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The data on management and outcomes of pelvic sepsis after re-do IPAA are scarce.The aim of this study is to report our management algorithm of pelvic sepsis in the setting of re-do IPAA and compare functional outcomes and quality of life after successful management of pelvic sepsis with a no sepsis control group.This is a retrospective cohort study.This investigation is based on a single academic practice group experience on re-do IPAA.Patients who underwent re-do IPAA for ileal pouch failure between September 2016 and September 2020 were included in the study.Management of pelvic sepsis was reported. Functional outcomes, restrictions, and quality-of-life scores were compared between the sepsis and no sepsis groups.One-hundred ten patients were included in our study, of whom 25 (22.7%) developed pelvic sepsis. Twenty-three patients presented with pelvic sepsis before ileostomy closure, and 2 patients presented with pelvic sepsis after ileostomy closure. There were 6 pouch failures in the study period due to pelvic sepsis. Our management was successful in 79% of the patients with median follow-up of 26 months. Treatments included interventional radiology abscess drainage (n = 7), IV antibiotics alone (n = 5), interventional radiology drainage and mushroom catheter placement (n = 1), mushroom catheter placement (n = 1), and endoluminal vacuum-assisted closure (n = 1). Average number of bowel movements, urgency, incontinence, pad use, and seepage were comparable between the pelvic sepsis and no pelvic sepsis groups ( p0.05). Lifestyle alterations, Cleveland Global Quality of Life scores, and happiness with the results of the surgery were similar ( p0.05).This study is limited by its low study power and limited follow-up time.Pelvic sepsis is common after re-do IPAA, and management varies according to the location and size of the abscess/sinus. If detected early, our management strategy was associated with high pouch salvage rates. See Video Abstract at http://links.lww.com/DCR/B823 .ANTECEDENTES:Los datos sobre el tratamiento y los resultados de la sepsis pélvica después de reconfección de anastomosis anal, de la bolsa ileal son escasos.OBJETIVO:El objetivo de este estudio es informar nuestro algoritmo de manejo de la sepsis pélvica en el contexto de reconfección de anastomosis anal de la bolsa ileal y comparar los resultados funcionales y la calidad de vida después del manejo exitoso de la sepsis pélvica con un grupo de control sin sepsis.DISEÑO:Este es un estudio de cohorte retrospectivo.AJUSTES:Esta investigación se basa en una experiencia de un solo grupo de práctica académica sobre reconfección de IPAA.PACIENTES:Se incluyeron en el estudio pacientes que se sometieron a una nueva anastomosis anal, del reservorio ileal por falla del reservorio ileal entre el 09/2016 y el 09/2020.PRINCIPALES MEDIDAS DE RESULTADO:Se informó el manejo de la sepsis pélvica. Los resultados funcionales, las restricciones y las puntuaciones de calidad de vida, se compararon entre los grupos con sepsis y sin sepsis.RESULTADOS:Se incluyeron 110 pacientes en nuestro estudio, de los cuales 25 (22,7) desarrollaron sepsis pélvica. Veintitrés pacientes presentaron sepsis pélvica antes del cierre de la ileostomía y 2 pacientes presentaron sepsis pélvica después del cierre de la ileostomía. Hubo 6 fallas de la bolsa en el período de estudio debido a sepsis pélvica. Nuestro manejo fue exitoso en el 79% de los pacientes con una mediana de seguimiento de 26 meses. Los tratamientos incluyeron drenaje de abscesos IR (n = 7), antibióticos intravenosos solos (n = 5), drenaje IR y colocación de catéter en forma de hongo (n = 1), colocación de catéter en forma de hongo (n = 1) y cierre endoluminal asistido por vacío (n = 1). El número promedio de evacuaciones intestinales, urgencia, incontinencia, uso de almohadillas y filtraciones fueron comparables entre los grupos con sepsis pélvica y sin sepsis pélvica ( p0,05). Las alteraciones del estilo de vida, las puntuaciones de la Calidad de vida global de Cleveland y la felicidad con los resultados de la cirugía fueron similares ( p0,05).LIMITACIONES:Este estudio está limitado por su bajo poder de estudio y su tiempo de seguimiento limitado.CONCLUSIONES:La sepsis pélvica es común después de la reconfección de anastomosis anal de la bolsa ileal y el manejo varía según la ubicación y el tamaño del absceso / seno. Si se detecta temprano, nuestra estrategia de manejo se asoció con altas tasas de recuperación de la bolsa. Consulte Video Resumen en http://links.lww.com/DCR/B823 . (Traducción-Dr. Mauricio Santamaria ).

