Faculty Bibliography

INTRODUCTION/BACKGROUND:Redo IPAA is a viable option to maintain intestinal continuity in patients with ileal pouch failure. Most patients with ileal pouch failure are physiologically and psychologically too deconditioned to undergo a 1- or 2-stage redo ileal pouch surgery, so a 3-staged redo ileal pouch surgery is needed. This consists of an initial proximal diverting loop ileostomy for 6 months, followed by redo ileal pouch construction with temporary stoma, and, lastly, stoma closure. The location of the initial diverting ileostomy is paramount, because 40% of cases will require pouch excision and construction of a de novo pouch, and a thoughtfully placed ileostomy will allow construction of a redo pouch without sacrificing any bowel length. In our report, we described our technique to create thoughtful ileostomy in patients who undergo redo IPAA. TECHNIQUE/METHODS:We create a loop ileostomy ≈20 cm proximal to the existing ileal pouch, from the level of the tip of the J or the proximal inlet of an S-pouch. We call this a thoughtful ileostomy. By doing that, the thoughtful ileostomy site can be used as the apex of the new ileal pouch and become the ileal-anal anastomosis when a de novo ileal pouch needs to be constructed. RESULTS:We created a thoughtful ileostomy in 50 patients in the Inflammatory Bowel Disease Center at New York University Langone Health who either subsequently underwent or will undergo a redo IPAA between September 2016 and March 2019 (laparoscopic, n = 37; open, n = 13). Ten of the laparoscopic cases were preemptively converted to open because of dense adhesions. CONCLUSION/CONCLUSIONS:A thoughtful ileostomy is important so as to not sacrifice bowel in patients being prepared for redo ileal pouch surgery. Initial diversion with thoughtful ileostomy 6 months before redo ileal pouch construction also allows patients to be prepared for a major operation both physiologically and psychologically.

Indocyanine green (ICG)-enhanced fluorescence has recently been used to assist in identifying perfusion of bowel and a healthy anastomosis. Feasibility of ICG for many colorectal procedures has been shown, however use of ICG in complex inflammatory bowel disease (IBD) operations is not well-known [1-5]. This article is protected by copyright. All rights reserved.

