Faculty Bibliography

BACKGROUND: The significance of backwash ileitis (BWI) relating to the risk of colon neoplasia in ulcerative colitis (UC) patients is controversial. AIM: We investigated the association between BWI and the presence of colon neoplasia in the colectomy specimen. METHODS: From 4,198 UC patients in a prospectively maintained pouch database from 1983 to 2011, patients with extensive colitis and BWI (n = 178) in proctocolectomy were compared with 537 controls [extensive colitis (n = 385) and left-sided colitis (n = 152)] without ileal inflammation. RESULTS: Colon neoplasia (colon dysplasia and/or colon cancer) was seen in 32 (18 %) patients with BWI in contrast to 45 (11.7 %) with extensive colitis and 13 (8.6 %) with left-sided colitis alone (p = 0.03). Of those with BWI, colon cancer was seen in 10 patients (5.6 %), while low grade and high grade dysplasia were seen in 7 (3.9 %) and 15 (8.4 %) patients respectively. On multivariate analysis, the presence of BWI with extensive colitis [odds ratio (OR) = 3.53; 95 % confidence interval (CI) 1.01-12.30, p = 0.04], presence of primary sclerosing cholangitis (PSC) (OR = 5.79, 95 % CI 1.92-17.40, p = 0.002) and moderate to severe disease activity at UC diagnosis (OR 4.29, 95 % CI 2.06-9.01, p < 0.001) were associated with an increased risk for identifying any colon neoplasia. For colon cancer, the presence of PSC (OR = 11.30, 95 % CI 1.54-80.9, p = 0.01) was the only factor independently associated with an increased risk. CONCLUSIONS: The presence of BWI with extensive colitis was associated with the risk of identifying colon neoplasia but not cancer alone in the proctocolectomy specimen.

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: 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: 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 AND AIMS: Risk factors for peristomal pyoderma gangrenosum (PPG) are not well defined. The aim of this study was to evaluate risk factors associated with development of PPG. METHODS: Both PPG patients and controls were obtained by searching a database of the Cleveland Clinic using the ICD-9 code from March 2005 to May 2011. The control group was selected by matching for underlying diseases and type of stoma in a ratio of 3:1. Univariate and multivariate analyses were performed. RESULTS: A total of 15 PPG cases and 45 controls were included. The mean age at the time of PPG diagnosis was 46.0 +/- 14.4 years. The underlying disease was Crohn's disease in 7 patients (46.7%), ulcerative colitis in 7 (46.7%) and indeterminate colitis in 1 (6.7%). Eleven patients (73.3%) had end ileostomy, 3 (20.0%) had loop ileostomy and 1 (6.7%) had colostomy. Eleven patients (73.3%) had active intestinal disease. In multivariate analysis, female gender, the presence of concurrent autoimmune disorders, and a high body mass index (BMI) were significantly associated with the presence of PPG, with odds ratios of 8.385 (95% confidence interval [CI]: 1.496-46.982, p=0.015), 6.882 (95% CI:1.438-32.941, p=0.016), and 9.895 (95% CI: 1.970-43.704, p=0.005), respectively. After a median follow-up of 12.8 (interquartile range: 7.9-20.1) months with appropriate therapy, PPG healed in 8 patients (53.3%) and improved in 7 (46.7%) patients, after treatment. CONCLUSIONS: Female gender, the presence of autoimmune disorders and a high BMI appeared to be associated with an increased risk for the development of PPG in IBD patients.

