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Up to 80% of Crohn’s disease (CD) patients require surgery. Fecal diversion is used selectively in CD proctocolitis refractory to medical treatment or advanced perianal disease. This study examines associations between clinical features in predicting clinical response (CR) to fecal diversion in CD. Charts of CD patients undergoing fecal diversion for medically refractory disease or perianal disease were reviewed. Clinical response was assessed focusing on improvements in urgency, abdominal and perineal pain, decreased anal fistula drainage, and weight gain. Univariate binary logistic regression and multivariate forward-stepwise modeling analysis were used to determine associations with CR. The study cohort comprised 79 patients. After a median follow-up of 36 (3-192) months, 40 (51%) patients achieved a CR. Binary logistic regression analysis revealed both age at diagnosis (hazard ratio [HR] 1.05; confidence interval [CI] 1.01-1.09; P = .007) and disease duration (HR .91; CI .86-.96; P = .001) to be significantly associated with CR. Later age of onset (HR 1.05; CI 1.01-1.10; P = .002) and shorter disease duration (HR .91; CI .86-.97; P = .02) remained significant on multivariate analysis. This largest reported series of fecal diversion for refractory CD in the biologic drug era revealed that young age at diagnosis and long disease duration are associated with a lower CR.

Minimally invasive approaches to total abdominal colectomy (TAC) in ulcerative colitis (UC) patients include straight laparoscopy (SL), hand-assisted laparoscopic surgery (HALS), and robotics. In this study, short-term outcomes of patients undergoing SL and HALS TAC were compared. Prospectively collected data on UC patients undergoing TAC were tabulated. The study cohort included 36 (27%) patients in the SL group and 95 (73%) patients in the HALS group. The groups were comparable in terms of preoperative characteristics and demographics. The mean operative time was 151 (range, 73–225) minutes in the SL group versus 164 (range, 103–295) minutes in the HALS group ( P = 0.09). Total 48-hour IV morphine use was 30 (range, 0–186) mg in the SL group compared with 56 (0–275) mg in the HALS group ( P < 0.01). Although overall morbidity was comparable between the groups, Clavien-Dindo Class III complications did not occur in any of the SL group patients versus 11 (11%) of the HALS group patients ( P = 0.03). The postoperative length of stay was 3 (3–21) days in the SL group versus 5 (3–15) days in the HALS group ( P < 0.01). Compared with HALS, SL is associated with lower postoperative narcotic use and hospital length of stay in UC patients undergoing TAC.

The utility of opioid-sparing multimodal analgesia protocols (OSMMAPs) in opioid-tolerant (OT) patients is unknown. We sought to determine the impact of a standardized OSMMAP in OT versus opioid-naïve (ON) patients after major colorectal surgery. Consecutive patients undergoing surgery before (January 2015–March 2017) and after OSMMAP implementation (April 2017–March 2018) were identified from a single-institution prospective colorectal surgery registry. OT was defined by the presence of an opioid on the preadmission medication record. Opioid use (measured in oral morphine equivalents (OMEs)) and surgical outcomes were compared between OT and ON patients pre- and post-OSMMAP. The study cohort of 201 patients included 59 OT patients (25 pre- and 34 post-OSMMAP) and 142 ON controls (34 pre- and 108 post-OSMMAP). The median age was 47.5 years (IQR 32), and 50% were male. 185 patients (92%) had a laparoscopic/ robotic resection and 16 (8%) open. There were statistically significant reductions in OME required post-OSMMAP on each postoperative day (days 1 to 4) and cumulative OME for both OT and ON patients. The reduction in opioid requirements was significantly larger in OT than ON patients. We present the first study highlighting a larger opioid usage reduction in OT than in ON patients after OSMMAP implementation.