Introduction The vacuum-assisted drainage has many applications in managing complex wound healing. It quickens the recovery period by its hyperemic effect on the exposed zone, decreasing bacterial colonization, preventing tissue edema, and promoting granulation of the wound. However, its use in anastomotic leak after IPAA is scarcely studied, especially because a proprietary endoluminal vacuum-assisted closure system was removed from the US market. Technique We applied a hand-crafted endoluminal vacuum-assisted closure system using the existing standard wound vacuum-assisted closure supplies to 2 patients who developed an anastomotic leak with a presacral abscess after completion proctectomy with J-pouch construction. Results We changed the endoluminal vacuum-assisted closure drain every 2 to 3 days, and both patients had substantial improvements in their abscess cavity after the seventh and ninth applications. Conclusions Anastomotic leak at the IPAA traditionally takes up to a year to heal, which causes a significant toll on the psychosocial life of the patient and delayed stoma closure. Therefore, we believe that facilitating the healing process by using our hand-crafted endoluminal vacuum-assisted closure drain might provide a great value to patients' quality of life.

Data regarding safety and feasibility of re-do ileal pouch anal anastomosis (IPAA) for failed ileal pouch in children are limited. In this study, we compared the short- and long-term outcomes of re-do IPAA in pediatric and adult populations in a case-matched setting. Between March 2007 and June 2017, pediatric patients undergoing a transabdominal re-do IPAA by single surgeon were reviewed and case matched with adult counterparts. Short- and long-term outcomes including complications, functional outcomes, and quality of life of the two groups were compared. 60 patients were included (pediatric, n = 30; adult, n = 30). Time between index IPAA and re-do IPAA was shorter in the pediatric group (30 ± 26 vs 86 ± 74 months, p = 0.001). In the pediatric population, the existing pouch was more commonly used to construct the re-do pouch (n = 19 vs n = 12, p = 0.07). There was a trend towards the presence of less postoperative complications in pediatric group (n = 13 vs n = 20, p = 0.07). There were no reoperations or mortality. Long-term pouch survival was comparable between two groups (p = 0.96). Six re-do IPAAs failed in the study period. Re-do IPAA is safe and feasible in pediatric population with failed IPAA and can be performed with similar short- and long-term outcomes compared to adults in experienced hands.

Background Failed pouches may tend to be managed with only a loop ileostomy in obese patients due to some safety concerns. The effect of obesity on ileal pouch excision outcomes is poorly studied. In our study, we aimed to assess the short-term outcomes after ileal pouch excision in obese patients compared to their nonobese counterparts. Methods The patients who underwent pouch excision between 2005 and 2017 were included using ACS-NSQIP participant user files. The operative outcomes were compared between obese (BMI ≥30 kg/m2) and nonobese (BMI2) groups. Results There were 507 pouch excision patients included of which eighty (15.7%) of them were obese. Physical status of the obese patients tended to be worse (ASA>3, 56.3 vs 42.9%, P = .027). There were more patients who had diabetes mellitus (DM) and hypertension (HT) in the obese group (26.3% vs. 11.2%, P = .015; 11.3 vs. 4.4%, P < .001, respectively). Operative time was similar between 2 groups (mean ± SD, 275 ± 111 vs. 252±111 minutes, P = .084). Deep incisional SSI was more commonly observed in the obese group (7.5 vs 2.8%, P = .038). In multivariate analysis, only deep incisional SSI was found to be independently associated with obesity (OR: 2.79, 95% CI: 1.02-7.67). Obese patients were readmitted more frequently than nonobese counterparts (28.3 vs 16%, P = .035). The length of hospital stay was comparable [median (IQR), 7 (4-13.5) vs. 7 (5-11) days, P = .942]. Conclusion Ileal pouch excision can be performed in obese patients with largely similar outcomes compared to their nonobese counterparts although obesity is associated with a higher rate of deep space infection.

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

We report the first case of a simultaneous pancreas and renal transplantation, in Australia, in a 45 year old male with long standing human immunodeficiency virus infection, type 1 diabetes mellitus and diabetic nephropathy requiring haemodialysis. This patient experienced previous virological failure and subsequent resistance to most nucleoside and non-nucleoside reverse transcriptase inhibitors. However, using novel combinations of anti-retroviral agents, along with careful monitoring, successful outcomes were achieved during the peri and post transplantation period, with excellent pancreas and renal graft function at one year.

