Search

Background & Aims: The Western diet, which is high in fat, is a modifiable risk factor for colorectal recurrence after curative resection. We investigated the mechanisms by which the Western diet promotes tumor recurrence, including changes in the microbiome, in mice that underwent colorectal resection., Methods: BALB/c male mice were fed either standard chow diet or Western-type diet (characterized by high fat, no fiber, and decreased minerals and vitamins) for 4 weeks; some mice were given antibiotics or ABA-PEG20k-Pi20 (Pi-PEG), which inhibits collagenase production by bacteria, but not bacterial growth, in drinking water. Colorectal resections and anastomoses were then performed. The first day after surgery, mice were given enemas containing a collagenolytic rodent-derived strain of Enterococcus faecalis (strain E2), and on the second day they were given mouse colon carcinoma cells (CT26). Twenty-one days later, distal colons were removed, and colon contents (feces, distal colon, and tumor) were collected. Colon tissues were analyzed by histology for the presence of collagenolytic colonies and by 16S ribosomal RNA sequencing, which determined the anatomic distribution of E faecalis at the site of the anastomosis and within tumors using in situ hybridization. Mouse imaging analyses were used to identify metastases., Results: Colorectal tumors were found in 88% of mice fed the Western diet and given antibiotics, surgery, and E faecalis compared with only 30% of mice fed the standard diet followed by the same procedures. Colon tumor formation correlated with the presence of collagenolytic E faecalis and Proteus mirabilis. Antibiotics eliminated collagenolytic E faecalis and P mirabilis but did not reduce tumor formation. However, antibiotics promoted emergence of Candida parapsilosis, a collagenase-producing microorganism. Administration of a Pi-PEG reduced tumor formation and maintained diversity of the colon microbiome., Conclusions: We identified a mechanisms by which diet and antibiotic use can promote tumorigenesis by colon cancer cells at the anastomosis after colorectal surgery. Strategies to prevent emergence of these microbe communities or their enzymatic activities might be used to reduce the risk of tumor recurrence in patients undergoing colorectal cancer surgery., (Copyright © 2020 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: Surgery for inflammatory bowel disease (IBD) involves a complex interplay between disease, surgery, and medications, exposing patients to increased risk of postoperative complications. Surgical best practices have been largely based on single-institution results and meta-analyses, with multicenter clinical data lacking. The American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) has revolutionized the way in which large-volume surgical outcomes data have been collected. Our aim was to employ the ACS-NSQIP to collect disease-specific variables relevant to surgical outcomes in IBD., Study Design: A collaborative of 13 high-volume IBD surgery centers was convened to collect 5 IBD-specific variables in NSQIP. Variables included biologic and immunomodulator medications usage, ileostomy utilization, ileal pouch anastomotic technique, and colonic dysplasia/neoplasia. A sample of the Surgical Clinical Reviewer collected data was validated by a colorectal surgeon at each institution, and kappa's agreement statistics generated., Results: Over 1 year, data were collected on a total of 956 cases. Overall, 41.4% of patients had taken a biologic agent in the 60 days before surgery. The 2 most commonly performed procedures were laparoscopic ileocolic resections (159 cases) and subtotal colectomies (151 cases). Overall, 56.8% of cases employed an ileostomy, and 134 ileal pouches were constructed, of which 92.4% used stapled technique. A sample of 214 (22.4%) consecutive cases was validated from 8 institutions. All 5 novel variables were shown to be reliably collected, with excellent agreement for 4 variables (kappa ≥ 0.70) and very good agreement for the presence of colonic dysplasia (kappa = 0.68)., Conclusion: We report the results of the initial year of implementation of the first disease-specific collaborative within NSQIP. The selected variables were demonstrated to be reliably collected, and this collaborative will facilitate high-quality, large case-volume research specific to the IBD patient population., (© 2019 Crohn’s & Colitis Foundation. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Many patients with Crohn's disease will develop complications that require surgery. Recurrence after surgery is common., Aim: To assess racial differences in postoperative recurrence between African-Americans and Caucasians., Methods: Medical records of Crohn's disease patients who underwent surgery (ileal, colonic, or ileocolonic resection) between June 2014 and June 2016 were reviewed. The primary endpoints were clinical and endoscopic remission at 6-12 months after a Crohn's disease surgery. Secondary outcomes included biological and histologic remission. Risks of recurrence were assessed by univariate, multivariate, and propensity score-matched analysis., Results: Thirty-six African-American and 167 Caucasian patients with Crohn's disease were included for analysis. There was no difference in disease location, disease behaviour, type of surgery performed, and pre- or postoperative medication use between the two groups. The rate of endoscopic remission did not differ between African-American and Caucasian patients (50% vs 42%, P = 0.76), and race did not influence the risk of endoscopic recurrence on univariate, multivariate, or propensity score-matched analysis. The rate of clinical remission was significantly lower in African-American patients compared to Caucasian patients (36% vs. 63%, P = 0.008). African-American race was significantly associated with clinical recurrence on univariate (odds ratio (OR) 6.76, 95% CI 1.50-30.40; P = 0.01), multivariate (OR 5.02, 95% CI 1.60-15.80; P = 0.006), and propensity-matched analysis (68% vs. 32% in Caucasians, P = 0.005). Rates of biologic and histologic remission were similar between the two groups on all analyses., Conclusions: We found that African-American patients with Crohn's disease have a similar degree of objective measures of mucosal inflammation after surgery including endoscopic recurrence as compared to Caucasian patients. However, African-American race was significantly associated with clinical recurrence, suggesting the presence of ethnic variation in postoperative presentation in Crohn's disease., (© 2018 John Wiley & Sons Ltd.)

