Faculty Bibliography

BACKGROUND: There are inconsistencies regarding the risk factors associated with pouchitis and Crohn's disease of the pouch after ileal pouch-anal anastomosis. The aim of this study was to evaluate the associations between precolectomy routine laboratory tests, including platelet counts, and occurrences of inflammatory pouch disorders. METHODS: All eligible patients were included from The Pouchitis Clinic. All patients undergoing ileal pouch-anal anastomosis for ulcerative colitis were included if their preoperative laboratory tests were available. Demographic, clinical, endoscopic, and laboratory tests were evaluated with univariate and multivariate analyses. RESULTS: A total of 251 patients were included. Fifty-five patients had acute pouchitis and 29 had chronic pouchitis. Forty-two patients were diagnosed with Crohn's disease of the pouch. In multivariate analysis, elevated platelet count was not associated with chronic pouchitis (odds ratio, 0.91; 95% confidence interval, 0.32-2.59; P = 0.86) or Crohn's disease of the pouch (odds ratio, 0.87; 95% confidence interval, 0.38-1.97, P = 0.73) after adjusting for gender, smoking, extraintestinal manifestations, and pouch duration. Active smoking was associated with Crohn's disease of the pouch (odds ratio, 5.64; 95% confidence interval, 1.98-16.1; P = 0.001). No other laboratory tests, including white blood cell counts, albumin levels, and hemoglobin levels, were associated with the pouch outcomes. The presence of extraintestinal manifestations was associated with acute pouchitis (odds ratio, 1.89; 95% confidence interval, 0.95-1.14; P = 0.05) and chronic pouchitis (odds ratio, 2.6; 95% confidence interval, 1.13-5.87; P = 0.03). CONCLUSION: Precolectomy laboratory tests, including platelet counts, did not appear to impact the occurrence of inflammatory pouch disorders after ileal pouch-anal anastomosis.

PURPOSE: This study was designed to evaluate factors that might be predictive of readmission and early and long-term outcomes for patients readmitted after ileal pouch-anal anastomosis. METHODS: Data for patients readmitted within 30 days after ileal pouch-anal anastomosis were identified from a prospectively maintained database and compared with the remaining patients. Early and delayed outcomes for readmitted patients, including long-term functional outcomes and quality of life, were evaluated. Potential predictors of readmission were assessed using a multivariate analysis of factors. RESULTS: Of 3,410 patients who underwent ileal pouch-anal anastomosis from 1984 to 2008, 410 (12%) were readmitted. Reasons for readmission included ileus, obstruction or dyselectrolytemia (54.9%), surgical site infection (19.8%), anastomotic problems (9.8%), and thrombotic (3.4%), hemorrhagic (3.2%), infectious (2.9%), cardiac (1.2%), and miscellaneous (4.3%) complications. Thirty-two (7.8%) patients underwent reoperation; 74 (18%) required invasive nonoperative interventions. Median hospital stay for readmission was four (range, 1-52) days. Readmitted patients had worse long-term functional results (P = 0.015) and social (P = 0.024), work (P = 0.008), and sexual (P = 0.046) restriction as compared with patients who were not readmitted. The Cleveland Global Quality of Life (P = 0.018) and physical SF-36 (P = 0.008) scores were also significantly lower for readmitted patients. On multivariate analysis, comorbid conditions (P = 0.014, odds ratio = 1.36), laparoscopic technique (P = 0.008, odds ratio = 1.8), proctocolectomy (rather than initial subtotal colectomy) at ileal pouch-anal anastomosis (P < 0.001, odds ratio = 1.55), and postoperative blood transfusion (P = 0.02, odds ratio = 1.54) were independently associated with readmission. CONCLUSION: Early readmission after ileal pouch-anal anastomosis is common. Associated comorbidity, laparoscopic approach, reconstruction of the ileal pouch-anal anastomosis at the index surgery, and postoperative blood transfusion are associated with readmission.

