Faculty Bibliography

BACKGROUND:Long rectal cuff (>2 cm) and remnant mesorectum are known causes of pouch dysfunction because of obstructive defecation as well as pelvic sepsis after prolonged obstruction. OBJECTIVE:The aim of this study was to report the rates and management of patients who underwent redo IPAA because of pouch failure associated with a retained mesorectum and long rectal cuff. DESIGN/METHODS:This is a retrospective study. SETTINGS/METHODS:The investigation is based on data from a quaternary IBD center. PATIENTS/METHODS:Patients undergoing redo IPAA surgery with a long rectal cuff and/or remnant mesorectum between September 2016 and September 2023 were included in the study. MAIN OUTCOME MEASURES/METHODS:The main outcomes were functioning pouch rate and functional results. RESULTS:Of the 245 patients who underwent redo IPAA surgery, 98 patients (40%) had long rectal cuff and/or remnant mesorectum. Redo IPAA in this patient group was successful (92%) at a median follow-up of 28 (18-52) months. LIMITATIONS/CONCLUSIONS:The retrospective nature of the study and inclusion of a single specialized center. CONCLUSIONS:Long rectal cuff and remnant mesorectum are major causes of pouch failure, which can be successfully managed with redo IPAA surgery. Nearly half of pouch failure patients who had successful redo IPAA surgery initially received unnecessary biologic therapy before coming to our center. See Video Abstract . MUON RECTAL LARGO Y MESORRECTO REMANENTE SON LAS PRINCIPALES CAUSAS PREVENIBLES DE DISFUNCIN DE LA BOLSA ILEAL/UNASSIGNED:ANTECEDENTES:El muñon rectal largo (>2 cm) y el mesorrecto remanente son causas conocidas de disfunción de la bolsa debido a defecación obstructiva, así como de sepsis pélvica tras obstrucción prolongada.OBJETIVO:El objetivo de este estudio es informar las tasas y el tratamiento de los pacientes que se sometieron a una nueva anastomosis anal con bolsa ileal debido al fracaso de la bolsa asociado a mesorrecto remanente y el muñon rectal largo.DISEÑO:Se trata de un estudio retrospectivo.LUGAR:La investigación se basa en un centro cuaternario de enfermedad inflamatoria intestinal.PACIENTES:Se incluyeron en el estudio los pacientes sometidos a una nueva cirugía de anastomosis anal con bolsa ileal y que tenían muñon rectal largo y/o mesorrecto remanente entre septiembre de 2016 y septiembre de 2023.PRINCIPALES MEDIDAS DE VALORACIÓN:Los principales resultados fueron la tasa de funcionamiento de la bolsa y los resultados funcionales.RESULTADOS:De los 245 pacientes que se sometieron a una nueva cirugía de anastomosis anal con bolsa ileal, 98 (40%) pacientes tenían un muñon rectal largo y/o mesorrecto remanente. La repetición de la anastomosis anal con bolsa ileal en este grupo de pacientes fue exitosa (92%) en una mediana de seguimiento de 28 (18-52) meses.LIMITACIONES:La naturaleza retrospectiva del estudio y la experiencia de un solo centro especializado.CONCLUSIONES:El muñon rectal largo y el mesorrecto remanente son las principales causas de fracaso de la bolsa, que pueden tratarse con éxito mediante una nueva cirugía de anastomosis anal con bolsa ileal. Casi la mitad de los pacientes con fracaso de la bolsa que se sometieron con éxito a una nueva cirugía de anastomosis anal con bolsa ileal recibieron inicialmente un tratamiento biológico innecesario antes de acudir a nuestro centro. (Traducción-Ingrid Melo ).

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.

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.

