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BACKGROUND Surgical and systemic therapies continue to advance, enabling restorative resections for distal rectal cancer. These operations are associated with low anterior resection syndrome. Recent studies with methodological and size limitations have investigated the incidence of low anterior resection syndrome after anterior resection. However, the long-term trajectory of low anterior resection syndrome and its effect on health-related quality-of-life remain unclear. OBJECTIVE To assess the impact of anterior resection and reversal of ileostomy on long term health-related quality-of-life and low anterior resection syndrome. SETTING Patients who underwent anterior resection of the rectum for cancer with defunctioning ileostomy between 2003 and 2016 at two high-volume centers in the United Kingdom were identified, excluding those suffering anastomotic leakage. DESIGN Patient demographics were analyzed alongside low anterior resection syndrome and health-related quality-of-life qualitative scores (EORTC-QLQ-C30) obtained through cross-sectional postal questionnaires. PATIENTS Amongst 478 eligible patients, 311 (65.1%) participated at a mean of 6.5±0.2 years after anterior resection. Demographics and neoadjuvant chemoradiotherapy rates were similar (p>0.05) between participants and non-participants. RESULTS The percentage of patients who experienced major low anterior resection syndrome was 53.4% (166/311). MAJOR OUTCOME MEASURES Health-related quality-of-life functional domain scores improved in the years following reversal of ileostomy, with significant changes in constipation (p=0.01), social function (p=0.03) and emotional scores (p=0.02), as well as a reduction in the prevalence of major low anterior resection syndrome (p=0.003). LIMITATIONS The main limitation of this study was that the data collected was cross-sectional rather than longitudinal, and that non responders may have had worse cancer symptoms. CONCLUSIONS In this first large-scale study assessing long-term function following anterior resection and reversal of ileostomy, there is a linear improvement in major low anterior resection syndrome beyond 6 years, alongside improvements in key quality-of-life measures. See Video Abstract at http://links.lww.com/DCR/B825.

Readmission after ileostomy creation continues to be a major cause of morbidity with rates ranging from 15% to 30% due to dehydration and obstruction. Rural environments pose an added risk of readmission due to larger travel distances and lack of consistent home health services.This study aimed to reduce ileostomy-related readmission rates in a rural academic medical center.This is a rapid cycle quality improvement study.This single-center study was conducted in a rural academic medical center.Colorectal surgery patients receiving a new ileostomy were included in this study.Improvement initiatives were identified through Plan-Do-Study-Act cycles (enhanced team continuity, standardized rehydration, nursing/staff education).Thirty-day readmission, average length of stay, and average time to readmission served as main outcome measures.Roughly equal rates of ileostomy were created in each time point, consistent with a tertiary care colorectal practice. The preimplementation readmission rate was 29%. Over the course of the entire quality improvement initiative, re-admission rates decreased by more than 50% (29% to 14%). PDSA cycle 1, which involved integrating a service-specific physician assistant to the team, allowed for greater continuity of care and had the most dramatic effect, decreasing rates by 27.5% (29% to 21%). Standardization of oral rehydration therapy and the implementation of a patient-directed intake/output sheet during PDSA cycle 2 resulted in further improvement in readmission rates (21% to 15%). Finally, implementation of nurse and physician assistant (PA)-driven patient education on fiber supplementation resulted in an additional yet nominal decrease in readmissions (15% to 14%). Latency to readmission also significantly increased throughout the study period.This study was limited by its small sample size in a single-center study.Implementation of initiatives targeting enhanced team continuity, the standardization of rehydration therapies, and improved patient education decreased readmission rates in patients with new ileostomies. Rural centers, where outpatient resources are not as readily available or accessible, stand to benefit the most from these types of targeted interventions to decrease readmission rates. See Video Abstract at http://links.lww.com/DCR/B771.ANTECEDENTES:La readmisión después de la creación de una ileostomía sigue siendo una de las principales causas de morbilidad con tasas que oscilan entre el 15% y el 30% debido a la deshidratación y la oclusión. Un entorno rurale presenta un riesgo adicional de readmisión debido a las mayores distancias de viaje y la falta de servicios de salud domiciliarios adecuados.OBJETIVO:Reducir las tasas de reingreso por ileostomía en un centro médico académico rural.DISEÑO:Estudio de mejoría de la calidad de ciclo rápido.AJUSTE:Estudio unicéntrico en una unidad de servicio médico académico rural.PACIENTES:Pacientes de cirugía colorrectal a quienes se les confeccionó una ileostomía.INTERVENCIONES:Iniciativas de mejoría identificadas a través de los ciclos Planificar-Hacer-Estudiar-Actuar (Continuidad del equipo mejorada, rehidratación estandarizada, educación de enfermería / personal).PRINCIPALES MEDIDAS DE RESULTADO:30 días de readmisión, duración media de la estadía hospitalaria, tiempo medio de reingreso.RESULTADOS:Se crearon tasas aproximadamente iguales de ileostomías un momento dado de tiempo, subsecuentes en la práctica colorrectal de atención terciaria. La tasa de readmisión previa a la implementación del estudio fue del 29%. En el transcurso de toda la iniciativa de mejoría en la calidad, las tasas de readmisión disminuyeron en más del 50% (29% a 14%). El ciclo 1 de PDSA, que implicó la integración en el equipo de un asistente médico específico, lo que permitió una mayor continuidad en la atención y tuvo el mayor efecto disminuyendo las tasas en un 27,5% (29% a 21%). La estandarización de una terapia de rehidratación oral y la implementación de una hoja de ingresos / perdidas dirigida al paciente durante el ciclo 2 de PDSA resultó en una mejoría adicional en las tasas de readmisión (21% a 15%). Finalmente, la implementación de la educación del paciente impulsada por enfermeras y AF sobre el consumo suplementario de dietas con fibra dio como resultado una disminución adicional, aunque nominal, de las readmisiones (15% a 14%). La latencia hasta la readmisión también aumentó significativamente durante el período de estudio.LIMITACIONES:Estudio de un solo centro con un muestreo de pequeño tamaño.CONCLUSIONES:La implementación de iniciativas dirigidas a mejorar la continuidad en el equipo, la estandarización de las terapias de rehidratación y la mejoría en la información de los pacientes disminuyeron las tasas de readmisión en todos aquellas personas con nuevas ileostomías. Los centros rurales, donde los recursos para pacientes ambulatorios no están tan fácilmente disponibles o accesibles, son los que más beneficiaron de este tipo de intervenciones específicas para reducir las tasas de readmisión. Consulte Video Resumen en http://links.lww.com/DCR/B771. (Traducción-Dr. Xavier Delgadillo).

