal group and 105 were in the subcutaneous group. There were no significant differences in demographics or preoperative data, with the exception of a significantly increased age-adjusted Charlson Comorbidity Index and preoperative total parental nutrition use in the intraperitoneal group. There was 1 postoperative death for myocardial infarction in the subcutaneous group. Overall postoperative morbidity, pelvic sepsis rates, and length of hospital stay were similar. Stump leaks occurred in 5 patients in the intraperitoneal group vs 10 patients in the subcutaneous group (p = 0.23). All stump leaks in the subcutaneous group only required local wound treatments without causing pelvic sepsis or need for reoperation. Pelvic sepsis in the intraperitoneal group required reoperation in 1 case, CT-guided drainage in 3, and antibiotics alone in 2 cases. Pelvic sepsis in the subcutaneous group required CT-guided drainage in 3 cases and antibiotics alone in 1 case. CONCLUSION: With the limitations of a retrospective study, postoperative outcomes were comparable after either technique of stump management, none of which could offset the risk of pelvic sepsis. Subcutaneous placement of colorectal stump was associated with more frequent but less morbid complications.

BACKGROUND: Endoscopic features as predictors in pouch failure have not been studied. A well-constructed J-pouch typically has an "owl's eye" appearance in the proximal pouch body. We hypothesized that loss of the owl's eyes is associated with a high risk for pouch failure. The aim of this study was to evaluate the association between the distorted endoscopic appearance of owl's eyes and pouch failure. METHODS: A total of 711 available pouch endoscopic images from 426 J-pouch patients were reviewed and scored blindly. A scoring system was generated for distorted owl's eyes. Multivariable analyses were performed to assess the link between the endoscopic feature or other variables and pouch failure. RESULTS: A total of 37 patients (8.7%) developed pouch failure, with a median of 5.0 (interquartile range, 2.0-11.0) years of follow-up. Multivariable analyses showed that 2 or more "beak" abnormalities were associated with failure rates of 33.3%, 44.4%, and 72.2% by 5, 10, and 15 years of ileal pouch-anal anastomosis, respectively (hazard ratio = 3.7; 95% confidence interval, 1.5-9.0). In addition, diagnosis of Crohn's disease or surgical complications, the postoperative use of anti-tumor necrosis factor biologics, and a high cuff endoscopy inflammation score had statistically significant hazard ratios of 3.2, 5.8, and 1.5 for pouch failure, respectively. CONCLUSIONS: Distorted appearance of "beak" portion of owl's eyes along with Crohn's disease of the pouch or surgery-related complications, postoperative use of biologics, and persistent cuffitis were the risk factors associated with pouch failure. The assessment of endoscopic owl's eye structure may provide an additional clue to predict pouch outcome.

BACKGROUND: Ileal pouch anal anastomosis (IPAA) is the treatment of choice for chronic, medically refractory mucosal ulcerative colitis, indeterminate colitis, familial adenomatous polyposis (FAP), and a select group of patients with Crohn's disease. AIM: : We report outcomes, complications, and quality of life (QOL) in a cohort of 3707 patients treated at our institution from January 1984 to March 2010. METHODS: Data were collected from a prospectively maintained database and chart review of 3707 consecutive primary IPAA cases. Patient demographics, postoperative complications, functional outcomes, and QOL data were available. Follow-up consisted of clinical examination with assessment of pouch function and QOL. RESULTS: A total of 3707 patients underwent primary pouch and 328 underwent redo pouch surgery. Postoperative histopathological diagnoses were mucosal ulcerative colitis (n = 2953, 79.7%), indeterminate colitis (n = 63, 1.7%), FAP (n = 223, 6%), Crohn's disease (n = 150, 4%), cancer/dysplasia (n = 97, 2.6%), and others (n = 221, 6.0%). Early perioperative complications were encountered in 33.5% of patients with a mortality rate of 0.1%. Excluding pouchitis, late complications were experienced by 29.1% of patients. Of those patients who had IPAA at our institution, pouch failure occurred in 197 patients (5.3%). During a median follow-up of 84 months, 119 patients (3.2%) required excision of the pouch, 32 (0.8%) had a nonfunctioning pouch, and 46 patients (1.2%) had redo IPAA. Functional outcomes and QOL were good or excellent in 95% of patients and similar in each histopathological subgroup. CONCLUSIONS: IPAA is an excellent option for patients with MUC, IC, FAP, and select patients with Crohn's disease.