Introduction: Ileal pouch-anal anastomosis (IPAA) failure is most commonly associated with pouch excision and permanent ileostomy. Motivated patients may choose to undergo a complex series of operations to attempt a re-do IPAA. We hypothesized that the outcomes of re-do IPAA are comparable to index IPAA.
Method(s): Patients undergoing index and redo IPAA at a specialized inflammatory bowel disease center between September 2016 and February 2019 were included. Operative and short-term outcomes were compared.
Result(s): There were 200 patients (index, n = 100 ; redo, n = 100). Eighty patients in the index and 70 in the redo group had their IPAA. Eight and 72 patients underwent 2 and 3-stage index IPAA surgery, respectively. Outside hospital system referrals were common for the cohort of redo operations (63% vs 29%, p < 0.001). Age, sex, BMI, American Society of Anesthesiologists (ASA) score, and primary diagnosis were comparable between the groups. Redo IPAA was associated with increased intraoperative bleeding (median, 200 vs 300 mL, p = 0.02), operative time (median, 223 vs 258 min, p = 0.001), and length of stay (median, 5 vs 6.5 days, p = 0.008). Thirty-day morbidity (41% vs 54%, p = 0.11), readmission (26% vs 24%, p = 0.78), and reoperation (1% vs 0, p = 1) were similar. One patient in the index group and 2 in the redo group had pouch failure with a median follow-up of 14 months.
Conclusion(s): In specialized high-volume centers, complex redo IPAA can safely be performed, with equivalent perioperative morbidity, when compared with index IPAA creation. Though redo IPAA was associated with greater blood loss, longer operative times, and length of stay, short-term morbidity was not significant.
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Introduction: Minimally invasive ileal pouch-anal anastomosis (MI-IPAA) are becoming more commonly utilized. However, the outcomes in re-do IPAA after a failed MI-IPAA are not well studied. This study aims to compare short- and long-term outcomes of re-do IPAA surgery in patients who had a failed minimally invasive or open IPAA creation.
Method(s): Patients undergoing transabdominal re-do surgery for a failed MI vs open IPAA by single surgeon between September 2007-September 2017 were case-matched 1:1 fashion based on primary diagnosis, indication for re-do IPAA, age and body mass index(BMI). Patient characteristics, short- and long-term outcomes were compared between two groups.
Result(s): Forty-two patients undergoing MI-IPAA were matched with 42 open counterparts. Patient characteristics were comparable. The time between index and re-do IPAA surgery was shorter in patients who had MI-IPAA(median, 28.5 months vs 56 months, p=0.03). A long rectal stump (>2 cm) was more common after MI-IPAA (26% vs 10%, p=0.046). Stapled re-do IPAA was more common in MI-IPAA group (26% vs 10%, p=0.046). Although short-term morbidity was similar, abscess formation (7% vs 24%, p=0.035) was more frequent in patients who had index open IPAA. After median 26 months of follow-up, survival was comparable between two groups.
Conclusion(s): A retained rectum leading to pouch failure is more common during MI-IPAA compared to open IPAA. While leaving a long rectal stump during MI-IPAA is a major technical drawback resulting failure, the long remnant rectum may allow for appropriate transection with a linear stapler. This allows for a double-stapled re-do IPAA which was associated with less septic complications.
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INTRODUCTION/BACKGROUND:The vacuum-assisted drainage has many applications in managing complex wound healing. It quickens the recovery period by its hyperemic effect on the exposed zone, decreasing bacterial colonization, preventing tissue edema, and promoting granulation of the wound. However, its use in anastomotic leak after IPAA is scarcely studied, especially because a proprietary endoluminal vacuum-assisted closure system was removed from the US market. TECHNIQUE/METHODS:We applied a hand-crafted endoluminal vacuum-assisted closure system using the existing standard wound vacuum-assisted closure supplies to 2 patients who developed an anastomotic leak with a presacral abscess after completion proctectomy with J-pouch construction. RESULTS:We changed the endoluminal vacuum-assisted closure drain every 2 to 3 days, and both patients had substantial improvements in their abscess cavity after the seventh and ninth applications. CONCLUSIONS:Anastomotic leak at the IPAA traditionally takes up to a year to heal, which causes a significant toll on the psychosocial life of the patient and delayed stoma closure. Therefore, we believe that facilitating the healing process by using our hand-crafted endoluminal vacuum-assisted closure drain might provide a great value to patients' quality of life.

Introduction: Re-do pelvic pouch surgery is a safe and feasible option to maintain intestinal continuity in patients with failed ileal pouch-anal anastomosis (IPAA). The decision to preserve (or augment) the primary pouch or create a new pouch is typically made intraoperatively. Our aim was to define factors associated with primary-pouch preservation/pouch augmentation in patients undergoing re-do IPAA surgery.
Method(s): Patients undergoing transabdominal re-do IPAA surgery between June 2016 and February 2019, in an inflammatory bowel disease center, were included. Full abdomino-pelvic pouch mobilization of the primary pouch was made in all cases. Indications, patient characteristics, and short-term (<=30 days) outcomes were evaluated and compared depending on preservation vs excision of the index pouch.
Result(s): Sixty-nine re-do IPAA patients were included. A new pouch was created in 42 (61%) patients. Most common indications for a new pouch creation were chronic infection (38%) and small pouch (36%) (Table ). Although patients having a new pouch were older (45 +/- 13 vs 32 +/- 13, p < 0.001), patients whose index pouches were preserved underwent a re-do IPAA surgery earlier (median, 120 vs 53 months, p < 0.001). A re-do, hand-sewn IPAA was more commonly performed when the primary pouch was excised and a new pouch needed to be created (88% vs 54%, p = 0.003). Postoperative short-term morbidity was similar between the 2 groups (52% vs 48%, p = 0.73). There were no re-operations or mortality.
Conclusion(s): Re-do IPAA surgery provides acceptable outcomes regardless of preserving or excising the primary pouch. Hand-sewn IPAA is more commonly performed when creating a new pouch during re-do IPAA. Index pouch preservation seems achievable in younger patients undergoing timely salvage operation. [Figure presented]
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Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the operation of choice for patients with ulcerative colitis (UC). The most common type of IPAA is a J-pouch. If despite all other mobilization maneuvers, inadequate mesenteric reach prevents a tension free anastomosis with J-pouch, a good alternative is S-pouch creation, which can provide an additional 2 to 4 cm of length (1). This article is protected by copyright. All rights reserved.