The ideal incision for specimen extraction during laparoscopic colorectal surgery is controversial. The objective of this study was to compare incision types (Pfannenstiel, periumbilical, lower midline, and right upper quadrant transverse) with regard to postoperative scar appearance, symptoms, preference, and satisfaction. This study is a retrospective survey review performed in an urban teaching hospital. The study participants were patients undergoing multiport laparoscopic colorectal surgery. Two web-based questionnaires, the Patient Scar Assessment Questionnaire and Photo-Series Questionnaire, were used to assess study parameters. The main outcome measures were incision symptoms and cosmetic satisfaction. The 112 study patients included 54 patients with a Pfannenstiel incision (Group P) and 58 patients with an alternate incision (Group A). Of the 58 patients in Group A, 19 (33%) had a periumbilical incision, 10 (17%) a lower midline incision, and 29 (50%) a right upper quadrant transverse incision. Although Groups P and Awere comparable in all five subscales of the Patient Scar Assessment Questionnaire, more Group P participants (n = 12; 22%) said their incision felt “fairly numb” than Group A participants (n = 2; 3%) (P = 0.008). There was no significant difference between study groups in all Photo-Series Questionnaire domains; however, after comparing patients’ own incisions with photographs of various alternative incisions, 36 (62%) Group A patients would choose an alternative incision compared with only 11 (19%) Group P patients (P = 0.001). Selection bias, recall bias, external validity, and variability of scar lengths were the limitations of the study. It was concluded that although a Pfannenstiel incision seems to be the optimal cosmetic choice, it is associated with a higher incidence of wound numbness than alternate extraction incisions.

Open resection remains the standard of care in the surgical management of rectal cancer with recent studies unable to prove noninferiority of laparoscopic resection. Few studies directly compare robotic versus open techniques. This is a retrospective chart review of all consecutive patients undergoing robotic or open rectal cancer resection during a three-year period. The primary endpoint was a composite of complete mesorectal excision, circumferential resection margin

Early postoperative feeding is the standard of care after colorectal surgery and is associated with improved outcomes. A controlled study performed at our center demonstrated faster bowel function recovery and shorter hospital stay without an increase in postoperative morbidity for a solid versus clear-liquid diet on postoperative day (POD) 1 after colorectal surgery. The present study aims to evaluate the impact of these findings on the practice of diet advancement by board-certified general surgeons (GS) and colorectal surgeons (CRS) at an urban teaching hospital. Patients undergoing elective colorectal surgery were prospectively evaluated. Data were compared with that of a study cohort that underwent elective colorectal surgery reported in 2012. Early postoperative feeding in the more recent cohort statistically increased for all cases on POD 0 and POD 1. Diet advancement over time revealed significant changes in early feeding on POD 0 for patients operated on by CRS (0% vs 83%; P < 0.0001) but not GS (13% vs 13%; P = 1). Patients operated on by either CRS or GS and offered early feeding on POD 1 did not significantly differ between time periods. Despite well-documented evidence of the advantages of early feeding, GS, but not CRS, remain reluctant to administer early diets to patients after colorectal surgery.

The risk of de novo Crohn's disease (CD) after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) versus inflammatory bowel disease unclassified (IBDU) or indeterminate colitis (IC) remains debatable. Here, we present updated results after long-term follow-up of a previously studied cohort of 334 patients with UC, IBDU, or IC who underwent IPAA during a 10-year period ending 2007. Of 334 study patients, 56 per cent were male and median age was 38 years (range: 8–81). Patients were classified as UC (n = 237) or IBDU (n = 97) preoperatively and UC (n = 236) or IC (n = 98) postoperatively. After a median follow-up of 76 months (range: 3–236), 63 patients (19%) developed CD within a median of 22 months (range: 1–213) from ileostomy closure compared with the previously published 40 patients (12%) with 26-month follow-up ( P = 0.01). The development of de novo CD was similar for patients undergoing IPAA for UC (n = 40; 17%), IBDU (n = 21; 22%) or those classified as having UC (n = 42; 18%) or IC (n = 19; 19%) postoperatively; P > 0.05. Thus, patients with IBDU and IC can expect equivalent long-term outcome to patients with UC after IPAA. Pouch failure occurred in 13 (4%) study patients and was equal among all four groups.