BACKGROUND: Long-term consequences of anastomotic leak after restorative proctectomy for rectal cancer, in terms of bowel function and quality of life, have been poorly delineated. OBJECTIVE: The purpose of this study is to evaluate the impact of anastomotic leak, when intestinal continuity can still be maintained, on bowel function and quality of life in patients undergoing rectal cancer resection with low colorectal or coloanal anastomoses. DESIGN: From 1980 to 2010, 864 patients undergoing restorative resection for rectal cancers were identified from a prospective cancer database. Anastomotic leak detected by a combination of clinical, radiographic, and operative means was diagnosed in 52 (6%) patients. MAIN OUTCOME MEASURES: Patients with anastomotic leak were compared with those without anastomotic leak for functional outcomes and quality of life at 1 year and most recent follow-up (mean 3.2 years) by using Short-Form 36 questionnaires (physical and mental component scales) and the Fecal Incontinence Severity Index. RESULTS: American Society of Anesthesiologists' class (p = 0.48), cancer stage (p = 0.39), and the use of neoadjuvant therapy (p = 0.4) were similar in the 2 groups. Patients with anastomotic leak were younger (56 years vs 61 years; p = 0.007), more likely to be male (82% vs 64%; p = 0.008), and more likely to have undergone proximal diversion at proctectomy (51.9% vs 26.6%; p = 0.001). One year after proctectomy, patients with anastomotic leak had worse physical and mental component scores (p = 0.01), more frequent daytime (p = 0.001) and nighttime bowel movements (p = 0.03), and worse control of solid stool (p = 0.01) in comparison with those without an anastomotic leak. At most recent follow-up (leak, 3.3 years vs no leak, 2.4 years), patients with an anastomotic leak reported worse mental component scores and increased use of perineal pads. CONCLUSION: Anastomotic leak after restorative resection for rectal cancer leads to early adverse consequences on bowel function and quality of life even when anastomotic continuity can be maintained. These findings may help counsel patients and clinicians regarding anticipated outcomes over the long term.

BACKGROUND: Laparoscopic surgery benefits obese patients but technical difficulties associated with suboptimal exposure and access in these subjects may prompt conversion to open surgery. Hand-assisted laparoscopic surgery (HALS) confers advantages over standard laparoscopy (LAP) by facilitating tactile feedback, assisted dissection, and retraction. These benefits could be particularly valuable in obese patients, allowing completion of difficult laparoscopic procedures in this subgroup. Our aim was to compare intra-operative and post-operative outcomes of HALS and LAP approaches in obese patients undergoing colorectal resection at our institution. METHODS: A retrospective study of a prospectively maintained laparoscopic colorectal surgery database was performed. HALS and LAP cases performed in obese patients (body mass index (BMI) >30) were identified and compared for the following outcomes: operative time, intra-operative complications, rate of conversion to open, blood loss, length of stay, post-operative morbidity, and mortality. Outcomes for the converted patients were included on an intention-to-treat basis for all primary analyses. A secondary analysis of nonconverted and converted cases was also performed. RESULTS: Over a 5-year period, 496 obese patients underwent laparoscopic colorectal resection; 86 HALS and 410 LAP cases. The two groups were comparable in terms of age, gender, BMI, and indications for surgery. Conversion to open surgery was less often necessary in HALS compared to LAP cases (3.5 % vs. 12.7 %, p = 0.014). The LAP group had a significantly smaller incision length for specimen extraction (HALS (7.0 +/- 1.3 cm) vs. LAP (5.7 +/- 2.1 cm), p < 0.001). Length of stay, operative time, morbidity, and mortality rates were comparable between the two groups. CONCLUSION: In obese patients who require colectomy, the HALS approach increases the likelihood of a successful minimally invasive operation. At the cost of a clinically negligible increase in incision length, HALS may save a high-risk group conversion to formal laparotomy and the adverse outcomes related to this.