PURPOSE: We hypothesized that organ space surgical site infections (organ space SSI) are a unique type of surgical site infection and therefore are associated with a unique set of risk factors. The aim of this study was to create a predictive model for organ space SSI after small bowel, colon, or rectal operations. METHODS: The 2006 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) sample (N = 12,373) was used to identify current procedural terminology codes for small bowel, colon, and rectal laparoscopic or open surgical procedures. The following variables were used to build a predictive model of organ space SSI within 30 days post-op: age, gender, body mass index, American Society of Anesthesiologists class, smoking, diabetes, steroid use, 30 days previous radiotherapy or surgery, preoperative serum creatinine and albumin, laparoscopic surgery, wound class, perioperative transfusion, operative time, and surgical site. Patients on chronic mechanical ventilation, dialysis, wound infection, or sepsis preoperatively were excluded. RESULTS: Our organ space SSI model achieved a concordance index of 0.65 when validated in 2007 ACS-NSQIP patients (N = 9,521). A risk calculator designed based upon our model is available at www.clinicriskcalculators.com . CONCLUSION: This novel and validated nomogram is useful to predict organ space SSI associated with small bowel, colon, and rectal surgical procedures. It may also be useful for risk stratification and risk modification.

BACKGROUND: The aim of this study was to compare outcomes after primary hand-sewn versus stapled ileal pouch-anal anastomosis (IPAA). METHODS: Patients undergoing a primary IPAA (1983-2007) were identified from a prospective pelvic pouch database. Differences between group A (hand-sewn) and group B (stapled) for pre-operative and peri-operative factors, complications, functional outcomes, and quality of life (QOL) were investigated. RESULTS: Of 3,382 patients with a primary IPAA, 3,109 were included. Median follow-up was 7.1 years (0.1-24). Mean age was 37.9 +/- 13.2 years. Overall, 1,741 patients (56%) were male. Group A (n = 474) and group B (n = 2635) had similar age (P = .28), sex (P = .8), albumin level (P = .74), prior colectomy (P = .98), and use of steroids (P = .1). Group A had a greater use of ileostomy (P = .001) and a longer duration of stay (P < .001). Group B had a greater body mass index (P < .001) and J-pouch (P < or = .001). Wound infection (P = .42) and pouchitis (P = .59) were similar. Anastomotic stricture (P = .002), septic complications (P = .019), bowel obstruction (P = .027), and pouch failure (P < .001) were greater in group A. At most recent follow-up, bowel frequency (P = .74) and rate of urgency were similar (P = .71). A greater proportion of patients in group A described incontinence (P < .001), seepage (P < .001), pad usage (P < .001), dietary (P < .001), social (P < .001), and work restrictions (P = .025). The Cleveland Global QOL score (P = .018) was greater in group B. CONCLUSION: Patients undergoing a stapled IPAA had better outcomes and QOL than those undergoing a hand-sewn IPAA.

