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Robotic ileocolic resection for Crohn's disease with iliopsoas fistula-A video vignette [Letter]

Aydinli, H Hande; da Luz Moreira, Andre; Erkan, Arman; Simon, Jessica; Remzi, Feza
PMID: 39262031
ISSN: 1463-1318
CID: 5690482

Sarcopenia Is a Risk Factor for Postoperative Complications Among Older Adults With Inflammatory Bowel Disease

Minawala, Ria; Kim, Michelle; Delau, Olivia; Ghiasian, Ghoncheh; McKenney, Anna Sophia; Da Luz Moreira, Andre; Chodosh, Joshua; McAdams-DeMarco, Mara; Segev, Dorry L; Adhikari, Samrachana; Dodson, John; Shaukat, Aasma; Dane, Bari; Faye, Adam S
BACKGROUND:Sarcopenia has been associated with adverse postoperative outcomes in older age cohorts, but has not been assessed in older adults with inflammatory bowel disease (IBD). Further, current assessments of sarcopenia among all aged individuals with IBD have used various measures of muscle mass as well as cutoffs to define its presence, leading to heterogeneous findings. METHODS:In this single-institution, multihospital retrospective study, we identified all patients aged 60 years and older with IBD who underwent disease-related intestinal resection between 2012 and 2022. Skeletal Muscle Index (SMI) and Total Psoas Index (TPI) were measured at the superior L3 endplate on preoperative computed tomography scans and compared through receiver operating characteristic curve. We then performed multivariable logistic regression to assess risk factors associated with an adverse 30-day postoperative outcome. Our primary outcome included a 30-day composite of postoperative mortality and complications, including infection, bleeding, cardiac event, cerebrovascular accident, acute kidney injury, venous thromboembolism, reoperation, all-cause rehospitalization, and need for intensive care unit-level care. RESULTS:A total of 120 individuals were included. Overall, 52% were female, 40% had ulcerative colitis, 60% had Crohn's disease, and median age at time of surgery was 70 years (interquartile range: 65-75). Forty percent of older adults had an adverse 30-day postoperative outcome, including infection (23%), readmission (17%), acute kidney injury (13%), bleeding (13%), intensive care unit admission (10%), cardiac event (8%), venous thromboembolism (7%), reoperation (6%), mortality (5%), and cerebrovascular accident (2%). When evaluating the predictive performance of SMI vs TPI for an adverse 30-day postoperative event, SMI had a significantly higher area under the curve of 0.66 (95% CI, 0.56-0.76) as compared to 0.58 (95% CI, 0.48-0.69) for TPI (P = .02). On multivariable logistic regression, prior IBD-related surgery (adjusted odds ratio [adjOR] 6.46, 95% CI, 1.85-22.51) and preoperative sepsis (adjOR 5.74, 95% CI, 1.36-24.17) significantly increased the odds of adverse postoperative outcomes, whereas increasing SMI was associated with a decreased risk of an adverse postoperative outcome (adjOR 0.88, 95% CI, 0.82-0.94). CONCLUSIONS:Sarcopenia, as measured by SMI, is associated with an increased risk of postoperative complications among older adults with IBD. Measurement of SMI from preoperative imaging can help risk stratify older adults with IBD undergoing intestinal resection.
PMID: 39177976
ISSN: 1536-4844
CID: 5681162

Temporary diverting loop ileostomy in Crohn's disease surgery; indications and outcome

DoÄŸru, Volkan; Akova, Umut; Esen, Eren; Wong, Daniel J; da Luz Moreira, Andre; Erkan, Arman; Kirat, John; Grieco, Michael J; Remzi, Feza H
INTRODUCTION/BACKGROUND:Crohn's disease can present with complex surgical pathologies, posing a significant risk of morbidity and mortality for patients. The implementation of a loop ileostomy for selected patients may help minimize associated risks. METHODS:In this retrospective cohort study, we investigated the utilization of temporary fecal diversion through the creation of a loop ileostomy in Crohn's surgery. Closure of all ostomies involved a hand-sewn single-layer technique. We then conducted bivariate analysis on 30-day outcomes for closures, focusing on favorable recovery defined as the restoration of bowel continuity without the occurrence of two challenges in recovery: newly developed organ dysfunction or the necessity for reoperation. RESULTS:In total, 168 patients were included. The median age of the patients was 38 years (IQR 27-51). The most common indication for a loop ostomy was peritonitis (49%). After ileostomy closure, 163 patients (97%) achieved favorable recovery, while five encountered challenges; four (2.4%) underwent abdominal surgery, and one (0.6%) developed acute renal failure requiring dialysis. Two patients (1.2%) had a re-creation of ileostomy. Patients encountering challenges were older (56 [IQR 41-61] vs. 37 [IQR 27-50]; p 0.039) and more often required secondary intention wound healing (40% vs. 6.7%; p 0.049) and postoperative parenteral nutrition following their index surgery (83% vs. 26%; p 0.006). CONCLUSION/CONCLUSIONS:Selectively staging the Crohn's disease operations with a loop ileostomy is a reliable practice with low morbidity and high restoration rates of bowel continuity. Our hand-sewn single-layer technique proves effective in achieving successful surgical recovery.
PMID: 39120756
ISSN: 1435-2451
CID: 5696922

