Faculty Bibliography

INTRODUCTION/BACKGROUND:Abdominal wound closure is a challenge in patients undergoing colorectal surgery with a complex history of multiple abdominopelvic operations. Loss of domain of the abdominal fascia because of prior laparotomies precludes the use of simple, everyday abdominal wound closure techniques. Furthermore, ongoing intra-abdominal sepsis, with or without a concurrent entero- or colocutaneous fistula, increases the risk of postoperative morbidity and mortality in this patient population. We propose an abdominal wound closure technique for patients with multiple previous complex operations and subsequent ongoing abdominopelvic sepsis. TECHNIQUE/METHODS:Following completion of the intra-abdominal component of the operation, the abdominal wall fascial edges are identified and mobilized to allow for a smooth skin closure. The skin is brought together with a small amount of subcutaneous tissue in the abdominal wound line and sutured with a 1.0 Prolene stitch by using the vertical mattress technique. For both wound edges, a dental roll is inserted between the entry and exit points of the suture, with the suture material placed above and over the dental roll, and thus the dental roll is incorporated within the stitch when it is tied down. These stitches and dental rolls are placed along the length of the wound. No mesh is utilized, and the technique achieves skin closure with development of a subsequent ventral hernia. RESULTS:Good postoperative short-term and long-term overall outcomes were achieved in 14 patients who underwent complex abdominal wound closure. Two patients required further late operative intervention because of the incarceration of the known ventral hernia (at 34 and 120 months postoperatively). CONCLUSIONS:Complex abdominal wound closure in this setting is safe and feasible to achieve a healthy abdominal wall closure and enable healing by primary intention after colorectal surgery.

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.

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: Postoperative ileus (POI) is a temporary delay of coordinated intestinal peristalsis following major abdominal surgery, leading to signifcant symptoms such as nausea, vomiting, abdominal pain, prolonged hospitalization, nosocomial complications, and physical deconditioning. Te use of opioids for postoperative pain control further exacerbates the problem. Opioids bind to the mu receptors in the intestinal tract, leading to gut hypomotility. Alvimopan, an oral, peripherally acting mu-opioid receptor antagonist, was FDA approved in 2008 for use before and afer bowel resection to help prevent and treat POI. Tere are no dedicated studies of alvimopan in patients with inflammatory bowel disease (IBD). Terefore, we conducted a study to investigate alvimopan's role in IBD patients who underwent either laparoscopic or open bowel resection. METHODS: A retrospective chart review was conducted at a 725-bed acute care teaching hospital in New York City between January 2012 and February 2017. Data collected included age, sex, type of IBD, length of stay, post-operative gastrointestinal symptoms (nausea, vomiting, constipation, abdominal distention, frst flatus, frst bowel movement, PO tolerance), and dose of alvimopan, were collected. Te primary outcome was time to GI recovery. Secondary outcomes were: time to frst flatus, time to frst bowel movement, time to tolerating a liquid diet, time to tolerating solid food, and total length of stay. Descriptive statistics reports were created through a secure web-based application called REDCap (Research Electronic Data Capture), and the data were exported into Stata to run further analyses. Of note, approximately 50% of patients who underwent bowel surgery afer March 2015 were placed on a "colon surgery pathwayTM, which is an order set dedicated to strategies that decrease length of stay and post-operative complications. Key features include early feeding, optimized analgesia regimen to allow patients to ambulate, encouraging use of incentive spirometry, and administration of alvimopan peri-procedurally. RESULTS: Of 247 patients, 121 received alvimopan (49.0%) and 126 (51.0%) did not. Te male to female ratio was 51:49. Te mean age of the control group was 44.4 + 16.3 and that of the alvimopan group was 43.2 + 16.4. Patients who received alvimopan had faster GI recovery, with a hazard ratio (HR) of 2.11 (P<0.001), shorter time to frst flatus (HR 2.02, P<0.001), shorter time to frst bowel movement (HR 1.93, P<0.001), shorter time to tolerating liquid diet (HR 2.48, P<0.001), and shorter time to tolerating solid food (HR 2.00, P<0.001). Afer controlling for type of bowel resected (large vs. small bowel), laparoscopic vs. open, age, and type of IBD (ulcerative colitis vs. Crohn's disease) using linear regression, patients who received alvimopan spent 2.59 fewer days in the hospital compared to the control group (P<0.01). CONCLUSION(S): Te results of this study suggest that alvimopan is effective in accelerating the time to GI recovery. Data analysis of all primary and secondary outcomes revealed that alvimopan had a statistically signifcant beneft during the post-operative period of IBD patients undergoing bowel resection. Length of stay for IBD patients was signifcantly decreased with peri-operative use of alvimopan

