Faculty Bibliography

BACKGROUND:Crohn's disease (CD) often affects the terminal ileum, leading to complications such as stricture, fistula, and abscesses, necessitating surgery in up to 80% of patients. Early and effective treatment is crucial to prevent disease progression and improve outcomes, although timing between medical and surgical treatments is challenging. METHODS:This study reviewed patients who underwent ileocolic resection for CD at our quaternary inflammatory bowel disease center from September 2016 to September 2023. A novel classification system categorized the severity and complexity of ileocolic CD. Preoperative characteristics, operative variables, and postoperative outcomes were analyzed to assess the impact of disease complexity. RESULTS:Among the 301 patients (median age 33.3 years, 48.5% female), 56.8% had complex ileocolic CD. Complex disease was associated with greater blood loss, longer hospital stays, longer operative time, and greater rates of open surgery and conversion compared with noncomplex disease (P < .01). Diversion rates were significantly greater in complex cases (P < .01). Emergent operations were more common among complex cases (P < .01). Delayed referral and increased complexity correlated with inferior surgical outcomes and greater stoma rates. CONCLUSION/CONCLUSIONS:The proposed classification system stratifies patients on the basis of CD severity and complexity, facilitating better preoperative planning and communication among multidisciplinary teams. Early surgical intervention, when appropriate, may reduce morbidity and improve outcomes in patients with ileocolic CD. This system highlights the importance of timely referrals and standardizing the management approach for complex CD.

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 ).

BACKGROUND:Ileal pouch anal anastomosis is the preferred method for restoration of intestinal continuity after proctocolectomy. Successful ileal pouch anal anastomosis requires adequate reach of the ileal mesentery to the pelvis. Reach issues are a common cause for intraoperative pouch abandonment; however, data regarding contemporary abandonment rates are rare and nonexistent in the revisional setting. METHODS:A retrospective review was conducted of consecutive ileal pouch anal anastomosis surgery at a single referral center. Both initial or "primary" pouches and revisional pouch surgery were included. RESULTS:In total, 447 attempts at pouch anal anastomosis were made, with an 1.6% overall rate of intraoperative abandonment. Pouch abandonment was attributed to inadequate mesenteric reach during 3 surgeries, desmoid tumors in 2 surgeries, and insufficient remaining small bowel in 2 surgeries. Twelve patients required lengthening maneuvers including 6 S pouches (1%) and 6 H pouches (1%). One half (49%) of operations were revisional ileal pouch anal anastomosis surgery. Overall, reach issues led to intraoperative abandonment in only 0.4% of attempted primary pouches and 1.0% of revisional surgeries. A preoperative diagnosis of familial adenomatous polyposis was associated with pouch abandonment (P < .001). CONCLUSION/CONCLUSIONS:Extremely low pouch abandonment rates as a result of mesenteric reach can be achieved even in the revisional setting at a high-volume center with institutional expertise. In the revisional setting, intra-abdominal desmoids or the potential for short gut affects pouch abandonment rates as much as reach issues.

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.

IntroductionOlder adults with IBD are at higher risk for postoperative complications as compared to their younger counterparts, however factors contributing to this are unknown. We assessed risk factors associated with adverse IBD-related surgical outcomes, evaluated trends in emergency surgery, and explored differential risks by age.MethodsUsing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified adults ≥18 years of age who underwent an IBD-related intestinal resection from 2005-2019. Our primary outcome included a 30-day composite of mortality, readmission, reoperation, and/or major postoperative complication.ResultsOverall, 49,746 intestinal resections were performed with 9,390 (18.8%) occurring among older adults with IBD. Nearly 37% of older adults experienced an adverse outcome as compared to 28.1% among younger adults with IBD (p<0.01). Among all adults with IBD, the presence of preoperative sepsis (aOR, 2.08; 95%CI 1.94-2.24), malnutrition (aOR, 1.22; 95%CI 1.14-1.31), dependent functional status (aOR, 6.92; 95%CI 4.36-11.57), and requiring emergency surgery (aOR, 1.50; 95%CI 1.38-1.64) increased the odds of an adverse postoperative outcome, with similar results observed when stratifying by age. Further, 8.8% of surgeries among older adults were emergent, with no change observed over time (p=0.16).DiscussionPreoperative factors contributing to the risk of an adverse surgical outcome are similar between younger and older individuals with IBD, and include elements such as malnutrition and functional status. Incorporating these measures into surgical decision-making can reduce surgical delays in older individuals at low-risk and help target interventions in those at high risk, transforming care for thousands of older adults with IBD.

BACKGROUND:The prognostic significance of histology in ileal pouch-anal anastomosis (IPAA) remains unclear. The aim of this study was to evaluate if histologic variables are predictive of IPAA clinical outcomes and healthcare utilization. METHODS:This was a retrospective cohort study of patients with IPAA undergoing surveillance pouchoscopy at a tertiary care institution. Pouch body biopsies were reviewed by gastrointestinal pathologists, who were blinded to clinical outcomes, for histologic features of acute or chronic inflammation. Charts were reviewed for clinical outcomes including development of acute pouchitis, chronic pouchitis, biologic or small molecule initiation, hospitalizations, and surgery. Predictors of outcomes were analyzed using univariable and multivariable logistic and Cox regression. RESULTS:A total of 167 patients undergoing surveillance pouchoscopy were included. Polymorphonuclear leukocytes (odds ratio [OR], 1.67), ulceration and erosion (OR, 2.44), chronic inflammation (OR, 1.97), and crypt distortion (OR, 1.89) were associated with future biologic or small molecule initiation for chronic pouchitis. Loss of goblet cells was associated with development of chronic pouchitis (OR, 4.65). Pyloric gland metaplasia was associated with hospitalizations (OR, 5.24). No histologic variables were predictive of development of acute pouchitis or surgery. In an exploratory subgroup analysis of new IPAA (<1 year), loss of goblet cells was associated with acute pouchitis (OR, 14.86) and chronic pouchitis (OR, 12.56). Pyloric gland metaplasia was again associated with hospitalizations (OR, 13.99). CONCLUSIONS:Histologic findings may be predictive of IPAA outcomes. Pathologists should incorporate key histologic variables into pouchoscopy pathology reports. Clinicians may need to more closely monitor IPAA patients with significant histologic findings.

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.