Stapled End-To-Side Ileocolic Anastomosis in Crohn's Disease: Old Dog, Reliable Tricks? A Retrospective Two-Center Cohort Study

DoÄŸru, Volkan; Ashburn, Jean H; Akova, Umut; Sutter, Alton G; Esen, Eren; Gardner, Emily M; da Luz Moreira, Andre; Erkan, Arman; Kirat, John; Grieco, Michael J; Remzi, Feza H
OBJECTIVE/UNASSIGNED:Analyze our long-term experience with a less-popularized but stalwart approach, the stapled end-to-side ileocolic anastomosis. BACKGROUND/UNASSIGNED:The choice of technical approach to ileocolic anastomosis after ileocecal resection for Crohn's disease affects surgical outcomes and recurrence. Yet, despite heterogeneous data from different anastomotic configurations, there remains no clear guidance as to the optimal technique. METHODS/UNASSIGNED:In a retrospective cohort design, patients undergoing ileocolic anastomosis in the setting of Crohn's disease between 2016 and 2021 at two institutions were identified. Patient characteristics and surgical outcomes in terms of recurrence (surgical, clinical, and endoscopic) were studied. RESULTS/UNASSIGNED:In total, 211 patients were included. Before surgery, 80% were exposed to at least 1 cycle of systemic steroids and 71% had at least 1 biologic agent; 60% exhibited penetrating disease and 38% developed an intra-abdominal abscess. After surgery, one anastomosis leaked (0.5%). Over 2.4 years of follow-up (IQR = 1.3-3.9), surgical recurrence was 0.9%. Two-year overall recurrence-free and endoscopic recurrence-free survivals were 74% and 85% (95% CI = 68-81 and 80-91), respectively. The adjusted hazard ratio of endoscopic recurrence was 3.0 (95% CI = 1.4-6.2) for males and 5.2 (1.2-22) for patients who received systemic steroids before the surgery. CONCLUSION/UNASSIGNED:The stapled end-to-side anastomosis is an efficient, reliable, and reproducible approach to maintain bowel continuity after ileocecal resection with durable outcomes. Our outcomes demonstrate low rates of disease recurrence and stand favorably in comparison to other more technically complex or protracted anastomotic approaches. This anastomosis is an ideal reconstructive approach after ileocecal resection for Crohn's disease.
PMCID:11175959
PMID: 38883936
ISSN: 2691-3593
CID: 5671852

Geosocial Features and Loss of Biodiversity Underlie Variable Rates of Inflammatory Bowel Disease in a Large Developing Country: A Population-Based Study

da Luz Moreira, Andre; de Campos Lobato, Luiz Felipe; de Lima Moreira, Jessica Pronestino; Luiz, Ronir Raggio; Elia, Celeste; Fiocchi, Claudio; de Souza, Heitor Siffert Pereira
BACKGROUND:The epidemiology of inflammatory bowel disease (IBD) in developing countries may uncover etiopathogenic factors. We investigated IBD prevalence in Brazil by investigating its geographic, spatial, and temporal distribution, and attempted to identify factors associated with its recent increase. METHODS:A drug prescription database was queried longitudinally to identify patients and verify population distribution and density, race, urbanicity, sanitation, and Human Development Index. Prevalence was calculated using the number of IBD patients and the population estimated during the same decade. Data were matched to indices using linear regression analyses. RESULTS:We identified 162 894 IBD patients, 59% with ulcerative colitis (UC) and 41% with Crohn's disease (CD). The overall prevalence of IBD was 80 per 100 000, with 46 per 100 000 for UC and 36 per 100 000 for CD. Estimated rates adjusted to total population showed that IBD more than triplicated from 2008 to 2017. The distribution of IBD demonstrated a South-to-North gradient that generally followed population apportionment. However, marked regional differences and disease clusters were identified that did not fit with conventionally accepted IBD epidemiological associations, revealing that the rise of IBD was variable. In some areas, loss of biodiversity was associated with high IBD prevalence. CONCLUSIONS:When distribution is considered in the context of IBD prevalence, marked regional differences become evident. Despite a background of Westernization, hotspots of IBD are recognized that are not explained by population density, urbanicity, sanitation, or other indices but apparently are explained by biodiversity loss. Thus, the rise of IBD in developing countries is not uniform, but rather is one that varies depending on yet unexplored factors like geoecological conditions.
PMID: 35089325
ISSN: 1536-4844
CID: 5154862