Background: Computed tomography (CT) scans often identify postoperative fluid collections of uncertain clinical relevance., Methods: Consecutive adult patients undergoing colorectal resection and postoperative CT scan from January 1, 2000 to December 31, 2008, at a university teaching hospital were identified from a prospective database. A host of clinical and CT findings were recorded. Fisher's exact test and logistic regression with univariate and multivariate analysis were used to assess the predictive value of clinical and radiologic variables., Results: Nine hundred six patients had a colon resection during the study period. Fifty-four patients had a postoperative fluid collection, of which 36 were found to be abscesses. Only high clinical suspicion of an abscess predicted the presence of an abscess (P = .009); of the radiologic criteria, only proximity to the anastomosis was predictive (P = .05)., Conclusions: Clinical judgment is superior to radiologic and individual clinical parameters. This finding has the potential to prevent many unnecessary procedures., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective(s): Profiling of hospitals using risk-adjusted mortality rates as a measure of quality is becoming increasingly frequent. We sought to determine the validity of this approach by comparing the risk-adjusted predicted mortality to the findings of concurrent peer review and retrospective chart review of deaths that occur on a general surgery service., Methods: Consecutive patients admitted to a busy general surgery service from January 2000 to January 2006 were prospectively entered into the Surgical Activity Tracking System. Rigorous, systematic peer review was performed concurrently by service members on all deaths. Adjudication was later validated by an independent senior surgeon. Three methodologies of risk adjustment (University Health Consortium, Physiological and Operative Severity Score for the enUmeration of Mortality, and the Charlson index) were used and compared the "excess mortality" predicted by each to the number of potentially preventable deaths determined by peer review., Results: A total of 9623 patients were admitted and 75 died (0.7%). University Health Consortium and Physiological and Operative Severity Score predicted an excess mortality of 62 and 65 deaths, respectively; Charlson predicted that 73% of the cohort would be dead in 1 year. Concurrent and retrospective peer review found that death was potentially preventable in only 22 and 21 patients, respectively., Conclusions: Peer adjudication and extensive clinical review adds much to the analysis of an adverse outcome, similar to the "black box" in an airplane crash. Although methods of risk adjustment may be helpful in identifying patients for peer review, they should be used for internal process improvement and not published as metrics of hospital or provider performance.

A leaking intestinal anastomosis is typically regarded as a devastating post-operative complication. The reported incidence ofanastomotic leakage is highly variable and depends on the definitions used and the anatomical location involved. Early leaks are usually readily diagnosed and aggressive management is warranted. Late leaks may be unrecognised and are likely to be underreported in the literature; diagnosis and treatment in this setting requires a thoughtful, individualised approach.

