Faculty Bibliography

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.

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.

The incidence of inflammatory bowel disease is increasing and despite advances in medical therapy, patients continue to require operations for complications of their disease. Minimally invasive surgical options have impacted postoperative morbidity dramatically with reduction of pain, length of stay and adhesion formation, but additionally, this population of patients are not only concerned with successful operative therapy but also the ability to return to their lifestyle and cosmetics. Laparoscopic and robotic surgery for Crohn's disease has proven to benefit patients with ileocolic or colonic disease, however complicated disease with phlegmon, abscess or fistulae is best served with a hybrid approach. Ulcerative colitis treatment has seen advancements with laparoscopic and robotic platforms, however the benefits of minimally invasive surgery must be balanced with producible and durable outcomes.

BACKGROUND:A continent ileostomy may be offered to patients in hopes of avoiding permanent ileostomy. Data on the outcomes of continent ileostomy patients with a history of a failed IPAA are limited. OBJECTIVE:This study aimed to assess whether a history of previous failed IPAA had an effect on continent ileostomy survival and the long-term outcomes. DESIGN/METHODS:This was a retrospective cohort study. SETTINGS/METHODS:This investigation took place in a high-volume, specialized colorectal surgery department. PATIENTS/METHODS:Patients who underwent continent ileostomy construction after IPAA failure between 1982 and 2013 were evaluated and compared with patients who have no history of IPAA surgery. MAIN OUTCOME MEASURES/METHODS:Functional outcomes and long-term complications were compared. RESULTS:A total of 67 patients fulfilled the case-matching criteria and were included in the analysis. Requirement of major (52% vs 61%; p = 0.756) and minor (15% vs 19%; p = 0.492) revisions were comparable between patients who had continent ileostomy after a failed IPAA and those who had continent ileostomy without having a previous restorative procedure. Intubations per day (5 vs 5; p = 0.804) and per night (1 vs 1; p = 0.700) were similar in both groups. Our data show no clear relationship between failure of continent ileostomy and history of failed IPAA (p = 0.638). The most common cause of continent ileostomy failure was enterocutaneous/enteroenteric fistula (n = 14). Six patients died during the study period because of other causes unrelated to continent ileostomy. LIMITATIONS/CONCLUSIONS:This study was limited by its retrospective and nonrandomized nature. CONCLUSIONS:Converting a failed IPAA to a continent ileostomy did not worsen continent ileostomy outcomes in this selected group of patients. When a redo IPAA is not feasible, continent ileostomy can be offered as an alternative to conventional end ileostomy in highly motivated patients. See Video Abstract at http://links.lww.com/DCR/A803.

Background: While laparoscopy is accepted as the preferable technique for most of the abdominal operations especially for patients with virgin abdomen, use of laparoscopy for restorative rectal operations has been under debate in terms their general applicability and outcomes. Tis paper specifcally focuses on the characteristics, management strategy and outcomes of transabdominal redo ileal pouchanal anastomosis (IPAA) surgery in patients who underwent laparoscopic IPAA creation.
METHOD(S): Between 4/2007 and 7/2016, data regarding patients undergoing transabdominal redo surgery for failed laparoscopic IPAA were reviewed. Patient demographics, primary diagnosis, technical details of the primary and redo IPAA, indications for redo surgery, perioperative and postoperative outcomes were evaluated.
RESULT(S): Tere were 76 [n=26 (34%) males] patients with a median age of 31 years (13-76 years) and a median body mass index of 23 kg/m2 (15-32 kg/m²) at the time of revision surgery. Diagnoses at the time of redo surgery were ulcerative colitis (n= 67, 88%), Crohn's disease (n=4, 5.2%), familial adenomatous polyposis (n=4, 5.2%), and colonic inertia (n=1, 1.6%). Median time to redo surgery was 2 years (0.2-12) afer laparoscopic IPAA creation. 73 (71%) patients required a diverting loop ileostomy prior to or during redo IPAA surgery. A new pouch was created in 57% (n=43) of patients, reuse of the previous pouch was done in 32 patients (42%) and repair of the pouch was done in 1 patient. Indications for redo IPAA surgery were leak and fstula (n=40, 52.6%), obstruction (n=21, 27.6%) and pelvic perianal abscess (n=17, 22.3%). 19 patients (25%) diagnosed with long remnant rectal cuff (>2cm from the dentate line) and 6 patients (7.8%) with mesenteric twist at the time of redo pouch surgery. Mean operative time was 270 minutes (SD: +/- 141 minutes) and length of stay was 7.7 days (SD: +/-3.9 days) afer redo IPAA surgery. 30-day morbidity was 45% (n=34). At a median follow-up of 3 (0.1-8) years afer redo surgery, a total of 25 patients (32.8%) were diagnosed with redo pouch failure. CONCLUSION(S): Te outcomes afer redo IPAA surgery are promising in patients with failed laparoscopic IPAA. While pelvic sepsis is the common cause of failure, long remnant rectal cuff and mesenteric twist seems technically preventable problems causing failure afer laparoscopic creation of the index IPAA