Background Pyoderma gangrenosum (PG) is a severe extraintestinal manifestation of inflammatory bowel disease (IBD). Objective To better characterize PG features and management among an IBD cohort. Methods Subjects with PG were identified using a large database at a tertiary center. Patient demographics and clinical characteristics were summarized using descriptive statistics. Results Eighty patients with an episode(s) of PG were identified, yielding an overall prevalence of 1.9%. Overall, 93% of patients with PG had some degree of colonic inflammation. Thirty-one (39%) patients required hospitalization for PG. Underlying bowel disease was active at the time of PG episode(s) in 52 (65%) patients. The PG location was variable, with the lower extremity being the most common. Most patients (71.3%) required multiple therapies to achieve PG healing. Conclusions We describe one of the largest case series of PG among patients with IBD. The variety of treatment strategies used highlights the lack of clear guidelines in managing this complex group of patients.

A Total abdominal colectomy (TAC) is recommended for fulminant Clostridium difficile colitis (FCDC) because intraoperative assessment of diseased segments is inaccurate. To determine whether computerized tomography (CT) provides an accurate assessment of disease, we examined the concordance between CT and histopathologic colitis distribution in patients undergoing TAC for FCDC. The ileocolon was divided into seven distinct segments. Of 20 patients meeting criteria, the median interval between preoperative CT and TAC was 1.5 days (range, 0 to 23 days), and mortality was 65 per cent. The CT distribution of colitis was pancolitis in 12 patients and segmental in eight. Nine of the 12 patients with CT pancolitis had histologic pancolitis (75% concordance). Four of the eight patients with CT-diagnosed segmental disease had histologic segmental disease (50% concordance). For patients with FCDC, the distribution of colitis on CT agrees with the histopathologic extent of disease in the majority of patients. However, discordance between CT and histologic extent of disease was present in 25 to 50 per cent of patients. Therefore, the recommendation for TAC rather than segmental resection for FCDC remains justified.

The primary aim of this study was to define predictors of computed tomography (CT)-guided percutaneous abscess drainage treatment failure in complicated diverticulitis. A 10-year retrospective analysis of inpatients seen in surgical consultation for diverticular abscess management subsequently referred for CT-guided percutaneous drainage (PD) was conducted. The clinical courses of patients undergoing a technically successful PD were categorized into three groups: 1) no colectomy; 2) elective colectomy; and 3) nonelective colectomy. Forty study patients were identified. Thirteen (33%) of the 40 patients required a nonelective colectomy, 20 patients (50%) underwent elective resection, and seven patients (18%) have been managed nonoperatively with no recurrent diverticulitis for a median of 46.8 months (range, 3.2 to 84.3 months). Forward logistic regression identified the presence of immunosuppression or renal insufficiency (creatinine 1.5 mg/dL or greater) as factors independently associated with failure of PD and need for non-elective colectomy. No clinical, laboratory, or radiologic variables were predictive of long-term nonoperative success. Although PD allows for the resolution of intra-abdominal sepsis for most cases of diverticulitis complicated by an abscess, a substantial proportion progress to nonelective colectomy, emphasizing the need for clinical vigilance in follow-up.