Background: Case volume and training have been considered as reasonable surrogates for competency that can be used as a basis to grant privileges for performing laparoscopic operations. To determine the validity of this practice, we assessed the relationship of surgical volume and training to provider-related complications after laparoscopic bowel resection., Study Design: All patients undergoing open or laparoscopic resection at a university hospital from July 2003 to June 2006 were entered into a prospectively maintained database. Complications were recorded by a specially trained nurse practitioner and adjudicated monthly by a team of gastrointestinal surgeons. Surgeon case volume, training, and operative indication were assessed for their ability to predict technical complications after laparoscopic resection using a logistic regression model., Results: Six hundred twenty-four bowel resections were performed during the study period, of which 112 were performed laparoscopically. Of the four study surgeons, the percentage of laparoscopic versus open cases ranged from 8% to 56%. Individual surgeon complication rates varied from 9% to 47%. Surgical volume and training had no notable relationship to incidence of complications (19% high volume/fellowship training versus 10% low volume/no fellowship, p = 0.25). An inflammatory indication was a strong predictor of technical complications on univariate (p = 0.02) and multivariate (p = 0.01) analysis., Conclusions: Surgeon case volume and training had no relationship to the complication rate after laparoscopic bowel operation. Case selection is a critical confounding variable because surgeons vary so greatly in their indications for using laparoscopic technique. Although documentation of training is appropriately considered in granting privileges, actually tracking outcomes is likely the only reliable way to assess competency.

Introduction: Colonic pouches have been used for 20 years to provide reservoir function after reconstructive proctectomy for rectal cancer. More recently coloplasty has been advocated as an alternative to a colonic pouch. However there have been no long-term randomized, controlled trials to compare functional outcomes of coloplasty, colonic J-Pouch (JP), or a straight anastomosis (SA) after the treatment of low rectal cancer., Aim: : To compare the complications, long-term functional outcome, and quality of life (QOL) of patients undergoing a coloplasty, JP, or an SA in reconstruction of the lower gastrointestinal tract after proctectomy for low rectal cancer., Methods: A multicenter study enrolled patients with low rectal cancer, who were randomized intraoperatively to coloplasty (CP-1) or SA if JP was not feasible, or JP or coloplasty (CP-2) if a JP was feasible. Patients were followed for 24 months with SF-36 surveys to evaluate the QOL. Bowel function was measured quantitatively and using Fecal Incontinence Severity Index (FISI). Urinary function and sexual function were also assessed., Results: Three hundred sixty-four patients were randomized. All patients were evaluated for complications and recurrence. Mean age was 60 +/-12 years, 71% were male. Twenty-three (7.4%) died within 24 months of surgery. No significant difference was observed in the complications among the 4 groups. Two hundred ninety-seven of 364 were evaluated for functional outcome at 24 months. There was no difference in bowel function between the CP-1 and SA groups. JP patients had fewer bowel movements, less clustering, used fewer pads and had a lower FISI than the CP-2 group. Other parameters were not statistically different. QOL scores at 24 months were similar for each of the 4 groups., Conclusions: In patients undergoing a restorative resection for low rectal cancer, a colonic JP offers significant advantages in function over an SA or a coloplasty. In patients who cannot have a pouch, coloplasty seems not to improve the bowel function of patients over that with an SA.

Purpose: Anastomotic leaks are among the most dreaded complications after colorectal surgery. However, problems with definitions and the retrospective nature of previous analyses have been major limitations. We sought to use a prospective database to define the true incidence and presentation of anastomotic leakage after intestinal anastomosis., Methods: A prospective database of two colorectal surgeons was reviewed over a 10-year period (1995-2004). The incidence of leak by surgical site, timing of diagnosis, method of detection, and treatment was noted. Complications were entered prospectively by a nurse practitioner directly involved in patient care. Standardized criteria for diagnosis were used. A logistic regression model was used to discriminate statistical variation., Results: A total of 1223 patients underwent resection and anastomosis during the study period. Mean age was 59.1 years. Leaks occurred in 33 patients (2.7%). Diagnosis was made a mean of 12.7 days postoperatively, including four beyond 30 days (12.1%). There was no difference in leak rate by surgeon (3.6% vs. 2.2%; P = 0.08). The leak rate was similar by surgical site except for a markedly increased leak rate with ileorectal anastomosis (P = 0.001). Twelve leaks were diagnosed clinically versus 21 radiographically. Contrast enema correctly identified only 4 of 10 leaks, whereas CT correctly identified 17 of 19. A total of 14 of 33 (42%) patients had their leak diagnosed only after readmission. Fifteen patients required fecal diversion, whereas 18 could be managed nonoperatively., Conclusions: Anastomotic leaks are frequently diagnosed late in the postoperative period and often after initial hospital discharge, highlighting the importance of prospective data entry and adequate follow-up. CT scan is the preferred diagnostic modality when imaging is required. More than half of leaks can be managed without fecal diversion.

