Faculty Bibliography

INTRODUCTION: The field of laparoscopic rectal cancer surgery is expanding. We compare short-term and early oncological outcomes after laparoscopic versus open resection in carefully matched rectal cancer patients. METHODS: All consecutive patients undergoing elective laparoscopic resection for rectal cancer were reviewed. Laparoscopic resections were matched 1:1 to open resections by age, gender, American Society of Anesthesiologists class, body mass index, neoadjuvant chemoradiation, and type of surgery. Data were analyzed using Fisher's exact, chi-square, Wilcoxon rank-sum tests, and Kaplan-Meier estimates. P-value <0.05 was considered statistically significant. RESULTS: Ninety-one rectal cancer patients with laparoscopic resection were included, 59% were male, and median age was 62 years. Conversion rate was 18.7%. Laparoscopic and open surgery had similar 30-day morbidity and mortality except wound infection, which was lower for the laparoscopic group (p = 0.02). Laparoscopic surgery had similar 30-day readmissions but shorter total length of hospital stay (5 versus 7 days, p < 0.01), time to first flatus (3 versus 4.5 days, p = 0.001), and time to first bowel movement (4 versus 5 days, p = 0.05) when compared with open surgery. The 3-year disease-free survival, local recurrence, and distant recurrence rates were also similar between the two groups. CONCLUSION: Laparoscopic surgery can be safely performed for rectal cancer, with better postoperative recovery and acceptable early oncological outcomes. Results from large ongoing randomized trials with longer follow-up time are pending to better define oncologic outcomes.

Restorative proctocolectomy with ileal pouch-anal anastomosis is the procedure of choice for patients with ulcerative colitis requiring surgery. A J-pouch with a stapled anastomosis has been the preferred technique because it is quicker, safer, and associated with good functional outcomes. A diverting loop ileostomy is usually created at the time of ileal pouch-anal anastomosis. In patients with severe fulminant colitis or toxic megacolon, restorative proctocolectomy with ileal pouch-anal anastomosis is performed in multistages. The technical aspects of ileal pouch-anal anastomosis in patients with ulcerative colitis are reviewed in this article.

BACKGROUND: This study aimed to investigate whether the learning curve during laparoscopic colectomy is associated with increased costs compared with the procedure after the learning curve has been achieved. METHODS: The direct costs for patients undergoing laparoscopic colectomy during the learning curve (group A) and after the attainment of proficiency by two colorectal surgeons performing the procedure (group B) between 2001 and 2007 were compared. The learning curve was defined as the first 40 laparoscopic colectomy cases for each surgeon. The distribution of cases for the surgeons ensured that cost-related differences were not influenced by lead time bias of cases performed during the learning curve. RESULTS: The study involved 80 group A and 74 group B patients. Groups A and B were similar in terms of age (P = 0.7), gender (P = 0.5), American Society of Anesthesiologists (ASA) score (P = 0.5), body mass index (P = 0.3), diagnosis (P = 0.8), previous abdominal surgery (P = 0.07), and comorbidity (P = 0.4). The two groups also were similar with regard to performance of anastomosis (P = 0.2) or resection (P = 0.6), conversion to open surgery (P = 0.7), postoperative morbidity (P = 0.6), readmission (P = 0.1), reoperation rate (P = 0.6), and hospital length of stay (P = 0.6). The operation time was significantly longer for group A (P = 0.01). The total direct costs (P = 0.7) and the operating room (P = 0.6), nursing (P = 0.7), pharmacy (P = 0.9), radiology (P = 1), and professional (P = 0.051) costs were however similar between the two groups. CONCLUSIONS: As expected, laparoscopic colectomy during the learning curve period is associated with prolonged operating time. Concerns pertaining to increased conversions, complications, and direct costs during this period were not substantiated in this study.

BACKGROUND: In patients with symptoms of pouchitis retractable to antibiotic therapy, serology is often ordered to exclude concurrent celiac disease. The clinical utility of celiac serology in patients with ileal pouches is unknown. The aim of this study was to investigate the clinical implications of false-positive celiac serology in patients with ileal pouches. METHODS: All patients with pouches who had underlying ulcerative colitis and available celiac serology were included from the subspecialty Pouchitis Clinic at the Cleveland Clinic between 2002 and 2007. Chronic antibiotic-refractory pouchitis was diagnosed based on persistent symptomatic pouchitis after a 4-week single- or dual-antibiotic therapy. RESULTS: A total of 126 patients were studied, and a false-positive celiac serology was observed in 19 patients. Chronic antibiotic-refractory pouchitis was diagnosed in 47% (9/19) of patients with false-positive celiac serology compared with 14% (15/107) of patients with a negative celiac serology (P = .003). In multivariate analysis, the association between false-positive celiac serology and chronic antibiotic-refractory pouchitis remained significant (odds ratio, 5.4; 95% confidence interval, 1.7-16.7; P = .004) after adjusting for sex (P = .03), pouch duration (P = .83), the presence of autoimmune disorders (P = .46), and extraintestinal manifestations (P = .63). CONCLUSION: False-positive celiac serology appeared to be common in patients with ileal pouch-anal anastomosis and it may be associated with chronic antibiotic-refractory pouchitis.