PURPOSE/OBJECTIVE:Data regarding safety and feasibility of re-do ileal pouch anal anastomosis (IPAA) for failed ileal pouch in children are limited. In this study, we compared the short- and long-term outcomes of re-do IPAA in pediatric and adult populations in a case-matched setting. METHODS:Between March 2007 and June 2017, pediatric patients undergoing a transabdominal re-do IPAA by single surgeon were reviewed and case matched with adult counterparts. Short- and long-term outcomes including complications, functional outcomes, and quality of life of the two groups were compared. RESULTS:60 patients were included (pediatric, n = 30; adult, n = 30). Time between index IPAA and re-do IPAA was shorter in the pediatric group (30 ± 26 vs 86 ± 74 months, p = 0.001). In the pediatric population, the existing pouch was more commonly used to construct the re-do pouch (n = 19 vs n = 12, p = 0.07). There was a trend towards the presence of less postoperative complications in pediatric group (n = 13 vs n = 20, p = 0.07). There were no reoperations or mortality. Long-term pouch survival was comparable between two groups (p = 0.96). Six re-do IPAAs failed in the study period. CONCLUSION/CONCLUSIONS:Re-do IPAA is safe and feasible in pediatric population with failed IPAA and can be performed with similar short- and long-term outcomes compared to adults in experienced hands.

BACKGROUND: Small bowel cancer (SBC) is a rare entity that can be associated with Crohn's Disease. The incidence of SBC in patients with CD is increased by 18.75-fold compared to normal population. The pathogenesis of SBC in the setting of CD is not fully understood, but the disease has a poor prognosis due to diagnostic challenges associated with the primary disease. The aim of this study is to present 2 cases treated within a year in a high volume IBD center and to conduct a systematic literature review of small bowel adenocarcinoma (SBA) associated with small bowel CD.
METHOD(S): Systematic literature review was done by using MEDLINE and EMBASE databases and data regarding demographics, presentation, diagnosis, treatment and survival were extracted. Articles that did not clearly state the location of the Crohn's disease and type of the cancer were excluded.
RESULT(S): We identified 216 patients diagnosed with small bowel adenocarcinoma in the setting of small bowel Crohn's disease from 117 studies. In this review obstruction was the most common initial symptom (n = 82, 59%; data are missing in 77 patients). Other common symptoms were abdominal pain (n = 12), anemia-bleeding (n = 11), diarrhea (n = 10), and fistulas (n = 5). there were 206 patients with one adenocarcinoma and 10 patients with 2 different adenocarcinomas. Among the patients with only one tumor, 154 patients (74.7%) were found to have ileal SBA. The median time to diagnosis of SBA from the diagnosis of CD was 18 months (1-300 months, data on 10 patients were missing). Out of 129, 64 patients (49.6%) were diagnosed with cancer after the surgical procedure whereas 46 patients (35.6%) were diagnosed intraoperatively and 15 (11.6%) were diagnosed preoperatively. Four patients (3.2%) were diagnosed at the autopsy without any surgical interventions and data were missing in 87 patients. 36.7% (18/49 patients) of the patients operated for obstruction were alive at one year, and 15.2% (7/46 patients) at 2-year. Although these percentages are lower than other studies reported in the literature, data was missing in 34 patients, so this might have affected the outcomes. CONCLUSION(S): Small bowel adenocarcinoma should be in the differential diagnosis in patients with longstanding ileal Crohn's disease presenting with small bowel obstruction, anemia, and perforation. Diagnosis and management of the small bowel adenocarcinoma in the setting of Crohn's disease is challenging and awareness and early diagnosis may avoid mortality