Background We evaluated factors associated with an increased preoperative carcinoembryonic antigen (CEA) level for colon cancer patients undergoing elective curative surgery and assessed whether this was associated with prognosis when accounting for other potential confounders. Methods Prospectively accrued data of patients with stage I, II, and III colon cancer undergoing surgery (1980–2008) were retrieved retrospectively. Patients with a preoperative CEA level greater than 5 ng/mL (group B) were compared with those with a CEA level of 5 ng/mL or less (group A). Results There were 651 patients (379 men) with a median age of 67 years (range, 21–94 y) and a median follow-up period of 5.9 years. Groups A (n = 451) and B (n = 200) had similar ages and tumor locations. Group B had larger tumors; more patients with T3 and N1/N2; and more patients with stage II/III tumors, and hence greater use of chemotherapy ( P = .04). On multivariate analysis, patient age, tumor stage, and differentiation were associated with oncologic outcomes. A CEA level greater than 5 ng/mL was not associated independently with recurrence, recurrence-free survival ( P = .47), or overall survival ( P = .3). Conclusions An increased preoperative CEA level is a marker for a more advanced tumor stage. For adequately staged patients, a high preoperative CEA level is not associated independently with oncologic outcomes.

Single-port laparoscopic surgery (SPLS) has been used in urologic, gynecologic, general, and colorectal surgery. We herein report our experience with the use of SPLS for total proctocolectomy with ileal pouch-anal anastomosis (RP/IPAA).All patients who underwent a RP/IPAA using SPLS between June and September 2009 were identified from a prospectively maintained laparoscopic database. All procedures were performed with the use of a 5-mm Olympus EndoEye™ and traditional laparoscopic instruments via a SILS™ port placed at the planned ileostomy site.There were five patients (3 male) included in the study. Median age was 43 years (range=13-47 years). Median body mass index was 20.66 kg/m2 (range=14.63-25.97 kg/m2). Diagnoses included ulcerative colitis (n=4) and familial adenomatous polyposis (n=1). Median ASA score was 2 (range=1-3). Median operative time was 153 min (range=132-278 min). Median estimated blood loss was 100 ml (range=50-200 ml). There were no conversions to either a conventional laparoscopic or an open procedure. Median time to return of bowel function was 2 days. Median length of stay was 4 days (range=3-6 days). Postoperative complications included two patients with partial small-bowel obstructions. Both resolved with conservative management. All patients had their ileostomies closed.RP/IPAA using SPLS is a safe technique. Additional studies are needed to compare SPLS to conventional laparoscopy and open surgery with respect to operative times, convalescence, and outcomes.

Laparoscopic ileocolic resection is feasible for Crohn's disease but few studies adjust for the various preoperative, intraoperative, and postoperative variables that may confound comparisons with open surgery. The aim of this study is to compare outcomes after laparoscopic (LICR) and open ileocolic resection (OICR) performed for regional enteritis using National Surgical Quality Improvement Program (NSQIP) data. Retrospective evaluation of data prospectively accrued into the NSQIP database for patients undergoing ileocolic resection for Crohn's by LICR and OICR was performed. LICR (n = 104) and OICR (n = 203) groups had similar age ( P = 0.1), body mass index ( P = 0.9), smoking history ( P = 0.6), steroid use ( P = 0.7), diabetes ( P = 0.3), serum albumin ( P = 0.07), and American Society of Anesthesiologists class ( P = 0.13). LICR group had more female patients ( P = 0.005). Complications including surgical site infections ( P = 0.5), wound dehiscence ( P = 1), pneumonia ( P = 0.1), deep vein thrombosis ( P = 0.3), pulmonary embolism ( P = 1), urinary infection ( P = 0.1), and return to the operating room ( P = 0.2) were similar. LICR had shorter length of hospital stay than OICR ( P < 0.001). In current practice, as observed with the NSQIP data, LICR, performed by experienced surgeons, is comparable in safety to OICR and is associated with a shorter hospital stay.

