Faculty Bibliography

BACKGROUND: The natural history of a pouch-related fistula in terms of timing of its development and its impact on pouch survival is poorly defined. OBJECTIVE: This study aimed to evaluate factors associated with the time of onset of ileoanal pouch-related fistulas and predictors of pouch failure after the development of fistulas. DESIGN: This study is an evaluation of prospectively collected data from a cohort of patients with pouch-related fistulas. SETTING: Patients were identified from a prospective ileoanal pouch database, with data recorded from 1983 to 2009. PARTICIPANTS: Patients who participated had developed a fistula after ileoanal pouch surgery. Patients were classified according to the time of onset, origin, and target of pouch fistulas into "early" and late" groups. MAIN OUTCOME MEASURE: Ileoanal pouch failure was the main outcome measure. RESULTS: Three hundred six patients (158 early-onset, 148 late-onset) with 373 pouch-related fistulas were identified. The early-onset group had a higher mean body mass index (P = .013) and more patients in this group developed a postoperative leak (P < .001), whereas diagnosis revision to Crohn's disease was more frequent in the late-onset group (P = .018). Overall, pouch failure occurred in 89 (29%) patients. Major abdominal procedures were more common in the early-onset group (18 vs 6%). There was no difference in pouch failure between the early- and late-onset groups (P = .24). On multivariate analysis, a current Crohn's diagnosis (P < .001), major fistula (P = .022), history of colectomy before ileoanal pouch (P = .005), handsewn anastomosis (P = .008), anastomotic leak (P = .012), and body mass index over 30 (P = .018) were independent risk factors for failure. No individual risk factor for failure was separately associated with either early or late fistula groups. CONCLUSIONS: The timing and etiology of pouch fistula appear to be interrelated. There is a temporal association between procedure-related sepsis and early and delayed diagnosis of Crohn's disease and late fistula development. Cause of the fistula and associated factors rather than timing after IPAA is associated with long term pouch retention.

BACKGROUND: Irritable pouch syndrome (IPS) is a functional disorder in patients with ileal pouch-anal anastomosis (IPAA), which presents with symptoms in the absence of structural abnormalities of the pouch. Thus, it resembles other functional disorders, such as irritable bowel syndrome characterized by visceral hypersensitivity in the presence of normal rectal biomechanics. The aim was to assess pouch biomechanics and perception of balloon distension in different groups of subjects with IPAA and to correlate the findings with clinical features. METHODS: Pouch tone, compliance, and sensation to balloon distension were measured in 18 patients with IPS, 11 patients with active pouch inflammation (pouchitis or Crohn's disease of the pouch), and 12 asymptomatic subjects with normal pouches. All patients were recruited from a subspecialty Pouchitis Clinic. RESULTS: Scores of sensation of gas, urge to defecate, and pain measured by visual analog scales at various distension pressures were significantly higher in IPS than pouchitis and normal pouch patients. Pouch tone was comparable among the groups and compliance was reduced in the pouchitis group. The visual analog scale showed a trend of correlation with the Pouchitis Disease Activity Index symptom scores in IPS. CONCLUSIONS: IPS, like other gut functional disorders, is characterized by visceral hypersensitivity, with normal pouch biomechanics.

OBJECTIVE: To evaluate the results and quality of life outcomes of transperineal repair using gracilis muscle interposition in patients who were candidates for attempted preservation of bowel and bladder function. There is currently no widely accepted procedure for the treatment of complex RUF, such as those complicated by radiotherapy, previous attempts at repair, or large in size. METHODS: Thirteen patients who underwent transperineal repair with gracilis muscle interposition for complex RUF were identified. Records were reviewed for fistula etiology, prior repair, intraoperative findings, hospital course, complications, diversion reversal, and outcome. Follow-up data were gathered from clinic visits and questionnaires. RESULTS: Preoperative diagnoses included: prostate cancer (PCA) (12) and imperforate anus (1). Treatment for PCA included radical prostatectomy (4); brachytherapy (BT) (3); external beam radiation therapy (EBRT) + BT (3); cryoablation (1); and EBRT + cryoablation (1). Five patients underwent prior unsuccessful repair. There were no intraoperative complications. Postoperative complications included fecal incontinence (3) and bladder neck contracture (1). Nine patients (75%) reported some degree of urinary incontinence, with 2 patients reporting this as significant, defined as incontinence "most of the time." Suprapubic catheters were removed after 6 weeks, and median stomal reversal was at 17.5 weeks (12-28). One patient developed a recurrent RUF. All patients completed quality-of-life questionnaires assessing urinary and fecal outcome. Fecal outcome measures were generally better than urinary, but both were reasonable given the complexity of the situation. CONCLUSIONS: Transperineal repair with gracilis muscle interposition is an effective treatment for selected patients with complex RUF. Our experience demonstrates low morbidity, high success rates, and reasonable bowel and bladder function postoperatively.