BACKGROUND: Cuffitis, considered a form of reminiscent ulcerative colitis (UC), is one of the common complications of ileal pouch-anal anastomosis (IPAA) and its disease course has not been systematically characterized. The aim was to examine the disease course of cuffitis in a large historical cohort. METHODS: All patients with cuffitis diagnosed based on a combined evaluation of symptom and pouch endoscopy at the initial visit to our Pouchitis Clinic were included. Pouch patients with diagnoses other than cuffitis served as controls. Patients with familial adenomatous polyposis were excluded. RESULTS: A total of 120 patients with cuffitis were included. The control group consisted of 811 patients (normal pouch, n = 85; irritable pouch syndrome, n = 155; acute pouchitis, n = 170; chronic pouchitis, n = 128; Crohn's disease [CD] of the pouch, n = 185; and surgical complications, n = 88). After a median follow-up of 6 years (interquartile range: 3-10 years) after pouch construction, there were 40 (33.3%) having 5-aminosalicylate (5-ASA)/steroid-responsive cuffitis; 22 (18.3%) having 5-ASA/steroid-dependent cuffitis, and 58 (48.4%) developing 5-ASA/steroid-refractory cuffitis. Further investigation of the 58 patients with refractory cuffitis showed that 19 (32.8%) had CD of the pouch and 14 (24.1%) had surgical complications including fistulae and anastomotic sinuses. There were 16 (13.3%) cuffitis patients who developed pouch failure during the follow-up period. CONCLUSIONS: Cuffitis may represent a spectrum of diseases. In patients with refractory cuffitis, a diagnosis of CD or surgery-associated anal transitional zone complications should be considered.

BACKGROUND: Accidental puncture or laceration during a surgical procedure is a patient safety indicator that is publicly reported and will factor into the Centers for Medicare and Medicaid's pay-for-performance plan. Accidental puncture or laceration includes serosal tear, enterotomy, and injury to the ureter, bladder, spleen, or blood vessels. OBJECTIVE: This study aimed to identify risk factors and assess surgical outcomes related to accidental puncture or laceration. DESIGN: This is a retrospective study. SETTINGS: This study was conducted in a single-hospital department of colorectal surgery. PATIENTS: Inpatients undergoing colorectal surgery in which an accidental puncture or laceration did or did not occur were selected. MAIN OUTCOME MEASURES: The primary outcomes measured were surgical complications, length of stay, and readmission. RESULTS: Of 2897 operations, 269 had accidental puncture or laceration (9.2%) including serosal tear (47%), enterotomy (38%), and extraintestinal injuries (15%). Accidental puncture or laceration cases had more diagnoses of enterocutaneous fistula (11% vs 2%, p < 0.001), reoperative cases (91% vs 61%, p < 0.001), open surgery (96% vs 77%, p < 0.001), longer operative times (186 vs 146 minutes, p = 0.001), and increased length of stay (10 vs 7 days, p = 0.002). Patients with serosal tears had entirely similar outcomes to those without an injury, whereas patients with enterotomies had increased operative times and length of stay, and patients with extraintestinal injuries had higher rates of reoperation and sepsis (p < 0.05 for all). LIMITATIONS: This study was limited by the loss of sensitivity due to grouping extraintestinal injuries. CONCLUSIONS: Accidental puncture or laceration is more likely to occur in complex colorectal operations. The clinical consequences range from none to significant depending on the specific type of injury. To make accidental puncture or laceration a more meaningful quality indicator, we advocate that groups who use the measure eliminate the injuries that have no bearing on surgical outcome and that risk adjustment for operative complexity is performed.

BACKGROUND: The feasibility and safety of single-incision laparoscopic total proctocolectomy (TPC) and ileal pouch anal anastomosis (IPAA) were first reported in 2010. To improve accuracy and efficiency while maintaining the cosmetic advantages of single-incision laparoscopic surgery, we have since modified the technique to include the use of a 5-mm instrument placed through the eventual drain site. The aim of this study is to compare reduced port laparoscopic (RPL) IPAA with conventional laparoscopic IPAA with respect to short-term outcomes to assess safety. METHODS: RPL cases were matched to conventional laparoscopy cases for patient age (+/-5 years), body mass index, gender, diagnosis, type and number of stages of surgical procedure, American Society of Anesthesiologists (ASA) classification, and year of surgery (+/-3 years). Groups were compared using chi(2) or Fisher exact tests for categorical and Wilcoxon rank-sum test for quantitative data. RESULTS: Twenty-four RPL patients were case-matched to an equal number of patients who underwent conventional laparoscopic IPAA. Short-term outcomes including postoperative complications, length of hospital stay, and time to first bowel movement were similar between groups. Despite similar diagnosis, previous surgery, and comorbidity, operative blood loss (p < 0.001) and operating time (p = 0.02) were lower for the RPL group. CONCLUSION: RPL IPAA can be safely performed with short-term outcomes comparable to conventional laparoscopy.