The aim of this study was to evaluate whether stapler size used at ileal pouch-anal anastomosis (IPAA) influences outcomes.Data of patients undergoing stapled IPAA (1983-2007) were obtained. Differences between groups A (stapler size 28-29 mm) and B (31-33 mm) for pre- and perioperative factors, stricture, leak, quality of life (QOL), and function were compared. Associations between stapler size and stricture or leak were assessed with a multivariable Cox model.Groups A (n = 1,221) and B (n = 899) had comparable age, diagnosis, body mass index (BMI), and albumin level. Group B had more males (P.001) but fewer patients with ileostomy (P.001). There was no significant difference in rates of leak (4.5% vs 6.2%, P = .08) or stricture (1.9% vs 2.7%, P = .1) for groups A and B. On multivariate analysis, female gender was associated with stricture, while greater BMI and male gender were associated with leak. Group A had greater urgency at 1 year and nighttime pad use at 15 years. The other determinants of function and QOL were similar.There was no significant association between the size of stapler used at IPAA and long-term complications.

Conceivably, the benefits of earlier recovery associated with a minimally invasive technique used in laparoscopic colectomy (LC) may be amplified for patients with comorbid disease. The dearth of evidence supporting the safety of laparoscopy for these patients led to a comparison of outcomes between LC and open colectomy (OC) for patients with American Society of Anesthesiology (ASA) classifications 3 and 4.Data for all ASA 3 and 4 patients who underwent elective LC were reviewed from a prospectively maintained laparoscopic database. The patients who underwent LC were matched with OC patients by age, gender, diagnosis, year, and type of surgery. Estimated blood loss, operation time, time to return of bowel function, length of hospital stay, readmission rate, and 30-day complication and mortality rates were compared using chi-square, Fisher's exact, and Wilcoxon tests as appropriate. A p value0.05 was considered statistically significant.In this study, 231 LCs were matched with 231 OCs. The median age of the patients was 68 years, and 234 (51%) of the patients were male. There were 44 (19%) conversions from LC to OC. More patients in the OC group had undergone previous major laparotomy (5 vs. 15%; p0.001). Estimated blood loss, return of bowel function, length of hospital stay, and total direct costs were decreased in the LC group. Wound infection was significantly greater with OC (p = 0.02). When patients with previous major laparotomy were excluded, the two groups had similar overall morbidity. The other benefits of LC, however, persisted.The findings show that LC is a safe option for patients with a high ASA classification. The LC approach is associated with faster postoperative recovery, lower morbidity rates, and lower hospital costs than the OC approach.

INTRODUCTION: Technical complications after ileal pouch-anal anastomosis may be mislabeled as Crohn's disease. The purpose of our study is to evaluate the presentation, treatment, and outcomes of patients with a potential misdiagnosis of Crohn's disease who have undergone redo ileal pouch-anal anastomosis. METHODS: We evaluated a historical cohort of patients, initially referred from outside institutions with a diagnosis of Crohn's disease of the pouch, who subsequently had redo ileal pouch-anal anastomosis (redo pouch or pouch revision for pouch failure) at our institution. With the use of validated questionnaires, the functional outcomes and quality of life of this cohort were compared with a control group of patients who underwent primary ileal pouch-anal anastomosis to assess whether a change in the diagnosis from Crohn's disease to technical complications was appropriate. RESULTS: Thirty-three patients underwent a redo pouch procedure for a previous diagnosis of Crohn's disease of the pouch. Precolectomy diagnosis included ulcerative colitis (31 patients) and indeterminate colitis (2 patients). Findings on our further evaluation and subsequent indications for repeat pouch surgery included pouch fistula (20 patients), pelvic sepsis or anastomotic leak (17 patients), stricture (4 patients), refractory pouchitis (2 patients), long exit conduit (1 patient), and retained rectal stump (1 patient). All patients had medical treatment for Crohn's disease before referral. Median time between primary and redo pouch was 2.1 years (interquartile range, 1.8–4.9). Median follow-up was 1.7 years (interquartile range, 1.0–3.5). Pouch retention rate was 84.8%. Five patients (15.2%) had pouch failure. Seven patients (21.2%) ultimately had pathology consistent with Crohn's disease. Comparison of the redo pouch and control groups revealed that functional outcomes and quality of life were similar between groups. CONCLUSION: Patients identified as having Crohn's disease need to be carefully reevaluated because some of these patients may actually have surgery-associated complications and can have a favorable long-term outcome after redo ileal pouch-anal anastomosis.