Management, Functional Outcomes and Quality of Life After Development of Pelvic Sepsis in Patients Undergoing Re-Do Ileal Pouch Anal Anastomosis

Esen, Eren; Grieco, Michael J; Erkan, Arman; Aytac, Erman; Sutter, Alton G; Lynn, Patricio B; Esterow, Joanna L; Da Luz Moreira, Andre; Kirat, Hasan T; Remzi, Feza H
BACKGROUND:The data on management and outcomes of pelvic sepsis after re-do ileal pouch anal anastomosis are scarce. OBJECTIVE:The aim of this study is to report our management algorithm of pelvic sepsis in the setting of re-do ileal pouch anal anastomosis, and compare functional outcomes and quality of life after successful management of pelvic sepsis with a no-sepsis control group. DESIGN/METHODS:This is a retrospective cohort study. SETTINGS/METHODS:This investigation is based on a single-academic practice group experience on re-do IPAA. PATIENTS/METHODS:Patients who underwent re-do ileal pouch anal anastomosis for ileal pouch failure between 09/2016 - 09/2020 were included in the study. MAIN OUTCOME MEASURES/METHODS:Management of the pelvic sepsis was reported. Functional outcomes, restrictions and quality of life scores were compared between sepsis and no sepsis groups. RESULTS:One-hundred and ten patients were included to our study, of whom 25 (22.7) developed pelvic sepsis. Twenty-three patients presented with pelvic sepsis before ileostomy closure and 2 patients presented with pelvic sepsis after ileostomy closure. There were 6 pouch failures in the study period due to pelvic sepsis. Our management was successful in 79% of the patients with median follow-up of 26 months. Treatments included included IR abscess drainage (n=7), IV antibiotics alone (n=5), IR drainage and mushroom catheter placement (n=1), mushroom catheter placement (n=1), and endoluminal vacuum assisted closure (n=1). Average number of bowel movements, urgency, incontinence, pad use, seepage between were comparable between pelvic sepsis and no pelvic sepsis groups (p>0.05). Lifestyle alterations, Cleveland Global Quality of Life scores and happiness with the results of the surgery were similar (p>0.05). LIMITATIONS/CONCLUSIONS:This study is limited by its low study power and limited follow-up time. CONCLUSIONS:Pelvic sepsis is common after re-do ileal pouch anal anastomosis and management varies according to the location and size of the abscess/sinus. If detected early, our management strategy was associated with high pouch salvage rates. See Video Abstract at http://links.lww.com/DCR/B823.
PMID: 34840297
ISSN: 1530-0358
CID: 5065362

Operative, long-term and quality of life outcomes after salvage of failed re-do ileal pouch anal anastomosis

Esen, Eren; Lynn, Patricio B; Da Luz Moreira, Andre; Erkan, Arman; Aytac, Erman; Grieco, Michael J; Kirat, Hasan T; Remzi, Feza H
AIM/OBJECTIVE:Approximately 20-40% of the patients with re-do ileal pouch anal anastomosis (IPAA) experience pouch failure. Salvage surgery can be attempted in this patient group with severe aversion to permanent ileostomy. The literature regarding secondary IPAA revision after re-do IPAA failure is scarce. METHODS:All patients who underwent a secondary IPAA revision after re-do IPAA failure between 09/2016 - 07/2021 in a single center were included. Short- and long-term outcomes and quality of life in this patient group were reported. RESULTS:Ten patients who had secondary IPAA revision for re-do IPAA failure were included. All patients had ulcerative colitis. Nine of these patients had pelvic sepsis and one patient had a mechanical issue. Mucosectomy and handsewn anastomosis was performed in 9 patients. The existing pouch was salvaged in 6 patients and 4 patients had pouch excision and re-creation. Two patients had postoperative pelvic sepsis. Pouch retention rate was 78% in median 28 months. None of the patients had short gut syndrome. The procedure was associated with good quality of life (median CGQL=0.8). All patients would undergo the same surgery if needed. CONCLUSION/CONCLUSIONS:Secondary IPAA revision after a failed re-do IPAA can be an option in patients with severe aversion to permanent ileostomy if re-do IPAA fails and it is associated with good outcomes. This patient group should be carefully evaluated and referred to specialized centers if required.
PMID: 35119788
ISSN: 1463-1318
CID: 5153912