OBJECTIVES: Liver involvement is common in patients with inflammatory bowel disease (IBD). However, the frequency and the significance of liver function test (LFT) abnormalities in patients with ileal pouch-anal anastomosis (IPAA) for underlying IBD have not been studied. The aim of this study was to evaluate the prevalence and to identify risk factors for abnormal LFTs in patients with IPAA and underlying IBD. METHODS: All patients were identified from our prospectively maintained Pouchitis Database between 2002 and 2008. Abnormal LFTs were classified as the following: (i) any abnormal elevation of transaminases, and/or alkaline phosphatase (ALP), and/or bilirubin; (ii) hepatitis, if there was more than twice the elevation of transaminases; and (iii) cholestatic, if there was more than 1.5 times elevation of ALP. Clinical, endoscopic, and histological variables were assessed using Cox proportional hazard models for evaluating risk for abnormal LFTs. RESULTS: A total of 545 IPAA patients with underlying IBD were identified from the database, of which 373 patients who had LFTs done after their pouch surgery were included. This included 346 patients with ulcerative colitis, 25 with indeterminate colitis, and 2 with Crohn's colitis before surgery. Their mean age was 45.9+/-13.8 years. A total of 65 patients (17.4%) (40 men, 25 women, median age: 47 years) had abnormal LFTs. Of the patients, 52 (13.9%) had abnormal transaminases, whereas 15 (4%) were classified as having hepatitis. Thirty-five (9.4%) patients had an abnormal ALP level, with 18 (4.8%) classified as cholestatic. The most common cause of an abnormal LFT was transient elevation in 32 (49.2%) patients, followed by fatty liver (fatty change on imaging with body mass index (BMI) > or =25 kg/m(2) in the absence of other causes, including alcohol abuse and drug-induced hepatitis) in 10 (15.4%), drug-induced abnormal LFTs in 7 (10.7%), and chronic hepatitis B or C in 6 (9.2%). Primary sclerosing cholangitis (PSC) was responsible for abnormal LFTs in 10 patients (15.4%). Cox proportional hazard model analysis showed that BMI (hazard ratio (HR)=1.07, 95% confidence interval (95% CI): 1.02, 1.12; P=0.003), the presence of PSC (HR=4.49, 95% CI: 1.45, 13.89; P=0.009), autoimmune disorder (HR=2.54, 95% CI: 1.09, 5.93; P=0.031), a family history of IBD (HR=2.32, 95% CI: 1.29, 4.17; P=0.005), and extensive colitis before colectomy (HR=4.59, 95% CI: 2.04, 10.33; P<0.001) predicted any abnormal LFTs. CONCLUSIONS: Abnormal LFTs were common in patients with IPAA in this cohort. The presence of co-existing autoimmune disorder, a family history of IBD, extensive colitis before colectomy, the presence of PSC, and a high BMI appear to be a significant risk factors for abnormal LFTs. Whether abnormal LFTs affect health-related quality of life, pouch survival, and selection of pouch-related medical therapy requires further investigation.

Background. A 61-year-old woman who had undergone an ileostomy closure 10 days previously presented to a tertiary medical center with abdominal pain, vomiting, diarrhea, dehydration, and oliguria. The patient had undergone a staged total proctocolectomy with ileal-pouch-anal anastomosis and a loop ileostomy 8 months previously to treat her steroid-refractory ulcerative colitis.Investigations. Physical examination, abdominal and pelvic CT scan, blood laboratory tests, pouch endoscopy, and fecal testing for Clostridium difficle toxins A and B.Diagnosis. Fulminant C. difficile-associated pouchitis and enteritis, which led to Psuedomonas aeruginosa septicemia, intravascular coagulopathy, acute renal failure, hemorrhagic ascites and respiratory failure and eventual death.Management. Intravenous hydration, aggressive therapy with oral and intravenous antibiotics, supportive care, hemodialysis, and intubation.

PURPOSE: Continent ileostomy is considered an alternative for patients with a failed ileal pouch-anal anastomosis. The aim of this study is to investigate outcomes for patients undergoing continent ileostomy after a failed ileal pouch-anal anastomosis at our institution. METHODS: Patients undergoing continent ileostomy after a failed ileal pouch-anal anastomosis were identified from a prospectively maintained pouch database. Quality-of-life scores were obtained by telephone follow-up or office visit and were determined by the Cleveland Global Quality of Life Score. RESULTS: Sixty-four patients were identified between 1982 and 2007. Forty-two percent were male. The median age was 36.5 (range, 14-61) years. Most common diagnoses included ulcerative colitis (n = 44, 68.8%) and Crohn's disease (n = 13, 20.3%). The indication for continent ileostomy was septic pouch complications in 56.3% patients. The previous pelvic pouch was used in 16 (25%) patients. The 30-day complication rate was 31.3%. There were no perioperative deaths. Median follow-up was five years. The long-term dysfunction rate was 50%, the complication rate was 60.9%, and the revision rate 45.3%. The median revision-free interval was 2.8 years (range, 3 months to 19 years) and the retention rate of continent ileostomy was 95.3% (61 of 64). Median continent ileostomy survival time was 4.2 (range, 1-19) years. The median quality-of-life score was 0.77. CONCLUSIONS: Continent ileostomy is possible in patients wishing to avoid an external appliance after pelvic pouch failure. Despite the associated morbidity, most of this select group of highly motivated patients retain their continent ileostomy long-term and are highly satisfied with their choice of continent ileostomy.