PURPOSE/OBJECTIVE:The safety and feasibility of minimally invasive surgery (MIS) in the setting of colorectal cancer emergencies have been debated. We sought to compare postoperative outcomes of MIS with open techniques in the setting of colorectal cancer emergencies from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. METHODS:We included patients undergoing colectomy for colorectal cancer emergency between 2012 and 2019 "2012-2019" from the ACS-NSQIP dataset. We compared short-term morbidity, mortality, short-term oncological outcomes, and secondary outcomes for MIS vs open colectomies using propensity score matching. We then evaluated the trends of MIS versus open colectomies using linear regression analysis. RESULTS:We examined a total of 5544 patients (open n = 4070; MIS n = 1474) and included 1352 patients for our postoperative outcome analyses after propensity score matching 1:1 (open n = 676; MIS n = 676). Within the matched cohort, mortality was significantly higher in the open group (open 6.95% vs MIS 3.99%, OR 1.8, p = 0.023). Anastomotic leak rates were comparable between the  two groups (open 4.46% vs MIS 4.02%, OR 1.12, p = 0.787). Pulmonary complications were significantly higher after open surgery (open 10.06% vs MIS 4.73%, OR 2.25, p < 0.001). Rates of ileus were significantly higher amongst open patients (open 29.08% vs MIS 19.94%, p < 0.001). Patients stayed on average 1 day longer in the hospital after open surgery (p < 0.001). Rates of MIS for early tumors (N0 and T1/T2, n = 289) did not significantly change over 7 years (p = 0.597, rate = - 0.065%/year); however, utilization of MIS for late tumors (N1 or T3/T4, n = 4359) increased by 2.06% per year (p < 0.001). CONCLUSIONS:This study demonstrates that MIS was associated with superior postoperative outcomes compared to open surgery without compromising oncological outcomes in patients undergoing emergency colectomy for colon cancer. Within the matched cohort, MIS was associated with lower rates of mortality, pulmonary complications, ileus, and shorter postoperative length of stay.

PURPOSE/OBJECTIVE:The aim of this study was to evaluate the diagnostic performance of preoperative cross-sectional imaging findings using the SAR-AGA definitions in Crohn's disease (CD) patients who underwent ileocolic resection (ICR) with and without surgically complex ileocolic CD (CIC-CD). METHODS:69 CD patients [38 men; mean (± SD) age: 40.6 (16.2) years] who underwent ICR were retrospectively classified by surgical complexity by a colorectal surgeon using operative findings. CIC-CD was defined as ileal CD, not confined to the distal ileum. Two radiologists retrospectively evaluated the preoperative imaging for the presence and type of penetrating disease, stricture, or probable stricture using the SAR-AGA consensus definitions. The diagnostic performance of preoperative imaging findings was compared for patients with and without CIC-CD. Estimated blood loss (EBL), operative time (OT), conversion to open surgery, diversion, and length of hospital stay (LOS) were compared. RESULTS:60.9% had CIC-CD and 79.7% underwent primary ICR. Penetrating disease was more common in patients with than without CIC-CD (76.2% vs. 40.7%, p = 0.0048) and similar among primary versus redo ICR (p = 0.12). Patients with CIC-CD had more complex fistulas (59.5% vs. 11.1%; p < 0.0001) and fewer simple fistulas (2.4% vs. 18.5%; p = 0.03) than those without. Mesenteric findings (abscess, inflammatory mass) were more frequent in patients with (35.7%) than without (0%) (p = 0.0002) CIC-CD. Stricture and probable stricture were similar (p = 0.59). CIC-CD patients had greater EBL (178 cc vs. 57 cc, p = 0.006), conversion rates (30% vs. 0%, p = 0.0026), and diversion (80% vs. 52%, p = 0.04). CONCLUSION/CONCLUSIONS:Complex fistula, mesenteric abscess, or inflammatory mass defined by the SAR-AGA guidelines suggests CIC-CD. ICR for CIC-CD had greater EBL, conversion to open surgery, and diversion.