Surgical intervention for Crohn's disease involving the colon is often a total proctocolectomy with end ileostomy. There are limited data regarding postoperative small bowel recurrence rates in the recent era.The purpose of this study was to determine the rate of small bowel Crohn's disease recurrence following total proctocolectomy and secondarily define risk factors for disease recurrence.This was a retrospective cohort study.The study was conducted at four hospitals within a single healthcare system.Patients were those with Crohn's disease undergoing total proctocolectomy with end ileostomy between 2009-2019.Main outcome measures were clinical, endoscopic, radiographic, and/or surgical Crohn's disease recurrence.In total, 193 patients were included with a median follow-up of 1.8 years (IQR 0.4-4.6). Overall, 74.6% (n = 144) of patients had been previously exposed to biologic therapy, and 51.3% (n = 99) had a history of small bowel Crohn's disease. Postoperatively, 14.5% (n = 28) of patients received biologic therapy. Crohn's disease recurrence occurred in 23.3% (n = 45) of patients with an estimated median 5-year recurrence rate of 40.8% (95% CI' 30.2-51.4). Surgical recurrence occurred in 8.8% (n = 17) of patients with an estimated median 5-year recurrence rate of 16.9% (95% CI' 8.5-25.3). On multivariable analysis, prior small bowel surgery for Crohn's disease (HR 2.61; 95% CI' 1.42-4.81) and Crohn's diagnosis at age18 years (HR 2.56; 95% CI' 1.40-4.71) were associated with Crohn's recurrence. In patients without prior small bowel Crohn's disease, 14.9% (n = 14) had Crohn's recurrence with an estimated 5-year overall recurrence rate of 31.1% (95% CI' 13.3-45.3) and 5-year surgical recurrence rate of 5.7% (95% CI' 0.0-12.0).The study was limited by its retrospective design and lack of consistent follow-up on all patients.Greater than one third of patients who underwent total proctocolectomy for Crohn's disease were estimated to have small bowel Crohn's recurrence at 5 years after surgery. Patients with a history of small bowel surgery for Crohn's and diagnosis at any early age may benefit from more intensive postoperative surveillance and consideration for early medical prophylaxis. See Video Abstract at http://links.lww.com/DCR/B762.ANTECEDENTES:La cirugia para la enfermedad de Crohn que involucra el colon es a menudo una proctocolectomía total con ileostomía terminal. Hay datos limitados con respecto a las tasas de recurrencia posoperatoria de la enfermedad de Crohn del intestino delgado en la actualidad.OBJETIVO:Buscamos determinar la tasa de recurrencia de la enfermedad de Crohn del intestino delgado después de la proctocolectomía total y, en segundo lugar, definir los factores de riesgo de recurrencia de la enfermedad.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:Cuatro hospitales de un mismo sistema sanitario.PACIENTES:Pacientes con enfermedad de Crohn sometidos a proctocolectomía total con ileostomía terminal entre 2009-2019.PRINCIPALES MEDIDAS DE VALORACIÓN:Recurrencia clínica, endoscópica, radiográfica y / o quirúrgica de la enfermedad de Crohn.RESULTADOS:Se incluyeron 193 pacientes con un seguimiento promedio de 1,8 años (IQR 0,4-4,6). El 74,6% (n = 144) de los pacientes habían recibido previamente terapia biológica y el 51,3% (n = 99) tenían antecedentes de enfermedad de Crohn del intestino delgado. Después de la operación, el 14,5% (n = 28) de los pacientes recibieron terapia biológica. La recurrencia de la enfermedad de Crohn ocurrió en el 23,3% (n = 45) de los pacientes con una tasa de recurrencia media estimada a los 5 años del 40,8% (IC del 95%: 30,2-51,4). La recidiva quirúrgica se produjo en el 8,8% (n = 17) de los pacientes con una tasa de recidiva media estimada a los 5 años del 16,9% (IC del 95%: 8,5-25,3). En el análisis multivariable, la cirugía previa del intestino delgado para la enfermedad de Crohn (HR 2,61, IC del 95%: 1,42-4,81) y el diagnóstico de Crohn a la edad18 (HR 2,56, IC del 95%: 1,40-4,71) se asociaron con la recurrencia de Crohn. En pacientes sin enfermedad previa de Crohn del intestino delgado, el 14,9% (n = 14) tuvo recurrencia de Crohn con una tasa de recurrencia general estimada a 5 años del 31,1% (IC del 95%: 13,3-45,3) y una tasa de recurrencia quirúrgica a 5 años del 5,7% (IC del 95%: 0,0-12,0).LIMITACIONES:Diseño retrospectivo, falta de seguimiento constante de todos los pacientes.CONCLUSIONES:Se estimó que más de un tercio de los pacientes que se sometieron a proctocolectomía total tenían recurrencia de Crohn del intestino delgado a los 5 años después de la cirugía. Los pacientes con antecedentes de cirugía por enfermedad de Crohn del intestino delgado y diagnóstico a una edad temprana pueden beneficiarse de una vigilancia posoperatoria más intensiva y la consideración de una profilaxis médica temprana. Consulte Video Resumen en http://links.lww.com/DCR/B762. (Traducción- Dr. Ingrid Melo).

BACKGROUND The optimum timing for temporary ileostomy closure after low anterior resection is still open. OBJECTIVE This trial aimed to compare early (2 wk) versus late (12 wk) stoma closure. DESIGN The study included 2 parallel groups in a multicenter, randomized controlled clinical trial. SETTINGS The study was conducted at 3 Swiss hospitals. PATIENTS Patients undergoing low anterior resection and temporary ileostomy for cancer were included. INTERVENTIONS Patients were randomly allocated to early or late stoma closure. Before closure, colonic anastomosis was examined for integrity. MAIN OUTCOME MEASURES The primary efficacy outcome was the Gastrointestinal Quality of Life Index 6 weeks after resection. Secondary end points included safety (morbidity), feasibility, and quality of life 4 months after low anterior resection. RESULTS The trial was stopped for safety concerns after 71 patients were randomly assigned to early closure (37 patients) or late closure (34 patients). There were comparable baseline data between the groups. No difference in quality of life occurred 6 weeks (mean Gastrointestinal Quality of Life Index: 99.8 vs 106.0; p = 0.139) and 4 months (108.6 vs 107.1; p = 0.904) after index surgery. Intraoperative tendency of oozing (visual analog scale: 35.8 vs 19.3; p = 0.011), adhesions (visual analog scale: 61.3 vs 46.2; p = 0.034), leak of colonic anastomosis (19% vs 0%; p = 0.012), leak of colonic or ileal anastomosis (24% vs 0%; p = 0.002), and reintervention (16% vs 0%; p = 0.026) were significantly higher after early closure. The concept of early closure failed in 10 patients (27% vs 0% in the late closure group (95% CI for the difference, 9.4%-44.4%)). LIMITATIONS The trial was prematurely stopped because of safety issues. The aimed group size was not reached. CONCLUSIONS Early stoma closure does not provide better quality of life up to 4 months after low anterior resection but is afflicted with significantly adverse feasibility and higher morbidity when compared with late closure. See Video Abstract at http://links.lww.com/DCR/B665. CIERRE DE LA ILEOSTOMA TEMPORAL VERSUS SEMANAS POSTERIOR A LA RESECCIN RECTAL POR CNCER UNA ADVERTENCIA DE UN ESTUDIO MULTICNTRICO CONTROLADO RANDOMIZADO PROSPECTIVO ANTECEDENTES:El momento optimo para el cierre temporal de la ileostomia posterior a la reseccion anterior baja es aun controversial.OBJETIVO:Este estudio tuvo como objetivo comparar el cierre del estoma temprano (2 semanas) versus tardio (12 semanas).DISENO:Estudio clinico controlado, randomizado, multicentrico, de dos grupos paralelos.ENTORNO CLINICO:El estudio se llevo a cabo en 3 hospitales suizos.PACIENTES:Se incluyeron pacientes sometidos a reseccion anterior baja e ileostomia temporal por cancer.INTERVENCIONES:Los pacientes fueron asignados aleatoriamente al cierre del estoma temprano o tardio. Antes del cierre, se examino la integridad de la anastomosis colonica.PRINCIPALES MEDIDAS DE VALORACION:El principal resultado de eficacia fue el Indice de Calidad de Vida Gastrointestinal 6 semanas despues de la reseccion. Los criterios secundarios incluyeron la seguridad (morbilidad), factibilidad y calidad de vida 4 meses posterior a la reseccion anterior baja.RESULTADOS:El estudio se detuvo por motivos de seguridad despues de que 71 pacientes fueron asignados aleatoriamente a cierre temprano (37 pacientes) o cierre tardio (34 pacientes). Hubo datos de referencia comparables entre los grupos. No se produjeron diferencias en la calidad de vida 6 semanas (indice de calidad de vida gastrointestinal, media 99,8 vs. 106; p = 0,139) y 4 meses (108,6 vs 107,1, p = 0,904) despues de la cirugia inicial. Tendencia intraoperatoria de supuracion (escala analogica visual 35,8 vs 19,3, p = 0,011), adherencias (escala analogica visual 61,3 vs 46,2, p = 0,034), fuga de anastomosis colonica (19% vs 0%, p = 0,012), fuga de anastomosis colonica o ileal (24% vs 0%, p = 0,002) y reintervencion (16% vs 0%, p = 0,026) fueron significativamente mayores despues del cierre temprano. El concepto de cierre temprano fracaso en 10 pacientes (27% vs ninguno en el grupo de cierre tardio (intervalo de confianza del 95% para la diferencia: 9,4% a 44,4%)).LIMITACIONES:El estudio se detuvo prematuramente debido a problemas de seguridad. No se alcanzo el tamano del grupo previsto.CONCLUSION:El cierre temprano del estoma no proporciona una mejor calidad de vida hasta 4 meses posterior a una reseccion anterior baja, esto se ve afectado por efectos adversos significativos durante su realizacion y una mayor morbilidad en comparacion con el cierre tardio. Consulte Video Resumen en http://links.lww.com/DCR/B665.

Introduction When patients with familial adenomatous polyposis have a severely affected rectum it is usually assumed that endoscopic control is impossible or unwise. The standard approach is proctectomy with either an end ileostomy, or an ileal pouch anal anastomosis. Here we show that application of aggressive, multistage snare polypectomy to this situation can be effective and allow the patient to avoid surgery, at least in the short term. Technique Standard polypectomy using snare excision with coagulation is used, taking two or three sessions, and beginning with the largest polyps. The procedures are done with the patient under general anesthesia. Endoscopic mucosal resection technique with fluid injection to lift polyps is not necessary. Results Complete control of the rectal polyps, sustained for at least 2 years, is possible without functional sequelae. Conclusions Familial adenomatous polyposis patients with severe rectal polyposis can be offered multistage rectal polypectomy and safely avoid proctectomy.IRB and consent approval through the David G Jagelman Inherited Colorectal Cancer Registry.