PURPOSE: Pouchitis is the most common complication of IPAA. Identifying factors predictive of pouchitis may improve outcomes by modifying contributing factors and enhancing patient selection. The most objective means for confirming pouchitis is by histology because the clinical and endoscopic diagnoses rely on more subjective assessments. The importance of histological pouchitis in the absence of clinical or endoscopic findings is unknown. METHODS: Prospectively collected data on patients with IPAA and pouch surveillance were evaluated. Patients who developed pouchitis, defined as symptoms of pouchitis confirmed by endoscopic biopsy (group B) were compared with those without any episode of clinical, endoscopic, or histological pouchitis (group A) for pre- and intraoperative factors and outcomes. Asymptomatic patients with histological pouchitis on surveillance biopsies (group C) were further compared with group A. Patients with Crohn's disease were excluded. RESULT: Of the 673 patients with pouch biopsies, 422 (62.7%) were in group A, 161 (23.9%) in group B, and 90 (13.4%) in group C. Mean follow-up was 9.8 (+/-5.1), 12.4 (+/-5.4), and 13. (+/-4.7) years. Of the 43 preoperative factors evaluated, those associated with group B included leukocytosis (P < .001), rheumatologic extraintestinal disease (P < .001), disease proximal to splenic flexure (P = .001), pulmonary comorbidity (P = .004), prior steroid use (P = .006), and age at operation and diagnosis (P = .018 and .021). Of the 10 intraoperative factors evaluated, pouchitis was associated with S-pouch reconstruction (P < .001), transfusion (P < .001), and 2-stage instead of 3-stage operation (P = .05), all surrogates for operative complexity. On multivariate analysis, pulmonary comorbidity (OR 3.38, 95% CI 1.62-7.07), disease proximal to splenic flexure (OR 2.37, 95% CI 1.18-4.77), extraintestinal disease manifestations (OR 1.6, 95% CI 1.01-2.54), and S-pouch reconstruction (OR 1.59, 95% CI 0.99 - 2.54) were associated with pouchitis. Patients in group B had worse outcomes, including more strictures (P = .015), bowel obstructions (P = .019), fistulas (P = .18), and lower quality of life (P < .001). Group C patients had the same outcomes as those in group A and the finding was not predicted by the above-mentioned parameters. CONCLUSION: Patients with symptomatic, biopsy-confirmed pouchitis have worse long-term outcomes than those without pouchitis. This complication is associated with specific pre- and intraoperative factors. Histological pouchitis incidentally found on surveillance biopsy in asymptomatic patients is of no clinical relevance and does not influence outcome. Identification of these preoperative factors associated with the subsequent development of pouchitis will strengthen patient counseling and may facilitate risk stratification.

BACKGROUND: To reduce cost, the Centers for Medicare and Medicaid Services adopted a nonpayment policy for "reasonably preventable events" including hospital acquired urinary tract infection (UTI). Type of operation a patient undergoes could be an inevitable nonmodifiable risk factor in the development of UTI. STUDY DESIGN: Using Participant User File for National Surgical Quality Improvement Program (NSQIP) data from 2005 to 2007, vascular and colorectal cases were identified using CPT codes and analyzed for UTI incidence and risk factors within each group. RESULTS: We identified 30,900 colorectal cases and 39,246 vascular cases with 1,289 (4.2%) colorectal and 952 (2.4%) vascular UTI cases. A multivariate analysis of the dataset revealed colorectal procedures as an independent risk factor for the development of UTI. Subset analysis revealed this significant relationship only for patients with low (<0.30) and intermediate (0.30 to 0.70) morbidity probability. Comparing only open intra-abdominal colorectal and vascular procedures revealed UTI rates of 3.9% versus 4.7%. Multivariate analysis revealed no significant difference in UTI rates in intraabdominal cases (all p values < 0.05). Subset analysis for the open cases revealed that colorectal procedures continued to be associated with UTI in low morbidity probability cases only. CONCLUSIONS: Current policy to reward higher quality fails to differentiate between UTI that may be preventable versus one likely due to nonmodifiable risk factors. Colorectal surgery is more likely to result in higher rates of UTI in comparison with vascular surgery, which may be related to type and complexity of a procedure. Further research needs to be done to change this policy to take into account this nonmodifiable risk factor.

BACKGROUND: There is sufficient evidence to support the use of hand-assisted laparoscopy for sigmoid, total, and proctocolectomy. As a result, the hand-assisted technique has gained acceptance for these relatively complex types of colorectal surgery. For right colectomy, the use of conventional laparoscopy is supported by studies that have demonstrated its advantages over open surgery. Although the hand-assisted technique is also being used by some surgeons for right colectomy, there are few reported data to justify its use. With this deficiency in mind, we performed a study to compare the short-term outcomes of right colectomy performed by either the hand-assisted or conventional laparoscopic technique. STUDY DESIGN: A single-center retrospective analysis was performed. Patients who underwent hand-assisted or conventional laparoscopic right colectomy were identified from a prospectively maintained departmental database. Preoperative clinical information, details of the operation, lymph node count for cancer cases, postoperative morbidity, length of stay, and 30-day hospital readmissions were evaluated. RESULTS: From 2006 to 2009, 43 hand-assisted and 84 conventional laparoscopic right colectomies were performed. Comparison of the hand-assisted and conventional laparoscopic groups revealed no differences in the preoperative clinical variables, including average body mass index (calculated as kg/m(2); 28 and 29), percent obese (33% and 34%), earlier abdominal surgery (30% and 39%), operative time (122 and 126 minutes), lymph nodes evaluated for cancer cases (22 and 21), postoperative morbidity (30%), length of stay (5 days), or 30-day hospital readmission (16% and 11%). CONCLUSIONS: Short-term outcomes of hand-assisted and conventional laparoscopic right colectomy are similar. The decision to perform hand-assisted or conventional laparoscopic right colectomy should be based on the surgeons' preference and not on the perception that one technique is preferable to the other.