Postoperative diet advancement in patients undergoing elective small bowel or colorectal surgery by general surgeons (GSs) and colorectal surgeons (CRSs) was prospectively evaluated. Demographic (age and gender), disease location (small bowel or colorectum), surgical approach (laparoscopic or open), and surgeon characteristics (GS or GRS) were tabulated. Postoperative feeding after surgery on postoperative Day (POD) 1 was assessed. Operations involved the colorectum (n = 43 [72%]) or small bowel (n = 17 [28%]) and were performed using laparoscopy (n = 38 [63%]) or open (n = 22 [37%]) techniques. Operations were performed by GSs (n = 30) or CRSs (n = 30). Early feeding was ordered on POD 1 on 34 patients (57%). The remaining 26 patients (43%) were kept nothing by mouth. Factors associated with early feeding included age younger than 50 years (P 5.004), surgery done by CRSs ( P < 0.0001), operations on the colorectum ( P = 0.04), and laparoscopic surgery ( P = 0.07). Multivariable analysis revealed that age younger than 50 years (odds ratio [OR], 9.5; 95% confidence interval [CI], 1.8 to 52; P = 0.01), surgery done by CRSs (OR, 16.3; 95% CI, 3.4 to 79.6; P = 0.001), and use of laparoscopic surgery (OR, 12; 95% CI, 2.1 to 67; P = 0.007) were associated with early postoperative feeding. Early postoperative feeding does not appear to be applied commonly in clinical practice. Younger patient age, surgery done by CRSs, and laparoscopy are associated with the use of early postoperative feeding after elective intestinal surgery.

Patients previously on corticosteroids within 1 year before surgery are routinely treated with perioperative high-dose corticosteroids. However, there is little evidence to support this practice. We postulated that patients off steroids but treated with corticosteroids within 1 year before surgery may be safely managed without perioperative steroids. A chart review was performed on patients with inflammatory bowel disease (IBD) treated with corticosteroids within 1 year before surgery. Patients received either perioperative high-dose steroids (HDS) or no steroids (NS). Perioperative vital signs were assessed. Forty-nine operations were performed. Eleven patients received HDS and 38 patients received NS. Aside from a higher incidence of tachycardia (heart rate greater than 100 beats/min) in the HDS group (82%) compared with the NS group (42%), there was no significant difference in hemodynamic instability between the two groups. One patient in the NS group required a single dose of intraoperative vasopressor after aggressive beta-blockade. All other episodes of hemodynamic instability resolved with no intervention, fluid boluses, or blood transfusion. No patients required rescue high-dose steroids for adrenal insufficiency. In patients with IBD undergoing major colorectal surgery, treated with corticosteroids within the past year, management without perioperative steroids seems safe. A prospective study assessing perioperative corticosteroid dosing is in progress.

We hypothesize that use of postoperative heparin deep vein thrombosis prophylaxis influences development of surgical site infection (SSI) after colorectal surgery. From July 2008 to June 2009, patients undergoing an abdominal operation by colorectal surgeons at a single university-affiliated teaching hospital were prospectively followed and more than 80 variables collected. One hundred eighty-one patients were identified. Forty-five per cent (n = 82) received heparin prophylaxis and 55 per cent (n = 99) did not. SSI occurred in 23 per cent (n = 19) of patients receiving heparin versus 9 per cent (n = 9) who did not ( P = 0.02). Univariate analysis found SSI to be associated with heparin ( P = 0.02) and increased operative time ( P = 0.03). Multivariate analysis showed that SSI was associated only with heparin use ( P = 0.04; OR, 2.6; 95% CI, 1.1 to 6.6).

Previous papers studying the effect of surgeon experience on patient outcomes after colorectal surgery are hampered by study design, variable measurements of outcome, and have shown conflicting results. The National Surgical Quality Improvement Program is a validated, risk-adjusted, outcomes-based program used to measure the quality of surgical care. Here, we sought to determine the association between colorectal surgeon experience and short-term patient outcomes using a colorectal surgery-specific National Surgical Quality Improvement Program methodology. We prospectively followed 300 patients operated on by eight colorectal surgeons. The median age was 46 years, male:female ratio was 163:137, and median body mass index was 23. Surgeons were divided into two groups: those with less (Group A) than or greater (Group B) than 5 years experience. Procedures were categorized into 137 (46%) major and 163 (54%) minor cases. Group A surgeons operated on 95 (32%) patients and Group B surgeons operated on 205 (68%) patients. Postoperatively, 101 (31%) patients had complications (Group A = 29; Group B = 72). Four (1%) patients had reoperations (Group A = 0; Group B = 4) and 24 (8%) were readmitted (Group A = 5; Group B = 19) within 30 days of surgery. This prospective study revealed no significant difference in short-term outcomes between colorectal surgeons with less than versus more than 5 years experience.