CASE SUMMARY A 27-year-old man with fistulizing terminal ileal Crohn's disease with an ileosigmoid fistula progressed through medical management and required an abdominal operation at an outside hospital. He underwent an ileocolic resection and a debridement with oversewing of his mesenteric sigmoid fistula with a diverting loop ileostomy. After a normal colonoscopy, his stoma was reversed; however, 2 weeks later he presented to the hospital with pelvic sepsis. A CT scan with oral, intravenous, and rectal contrast demonstrated a persistent sigmoid fistula with associated abscess. After treatment with antibiotics and percutaneous drainage, the patient underwent a segmental sigmoid resection to repair the mesenteric fistula and a diverting loop ileostomy. The ileostomy has been reversed and the patient's Crohn's disease is in remission.

Background For rectal cancer with unresectable metastases, current practice favors omitting interventions directed at the primary tumor in asymptomatic patients. Objective This study aimed to determine the proportion of patients with primary tumor-related complications, characterize salvage outcomes, and measure survival in patients with metastatic rectal cancer who did not undergo upfront intervention for their primary tumor. Design This is a retrospective analysis. Setting This study was conducted at a comprehensive cancer center. Patients Patients who presented between January 1, 2008, and December 31, 2015, with synchronous stage IV rectal cancer, an unresected primary tumor, and no prior primary tumor-directed intervention were selected. Main outcome measures The main outcome measured was the rate of primary tumor-related complications in the cohort that did not receive any primary tumor-directed intervention. The Kaplan-Meier method and Cox regression analysis were used to determine whether complications are associated with survival. Results The cohort comprised 358 patients with a median age of 56 years (22-92). Median follow-up was 26 months (range, 1-93 months). Among the 168 patients (46.9%) who eventually underwent elective resection of the primary tumor, the surgery was performed with curative intent in 66 patients (18.4%) and preemptive intent in 102 patients (28.5%). Of the 190 patients who did not undergo an upfront or elective intervention for the primary tumor, 68 (35.8%) experienced complications. Nonsurgical intervention for complications was attempted in 34 patients with an overall success rate of 61.8% (21/34). Surgical intervention was performed in 47 patients (including 13 patients for whom nonsurgical intervention failed): diversion in 26 patients and resection in 21 patients. Of those 47 patients, 42 (89.4%) ended up with a colostomy or ileostomy. Limitations This study was conducted at a single center. Conclusion A significant proportion of patients with metastatic rectal cancer and untreated primary tumor experience primary tumor-related complications. These patients should be followed closely, and preemptive intervention (resection, diversion, or radiation) should be considered if the primary tumor progresses despite systemic therapy. See Video Abstract at http://links.lww.com/DCR/B400. COMPLICACIONES RELACIONADAS CON EL TUMOR PRIMARIO Y RESULTADOS DE RESCATE EN PACIENTES CON CANCER DE RECTO METASTASICO Y UN TUMOR PRIMARIO NO TRATADO: Para el cancer de recto con metastasis no resecables, la practica actual favorece la omision de las intervenciones dirigidas al tumor primario en pacientes asintomaticos.Determinar la proporcion de pacientes con complicaciones relacionadas con el tumor primario, caracterizar los resultados de rescate y medir la supervivencia en pacientes con cancer rectal metastasico que no se sometieron a una intervencion inicial para su tumor primario.Analisis retrospectivo.Centro oncologico integral.Pacientes que se presentaron entre el 1 de enero de 2008 y el 31 de diciembre de 2015 con cancer de recto en estadio IV sincronico, un tumor primario no resecado y sin intervencion previa dirigida al tumor primario.Tasa de complicaciones relacionadas con el tumor primario en la cohorte que no recibio ninguna intervencion dirigida al tumor primario. Se utilizo el metodo de Kaplan-Meier y el analisis de regresion de Cox para determinar si las complicaciones estan asociadas con la supervivencia.La cohorte estuvo compuesta por 358 pacientes con una mediana de edad de 56 anos (22-92). La mediana de seguimiento fue de 26 meses (rango, 1 a 93 meses). Entre los 168 pacientes (46,9%) que finalmente se sometieron a reseccion electiva del tumor primario, la cirugia se realizo con intencion curativa en 66 pacientes (18,4%) y con intencion preventiva en 102 pacientes (28,5%). De los 190 pacientes que no se sometieron a una intervencion inicial o electiva para el tumor primario, 68 (35,8%) experimentaron complicaciones. Se intento una intervencion no quirurgica para las complicaciones en 34 pacientes con una tasa de exito global del 61,8% (21 de 34). La intervencion quirurgica se realizo en 47 pacientes (incluidos 13 pacientes en los que fallo la intervencion no quirurgica): derivacion en 26 pacientes y reseccion en 21 pacientes. De esos 47 pacientes, 42 (89,4%) terminaron con una colostomia o ileostomia.Unico centro.Una proporcion significativa de pacientes con cancer de recto metastasico y primario no tratado experimentan complicaciones relacionadas con el tumor primario. Se debe hacer un seguimiento estrecho de estos pacientes y considerar la posibilidad de una intervencion preventiva (reseccion, derivacion o radiacion) si el tumor primario progresa a pesar de la terapia sistemica. Consulte Video Resumen en http://links.lww.com/DCR/B400.

BACKGROUND Anastomotic leaks cause significant patient morbidity that may require redo pelvic surgery. Transanal minimally invasive surgery facilitates direct access to the pelvis with increased visualization and maneuverability for technically difficult redo surgery. OBJECTIVE This study aimed to assess the feasibility and outcomes of transanal minimally invasive surgery in redo proctectomy for anastomotic complications. DESIGN This was a retrospective cohort study. SETTINGS This study was conducted at a single tertiary-care institution. PATIENTS Consecutive patients undergoing transanal minimally invasive redo proctectomy were included. INTERVENTIONS Transanal minimally invasive redo proctectomy was performed. MAIN OUTCOME MEASURES The primary end point was intraoperative feasibility. The secondary end points were safety, perioperative morbidity, and symptom resolution. RESULTS Seven patients underwent redo proctectomy via transanal minimally invasive surgery for anastomotic defect (n = 6) or stricture (n = 1). Median time from initial to redo operation was 27 months (range, 13-67). Redo proctectomy included redo low anterior resection with coloanal anastomosis and diverting loop ileostomy (n = 4), completion proctectomy with end colostomy (n = 2), and pouch resection with end ileostomy (n = 1). Six patients had an open abdominal approach. There were no conversions for the anal approach. Median operative time was 6.4 hours (range, 4.0-7.1). All 4 planned redo coloanal anastomoses were successfully created. Hospital length of stay was a median of 8 days (interquartile range, 6-9). Intraoperative complications included 2 patients with carbon dioxide emboli, which resolved with supportive care; there was no adjacent organ injury. Three patients were readmitted within 30 days. There were no postoperative anastomotic leaks, and all 4 patients with diverted ileostomies underwent reversal at a median of 4 months (interquartile range, 4-6). All symptoms prompting redo surgery remain resolved at a median follow-up of 20 months. LIMITATIONS This study was limited by its small sample size and its single-institution focus. CONCLUSION For those with expertise in transanal surgery, transanal minimally invasive surgery is a safe and effective option for patients with anastomotic failure requiring redo proctectomy because it provides direct access to and visualization of the pelvis.