BACKGROUND: A system-wide, multi-ethnicity study on Crohn's disease (CD) of the pouch, including Indian American (IA) patients has not been conducted. AIM: To compare the frequency of subsequent development of CD of the pouch for African-American (AA), Hispanic-American (HA), IA and Caucasian patients with ulcerative (UC) undergoing ileal-pouch anal anastomosis (IPAA). METHODS: In this historical cohort study from our Pouch Registry, patients with restorative proctocolectomy and IPAA for IBD with identifiable, self-declared racial background (i.e. AA, HA, IA or Caucasian) were included. Univariable and multivariable analyses were performed to identify risk factors for CD of the pouch. RESULTS: The study included 235 patients: AA (N=26), HA (N=37), IA (N=22) and randomly selected Caucasian (N=150) controls. Greater number of HA and Caucasians had a history of smoking than IA (27.3% and 27.0% vs. 0; p=0.007). Caucasians and HA were also more likely to have a family history of IBD than IA or AA (25% vs. 27% vs. 5% vs. 4%; p=0.016.) IA less frequently had extensive colitis before colectomy than Caucasians (71.4% vs. 94.0%; p=0.004) and more frequently required anti-TNF biologics than HA (22.7% vs. 0; p=0.016). On multivariable logistic regression analysis, AA (odds ratio [OR]=10.1, 95% confidence interval [CI]: 1.03, 1365.8, p=0.004) and Caucasians (OR=11.1, 95% CI: 1.4, 1427.2, p=0.015) had a higher risk of developing CD of the pouch than IA. However, the event-free survival was not significantly different between the groups on Cox regression analysis, presumably due to the sample size. CONCLUSION: Racial background may be associated with different risk for the development of CD of the pouch for patients with IBD undergoing IPAA.

BACKGROUND: Patients with locally advanced or recurrent rectal cancer often require multimodality treatment. Intraoperative radiation therapy (IORT) is a focal approach which aims to improve local control. METHODS: We retrospectively reviewed 42 patients treated with IORT following definitive resection of a locally advanced or recurrent rectal cancer from 2000-2009. All patients were treated with the Intrabeam(R) Photon Radiosurgery System (PRS). A dose of 5 Gy was prescribed to a depth of 1 cm (surface dose range: 13.4-23.1, median: 14.4 Gy). Median survival times were calculated using Kaplan-Meier analysis. RESULTS: Of 42 patients, 32 had recurrent disease (76%) while 10 had locally advanced disease (24%). Eighteen patients (43%) had tumors fixed to the sidewall. Margins were positive in 19 patients (45%). Median follow-up after IORT was 22 months (range 0.2-101). Median survival time after IORT was 34 months. The 3-year overall survival rate was 49% (43% for recurrent and 65% for locally advanced patients). Local recurrence was evaluable in 34 patients, of whom 32% failed. The 1-year local recurrence rate was 16%. Distant metastasis was evaluable in 30 patients, of whom 60% failed. The 1-year distant metastasis rate was 32%. No intraoperative complications were attributed to IORT. Median duration of IORT was 35 minutes (range: 14-39). Median discharge time after surgery was 7 days (range: 2-59). Hydronephrosis after IORT occurred in 10 patients (24%), 7 of whom had documented concomitant disease recurrence. CONCLUSIONS: The Intrabeam(R) PRS appears to be a safe technique for delivering IORT in rectal cancer patients. IORT with PRS marginally increased operative time, and did not appear to prolong hospitalization. Our rates of long-term toxicity, local recurrence, and survival rates compare favorably with published reports of IORT delivery with other methods.

BACKGROUND AND OBJECTIVE: There is limited data on the appropriate management of dysplasia in Crohn's colitis. An evidence-based surgical strategy is provided. METHODS: Patients with a pathologic diagnosis of dysplasia in Crohn's colitis from 1987 to 2009 were identified. Patients were classified by dysplasia grade (low grade or LGD, high grade or HGD). Clinical, endoscopic, operative, and pathologic data were retrieved. Factors associated with a final cancer diagnosis were analyzed. Survival data on patients undergoing limited versus radical resection for cancer and HGD was compared. RESULTS: From 1987 to 2009, 50 patients underwent a colectomy for Crohn's colitis-associated dysplasia. The predictive value of HGD for a final HGD or cancer diagnosis was 73%. The predictive value of LGD on biopsy for HGD in the colectomy was 36%. Sixteen patients (44%) who underwent a total proctocolectomy (TPC) or subtotal colectomy (STC) had multifocal dysplasia. Four of 10 (40%) cancer patients had evidence of dysplasia remote from cancer site on pathologic examination. During follow-up, there were 3 cancer-related deaths. One patient died of metachronous cancer after STC. CONCLUSIONS: The findings confirm the risk of cancer in patients with CD dysplasia. Because of the multifocal nature of dysplasia in Crohn's colitis, TPC is recommended in good-risk patients. In specific circumstances, such as poor-risk patients especially in the setting of LGD, close endoscopic surveillance or alternatively segmental or STC with close postoperative endoscopic surveillance, depending upon the individual circumstance, may be discussed.