BACKGROUND: Patients undergoing abdominal surgery for Crohn's disease are predisposed to recurrence requiring reoperation. The effectiveness of laparoscopic versus open resection in patients with previous intestinal resection for Crohn's through midline laparotomy is controversial. METHODS: Patients with previous open resection for intestinal Crohn's disease undergoing elective laparoscopic surgery for recurrent bowel disease from 1997 to 2011 were case-matched with open counterparts based on age (+/-5 years), gender, body mass index (+/-2 kg/m(2)), American Society of Anesthesiologists (ASA) score, surgical procedure, and year of surgery (+/-3 years). Groups were compared using Chi-square or Fisher exact tests for categorical and the Wilcoxon rank-sum test for quantitative data. RESULTS: 26 patients undergoing laparoscopic ileocolectomy (n = 14), proctocolectomy (n = 5), small bowel resection (n = 4), abdominoperineal resection (n = 1), extended right colectomy (n = 1), and strictureplasty (n = 1) were well matched to 26 patients undergoing open surgery. The number of previous operations, disease phenotypes, steroid use, and comorbidities were comparable in the two groups. There were no deaths, and three patients (12%) required conversion because of adhesions. Laparoscopic and open groups had statistically similar operating times (169 versus 158 min, p = 0.94), estimated blood loss (222 versus 427 ml, p = 0.32), overall morbidity (39 versus 69%, p = 0.051), reoperation rates (8 versus 0%, p = 0.5), postoperative return of bowel function (3.5 +/- 1.4 versus 3.9 +/- 1.7 days, p = 0.3), mean length of hospital stay (6.4 +/- 6.2 versus 6.9 +/- 3.5 days, p = 0.12), and readmission rates (8 versus 12%, p = 0.64). Wound infection rate was decreased after laparoscopic surgery (0 versus 27%, p = 0.01). CONCLUSIONS: Surgery for recurrent Crohn's disease in patients with previous primary resection through laparotomy can be frequently and safely completed laparoscopically. Wound infection rates are reduced, but the recovery advantages of a minimally invasive approach are not maintained when compared with open surgery. The decision to operate laparoscopically should therefore be carefully calibrated.

BACKGROUND AND AIM: Surveillance for colon cancer is recommended in patients with primary sclerosing cholangitis (PSC) and ulcerative colitis (UC). It is unclear whether characteristics of colon neoplasia have changed over time. The aim of the study was to examine the temporal trends in colon neoplasia in patients with PSC and UC. METHODS: A total of 167 patients followed up at our institution between 1985 and 2011, 55 of these with neoplasia detected on colonoscopic biopsy were identified. Characteristics of patients with colon neoplasia in PSC-UC were studied for two different time periods: 1985-1998 (early cohort) compared to 1999-2011 (recent cohort). RESULTS: The median age at diagnosis of colon neoplasms was 53 years (median IQR, 43-63). The baseline characteristics were similar in both cohorts. The colonic neoplasms that developed in PSC-UC patients were spread throughout the colon on colonoscopy, while there was predominant right sided distribution on colectomy in both cohorts. (81.7% vs. 18.3%, p<0.001) Compared to the recent cohort, both the PSC (17 vs. 11 years, p=0.02) and UC duration (20 vs. 12 years, p=0.02) were longer in the early cohort. There were no differences in the grades and stages of cancer diagnosis. In addition, no differences in transplant-free survival or UC characteristics were revealed. CONCLUSIONS: With annual colonoscopic surveillance, dysplasia and cancer in patients with a combined diagnosis of PSC//UC is being diagnosed in patients with a shorter duration of these conditions. The nature and the location of neoplasia have, however, not changed.