BACKGROUND To avoid a permanent stoma, restorative surgery is performed after the colectomy. Previous studies have shown that less than half of patients with ulcerative colitis undergo restorative surgery. OBJECTIVE The primary aim was to explore the association between socioeconomic status and restorative surgery after colectomy. DESIGN This was a nationwide register-based cohort study. SETTINGS The study was conducted in Sweden. PATIENTS All Swedish patients with ulcerative colitis who underwent colectomy between 1990 and 2017 at the age of 15 to 69 years were included. MAIN OUTCOME MEASURES The main outcome was restorative surgery, and the secondary outcome was failure of the reconstruction (defined as the need for a new ileostomy after the reconstruction or nonreversal of a defunctioning stoma within 2 years of the reconstruction). To calculate HRs for restorative surgery after colectomy, as well as failure after restorative surgery, multivariable Cox regression models were performed (adjusted for sex, year of colectomy, colorectal cancer diagnosis, education, civil status, country of birth, income (quartiles 1 to 4, where Q4 represents highest income), hospital volume, and stratified by age). RESULTS In all, 5969 patients with ulcerative colitis underwent colectomy, and of those, 2794 (46.8%) underwent restorative surgery. Restorative surgery was more common in patients with a high income at the time of colectomy (quartile 1, reference; quartile 2, 1.09 (0.98-1.21); quartile 3, 1.20 (1.07-1.34); quartile 4, 1.27 (1.13-1.43)) and less common in those born in a Nordic country than in immigrants born in a non-Nordic country (0.86 (0.74-0.99)), whereas no association was seen with educational level and civil status. There was no association between socioeconomic status and the risk of failure after restorative surgery. LIMITATIONS The study was restricted to register data. CONCLUSIONS Restorative surgery in ulcerative colitis appears to be more common in patients with a high income and patients born in a non-Nordic country, indicating inequality in the provided care. See Video Abstract at http://links.lww.com/DCR/B433. LA CIRUGA RESTAURADORA ES MS COMN EN PACIENTES CON COLITIS ULCEROSA CON INGRESOS ALTOS UN ESTUDIO POBLACIONAL ANTECEDENTES:Para evitar un estoma permanente, se realiza una cirugia reparadora despues de la colectomia. Estudios anteriores han demostrado que menos de la mitad de los pacientes con colitis ulcerosa se someten a cirugia reconstituyente.OBJETIVO:El objetivo principal fue explorar la asociacion entre el nivel socioeconomico y la cirugia reconstituyente despues de la colectomia.DISENO:Estudio de cohorte basado en registros a nivel nacional.MARCO:Suecia.PACIENTES:Todos los pacientes Suecos con colitis ulcerosa que se sometieron a colectomia desde el 1990 a 2017 a la edad de 15 a 69 anos.MEDIDAS DE RESULTADOS PRINCIPALES:El resultado principal fue la cirugia restaurativa y el resultado secundario fue el fracaso de la reconstruccion (definida como la necesidad de una nueva ileostomia despues de la reconstruccion o la no-reversion de un estoma disfuncional dentro de los dos anos posteriores a la reconstruccion). Para calcular los cocientes de riesgo para la cirugia restauradora despues de la colectomia, asi como el fracaso despues de la cirugia restauradora, se realizaron modelos de regresion de Cox multivariables (ajustados por sexo, ano de colectomia, diagnostico de cancer colorrectal, educacion, estado civil, pais de nacimiento e ingresos (cuartiles 1- 4; donde Q4 representa los mayores ingresos), volumen de hospitales y estratificado por edad).RESULTADOS:En total 5969 pacientes con colitis ulcerosa se sometieron a colectomia, y de ellos 2794 (46,8%) se sometieron a cirugia restauradora. La cirugia restauradora fue mas comun en pacientes con altos ingresos en el momento de la colectomia (referencia del cuartil 1, cuartil 2: 1,09 (0,98-1,21), cuartil 3: 1,20 (1,07-1,34), cuartil 4: 1,27 (1,13-1,43)), y menos comun en los nacidos en un pais nordico que en los inmigrantes nacidos en un pais no-nordico (0,86 (0,74-0,99)), mientras que no se observo asociacion con el nivel educativo y el estado civil. No hubo asociacion entre el nivel socioeconomico y el riesgo de fracaso despues de la cirugia reparadora.LIMITACIONES:Restriccion para registrar datos.CONCLUSIONES:La cirugia reparadora en colitis ulcerosa parece ser mas comun en pacientes con ingresos altos y en pacientes nacidos en un pais no-nordico, lo que indica desigualdad en la atencion brindada. Consulte Video Resumen en http://links.lww.com/DCR/B433.

Introduction Severe skin scarring after multiple abdominal surgeries may lead to serious difficulties in stoma care, especially in patients with IBD. We demonstrate the technique of Donut Island Flap that we used in a female patient with colonic Crohn's disease that presented with intractable chronic ileostomy leakage. A relocation of the ileostomy was not possible because an alternative stoma site was not available anymore. Technique The scarred peristomal skin was radially excised up to a diameter of 10 cm. A pedicled anterolateral thigh perforator island flap was elevated from the right leg and was passed behind the rectus femoris muscle and through the inguinal tunnel into the defect. The ileostomy was passed through a small opening in the middle of the flap. The donor site at the thigh was closed primarily. Results No postoperative complications occurred. Three months after surgery, the ostomy care is providing no difficulties for the patient. Conclusion The Donut Island Flap is a reliable and relatively simple technique to provide an adequate surrounding for ileostomy whose care is seriously impeded by severe skin scarring.

Background Anorectal stricturing is a particularly morbid manifestation of Crohn's disease resulting in a diminished quality of life related to pain, incontinence, and recurrent operative interventions. Objective To determine the role of medical therapy, endoscopic dilation, and surgical intervention for the treatment of isolated anorectal stricturing. Data sources An organized search of MEDLINE, PubMed, EMBASE, Scopus, and the Cochrane Database of Collected Reviews was performed from January 1, 1990 through May 1, 2020. Study selection Full text papers which included management of isolated anorectal strictures in the setting of Crohn's disease. Intervention(s) Medical and surgical management. Main outcome measures Symptomatic relief, need for proctocolectomy. Results Our search identified a total of 553 papers; after exclusion based on title (n = 430) and abstract (n = 47), 76 underwent full text review with 65 relevant to the management of anorectal strictures. A summary of the retrospective reports suggests that medical therapy can help control luminal inflammation, but fibrosis may ultimately set in resulting in a need for endoscopic or surgical intervention. Surgical options are limited in the anal canal due to inflammation and ulceration and concomitant perianal fistulizing disease. While fecal diversion can provide symptomatic relief, successful restoration of intestinal continuity remains uncommon and most patients ultimately undergo a total proctocolectomy with end ileostomy. Limitations Limited literature published, all retrospective in nature. Conclusions Despite significant advances in medical and surgical therapy in Crohn's disease over the last decades, there is clearly an unmet need in the management of anorectal strictures in Crohn's disease.

BACKGROUND Existing studies on the effects of biological medications on surgical complications among patients with ulcerative colitis have mixed results. Because biologicals may hinder response to infections and wound healing, preoperative exposure may increase postoperative complications. OBJECTIVE The purpose of this study was to evaluate associations between biological exposure within 6 months preceding colectomy or proctocolectomy and postoperative complications among patients with ulcerative colitis. DESIGN This was a retrospective cohort study with multivariate regression analysis after coarsened exact matching. SETTINGS A large commercial insurance claims database (2003-2016) was used. PATIENTS A total of 1794 patients with ulcerative colitis underwent total abdominal colectomy with end ileostomy, total proctocolectomy with end ileostomy, or total proctocolectomy with IPAA. Twenty-two percent were exposed to biologicals in the 6 months preceding surgery. MAIN OUTCOMES MEASURES Healthcare use (length of stay, unplanned reoperation/procedure, emergency department visit, or readmission) and complications (infectious, hernia or wound disruption, thromboembolic, or cardiopulmonary) within 30 postoperative days were measured. RESULTS Exposure to biological medications was associated with shorter surgical hospitalization (7 vs 8 d; p

Chronic opioid use in the United States is a well-recognized public health concern with many negative downstream consequences. Few data exist regarding the use of preoperative opioids in relation to outcomes after elective colorectal surgery.The purpose of this study was to determine if chronic opioid use before colorectal surgery is associated with a detriment in postoperative outcomes.This is a retrospective review of administrative data supplemented by individual chart review.This study was conducted in a single-institution, multisurgeon, community colorectal training practice.All patients undergoing elective colorectal surgery over a 3-year time frame (2011-2014) were selected.Opioid use was stratified based on total dose of morphine milligram equivalents (naive, sporadic use (0-15 mg/day), regular use (15-45 mg/day), and frequent use (45 mg/day)). Primary outcomes were surgical site infections, length of hospital stay, and readmissions.Of the 923 patients, 23% (n = 213) were using opioids preoperatively. The preoperative opioid group contained more women (p = 0.047), underwent more open surgery (p = 0.003), had more nonmalignant indications (p = 0.013), and had a higher ASA classification (p = 0.003). Although median hospital stay was longer (4.7 days vs 4.0, p0.001), there was no difference in any surgical site infections (10.3% vs 7.1%, p = 0.123) or readmissions (14.2% vs 14.1%, p=0.954). Multivariable analysis identified preoperative opioid use (17.0% longer length of stay; 95% CI, 6.8%-28.2%) and ASA 3 or 4 (27.2% longer length of stay; 95% CI, 17.1-38.3) to be associated with an increase in length of stay.Retrospectively abstracted opioid use and small numbers limit the conclusions regarding any dose-related responses on outcomes.Although preoperative opioid use was not associated with an increased rate of surgical site infections or readmissions, it was independently associated with an increased hospital length of stay. Innovative perioperative strategies will be necessary to eliminate these differences for patients on chronic opioids. See Video Abstract at http://links.lww.com/DCR/B280. EFECTOS DEL CONSUMO CRÓNICO DE OPIOIDES EN EL PREOPERATORIO CON RELACIÓN A LAS INFECCIONES DE LA HERIDA QUIRÚRGICA, LA DURACIÓN DE LA ESTADÍA Y LA READMISIÓN: El consumo crónico de opioides en los Estados Unidos es un problema de salud pública bien reconocido a causa de sus multiples consecuencias negativas ulteriores. Existen pocos datos sobre el consumo de opioides en el preoperatorio relacionado con los resultados consecuentes a una cirugía colorrectal electiva.El propósito es determinar si el consumo crónico de opioides antes de la cirugía colorrectal se asocia con un detrimento en los resultados postoperatorios.Revisión retrospectiva de datos administrativos complementada por la revisión de un gráfico individual.Ejercicio durante la formación de multiples residentes en cirugía colorrectal enTodos los pacientes de cirugía colorrectal electiva durante un período de 3 años (2011-2014).El uso de opioides se estratificó en función de la dosis total de equivalentes de miligramos de morfínicos (uso previo, uso esporádico [0-15 mg / día], uso regular (15-45 mg / día) y uso frecuente (45 mg / día)). Los resultados primarios fueron las infecciones de la herida quirúrgica, la duración de la estadía hospitalaria y la readmisión.De los 923 pacientes, el 23% (n = 213) consumían opioides antes de la operación. El grupo con opioides preoperatorios tenía más mujeres (p = 0.047), se sometió a una cirugía abierta (p = 0.003), tenía mas indicaciones no malignas (p = 0.013) y tenía una clasificación ASA más alta (p = 0.003). Aunque la mediana de la estadía hospitalaria fue más larga (4,7 días frente a 4,0; p0,001), no hubo diferencia en ninguna infección de la herida quirúrgica (10,3% frente a 7,1%, p = 0,123) o las readmisiones (14,2% frente a 14,1%, p = 0,954). El análisis multivariable identificó que el uso de opioides preoperatorios (17.0% más larga LOS; IC 95%: 6.8%, 28.2%) y ASA 3 o 4 (27.2% más larga LOS; IC 95%: 17.1, 38.3) se asocia con un aumento en LOS.La evaluación retrospectiva poco precisa del consumo de opioides y el pequeño número de casos limitan las conclusiones sobre cualquier respuesta relacionada con la dosis - resultado.Si bien el consumo de opioides preoperatorios no se asoció con un aumento en la tasa de infecciones de la herida quirúrgica o las readmisiones, ella se asoció de forma independiente con un aumento de la LOS hospitalaria. Serán necesarias estrategias perioperatorias innovadoras para eliminar estas diferencias en los pacientes consumidores cronicos de opioides. Consulte Video Resumen en http://links.lww.com/DCR/B280.