AIM: The aim of this study was to determine preoperative clinical factors associated with subsequent diagnosis revision to Crohn's disease (CD) following total proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) or indeterminate colitis (IC) patients. METHOD: Presumed UC and IC patients undergoing IPAA from a large single-institution prospective database with change of diagnosis to CD were identified and compared with patients without diagnosis change. RESULTS: A total of 2814 patients (47% male, median age 37 years) with presumed UC (85%) or IC (15%) underwent primary IPAA. At a median follow up of 9.6 years, 184 (7%) had the diagnosis revised to CD from histopathological examination of the colectomy specimen immediately in 97 (53%) or at a median interval of 36 months in 87 (47%). CD and UC/IC patients had had a similar operative technique, length of stay and 30-day morbidity. The postoperative CD diagnosis was associated with a preoperative diagnosis of IC (P < 0.0001) and perianal fistula (P = 0.002). Patients with a delayed diagnosis of CD were associated with a 3-stage procedure (P < 0.0001, OR = 2.8) (95% CI = 1.8-4.4), colonic stricture (P = 0.04, OR = 2.9 [95% CI = 1.1-7.4]), perianal fistula (P = 0.02, OR = 2.9 [95% CI = 1.2-7.2]), oral ulceration (P = 0.009, OR = 3.8 [95% CI = 1.2-9.6]) and younger age (P < 0.0001, OR = 0.048 [95% CI = 0.011-0.19]). CONCLUSION: A few patients having IPAA for presumed UC/IC were subsequently diagnosed to have CD which was associated with perianal fistula and the diagnosis of postoperative preoperative IC. The delayed diagnosis of CD was associated with a three-stage procedure, colorectal stricture, anal fissure, mouth ulceration and younger age.

BACKGROUND: Despite the routine use of prophylactic systemic antibiotics, surgical-site infection continues to be associated with significant morbidity and cost after colorectal surgery. The gentamicin-collagen sponge, an implantable topical antibiotic agent, is approved for surgical implantation in 54 countries. Since 1985, more than 1 million patients have been treated with the sponges. METHODS: In a phase 3 trial, we randomly assigned 602 patients undergoing open or laparoscopically assisted colorectal surgery at 39 U.S. sites to undergo either the insertion of two gentamicin-collagen sponges above the fascia at the time of surgical closure (the sponge group) or no intervention (the control group). All patients received standard care, including prophylactic systemic antibiotics. The primary end point was surgical-site infection occurring within 60 days after surgery, as adjudicated by a clinical-events classification committee that was unaware of the study-group assignments. RESULTS: The incidence of surgical-site infection was higher in the sponge group (90 of 300 patients [30.0%]) than in the control group (63 of 302 patients [20.9%], P=0.01). Superficial surgical-site infection occurred in 20.3% of patients in the sponge group and 13.6% of patients in the control group (P=0.03), and deep surgical-site infection in 8.3% and 6.0% (P=0.26), respectively. Patients in the sponge group were more likely to visit an emergency room or surgeon's office owing to a wound-related sign or symptom (19.7%, vs. 11.0% in the control group; P=0.004) and to be rehospitalized for surgical-site infection (7.0% vs. 4.3%, P=0.15). The frequency of adverse events did not differ significantly between the two groups. CONCLUSIONS: Our large, multicenter trial shows that the gentamicin-collagen sponge is not effective at preventing surgical-site infection in patients who undergo colorectal surgery; paradoxically, it appears to result in significantly more surgical-site infections. (Funded by Innocoll Technologies; ClinicalTrials.gov number, NCT00600925.)