Restorative proctocolectomy and ileal pouch anal anastomosis (RP/IPAA) have been the procedures of choice for patients with ulcerative colitis, or familial adenomatous polyposis, and those with other diagnoses who require surgery. The options for this procedure are J, S, or W ileal pelvic pouch anastomosed by either stapled or hand-sewn technique. J-pouch is the preferred technique of most surgeons. The stapled IPAA is quicker, more secure, and safer, with better function, while the hand-sewn IPAA allows removal of the diseased anal transitional zone. Recently, in most of the centers, the use of a hand-sewn IPAA has been limited to those with dysplasia or lower rectum cancer and to when a stapled IPAA has failed. Although leaving intact rectal mucosa after stapled IPAA could be a potential concern in the development of dysplasia or cancer, it has been shown that anal transitional zone preservation rarely leads to the development of cancer. This review describes indications and techniques of RP/IPAA.

Background The Turnbull–Cutait abdominoperineal pull-through procedure (T-C) is used as a last resort to avoid permanent diversion in patients with complex anorectal conditions. The aim was to evaluate short- and long-term outcomes after T-C. Methods Patients undergoing T-C from 1996 to 2007 were reviewed retrospectively in terms of demographics, diagnosis, indications and postoperative complications. Patients were contacted to obtain functional outcomes using a standardized questionnaire. Functional outcomes were compared with those in a matched group of patients undergoing handsewn coloanal anastomosis (CAA) for rectal cancer. Results Sixty-seven patients (40 men) underwent T-C. Postoperative complications included stricture in 11 patients (16 per cent), fistula in five (7 per cent), prolapse of the colon in five (7 per cent) and leak in two (3 per cent). Mean follow-up was 5·6 (s.d. 3·2) years. The operation failed in 17 patients (25 per cent). Among 44 patients (66 per cent) who completed questionnaires, faecal (P = 0·121) and urinary (P = 0·073) incontinence, and sexual function (P = 0·063) were comparable to those in patients who had CAA. Conclusion T-C is an option for patients with complex anorectal conditions that might otherwise require permanent diversion. Functional outcomes are comparable to those of CAA.

BACKGROUND: The risks and benefits of pouch excision and end ileostomy creation when compared to the alternative option of a permanent diversion with the pouch left in situ when restoration of intestinal continuity is not pursued for patients who develop pouch failure after IPAA have not been well characterized. OBJECTIVE: This study aimed to compare the early and long-term outcomes after permanent diversion with the pouch left in situ vs pouch excision with end ileostomy creation for pouch failure. DESIGN: This study is a retrospective review of prospectively gathered data. SETTINGS: This investigation was conducted at a tertiary center. PATIENTS: Patients with pouch failure who underwent a permanent ileostomy with the pouch left in situ and those who underwent pouch excision were included in the study. MAIN OUTCOME MEASURES: The primary outcomes measured were the perioperative outcomes and quality of life using the pouch and Short Form 12 questionnaires. RESULTS: One hundred thirty-six patients with pouch failure underwent either pouch left in situ (n = 31) or pouch excision (n = 105). Age (p = 0.72), sex (p = 0.72), ASA score (p = 0.22), BMI (p = 0.83), disease duration (p = 0.74), time to surgery for pouch failure (p = 0.053), diagnosis at pouch failure (p = 0.18), and follow-up (p = 0.76) were similar. The predominant reason for pouch failure was septic complications in 15 (48.4%) patients in the pouch left in situ group and 39 (37.1%) patients in the pouch excision group (p = 0.3). Thirty-day complications, including prolonged ileus (p = 0.59), pelvic abscess (p = 1.0), wound infection (p = 1.0), and bowel obstruction (p = 1.0), were similar. At the most recent follow-up (median, 9.9 y), quality of life (p = 0.005) and health (p = 0.008), current energy level (p = 0.026), Cleveland Global Quality of Life score (p = 0.005), and Short Form 12 mental (p = 0.004) and physical (p = 0.014) component scales were significantly higher after pouch excision than after pouch left in situ. Urinary and sexual function was similar between the groups. Anal pain (n = 4) and seepage with pad use (n = 8) were the predominant concerns of the pouch left in situ group on long-term follow-up. None of the 18 patients with pouch in situ, for whom information relating to long-term pouch surveillance was available, developed dysplasia or cancer. LIMITATIONS: This study was limited by its retrospective nature. CONCLUSIONS: Although technically more challenging, pouch excision, rather than pouch left in situ, is the preferable option for patients who develop pouch failure and are not candidates for restoration of intestinal continuity. Because pouch left in situ was not associated with neoplasia, this option is a reasonable intermediate or long-term alternative when pouch excision is not feasible or advisable. ©The ASCRS 2012.