BACKGROUND The ileostomy pathway, introduced in 2011, has proved to be successful in eliminating hospital readmissions for high-output ileostomy or dehydration in the following period of 7 months in a single institution. However, it is unclear whether this short-term success, immediately after the initiation of the program, can be sustainable in the long term. OBJECTIVE The aim of this study was to assess the efficacy and the durability of the ileostomy pathway in reducing readmissions for dehydration over a longer period of time. DESIGN This was a retrospective review of the patients who entered into the ileostomy pathway, since its introduction on March 1, 2011, until January 31, 2015. SETTINGS This study was conducted at a tertiary academic center. PATIENTS Patients undergoing colorectal surgery with the creation of a new end or loop ileostomy were included. INTERVENTION The long-term sustainability of the ileostomy pathway was assessed. MAIN OUTCOME MEASURES The primary end point was readmission within 30 days after discharge for a high-output ileostomy or dehydration. RESULTS A total of 393 patients (male n = 195, female n = 198, median age 52 (18-87) years) were included: 161 prepathway and 232 on-pathway. Overall 30-day postdischarge readmission rates decreased from 35.4% to 25.9% (p = 0.04). Readmissions due to high output and/or dehydration dropped from 15.5% to 3.9% (p < 0.001). Readmissions due to small-bowel obstructions dropped from 9.9% to 4.3%, (p = 0.03). LIMITATIONS The possible limitations of the study included a nonrandomized comparison of the patient groups and those patients who were possibly admitted to different institutions. CONCLUSIONS The present ileostomy pathway decreases readmissions for high-output ileostomy and dehydration in patients with new ileostomies and is durable in the long term. See Video Abstract at http://links.lww.com/DCR/B233. EFICACIA DE VIA DE ILEOSTOMIA PARA REDUCIR LOS REINGRESOS POR DESHIDRATACION: ?RESISTE LA PRUEBA DEL TIEMPO?: La via de ileostomia, introducida en 2011, ha demostrado ser exitosa en la eliminacion de reingresos hospitalarios por ileostomia de alto rendimiento o deshidratacion, por un periodo de 7 meses, en una sola institucion. Sin embargo, no se ha aclarado si el exito es a corto plazo, inmediatamente despues del inicio del programa, y de que pueda ser sostenible a largo plazo.El objetivo de este estudio fue evaluar la eficacia y la durabilidad de la via de ileostomia, para disminuir los reingresos por deshidratacion, durante un periodo de tiempo mas largo.Esta fue una revision retrospectiva de pacientes que ingresaron a la via de ileostomia, desde su introduccion el 1 de marzo de 2011 hasta el 31 de enero de 2015.Este estudio se realizo en un centro academico terciario.Se incluyeron pacientes sometidos a cirugia colorrectal con la creacion de una nueva ileostomia de extremo o asa.Evaluar la sostenibilidad de la via de ileostomia a largo plazo.El punto final primario fue el reingreso dentro de los 30 dias posteriores al alta, por una ileostomia de alto gasto o deshidratacion.Se incluyeron un total de 393 pacientes (hombres n = 195, mujeres n = 198, edad media 52 [18-87] anos), 161 antes de la via y 232 en la via. En general, las tasas de reingreso despues del alta a 30 dias, disminuyeron de 35.4% a 25.9% (p = 0.04). Los reingresos por alto rendimiento y / o deshidratacion, disminuyeron del 15.5% al 3.9% (p < 0.001). Los reingresos debidos a obstrucciones del intestino delgado, disminuyeron del 9.9% al 4.3% (p = 0.03).Las posibles limitaciones del estudio incluyeron una comparacion no aleatoria de los grupos de pacientes, y de aquellos pacientes que posiblemente fueron admitidos en diferentes instituciones.La via de ileostomia disminuye los reingresos por ileostomia de alto gasto y deshidratacion, en nuevos pacientes con ileostomia, y es duradera a largo plazo. Consulte Video Resumen en http://links.lww.com/DCR/B233.

CASE SUMMARY A 28-year-old nulliparous woman presented with rectal bleeding. Colonoscopy revealed a 4-cm malignant-appearing mass in the proximal rectum, and biopsies confirmed invasive adenocarcinoma of the rectum. Computed tomography scan showed no evidence of metastatic disease. Staging MRI found transmural extension with minimal stranding in the adjacent fat, as well as no evidence of pathological pelvic adenopathy, consistent with a T3N0 lesion. The proposed treatment plan involved neoadjuvant chemotherapy and radiation therapy before primary surgical resection. The patient desired fertility preservation and was referred immediately to Reproductive Endocrinology and Infertility. She underwent assisted reproduction with oocyte and blastocyst cryopreservation followed by laparoscopic ovarian transposition. Nine months after surgical low anterior resection of the tumor and completion of her cancer treatment, her ovaries were repositioned to their normal pelvic position during an ileostomy takedown procedure. She underwent a frozen embryo transfer but did not conceive. She resumed menses and later conceived spontaneously. Her pregnancy was complicated by cervical incompetence, requiring cervical cerclage. She delivered a live male infant via cesarean delivery at 32 weeks gestation, approximately 2 years after completion of cancer therapy. Four years after diagnosis, the patient remains in remission with undetectable CEA levels.