Background: Ileal pouch anal anastomosis (IPAA) is the preferred surgical option in patients with medically refractory ulcerative colitis (UC) to preserve gastrointestinal continuity. Tis study aimed to describe 30-day readmission rates, as well as predictive factors for it from a national dataset. METHODS: Patients who underwent IPAA surgery for UC between 2012 and 2015 were identifed from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database using current procedural terminology codes. Demographics, perioperative, and operative variables were collected. Patients were grouped according to the presence of 30-day readmission: (+)/(-). RESULTS: Query identifed 1882 patients, mean age was 40.8+/- 13.9 years, mean length of stay was 7.2+/- 5 days and postoperative 30-day morbidity rate was 28% (n=530). Most common complications in the study group were transfusion (7.5%), organ space surgical site infection (SSI) (3.3%), reoperation (3%) and superfcial SSI (2%). Twenty-two percent (n=416) were readmitted within 30 days of surgery. Reasons for readmission were: surgical site infection (n=88), dehydration (n=77), small bowel obstruction/ileus (n=38/18) and abdominal pain (n=28). Mean time for readmission was 14+/- 7 days, 39 patients had second readmission and 4 had a third readmission within 30-days of surgery. Multivariate analysis showed an ASA score of 4 [OR: 14.4 (2.3-89.7), P=0.004] and age<40 [OR: 1.3 (1.08-1.7), P=0.006] were associated with 30-day readmission. Preoperative albumin level of <3.5 was associated with a second readmission [OR:3 (1.1-8.2), P=0.02)]. CONCLUSION(S): IPAA surgery for UC has high morbidity. One ffh of patients were readmitted within 30 days from IPAA surgery for UC and one third of them had a second readmission. Tis study brings the possibility and consideration for national health care initiative in surgical management of patients with UC, undergoing IPAA surgery

After extended left colon resections for either benign or malignant diseases of the colon, achieving a tension-free colorectal anastomosis might be difficult due to reach issues1 . There are several manoeuvers to overcome the reaching problems and to achieve a tension-free colorectal anastomosis. In this video, we demonstrated the techniques to manage reach related issues in different scenarios to perform a healthy colorectal anastomosis.

BACKGROUND:There are scant published data in the impact of prostate cancer and its treatment on functional outcomes and quality of life (QOL) in patients with ileal pouch-anal anastomosis (IPAA). The aim of the study was to evaluate the influence of prostate cancer and its treatment on functional outcomes and QOL in patients with IPAA. METHODS:Patients with IPAA with prostate cancer were compared to age and pouch duration-matched controls without prostate cancer in a 1:2 ratio. Pouch function and QOL were compared between pretreatment and posttreatment for prostate cancer as well as between subjects and controls. RESULTS:A total of 30 patients with IPAA with prostate cancer and 60 matched controls were included. Treatment modalities of prostate cancer included prostatectomy (n = 22), brachytherapy (n = 5), watchful waiting (n = 2), and hormonal therapy (n = 1). The median length of follow-up was 6 (interquartile range, 2.7-8) years. Permanent fecal diversion was required in 5 (16.7%) patients with prostate cancer who developed pouch failure, as compared with 2 patients in the control group (P = 0.04). In patients who retained their pouches, the pouch functional outcomes at the latest follow-up were similar to that before prostate cancer treatment and to that of the matched controls, in terms of bowel movements, daytime seepage, nighttime bowel movements, nighttime seepage, and QOL score. CONCLUSIONS:The risk of pouch failure may be increased after the diagnosis of prostate cancer with or without treatment. However, for those with retained pouches, their pouch function and QOL did not seem to be adversely affected.

INTRODUCTION: The aim of this study was to evaluate 30-day postoperative morbidity in patients undergoing colectomy for cecal volvulus. METHODS: Patients who underwent surgery for cecal volvulus between 2012 and 2015 were identified from the American College of Surgeons-NSQIP by using current procedural terminology codes and ICD-9 code. Demographics, perioperative, and operative factors were assessed and compared between 2 groups, which were classified according to the presence or absence of postoperative morbidity. RESULTS: A total of 591 patients were identified with a mean age of 61.8 (range 18-89) of which 74% were female. Forty-three percent of patients had postoperative complications and 3% of patients died within 30 days of surgery. Most common postoperative complication was ileus (23%) followed by transfusion (10%) and superficial surgical site infection (8%). Mean length of stay was 8.5 days >=days and 9% of patients were readmitted within 30 days of surgery. African American (AA) race (odds ratio [OR]: 2.3, p=0.03), preoperative septic status (OR: 1.8, p=0.04) and wound class of 3-4 (OR: 1.9, p=0.01) were associated with 30-day postoperative morbidity. Length of stay (5.7+/- 2.6 vs 12.2+/- 10, p<0.0001) was longer and readmission rates (11 (3.2) vs 44 (17.1), p<0.0001) were higher among the patents with postoperative morbidity. CONCLUSIONS: Thirty-day postoperative morbidity in patients who underwent colectomy for cecal volvulus is high with a longer length of stay. Severity of infection seems strictly related to postoperative morbidity and individualized patient care can be designed based on the extent of infection in these patients