There is an increased risk of morbidity and mortality after nonhepatic surgery in patients with liver failure compared to patients without liver failure. Mortality was shown to be higher after emergent surgery than after elective surgery in patients with cirrhosis. In patients with liver failure who undergo nonhepatic surgery, preoperative assessment is vital in order to reduce the high risk of postoperative complications and mortality.

Aim The study aimed to establish a method for the measurement of mesenteric tension after ileal pouch-anal anastomosis (IPAA) and to evaluate the impact of tension on clinical outcome and quality of life. Methods All consecutive patients undergoing an open IPAA from July 2008 to October 2009 were prospectively enrolled. After the creation of the anastomosis, mesenteric tension was estimated by the surgeon in the operating room on a 10-point scale (1, least tension; 10, most tension). The association was analysed between mesenteric tension defined as low (1–2), medium (3–7) and high (8–10) and postoperative complications and quality of life (Cleveland Clinic Global Scale). Results A mesenteric tension score was obtained in 134 patients (71 men, 53.0%). Median age was 38.5 (29.3–47.0) years. Fifty-six patients (41.8%) had a low, 59 (44.0%) a medium and 19 (14.2%) a high degree of mesenteric tension. Patients with a high mesenteric tension had a shorter anal transitional zone, a longer distance from the upper border of the symphysis pubis to the apex of the small bowel loop designated for the ileoanal anastomosis, a thinner abdominal wall at the stoma site and a longer distance from the pouch to the ileostomy. The proportion of patients with high mesenteric tension was less after stapled anastomosis. On long-term follow-up, patients with high mesenteric tension were more likely to suffer from anastomotic stricture and pouch failure. Pouch function was not influenced by mesenteric tension. Conclusion High mesenteric tension after IPAA is adversely associated with postoperative complications and pouch survival.

Single-port laparoscopic surgery can be performed via one incision hidden in the umbilicus. Herein, we report a patient with a sigmoid colon cancer undergoing single-port laparoscopic sigmoid colectomy. Laparoscopic single-port sigmoid colectomy through a 3-cm umbilical incision was performed on a patient with a diagnosis of sigmoid cancer. Patient was 54-year-old female with a body mass index of 25.8 kg/m2. Preoperatively, a CAT scan in the metastasis evaluation did not show any lesion. The total operative time was 198 min. Estimated blood loss was 300 ml. Length of hospital stay was 3 days. Patient had no intraoperative or postoperative complications. Examination of pathological specimen showed a specimen containing a circumferential lesion measuring 5 cm × 2.5 cm × 2.5 cm with adequate surgical margins (10 and 5.5 cm), and no regional lymph node metastases in 14 lymph nodes collected. Patient did not receive adjuvant chemotherapy after surgery. Colonoscopy performed 1 year after surgery showed no neoplasm or polyp identified. Abdomen and pelvis CT also found no evidence of recurrence or metastatic disease. Single-port laparoscopic surgery may allow common benign procedures via an incision in the umbilicus. It can also be performed with good surgical and oncologic results in selected patients with a colorectal cancer.

Ileal pouch anal anastomosis (IPAA) is the treatment of choice for chronic, medically refractory mucosal ulcerative colitis, indeterminate colitis, familial adenomatous polyposis (FAP), and a select group of patients with Crohn's disease.: We report outcomes, complications, and quality of life (QOL) in a cohort of 3707 patients treated at our institution from January 1984 to March 2010.Data were collected from a prospectively maintained database and chart review of 3707 consecutive primary IPAA cases. Patient demographics, postoperative complications, functional outcomes, and QOL data were available. Follow-up consisted of clinical examination with assessment of pouch function and QOL.A total of 3707 patients underwent primary pouch and 328 underwent redo pouch surgery. Postoperative histopathological diagnoses were mucosal ulcerative colitis (n = 2953, 79.7%), indeterminate colitis (n = 63, 1.7%), FAP (n = 223, 6%), Crohn's disease (n = 150, 4%), cancer/dysplasia (n = 97, 2.6%), and others (n = 221, 6.0%). Early perioperative complications were encountered in 33.5% of patients with a mortality rate of 0.1%. Excluding pouchitis, late complications were experienced by 29.1% of patients. Of those patients who had IPAA at our institution, pouch failure occurred in 197 patients (5.3%). During a median follow-up of 84 months, 119 patients (3.2%) required excision of the pouch, 32 (0.8%) had a nonfunctioning pouch, and 46 patients (1.2%) had redo IPAA. Functional outcomes and QOL were good or excellent in 95% of patients and similar in each histopathological subgroup.IPAA is an excellent option for patients with MUC, IC, FAP, and select patients with Crohn's disease.