BACKGROUND: The vitalHEAT vH(2) (Dynatherm Medical, Inc., Fremont, California) system transfers heat through a single extremity using a combination of conductive heat (circulating warm water within soft fluid pads) with mild vacuum, which improves both vasodilation and contact between the heating element and the skin surface. We tested the hypothesis that core temperatures were not >0.5 degrees C lower in patients warmed with the vitalHEAT system than with forced air. METHODS: Patients having general anesthesia for open abdominal surgery were randomly assigned to the circulating-water sleeve on 1 arm (n = 37) or an upper-body forced-air warming cover (n = 34). Patients were eligible to participate when body mass index was 20 to 36 kg/m(2), age was 18 to 75 years, and ASA physical status was 1 to 3. Intraoperative distal esophageal (core) temperatures were recorded. Repeated-measures analysis and 1-tailed t tests were used to assess noninferiority of vitalHEAT to forced air using a noninferiority delta of -0.5 degrees C. RESULTS: Demographic and morphometric characteristics were similar, as were surgical details. Preoperative core temperatures were similar in each group. Intraoperative core temperatures were also similar with each warming system and were significantly noninferior during the first four hours of surgery. The observed difference in means was never more than about 0.2 degrees C. After 4 hours of surgery, the average temperature was 36.3 degrees C +/- 0.6 degrees C (mean +/- sd) with the circulating-water sleeve (n = 18) and 36.4 degrees C +/- 0.5 degrees C with forced air (n = 20), for a difference (95% confidence interval) of -0.21 degrees C (-0.47, 0.06). CONCLUSIONS: The 2 systems thus apparently transfer comparable amounts of heat. Both appear suitable for maintaining normothermia even during large and long operations.

Screening for prostate cancer after restorative proctocolectomy with ileal pouch-anal anastomosis can be challenging. Diagnostic biopsy for an elevated level of prostate-specific antigen may present difficulties as well. No guidelines have been issued regarding the value and accuracy of digital examination and the best route to obtain prostate biopsy specimens. A screening and diagnostic algorithm for prostate cancer was developed by an expert consensus panel

There is an increased risk of morbidity and mortality after nonhepatic surgery in patients with liver failure compared to patients without liver failure. Mortality was shown to be higher after emergent surgery than after elective surgery in patients with cirrhosis. In patients with liver failure who undergo nonhepatic surgery, preoperative assessment is vital in order to reduce the high risk of postoperative complications and mortality.

HYPOTHESIS: A model could be developed to identify patients who can safely undergo restorative proctocolectomy (RPC) without proximal diversion. DESIGN: Logistic regression analysis was used to identify independent factors favoring omission of ileostomy at the time of RPC. A propensity nomogram was developed and validated using measures of calibration, discrimination, and subgroup analysis. SETTING: Two tertiary referral centers. PATIENTS: A total of 4013 patients undergoing RPC between January 1977 and December 2005 were included in the study sample. MAIN OUTCOME MEASURE: The decision to omit loop ileostomy at the time of RPC. RESULTS: After study group exclusions, proximal diversion was performed in 3196 of 3733 patients (85.6%) undergoing RPC; 45.4% of 3733 patients were women. The mean (SD) age at surgery was 37.4 (12.8) years. Ulcerative colitis was the indication for RPC in 2304 patients (61.7%) and familial adenomatous polyposis in 364 patients (9.8%), and a J pouch was performed in 2657 patients (71.2%). The following were found to be associated with ileostomy omission: stapled anastomosis (odds ratio [OR], 6.4), no preoperative corticosteroid use (OR, 3.2), familial adenomatous polyposis diagnosis (OR, 2.6), cancer diagnosis (OR, 3.4), female sex (OR, 1.6), and age at surgery younger than 26 years (OR, 2.1) (P < .01 for all). The model discriminated well (area under the receiver operating characteristic curve, 74.9%), with no significant differences between observed and expected outcomes (P = .49). Omission of proximal diversion demonstrated no significant effect on postoperative adverse events, although it was associated with a 2-day increase in the median length of hospital stay (P < .01). CONCLUSION: Incorporation of a 5-point nomogram in the preoperative assessment of patients undergoing RPC may aid clinicians in identifying a select group of patients who may be candidates for ileostomy omission during RPC.