Background Anastomotic leak remains a critical complication after restorative rectal cancer surgery and is associated with significant morbidity and mortality rates, whereas reported rates range from 4% to 29%. Whether the occurrence of leak may have an impact on long-term oncological outcomes is under debate. Objective This study aimed to describe the oncological impact of anastomotic leak on patients undergoing sphincter-preserving surgery for rectal adenocarcinoma. Design This is a retrospective review of a prospectively maintained database. Settings The study was conducted at a high-volume colorectal center. Patients Data on patients who underwent restorative surgery for rectal adenocarcinoma from January 2000 until December 2013 were retrospectively analyzed. Main outcome measures The primary outcome measured was the impact of anastomotic leak, defined according to the classification proposed by the International Study Group of Rectal Cancer, on long-term overall survival, disease-free survival, disease-specific survival, and local recurrence. Results A total of 787 patients undergoing sphincter-preserving surgery for rectal cancer met the inclusion criteria. Forty-two (5.3%) patients presented a symptomatic anastomotic leak. The median follow-up period was 64 months. Fifty-one (6.5%) patients experienced a cancer-related death, 2 of 42 in the anastomotic leak group. Five-year overall survival, disease-specific survival, and disease-free survival were 88%, 94.7%, and 85.3%. Local recurrence rate was 2%. There was no difference in long-term overall survival, disease-specific survival, disease-free survival, and local recurrence rate between groups. On a multivariable analysis, anastomotic leak did not impact oncological outcomes. Limitations This study was limited by retrospective analysis. Conclusions The occurrence of anastomotic leak after restorative resection for rectal cancer did not impact long-term oncological outcomes in our cohort of patients. See Video Abstract at http://links.lww.com/DCR/B187. RESULTADOS ONCOLOGICOS A LARGO PLAZO DESPUES DE UNA FUGA ANASTOMOTICA EN CIRUGIA DE CANCER RECTAL: La fuga anastomotica sigue siendo una complicacion critica despues de la cirugia restauradora del cancer rectal y se asocia con tasas significativas de morbilidad y mortalidad, mientras que las tasas reportadas varian del 4% al 29%. Se esta debatiendo si la aparicion de fugas puede tener un impacto en los resultados oncologicos a largo plazo.Describir el impacto oncologico de la fuga anastomotica en pacientes sometidos a cirugia de preservacion del esfinter para adenocarcinoma rectal.Revision retrospectiva de una base de datos mantenida prospectivamente.El estudio se realizo en un centro colorrectal de alto volumen.Se analizaron retrospectivamente los datos de pacientes que se sometieron a cirugia reparadora por adenocarcinoma rectal desde Enero de 2000 hasta Diciembre de 2013.Impacto de la fuga anastomotica, definida de acuerdo con la clasificacion propuesta por el Grupo de Estudio Internacional del Cancer Rectal (International Study Group of Rectal Cancer), sobre la supervivencia general a largo plazo, la supervivencia libre de enfermedad, la supervivencia especifica de la enfermedad y la recurrencia local.Un total de 787 pacientes sometidos a cirugia para preservar el esfinter por cancer rectal cumplieron con los criterios de inclusion. Cuarenta y dos (5.3%) pacientes presentaron una fuga anastomotica sintomatica. El tiempo mediano del periodo de seguimiento fue de 64 meses. Cincuenta y un (6.5%) pacientes sufrieron muerte relacionada con el cancer, 2 de 42 en el grupo de fuga anastomotica. La supervivencia global a cinco anos, la supervivencia especifica de la enfermedad y la supervivencia libre de enfermedad fueron del 88%, 94.7% y 85.3%, respectivamente. La tasa de recurrencia local fue del 2%. No hubo diferencias en la supervivencia global a largo plazo, la supervivencia especifica de la enfermedad, la supervivencia libre de enfermedad y la tasa de recurrencia local entre los grupos. En un analisis multivariable, la fuga anastomotica no afecto los resultados oncologicos.Este estudio fue limitado por analisis retrospectivo.La aparicion de fuga anastomotica despues de la reseccion restauradora para el cancer rectal no afecto los resultados oncologicos a largo plazo en nuestra cohorte de pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B187. (Traduccion-Dr. Yesenia Rojas-Kahlil).

BACKGROUND Anastomotic complications after restorative total proctocolectomy with IPAA for ulcerative colitis alter functional outcomes and quality of life and may lead to pouch failure. Routine contrast enema of the pouch assesses anastomotic integrity before ileostomy reversal, but its clinical use is challenged. OBJECTIVE The purpose of this research was to assess the relationship among preoperative clinical characteristics, abnormal pouchography, and long-term pouch complications. DESIGN This was a retrospective chart review. SETTINGS The study was conducted at a tertiary care center between 2000 and 2010. PATIENTS Ulcerative colitis patients with IPAA undergoing pouchography before ileostomy closure were included. MAIN OUTCOME MEASURES Patient demographics, incidence of pouch-related complications, and findings on pouchogram were recorded. Primary outcome was pouch failure, defined as excision or permanent diversion of the ileoanal pouch. Independent predictors of pouch failure were determined by multivariate regression. RESULTS A total of 262 patients with ulcerative colitis were included. Contrast extravasation was seen in 27 patients (10.3%): 14 (51.9%) were clinically asymptomatic at the time of pouchogram. Six (22.2%) of 27 patients with extravasation developed pouch failure despite normalization of the pouchogram before ileostomy closure. Forty patients (15.3%) were found to have pouch-anal anastomotic stenosis; only 1 developed pouch failure. Pre-IPAA serum albumin and hemoglobin levels were inversely associated with contrast extravasation (serum albumin: OR = 0.42; hemoglobin: OR = 0.77; p < 0.05). Contrast extravasation was associated with delayed takedown operation (average = 67 d), increased risk (OR = 5.25; p < 0.01), and shorter time (median = 32.0 vs 72.5 mo; HR = 5.88; p < 0.05) to pouch failure, as well as increased risk of pouch-related complications (p < 0.05). LIMITATIONS The study was limited by its retrospective nature and small number of patients who developed pouch failure. CONCLUSIONS Pouchography before ileostomy takedown is useful in identifying patients with ulcerative colitis at risk for postoperative complications. Radiologic resolution of IPAA-related leak does not reliably predict healing; caution is warranted in this subgroup. See Video Abstract at http://links.lww.com/DCR/A818.

Background Pouch excision is required for many of those patients experiencing pouch failure in whom ileostomy alone is inadequate and revision surgery is not appropriate. The published rate of pouch failure is approximately 10% at 10 years, resulting in a growing cohort of patients requiring excision. Objective In this article, we aim to describe the indications for excision and postoperative outcomes at our center since 2004. Design This is a retrospective observational study. Settings This study was conducted at a tertiary referral center for ileal pouch dysfunction. Cases were documented from 2004 to 2017. Patients The cohort comprised 92 patients; 83% were diagnosed with ulcerative colitis, 15% with familial adenomatous polyposis, and 2% with indeterminate colitis. Interventions Patients underwent excision of pelvic ileal pouches. Main outcome measures The primary outcomes measured were the time to perineal wound healing and healing at 6 months. Thirty- and 90-day morbidity and mortality were evaluated. Results Postoperative histology was consistent with Crohn's disease in 1 patient. The median time from pouch creation to excision was 7 years. The rate of perineal wound healing at 6 months was 78%, and regression analysis demonstrated significantly improved chances of healing for noninfective indications for excision (p = 0.023; OR, 15.22; 95% CI, 1.45-160.27) and for more recent procedures (p = 0.032; OR, 12.00; 95% CI, 1.87-76.87). Limitations This study was limited because it was retrospective in nature, and it was a single-center experience. Conclusions This study represents the most contemporary cohort of patients undergoing pouch excision surgery. The procedure retains a relatively high postoperative morbidity, but this study demonstrates a learning curve with improving perineal healing over time associated with a high institutional volume. Defunctioning ileostomy may improve perineal wound healing in patients with infective indications for excision. Further investigation is required to establish the quality-of-life benefits of pouch excision in this modern cohort. See Video Abstract at http://links.lww.com/DCR/A804.

Hospital readmission is common after ileostomy formation and frequently associated with dehydration.This study was conducted to evaluate a previously published intervention to prevent dehydration and readmission.This is a randomized controlled trial.This study was conducted in 3 hospitals within a single health care system.Patients undergoing elective or nonelective ileostomy as part of their operative procedure were selected.Surgeons, advanced practice providers, inpatient and outpatient nurses, and wound ostomy continence nurses participated in a robust ileostomy education and monitoring program (Education Program for Prevention of Ileostomy Complications) based on the published intervention. After informed consent, patients were randomly assigned to a postoperative compliance surveillance and prompting strategy that was directed toward the care team, versus usual care.Unplanned hospital readmission within 30 days of discharge, readmission for dehydration, acute renal failure, estimated direct costs, and patient satisfaction were the primary outcomes measured.One hundred patients with an ileostomy were randomly assigned. The most common indications were rectal cancer (n = 26) and ulcerative colitis (n = 21), and 12 were emergency procedures. Although intervention patients had better postdischarge phone follow-up (90% vs 72%; p = 0.025) and were more likely to receive outpatient intravenous fluids (25% vs 6%; p = 0.008), they had similar overall hospital readmissions (20.4% vs 19.6%; p = 1.0), readmissions for dehydration (8.2% vs 5.9%; p = 0.71), and acute renal failure events (10.2% vs 3.9%; p = 0.26). Multivariable analysis found that weekend discharges to home were significantly associated with readmission (OR, 4.5 (95% CI, 1.2-16.9); p = 0.03). Direct costs and patient satisfaction were similar.This study was limited by the heterogeneous patient population and by the potential effect of the intervention on providers taking care of patients randomly assigned to usual care.A surveillance strategy to ensure compliance with an ileostomy education program tracked patients more closely and was cost neutral, but did not result in decreased hospital readmissions compared with usual care. See Video Abstract at http://links.lww.com/DCR/A812.