PURPOSE: Outcomes for patients developing a leak after ileal pouch-anal anastomosis have not been well investigated. This study explored whether the use of a stapled or handsewn anastomosis was associated with different outcomes when an anastomotic leak developed. PATIENTS AND METHODS: Patients were identified from a prospectively maintained pouch database. Functional outcomes regarding bowel movements, urgency, continence, and seepage were evaluated. Quality of life was assessed by the Cleveland Global Quality of Life Score. RESULTS: One hundred and seventy-five patients with anastomotic leak (141 stapled and 34 handsewn anastomosis) were identified. The two groups were similar in gender and diagnosis. Patients with handsewn anastomosis were younger (P = 0.04), had less perioperative steroid use (P = 0.05), more proximal diversion (P = 0.02), and S-pouch creation (P = 0.003). More handsewn cases had intraoperative transfusion (P = 0.04) and postoperative hemorrhage within the pelvis (P = 0.003). Long-term pouch failure was 35.3 percent in the handsewn group and 12 percent in the stapled group (P = 0.002), which was confirmed by Kaplan-Meier analysis (Log-rank P = 0.007). On multivariate analysis, leak after handsewn anastomosis was independently associated with pouch failure. Leak after stapled anastomosis carried a lower incontinence rate at 5 years (P = 0.03), while handsewn had higher nocturnal seepage rate at 3, 5, and 10 years, and most recent follow-up. Cleveland Global Quality of Life Score was comparable between the groups during follow-up. CONCLUSION: Outcomes including functional results and pouch failure rates for patients developing a leak after stapled anastomosis at ileal pouch-anal anastomosis were significantly better than outcomes for patients who develop a leak after handsewn anastomosis.

PURPOSE: In 2006, the Cleveland Clinic was a "high outlier" for surgical site infections in the National Surgical Quality Improvement Program. Because this finding may be due to a high proportion of colorectal procedures at the Cleveland Clinic, the purpose of the present study was to compare the national and Cleveland Clinic databases regarding proportion of colorectal procedures and to investigate the frequency of SSI after colorectal versus general and vascular surgery and the factors that predict risk of SSI. METHODS: Logistic regression analysis was used to analyze patient and procedure factors in cases with and those without surgical site infections from the Cleveland Clinic's National Surgical Quality Improvement Program database. RESULTS: Compared with the national database, the Clinic database had a significantly higher proportion of patients who had undergone colorectal procedures: 9.4 percent (11,102/118,391) vs. 17.0 percent (280/1,646) (P < 0.05). The overall surgical site infection (SSI) rate was 5.6 percent for the national database and 9.4 percent for the Clinic. However, in both databases, SSI rates were considerably higher for colorectal procedures than for general and vascular surgery: Clinic, 14.3 percent for colorectal and 9.4 percent for general and vascular procedures (P < 0.05); national database, 15.7 percent for colorectal and 5.6 percent for general and vascular (P < 0.05). Patient-related risks for surgical site infection in colorectal cases were body mass index >30, platelet count <150/microl, age > 55. Procedure-related risk was operation duration >180 min (all P < 0.05). CONCLUSION: Participation in the National Surgical Quality Improvement Program brought attention to our high rate of SSI, which appeared to be due to a high proportion of colorectal patients, a high-risk subset. Further analysis identified unique SSI risk factors in this subgroup; most are not amenable to modification. Colorectal surgery may require unique risk adjustment for SSIs because of the nature of the operations and inherent risk of SSIs.