Faculty Bibliography

BACKGROUND: Total abdominal colectomy with ileorectal anastomosis for Crohn's colitis is acceptable in the presence of a suitable rectum. Intentional IPAA has been proposed for diffuse Crohn's proctocolitis without enteric or anoperineal disease. OBJECTIVE: The aim of this study was to evaluate the long-term outcomes of sphincter-saving procedures for large-bowel Crohn's disease. DESIGN: Patients with preoperative Crohn's disease diagnosis undergoing intentional IPAA and ileorectal anastomosis were included. SETTINGS: The study was conducted at a tertiary care research center. PATIENTS: Ileorectal anastomosis was performed in 75 patients with Crohn's disease, whereas 32 patients underwent intentional IPAA. MAIN OUTCOME MEASURES: Long-term functional results and permanent stoma requirement of sphincter-saving operations were assessed. Quality of life and postoperative medication use were also compared with a control group of patients undergoing total proctocolectomy and end ileostomy. RESULTS: Patients undergoing ileorectal anastomosis were older and had longer disease duration, higher prevalence of perianal and penetrating disease, and history of small-bowel resection than those receiving IPAA. Indications for surgery, preoperative use of immunomodulators, and postoperative use of biologics were also significantly different. Although functional defecatory outcomes were comparable, reported quality of life 3 years after surgery was significantly better in patients who underwent IPAA than in patients with ileorectal anastomosis. Patients with IPAA were associated with significantly lower cumulative rates of surgical recurrence (HR = 0.28 (95% CI, 0.09-0.84); p = 0.017), indefinite stoma diversion (HR = 0.35 (95% CI, 0.13-0.99); p = 0.039), and proctectomy with end ileostomy (HR = 0.27 (95% CI, 0.07-0.96); p = 0.030) than those with ileorectal anastomosis. LIMITATIONS: The study was limited by its retrospective nature and small sample size. CONCLUSIONS: Contemporary patients selected to have intentional IPAA for Crohn's colitis have disease characteristics very different from those selected to have ileorectal anastomosis. Long-term follow-up confirms intentional IPAA as an acceptable option in selected patients with Crohn's colitis.

PURPOSE: Risks and benefits of colorectal cancer resection in octogenarians are not clearly defined. This study aimed to assess the relationship between morbidity and mortality within 1 year after colorectal cancer resection in octogenarians compared with other age groups. METHODS: A single-institution, prospectively maintained database was queried to identify patients with sporadic, pathological stages I-III colorectal adenocarcinoma, electively undergoing radical resection with curative intent between 2000 and 2012. Patients were divided into three age groups: 'octogenarians' if >/=80 years of age; 'intermediate' if >/=65 and <80 years of age; and 'younger' if <65 years of age. RESULTS: Overall, 2485 patients fulfilled the inclusion criteria-326 in the octogenarian age group, 949 in the intermediate age group, and 1210 in the younger age group. Postoperative morbidity disproportionally increased 1-year mortality in octogenarians when compared with the younger age group (37 vs. 6.5 %; p < 0.001). Anastomotic leak, abdominopelvic abscess, reoperation, and readmission rates were comparable among different age groups, but were associated with a disproportionate risk of 1-year mortality in octogenarians (67, 43, 33, and 41 %, respectively). Multivariate analysis indicated that older age and postoperative complications were the only two independent variables associated with 30- and 90-day mortality. Besides these, American Society of Anesthesiologists (ASA) and pathological stage III were additional independent variables associated with 1-year mortality. An interaction test confirmed that age and postoperative complications were independent variables, with additive effect on 30-day, 90-day, and 1-year mortality. CONCLUSIONS: Age plays an important and independent role in affecting mortality when complications occur following surgery for colorectal cancer. The full magnitude of postoperative risks should be taken into consideration when discussing colorectal cancer surgery in octogenarians.

PURPOSE: There are no published data or guidelines on whether the same anti-tumor-necrosis factor (TNF) agents used preoperatively or different anti-TNF agents are preferable to treat postoperative recurrence. Our aim was to compare the efficacy of the consistent vs. switched anti-TNF approaches in patients with recurrent Crohn's disease (CD) after their inception ileocolonic resection (ICR). METHODS: Patients with CD receiving anti-TNF agents before the inception ICR who were treated for clinical recurrence with the same or different anti-TNF agents after surgical resection were included in the study. The outcome of the study was the need for the subsequent resection of ileocolonic anastomosis (ICA) as calculated with survival curves. RESULTS: Eighty-five patients were included in the study. The mean age of the whole cohort at the inception ICR was 35.1 +/- 13.5 years. The whole cohort consisted 42 (49.4 %) in the consistent group and 43 (50.6 %) in the switched group. No significant differences were observed in demographic and clinical variables between the two groups. During the median follow-up of 1.5 (interquartile range, 0.8-3.1) years, seven (16.7 %) patients in the consistent group and eight (18.6 %) in the switched group required the repeat resection of ICA. Similar results were found in terms of the subsequent resection of ICA-free survival (hazard ratio = 1.36, 95 % confidence interval 0.49-3.76, P = 0.54) between the consistent and switched groups. CONCLUSIONS: The adherence to the same anti-TNF agent appeared to be as effective as the switching approach to different anti-TNF agent in treating postoperative recurrent CD after the inception ICR.

AIM: Obesity adds to the technical difficulty of laparoscopic colorectal surgery. The robotic approach has the potential to overcome this limitation because of its proposed technical advantages over laparoscopy. The aim of this retrospective study was to compare the short-term outcomes of robotic surgery (RS) versus conventional laparoscopy surgery (LS) in this patient population. METHOD: Patients with a body mass index >/= 30 kg/m2 undergoing RS or LS for rectal cancer between 01/2011 and 6/2014 were identified from an institutional database. Perioperative parameters, oncologic findings and postoperative 30-day short-term outcomes were compared between the RS and LS groups. RESULTS: The RS and LS groups included 29 and 27 patients, respectively. Groups were comparable in terms of patient demographics, body mass index (34.9+/-7.2 vs. 35.2+/-5.0 kg/m2 , p = 0.71), co-morbidities, surgical and tumour characteristics. Comparison of the intraoperative findings revealed no significant differences between the groups including operative time (329.0+/-102.2 vs. 294.6+/-81.1 min, p = 0.13), blood loss (434.0+/-612.4 vs. 339.4+/-271.9 ml, p = 0.68), resection margin involvement (6.9% vs. 7.4%, p = 0.99), conversions (3.4% vs. 18.5%, p = 0.09) and complications (6.9% vs. 0%, p = 0.49). Regarding postoperative outcomes, there were no significant differences in morbidity except that robotic surgery was associated with a quicker return of bowel function (median, 3 vs. 4 days, p = 0.01) and shorter hospital stay (median, 6 vs. 7 days, p = 0.02). CONCLUSION: Robotic surgery for rectal cancer in obese patients has short-term outcomes similar to laparoscopy, but accelerated postoperative recovery