BACKGROUND: The optimum timing for temporary ileostomy closure after low anterior resection is still open. OBJECTIVE: This trial aimed to compare early (2 wk) versus late (12 wk) stoma closure. DESIGN: The study included 2 parallel groups in a multicenter, randomized controlled clinical trial. SETTINGS: The study was conducted at 3 Swiss hospitals. PATIENTS: Patients undergoing low anterior resection and temporary ileostomy for cancer were included. INTERVENTIONS: Patients were randomly allocated to early or late stoma closure. Before closure, colonic anastomosis was examined for integrity. MAIN OUTCOME MEASURES: The primary efficacy outcome was the Gastrointestinal Quality of Life Index 6 weeks after resection. Secondary end points included safety (morbidity), feasibility, and quality of life 4 months after low anterior resection. RESULTS: The trial was stopped for safety concerns after 71 patients were randomly assigned to early closure (37 patients) or late closure (34 patients). There were comparable baseline data between the groups. No difference in quality of life occurred 6 weeks (mean Gastrointestinal Quality of Life Index: 99.8 vs 106.0; p = 0.139) and 4 months (108.6 vs 107.1; p = 0.904) after index surgery. Intraoperative tendency of oozing (visual analog scale: 35.8 vs 19.3; p = 0.011), adhesions (visual analog scale: 61.3 vs 46.2; p = 0.034), leak of colonic anastomosis (19% vs 0%; p = 0.012), leak of colonic or ileal anastomosis (24% vs 0%; p = 0.002), and reintervention (16% vs 0%; p = 0.026) were significantly higher after early closure. The concept of early closure failed in 10 patients (27% vs 0% in the late closure group (95% CI for the difference, 9.4%–44.4%)). LIMITATIONS: The trial was prematurely stopped because of safety issues. The aimed group size was not reached. CONCLUSIONS: Early stoma closure does not provide better quality of life up to 4 months after low anterior resection but is afflicted with significantly adverse feasibility and higher morbidity when compared with late closure. See Video Abstract at http://links.lww.com/DCR/B665. CIERRE DE LA ILEOSTOMÍA TEMPORAL: 2 VERSUS 12 SEMANAS POSTERIOR A LA RESECCIÓN RECTAL POR CÁNCER: UNA ADVERTENCIA DE UN ESTUDIO MULTICÉNTRICO CONTROLADO RANDOMIZADO PROSPECTIVO ANTECEDENTES: El momento óptimo para el cierre temporal de la ileostomía posterior a la resección anterior baja es aun controversial. OBJETIVO: Este estudio tuvo como objetivo comparar el cierre del estoma temprano (2 semanas) versus tardío (12 semanas). DISEÑO: Estudio clínico controlado, randomizado, multicéntrico, de dos grupos paralelos. ENTORNO CLINICO: El estudio se llevó a cabo en 3 hospitales suizos. PACIENTES: Se incluyeron pacientes sometidos a resección anterior baja e ileostomía temporal por cáncer. INTERVENCIONES: Los pacientes fueron asignados aleatoriamente al cierre del estoma temprano o tardío. Antes del cierre, se examinó la integridad de la anastomosis colónica. PRINCIPALES MEDIDAS DE VALORACION: El principal resultado de eficacia fue el Índice de Calidad de Vida Gastrointestinal 6 semanas después de la resección. Los criterios secundarios incluyeron la seguridad (morbilidad), factibilidad y calidad de vida 4 meses posterior a la resección anterior baja. RESULTADOS: El estudio se detuvo por motivos de seguridad después de que 71 pacientes fueron asignados aleatoriamente a cierre temprano (37 pacientes) o cierre tardío (34 pacientes). Hubo datos de referencia comparables entre los grupos. No se produjeron diferencias en la calidad de vida 6 semanas (índice de calidad de vida gastrointestinal, media 99,8 vs. 106; p = 0,139) y 4 meses (108,6 vs 107,1, p = 0,904) después de la cirugía inicial. Tendencia intraoperatoria de supuración (escala analógica visual 35,8 vs 19,3, p = 0,011), adherencias (escala analógica visual 61,3 vs 46,2, p = 0,034), fuga de anastomosis colónica (19% vs 0%, p = 0,012), fuga de anastomosis colónica o ileal (24% vs 0%, p = 0,002) y reintervención (16% vs 0%, p = 0,026) fueron significativamente mayores después del cierre temprano. El concepto de cierre temprano fracasó en 10 pacientes (27% vs ninguno en el grupo de cierre tardío (intervalo de confianza del 95% para la diferencia: 9,4% a 44,4%)). LIMITACIONES: El estudio se detuvo prematuramente debido a problemas de seguridad. No se alcanzó el tamaño del grupo previsto. CONCLUSIÓN: El cierre temprano del estoma no proporciona una mejor calidad de vida hasta 4 meses posterior a una resección anterior baja, esto se ve afectado por efectos adversos significativos durante su realización y una mayor morbilidad en comparación con el cierre tardío. Consulte Video Resumen en http://links.lww.com/DCR/B665.

Twenty-nine percent of postileostomy discharges are readmitted, most commonly because of dehydration. However, there is a lack of detailed data specifically evaluating factors associated with readmission with dehydration. In addition, patients with a history of an ileostomy have often been excluded from previous studies and therefore represent a group of understudied ileostomates.This study aimed to evaluate factors available at discharge associated with 30-day readmission for dehydration, rather than all-cause readmissions.This was a retrospective cohort study.Study patients received ileostomies at a tertiary academic medical center from 2014 to 2016.Patients with a preexisting ileostomy that was not recreated per the operative note were excluded, whereas those who received a new ileostomy were included.The primary outcome measured was 30-day readmission for dehydration as defined by objective clinical criteria.A total of 262 patients underwent ileostomy creation and were discharged alive. Twenty-five percent were ≥65 years of age, 53% were men, 14% had a history of ileostomy, 18% had a creatinine1.0 on discharge, and 26% had high ileostomy output at any time during the index admission. Among all ileostomates, the all-cause readmission rate was 30%. Mean days to readmission for any cause was 8.5, whereas for dehydration it was 11.6 days. Of the readmissions, 37% were readmitted with a diagnosis of dehydration, and dehydration was the sole reason in 26%. Among those with dehydration, the most common length of stay was 2 days. In multivariable logistic regression, 30-day readmission with dehydration was associated with older age, male sex, history of an ileostomy, high ileostomy output during index admission, and a discharge creatinine1.0.This study was limited by its retrospective design.Ileostomy dehydration efforts have focused on new ileostomy patients; however, our data suggest that patients with a history of an ileostomy are actually at risk for readmission with dehydration. Further studies aimed at the reduction of readmission with dehydration after ileostomy are warranted and should include patients with a history of an ileostomy. See Video Abstract at http://links.lww.com/DCR/A643.

Patients with a newly formed ileostomy often develop electrolyte abnormalities and dehydration.The study assessed the prophylactic effect of an isotonic hydration solution on dehydration and electrolyte abnormalities in patients with a newly formed ileostomy.This was a prospective, randomized, controlled trial (NCT02036346).The study was conducted at a single surgical unit of a public university hospital.Patients scheduled for elective rectosigmoid resection were considered for study inclusion.Patients in whom a diverting ileostomy was created were randomly assigned to the intervention group (n = 39), which received an oral isotonic glucose-sodium hydration solution for 40 days postdischarge and the control group (n = 41) which did not receive an intervention. The 2 groups were compared with a group of patients who underwent rectosigmoid resection without diverting ileostomy (n = 37).Serum electrolyte and renal function markers were assessed preoperatively and at 20 and 40 days postdischarge.At 20 days postdischarge, the serum sodium of the control group appeared lower than the serum sodium of the intervention group and the nonileostomy group (p = 0.007). At the same time point, urea and creatinine levels of the control group were higher than the urea and creatinine levels of the other 2 groups (p = 0.01 and p = 0.02). At 40 days postdischarge, mean sodium and renal function markers improved in the control group, but sodium and creatinine continued to differ in comparison with the intervention and nonileostomy groups (p = 0.01 and p = 0.04). The readmission rate for fluid and electrolyte abnormalities was higher in the control group (24%) than in the other 2 groups, where no rehospitalization for such a reason was required (p = 0.001).The study was limited by its single-center design.An oral isotonic drink postdischarge can have a prophylactic effect on patients with a newly formed ileostomy, preventing readmission for fluid and electrolyte abnormalities. See Video Abstract at http://links.lww.com/DCR/A603.

BACKGROUND Previous studies suggest that urgent colectomy and primary anastomosis with diversion is safe for perforated diverticulitis. Current guidelines support this approach. OBJECTIVE The purpose of this study was to describe the use of urgent or emergent primary anastomosis with diversion in diverticulitis before the 2014 American Society of Colon and Rectal Surgeons guidelines and compare national outcomes of primary anastomosis with diversion to the Hartmann procedure. DESIGN This was a national retrospective cohort study. SETTINGS The study was conducted with a national all-payer US sample from 1998 to 2011. PATIENTS Patients included those admitted and treated with urgent or emergent colectomy for diverticulitis. Exclusion criteria were age 24 hours after admission. MAIN OUTCOME MEASURES In-hospital mortality was measured. RESULTS A total of 124,198 patients underwent emergent or urgent colectomy for acute diverticulitis; 67,721 underwent concurrent fecal diversion, including 65,084 (96.1%) who underwent end colostomy and 2637 (3.9%) who underwent anastomosis with ileostomy. The rate of primary anastomosis with diverting ileostomy increased from 30 to 60 diverting ileostomy cases per 1000 operative diverticulitis cases in 1998 versus 2011 (incidence rate ratio = 2.04 (95% CI, 1.70-2.50). However, overall use remained low, with >90% of patients undergoing end colostomy. Complication rates were higher (32.1% vs 23.3%; p < 0.001) and in-hospital mortality rates were higher (16.0% vs 6.4%; p < 0.001) for primary anastomosis with diversion patients compared with end colostomy. These findings were consistent on multivariable logistic regression. Other factors that contributed to in-hospital mortality included increasing age, increasing comorbid disease burden, and socioeconomic status. LIMITATIONS Billing data can be inaccurate or biased because of nonmedically trained professional data entry. Selection bias could have affected the results of this retrospective study. CONCLUSIONS The use of primary anastomosis with proximal diversion for urgent colectomy in diverticulitis increased over our study period; however, overall use remained low. Poor national outcomes after primary anastomosis with proximal diversion might affect compliance with new guidelines. See Video Abstract at http://links.lww.com/DCR/A600.