Background:Vedolizumab is now widely available for the treatment of moderate to severe ulcerative colitis (UC) and Crohn's disease (CD). We sought to quantify the rates of postoperative complications with preoperative vedolizumab compared with anti-tumor necrosis factor (anti-TNF) therapy. Methods:A multicenter retrospective review of adult inflammatory bowel disease (IBD) patients who underwent an abdominal operation between May 20, 2014, and December 31, 2015, was performed. The study cohort was comprised of patients who had received vedolizumab within 12 weeks of their abdominal operation, and the control cohort was IBD patients who had received anti-TNF therapy. Results:A total of 146 patients received vedolizumab within 12 weeks before an abdominal operation (64% female; n = 93; median age, 33 years; range, 15-74 years), and 289 patients received anti-TNF therapy (49% female; n = 142; median age, 36 years; range, 17-73 years). Vedolizumab-treated patients were younger (P = 0.015) and were more likely to have taken corticosteroids (P < 0.01) within the 12 weeks before surgery. Vedolizumab-treated patients had a significantly increased risk of any postoperative surgical site infection (SSI; P < 0.01), superficial SSI (P < 0.01), deep space SSI (P = 0.39), and mucocutaneous separation of the diverting stoma (P < 0.00) as compared with patients taking anti-TNF therapy. On multivariate analysis, after adjusting for body mass index, steroids at the time of operation, and institution, exposure to vedolizumab remained a significant predictor of postoperative SSI (P < 0.01). Conclusions:We observed that vedolizumab-treated patients were at significantly increased risk of postoperative SSIs after a major abdominal operation, as compared with anti-TNF-treated patients.

STUDY OBJECTIVES/OBJECTIVE:The postoperative period is associated with an inflammatory response that may contribute to a number of complications including postoperative fatigue (POF) that impair patients' quality of life (QoL). We studied the impact of three potentially anti-inflammatory interventions (steroid administration, tight intraoperative glucose control, and light anesthesia) on POF and QoL in patients having major noncardiac surgery. DESIGN/METHODS:A randomized Trial. SETTING/METHODS:Operating room and postoperative recovery area/ICU/hospital floors. PATIENTS/METHODS:Patients undergoing major noncardiac surgery. INTERVENTIONS/METHODS:), and light versus deep anesthesia (Bispectral Index target of 55 vs. 35) in a 3-way factorial design. MEASUREMENTS/METHODS:In this planned sub-analysis, QoL was measured using SF-12 preoperatively and on postoperative day (POD) 30. POF was measured using Christensen VAS, pre-operatively, POD 1, and POD 3. We assessed the effect of each intervention on POF and on the physical and mental components of SF-12 summary scores with repeated-measures linear regression models. MAIN RESULTS/RESULTS:326 patients with complete data were included in the SF-12 analysis and 306 were included in the QoL analysis. No difference was found between any of the intervention groups on fatigue or mean 30-day physical and mental components of SF-12 scores, after adjusting for preoperative score and imbalanced baseline variables (all P-value >0.07 for POF and >0.40 for QoL). CONCLUSIONS:Steroid administration, tight intraoperative glucose control, and light anesthesia do not improve quality of life or postoperative fatigue after major surgery.

PURPOSE OF REVIEW/OBJECTIVE:Ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment for patients undergoing colectomy to maintain intestinal continuity. Earlier studies have suggested that outcomes are worse in elderly patients who underwent IPAA. However, more recent reports have shown that IPAA outcomes in the elderly are comparable to younger patients. We review the recent medical literature regarding outcomes and treatments for common complications in elderly IPAA patients. RECENT FINDINGS/RESULTS:Compared to younger patients, IPAA in the elderly is not associated with increased major surgical complications, but is associated with increased length of stay and re-admission rate for dehydration in older patients. Rates of fecal incontinence after IPAA were similar between younger and older patients. Sacral nerve stimulation has shown early promise as a possible treatment for fecal incontinence after IPAA, but more research is needed. Pouchitis is a common complication, and antibiotics remain first-line treatment options. Other treatment options include mesalamines, steroids, immunomodulators, and biologics. The efficacy of newer biologics such as vedolizumab and ustekinumab has been reported, but more data is needed. IPAA is safe in the elderly with high self-reported patient satisfaction. However, the elderly IPAA patient warrants special consideration regarding outcomes and management.