Prevalence, Indirect Costs, and Risk Factors for Work Disability in Patients with Crohn's Disease at a Tertiary Care Center in Rio de Janeiro

de Sá Brito Fróes, Renata; da Luz Moreira, André; Carneiro, Antonio José de V; Moreira, Jessica P L; Luiz, Ronir R; de Barros Moreira, Adriana Maria Hilu; Monnerat, Camila Cesar; de Souza, Heitor Siffert Pereira; Carvalho, Ana Teresa Pugas
BACKGROUND AND AIMS/OBJECTIVE:Crohn's disease (CD) can lead to work disability with social and economic impacts worldwide. In Brazil, where its prevalence is increasing, we assessed the indirect costs, prevalence, and risk factors for work disability in the state of Rio de Janeiro and in a tertiary care referral center of the state. METHODS:Data were retrieved from the database of the Single System of Social Security Benefits Information, with a cross-check for aid pension and disability retirement. A subanalysis was performed with CD patients followed up at the tertiary care referral center using a prospective CD database, including clinical variables assessed as possible risk factors for work disability. RESULTS:From 2010 to 2018, the estimated prevalence of CD was 26.05 per 100,000 inhabitants, while the associated work disability was 16.6%, with indirect costs of US$ 8,562,195.86. Permanent disability occurred more frequently in those aged 40 to 49 years. In the referral center, the prevalence of work disability was 16.7%, with a mean interval of 3 years between diagnosis and the first benefit. Risk factors for absence from work were predominantly abdominal surgery, anovaginal fistulas, disease duration, and the A2 profile of the Montreal classification. CONCLUSIONS:In Rio de Janeiro, work disability affects one-sixth of CD patients, and risk factors are associated with disease duration and complications. In the context of increasing prevalence, as this disability compromises young patients after a relatively short period of disease, the socioeconomic burden of CD is expected to increase in the future.
PMID: 33044678
ISSN: 1573-2568
CID: 4684962

Perianal complete remission with combined therapy (seton placement and anti-TNF agents) in Crohn's disease: a Brazilian multicenter observational study

Kotze, Paulo Gustavo; Albuquerque, Idblan Carvalho de; da Luz Moreira, André; Tonini, Wanessa Bertrami; Olandoski, Marcia; Coy, Claudio Saddy Rodrigues
BACKGROUND:Perianal fistulizing Crohn's disease is one of the most severe phenotypes of inflammatory bowel diseases. Combined therapy with seton placement and anti-TNF therapy is the most common strategy for this condition. OBJECTIVES/OBJECTIVE:The aim of this study was to analyze the rates of complete perianal remission after combined therapy for perianal fistulizing Crohn's disease. METHODS:This was a retrospective observational study with perianal fistulizing Crohn's disease patients submitted to combined therapy from four inflammatory bowel diseases referral centers. We analyzed patients' demographic characteristics, Montreal classification, concomitant medication, classification of the fistulae, occurrence of perianal complete remission and recurrence after remission. Complete perianal remission was defined as absence of drainage from the fistulae associated with seton removal. DISCUSSION/CONCLUSIONS:A total of 78 patients were included, 44 (55.8%) females with a mean age of 33.8 (±15) years. Most patients were treated with Infliximab, 66.2%, than with Adalimumab, 33.8%. Complex fistulae were found in 52/78 patients (66.7%). After a medium follow-up of 48.2 months, 41/78 patients (52.6%) had complete perianal remission (95% CI: 43.5%-63.6%). Recurrence occurred in four (9.8%) patients (95% CI: 0.7%-18.8%) in an average period of 74.8 months. CONCLUSIONS:Combined therapy lead to favorable and durable results in perianal fistulizing Crohn's disease.
PMID: 25591155
ISSN: 1678-4219
CID: 4684952

Wireless capsule endoscopy fragmentation in a patient with Crohn's disease [Case Report]

de Magalhães Costa, Marcia Henriques; da Luz Moreira, Andre; Zaltman, Cyrla
PMID: 21601654
ISSN: 1542-7714
CID: 4684932