Background Restorative proctocolectomy is the procedure of choice in patients with ulcerative colitis refractory to medical therapy. Prepouch ileitis is characterized by mucosal inflammation immediately proximal to the pouch. Prepouch ileitis is uncommon, and long-term follow-up data are lacking. Objective The aim of this study is to report the long-term outcomes of prepouch ileitis. Design We followed up a cohort of patients with prepouch ileitis that was originally described in 2009. Patients were followed up until the last recorded clinic attendance or at the point of pouch failure. Follow-up data collected included stool frequency, endoscopic findings, treatment, and overall pouch function. Setting We accessed a prospectively maintained database at our institution between January 2009 and January 2017. Patients Three of the 34 patients originally described in 2009 were lost to follow-up; we reanalyzed data on the remaining 31. Main outcome measure The rate of pouch failure was defined as the need for ileostomy or pouch revision. Results All 31 patients had coexisting pouchitis at index diagnosis of prepouch ileitis. The median length of follow-up from the index pouchoscopy was 98 (range, 27-143) months. Seven (23%) patients who had an index pouchoscopy with prepouch ileitis went on to pouch failure, which is significantly higher than expected (p = 0.03). Five (71%) of these patients had chronic pouchitis, and 2 (29%) had small-bowel obstruction due to prepouch stricture. Two patients had evidence that would support possible Crohn's disease at long-term follow-up. Limitations This was a retrospective analysis. Because of the nature of the study, there was some missing information that may have influenced the results. Our study is further limited by small patient numbers. Conclusions Prepouch ileitis is associated with a significantly increased risk of pouch failure compared with the overall reported literature for restorative proctocolectomy. Prepouch ileitis does not appear to be strongly predictive of Crohn's disease at long-term follow-up. See Video Abstract at http://links.lww.com/DCR/A480.

Background Severe acute refractory colitis has traditionally been an indication for emergent colectomy in IBD, yet under these circumstances patients are at elevated risk for complications because of their heightened inflammatory state, nutritional deficiencies, and immunocompromised state. Objective We hypothesized that rescue diverting loop ileostomy may be a viable alternative to emergent colectomy, providing the opportunity for colonic healing and patient optimization before more definitive surgery. Design This was a retrospective case series. Settings The study was conducted at a single academic center. Patients Patients with severe acute medically refractory IBD-related colitis were included. Intervention Rescue diverting loop ileostomy was the intervening procedure. Main outcome measures The primary outcome was avoidance of urgent/emergent colectomy. The secondary outcome was efficacy, defined by 3 clinical aims: 1) reduced steroid dependence or opportunity for bridge to medical rescue, 2) improved nutritional status, and 3) ability to undergo an elective laparoscopic definitive procedure or ileostomy reversal with colon salvage. Results Among 33 patients, 14 had Crohn's disease and 19 had ulcerative colitis. Three patients required urgent/emergent colectomy, 2 with ulcerative colitis and 1 with Crohn's disease. Across both disease cohorts, >80% of patients achieved each clinical aim for efficacy: 88% reduced their steroid dependence or were able to bridge to medical rescue, 87% improved their nutritional status, and 82% underwent an elective laparoscopic definitive procedure or ileostomy reversal. A total of 4 patients (11.7%) experienced a postoperative complication following diversion, including 3 surgical site infections and 1 episode of acute kidney injury. Limitations The study was limited by being a single-center, retrospective series. Conclusions Rescue diverting loop ileostomy in the setting of severe, refractory IBD-colitis is a safe and effective alternative to emergent colectomy. This procedure has acceptably low complication rates and affords patients time for medical and nutritional optimization before definitive surgical intervention. See Video Abstract at http://links.lww.com/DCR/A520.

An otherwise healthy 59-year-old man presented to the emergency department with 2 weeks of narrowed stools, 5 days of obstipation, and 1 day of abdominal pain, nausea, and vomiting. Computed tomography revealed an obstructing sigmoid mass without evidence of metastatic disease, and the CEA was 1.2 ng/mL. Flexible sigmoidoscopy confirmed a circumferentially obstructing distal sigmoid neoplasm. Endoscopic stent placement was immediately followed by a firm distended abdomen. An upright radiograph obtained following the procedure demonstrated free intraperitoneal air. An emergent Hartmann procedure was performed for iatrogenic colon perforation in a patient with malignant obstruction and chronic dilation of the proximal colon.

BACKGROUND Enhanced recovery pathways have decreased length of stay after colorectal surgery. Loop ileostomy closure remains a challenge, because patients experience high readmission rates, and validation of enhanced recovery pathways has not been demonstrated. This study examined a protocol whereby patients were discharged on the first postoperative day and instructed to advance their diet at home with close telephone follow-up. OBJECTIVE The hypothesis was that patients can be safely discharged the day after loop closure, leading to shorter length of stay without increased rates of readmission or complications. DESIGN Patients undergoing loop ileostomy closure were queried from the American College of Surgeons National Surgical Quality Improvement Project and compared with a single institution (2012-2015). Length of stay, 30-day readmission, and 30-day morbidity data were analyzed. SETTINGS The study was conducted at a tertiary university department. PATIENTS The study includes 1602 patients: 1517 from the National Surgical Quality Improvement Project database and 85 from a single institution. MAIN OUTCOME MEASURES Length of stay and readmission rates were measured. RESULTS Median length of stay was less at the single institution compared with control (2 vs 4 d; p < 0.001). Thirty-day readmission (15.3% vs 10.4%; p = 0.15) and overall 30-day complications (15.3% vs 16.7%; p = 0.73) were similar between cohorts. Estimated adjusted length of stay was less in the single institution (2.93 vs 5.58 d; p < 0.0001). There was no difference in the odds of readmission (p = 0.22). LIMITATIONS The main limitations of this study include its retrospective nature and limitations of the National Surgical Quality Improvement Program database. CONCLUSIONS Next-day discharge with protocoled diet advancement and telephone follow-up is acceptable after loop ileostomy closure. Patients can benefit from decreased length of stay without an increase in readmission or complications. This has the potential to change the practice of postoperative management of loop ileostomy closure, as well as to decrease cost. See Video Abstract at http://links.lww.com/DCR/A310.

Anastomotic leak after colorectal surgery increases postoperative mortality, cancer recurrence, permanent stoma formation, and poor bowel function. Anastomosis between the colon and rectum is a particularly high risk. Traditional management mandates laparotomy, disassembly of the anastomosis, and formation of an often-permanent stoma. After laparoscopic colorectal surgery it may be possible to manage anastomotic failure with laparoscopy, thus avoiding laparotomy.The purpose of this study was to determine the feasibility of the laparoscopic management of failed low colorectal anastomoses.This was a single-institute case series.A total of 555 laparoscopic patients undergoing anterior resection with primary anastomosis within 10 cm of the anus in the period 2000-2012 were included.Anastomotic failure, defined as any clinical or radiological demonstrable defect in the anastomosis; complications using the Clavien-Dindo system; mortality within 30 days; and patient demographics and risk factors, as defined by the Charlson index, were measured.Leakage occurred in 44 (7.9%) of 555 patients, 16 patients with a diverting ileostomy and 28 with no diverting ileostomy. Leakage was more common in those with anastomoses5 cm form the anus, male patients, and those with a colonic J-pouch and rectal cancer. Diverting ileostomy was not protective of anastomotic leakage. In those patients with anastomotic leakage and a primary diverting ileostomy, recourse to the peritoneal cavity was required in 4 of 16 patients versus 24 of 28 without a diverting ileostomy (p = 0.0002). In 74% of those cases, access to the peritoneal cavity was achieved through laparoscopy. Permanent stoma rates were very low, including 14 (2.5%) of 555 total patients or 8 (18.0%) of 44 patients with anastomotic leakage. Thirty-day mortality was rare (0.6%).This study was limited by the lack of a cohort of open cases for comparison.Laparoscopic anterior resection is associated with low levels of complications, including anastomotic leak, postoperative mortality, and permanent stoma formation. Anastomotic leakage can be managed with laparoscopy in the majority of cases. See Video Abstract at http://links.lww.com/DCR/A353.