Purpose: Lateral internal sphincterotomy is an effective treatment for chronic anal fissures; however, the risk of "incontinence" has generated interest in pharmacologic approaches that are far less effective and may be poorly tolerated. This study was designed to objectively define the risk of incontinence with sphincterotomy using the Fecal Incontinence Severity Index and assess the implications for quality of life using the Fecal Incontinence Quality of Life Scale., Methods: A prospective study was undertaken on all patients undergoing lateral internal sphincterotomy for a chronic anal fissure by a single surgeon at a university teaching hospital from January 1, 2000 to September 30, 2002. All patients had failed at least six weeks of nonoperative management. Patient demographics and use of nitroglycerin were noted. The Fecal Incontinence Severity Index was measured preoperatively and at a six-week postoperative visit when fissure healing and postoperative complications were assessed. The Fecal Incontinence Quality of Life Scale was administered to patients with an incontinence score>0., Results: Thirty-five patients (15 males) underwent sphincterotomy during the study period. Thirty-one of 35 had failed nitrates: 10 because of unacceptable side effects, and 21 because of lack of efficacy. Thirty-two patients returned for their six-week postoperative visits, and two completed their questionnaires by telephone. One patient was lost to follow-up. Mean age was 41.2 (range, 21-67) years. Thirty of 32 (94 percent) evaluable fissures had healed by six weeks, one healed by three months, and the other required V-Y anoplasty. There were two minor complications. Three patients had postoperative deterioration in their continence score. Quality of life deteriorated in only one patient., Conclusions: Lateral internal sphincterotomy is a safe and effective treatment for chronic anal fissures that only occasionally impairs continence and rarely diminishes quality of life.

Purpose: The purpose of this study was to use the Fecal Incontinence Severity Index to assess fecal incontinence after fistulotomy and to correlate the Fecal Incontinence Severity Index score with quality-of-life measures., Methods: A retrospective chart review was performed on consecutive patients undergoing fistulotomy by a single colon and rectal surgeon at a university hospital from 1991 to 1999. Demographics, fistula anatomy, surgical technique, and length of follow-up were recorded. Mailed questionnaires and telephone interviews were conducted to determine the Fecal Incontinence Severity Index score, pad usage, lifestyle restriction, and psychosocial factors. A linear regression model was used to determine the relationship of clinical factors with Fecal Incontinence Severity Index. One-way ANOVA was used to correlate Fecal Incontinence Severity Index with quality-of-life measures., Results: Of 110 patients who underwent fistulotomy, 96 (88 percent) had complete follow-up. Mean age was 48 (range, 17-84) years, and 68 percent were male. Follow-up was less than two years in 26 percent, two to five years in 39 percent, and more than five years in 35 percent. Of these patients, 41 percent had intersphincteric fistulas, whereas 59 percent had transsphincteric fistulas. Median Fecal Incontinence Severity Index score was 6, with a mean of 13 (maximum Fecal Incontinence Severity Index = 61); 36 percent had a Fecal Incontinence Severity Index score of zero. Linear regression revealed that only the amount of external sphincter divided correlated with Fecal Incontinence Severity Index score (P = 0.05). Quality-of-life measures strongly correlated with Fecal Incontinence Severity Index by analysis of variance (P < 0.01 for pad usage, lifestyle restriction, depression, and embarrassment), with substantial quality-of-life drop-off documented with Fecal Incontinence Severity Index >30., Conclusion: The Fecal Incontinence Severity Index is an excellent tool to gauge quality of life after fistulotomy. Fecal Incontinence Severity Index scores >30 predict a detrimental effect on quality of life.

A case of rectal cancer developing several years after a stapled pelvic pouch procedure is described. The need for concern about leaving residual columnar epithelium in patients with dysplasia or a synchronous cancer is highlighted. In this setting, leaving long segments of native rectum is particularly ill advised.