BACKGROUND & AIMS: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has substantially reduced the risk for ulcerative colitis (UC)-associated dysplasia or cancer (neoplasia). We characterized features, risk factors, and outcomes of pouch neoplasia in patients with inflammatory bowel disease in a historical cohort study. METHODS: A total of 3203 patients with a preoperative diagnosis of inflammatory bowel disease underwent restorative proctocolectomy with IPAA from 1984 to 2009 at the Cleveland Clinic. Demographic, clinical, and endoscopic data were reviewed and samples were examined by histological analyses. Univariable and Cox regression analyses were performed. RESULTS: Cumulative incidences for pouch neoplasia at 5, 10, 15, 20, and 25 years were 0.9%, 1.3%, 1.9%, 4.2%, and 5.1%, respectively. Thirty-eight patients (1.19%) had pouch neoplasia, including 11 (0.36%) with adenocarcinoma of the pouch and/or the anal-transitional zone (ATZ), 1 (0.03%) with pouch lymphoma, 3 with squamous cell cancer of the ATZ, and 23 with dysplasia (0.72%). In the Cox model, the risk factor associated with pouch neoplasia was a preoperative diagnosis of UC-associated cancer or dysplasia, with adjusted hazard ratios of 13.43 (95% confidence interval: 3.96-45.53; P < .001) and 3.62 (95% confidence interval: 1.59-8.23; P = .002), respectively. Mucosectomy did not protect against pouch neoplasia. CONCLUSIONS: Risk for neoplasia in patients with UC and IPAA is small and not eliminated by colectomy or mucosectomy. A preoperative diagnosis of dysplasia or cancer of colon or rectum is a risk factor for pouch dysplasia or adenocarcinoma.

BACKGROUND: The goal of this study was to compare surgical site infection (SSI) rates between laparoscopic (LAP) and open colorectal surgery using the National Surgical Quality Improvement Program (NSQIP) database. STUDY DESIGN: We identified patients included in the NSQIP database from 2006 to 2007 who underwent LAP and open colorectal surgery. SSI rates were compared for the 2 groups. Association between patient demographics, diagnosis, type of procedure, comorbidities, laboratory values, intraoperative factors, and SSI within 30 days of surgery, were determined using a logistic regression analysis. RESULTS: Among 10,979 patients undergoing colorectal surgery (LAP 31.1%, open 68.9%), the SSI rate was 14.0% (9.5% LAP vs 16.1% open, p < 0.001). LAP patients were younger (p < 0.001), with lower American Society of Anesthesiologists (ASA) scores (p < 0.001) and comorbidities (p = 0.001) involving benign and inflammatory conditions rather than malignancy (p < 0.001), but operative time was greater (p = 0.001). On multivariate analysis age, ASA > or = 3, smoking, diabetes, operative time >180 minutes, appendicitis or diverticulitis, and regional enteritis diseases were found to be significantly associated with high SSI; the LAP approach was associated with a reduced SSI rate. CONCLUSIONS: The LAP approach is independently associated with a reduced SSI when compared with open surgery and should, when feasible, be considered for colon and rectal conditions.

INTRODUCTION: The aim of this study was to evaluate patient- and tumor-related characteristics for patients undergoing surgery for cancer complicating inflammatory bowel disease (IBD), and to assess differences between patients with Crohn's disease (CD) and ulcerative colitis (UC). METHODS: Data on all IBD patients with colon and rectal cancer (CRC) undergoing surgery between 1980 and 2007 were evaluated from prospectively maintained CRC and IBD databases. Clinical presentation, tumor stage, presence of associated dysplasia, and short- and long-term outcomes after surgery were investigated. Outcomes for IBD patients were compared with a matched group of patients with sporadic cancer. RESULTS: A total of 240 IBD patients (64 CD and 176 UC) with CRC were identified. At the time of CRC diagnosis, 68% UC and 26% CD patients had pancolitis. About 92% of the patients who underwent preoperative colonoscopy were noted to have suspicious lesions. Although 92.5% of the patients had a preoperative histopathologic diagnosis of cancer or dysplasia, incidental diagnosis of cancer in the resection specimen was made in 3%. Examination of the resection specimen revealed synchronous dysplasia in 48% of the patients and synchronous cancer in 12% patients. Tumor location was rectum in 36%, right colon in 28%, sigmoid colon in 17%, transverse colon 10%, and left colon in 9% of patients. CD patients were diagnosed at a more advanced cancer stage than UC. Local recurrence and overall 5-year survival rates were comparable (5.6% vs. 6.7%, P = 0.78 and 77% vs. 72%, P = 0.5, respectively) for patients with IBD and sporadic cancer. CONCLUSIONS: Most IBD cancer can be diagnosed or suspected on the basis of endoscopic findings, biopsy of areas of active colitis, and an incidental finding of malignancy after colorectal resection for other indications is rare. CD patients present with a more advanced cancer stage. Optimal endoscopic surveillance may identify most patients with IBD cancer.