Introduction: Redo ileal pouch anal anastomosis (IPAA), the procedure of choice for IPAA, is mainly attempted in specialized centers but referral patterns for redo IPAA are not well known. Social media may be a valuable tool for patients to find surgeons. In our study we evaluated referral patterns of redo IPAA.
Method(s): All redo IPAA procedures performed at our center for IPAA failure between 09/2016 and 02/2022 were included. Patient demographics, disease characteristics and referral patterns were reported.
Result(s): A total of 141 patients with IPAA failure who had redo IPAA surgery were included. The median age was 40 years. The median time between the index surgery and the redo surgery was 5 years (interquartile range: 2-11). There were 108 ulcerative colitis, 25 indeterminate colitis and 8 familial adenomatous polyposis patients. Referrals for 49 patients were via social media or word of mouth (33.1%), 48 were referred by gastroenterologists (32.4%), 33 by colorectal surgeons (22.3%) and 1 by an oncologist (0.7%). The index case was done by our team in 11 patients (7.4%). A significant majority of patients, 30%, were from outside of our center's tristate area.
Conclusion(s): Social media and patient-patient interaction was the number one referral source, followed closely by the gastroenterologists. The small number of referrals by the primary surgeon is a source of concern since the majority of redo IPAAs are done to fix surgical failures

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.

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.

BACKGROUND:Salvage of the existing ileal pouch is favored during re-do ileal pouch anal anastomosis if the pouch is not damaged after pelvic dissection and there are no other mechanical reasons that may necessitate construction of a new pouch. Excision of the existing pouch may be associated with some concerns for short-bowel syndrome and poor functional outcomes. This study aimed to report indications and compare functional and quality of life outcomes of new pouch creation versus salvage of the existing pouch during re-do ileal pouch anal anastomosis. METHODS:Patients who underwent re-do ileal pouch anal anastomosis between September 2016 and June 2020 were included. The reasons for pouch excision and new pouch creation were reported. Perioperative, functional outcomes and quality of life were compared between patients who had creation of a new pouch versus salvage of existing pouch. RESULTS:A total of 105 patients with re-do ileal pouch anal anastomosis (new pouch, n = 63) were included. Most common indications for a new pouch creation were chronic pelvic infection that compromised the integrity and viability of the existing pouch (n = 32) and small pouch (n = 21). No patient developed short-bowel syndrome. The number of bowel movements, daily restrictions and Cleveland Global Quality of Life score scores were similar between 2 groups. Day-time seepage, day-time and night-time pad usage were more common after new pouch creation. Two-year pouch survival rates were comparable (new pouch: 92% versus existing pouch: 85%, P = .31). CONCLUSION/CONCLUSIONS:New pouch creation can be safely performed at the time of re-do ileal pouch anal anastomosis. It provides acceptable functional and quality of life outcomes if existing pouch salvage is not feasible.

Introduction: Strictures are reported in around 35%-40% of patients after primary ileal pouch anal anastomosis (IPAA). So far, there are no reports focusing on strictures after re-do IPAA. In our study, we evaluated the incidence, management, long-term functional outcomes, and quality of life scores of anastomotic strictures after re-do IPAA.
Method(s): Patients undergoing redo IPAA between 9/2016 and 9/2020 were included. Incidence and management strategy of re-do IPAA strictures were evaluated. Functional outcomes, lifestyle alterations, and quality of life scores were compared between stricture vs no-stricture groups.
Result(s): Ninety patients were included in the analysis after ileostomy closure. Twenty-two patients developed symptomatic strictures, all of which were at the pouch-anal anastomosis (first year: 25.3%;2 years: 31.8%) In 5 (23%) patients, the strictures were mild, and digital dilation was easily performed. Seventeen (77%) patients had tight strictures dilated with pilling dilators. Median number of dilations required to achieve permanent symptomatic relief was 1. None of the patients required pouch excision due to strictures. Incidence of pouch-anal anastomotic stricture was higher in the re-do IPAA compared with the primary IPAA. Lifestyle alterations were similar between the stricture and no stricture groups. Cleveland Global Quality of Life score was lower in patients with strictures. Strictures were associated with decreased patient happiness with their IPAA (p=0.005) (Table).
Conclusion(s): Stricture development after re-do IPAAs are common and have a higher incidence than primary IPAA, but it can be managed aggressively with a subsequent high pouch retention rate. Lower patient happiness after surgery and decreased QOL are associated with stricture development after re-do IPAAs. [Formula presented]
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