Unplanned readmission (UR) is considered to be an index of quality surgical care. We examined whether any perioperative factor was associated with UR after colectomy for ulcerative colitis (UC) or indeterminate colitis (IC). Patients undergoing a two-stage or three-stage ileal pouch-anal anastomosis were included. Patient, disease, and surgical factors were collected. UR occurring within 30 days of hospital discharge was assessed. The 202 study patients had a median age of 38 years. Median body mass index was 22. There were 130 (64%) UC patients and 72 (36%) IC patients. Indications for surgery were medically refractory disease (n = 176, 87%) and dysplasia/cancer (n = 26, 13%). Preoperative medical therapy included steroids alone in 25 patients and steroids combined with other immunomodulators in 151 patients. A two-stage and three-stage ileal pouch-anal anastomosis was used in 146 (72%) and 56 (28%) patients, respectively. Median white blood cell count before discharge was 8600 cells/mm3. Median length of stay after surgery was 7 days. Complications before discharge were observed in 28 patients (14%). Thirty-eight patients (19%) had a UR. No preoperative or surgical factor was associated with UR. Although UR occurs frequently (19%) after colectomy for UC or IC, it cannot be predicted.

Although ileal pouch-anal anastomosis (IPAA) is the procedure of choice for polyposis and ulcerative colitis with medically refractory disease or dysplasia, controversy exists concerning whether mucosal preservation with double-stapled (DS) IPAA is superior to mucosectomy and handsewn (HS) IPAA anastomosis for postoperative function. Prospective studies have shown no statistically significant differences. The use of meta-analysis can strengthen statistical power by combining the data from related studies. A meta-analysis was performed to determine whether there was a significant difference in functional and manometric outcome between HS-IPAA and DS-IPAA. Prospective, randomized studies were identified using a literature search. Functional outcome variables included number of normal continence, minor incontinence, nocturnal evacuation, the ability to discriminate flatus from stool, and antidiarrheal medication. Manometric outcomes included postoperative resting and squeeze anal pressures. Four prospective, randomized trials were identified. Of the 184 total patients, the HS-IPAA group included 86 patients (48 men and 38 women) and the DS-IPAA group included 98 patients (49 men and 49 women). There were no significant differences in functional outcome between HS-IPAA and DS-IPAA. In addition, there was no significant difference in sphincter resting and squeeze pressures between the two patient groups. This meta-analysis demonstrates that DS-IPAA offers no advantage in functional or manometric outcome when compared with HS-IPAA.

Acute pouchitis (AP) after ileal pouch–anal anastomosis (IPAA) is common and easily treated. However, chronic pouchitis (CP) remains a difficult management problem and may represent a form of Crohn disease (CD) of the ileal pouch. Because CD patients have higher platelet counts than ulcerative colotis (UC) patients, we prospectively evaluated the association between preoperative platelet count and pouchitis development in 159 patients undergoing IPAA. Reactive thrombocytosis (RT) was defined as a platelet count >450 x 109/L. Median preoperative platelet count was 312 x 109/L (range, 103 x 109/L to 886 x 109/L). One hundred twenty-five patients (79%) had a normal (150 x 109/L to 450 x 109/L) platelet count (-RT patient group). Twenty-eight patients (18%) had RT. Six patients (3%) had a platelet count below 150 x 109/L. After a median follow-up of 13 months, 45 patients (28%) developed pouchitis. Pouchitis developed in 33 +RT patients (26%) versus 9 -RT patients (32%) ( P = NS). UC patients who had +RT had a 25 per cent incidence of CP compared to only 7 per cent of those UC patients who had -RT ( P = 0.03). The incidence of CP was significantly higher after IPAA in UC patients having thrombocytosis before surgery compared to UC patients having a normal platelet count before surgery.