Restorative proctocolectomy with ileal pouch-anal anastomosis is the procedure of choice for patients with ulcerative colitis requiring surgery. A J-pouch with a stapled anastomosis has been the preferred technique because it is quicker, safer, and associated with good functional outcomes. A diverting loop ileostomy is usually created at the time of ileal pouch-anal anastomosis. In patients with severe fulminant colitis or toxic megacolon, restorative proctocolectomy with ileal pouch-anal anastomosis is performed in multistages. The technical aspects of ileal pouch-anal anastomosis in patients with ulcerative colitis are reviewed in this article.

Evidence is lacking whether an abscess associated with anastomotic leak after an ileal pouch-anal anastomosis (IPAA) should be drained by transanal or CT-guided drainage. Therefore, the aim of this study was to compare outcomes after the two techniques for drainage. Patients who underwent IPAA (1984–2009) and diagnosed with a pelvic abscess associated with an anastomotic leak were identified. The choice of operative or image-guided drainage was based on surgeon preference. Differences between patients undergoing transanal (group TA) and CT-guided drainage (group CT) were determined. Groups TA (n = 53) and CT (n = 18) had similar age (p = 0.3), gender (p = 0.3), body mass index (p = 0.6), steroid use (p = 0.4), albumin level (p = 0.9), ileostomy (p = 0.6), and follow-up time (p = 0.5). The size of the abscess was greater in group CT (p = 0.012). Two patients developed fistula at the CT-guided drainage site. Both healed after conservative treatment and drainage of associated gluteal abscess, respectively. Thirteen patients in group TA and three patients in group CT (p = 0.6) had failure of drainage and underwent surgery. The success rates for the procedures in terms of long-term pouch retention were 75.5% and 83%, respectively, for TA and CT. Groups TA and CT had similar bowel frequency (p = 0.9), incontinence (p = 0.6), urgency (p = 0.9), seepage (p = 0.6), pad usage (p = 0.1), quality of life (p = 0.9), and happiness with surgery (p = 0.9). There is a risk of fistula at drainage site after a CT-guided drainage of the pelvic abscess associated with anastomotic leak following IPAA. Transanal and CT-guided drainage are equally effective and result in similar long-term pouch-related outcomes.

Adjuvant chemotherapy is currently offered, as standard, after curative resection for patients with rectal cancer who receive neoadjuvant chemoradiation (NCRT). We postulate that adjuvant chemotherapy adds minimal oncologic benefit for patients who undergo total mesorectal excision who are node-negative after neoadjuvant chemoradiation.From a prospective, institutional cancer database, rectal cancer patients who completed neoadjuvant chemoradiation and curative surgery (2000-2008) and were node-negative on final pathology were identified. Patient, tumor, treatment characteristics, and oncologic outcomes were compared for patients who completed intended adjuvant chemotherapy (group chemo) or did not receive any chemotherapy (group no-chemo).Chemo (n=58) and no-chemo (n=70) patients had similar age (P=0.13), gender (P=0.67), body mass index (P=0.46), American Society of Anesthesiologists class (P=0.67), preoperative tumor stage (P=0.16), type of surgery (P=0.76), and postoperative complications. The no-chemo group had greater complete pathologic response (n=34, 48.6% vs. n=14, 24.1%). After prolonged follow-up, local recurrence (P=1), disease-free survival (P=0.41), and overall survival (P=0.52) were similar. Oncologic benefits of adjuvant chemotherapy were especially questionable for patients with complete pathologic response (chemo vs. no-chemo, local recurrence at 5 years: 0 vs. 2.9%, P0.99), disease-free (79.1% vs. 88%, P=0.51), and overall survival (90.9% vs. 95.2%, P=0.41).These results question the routine use of adjuvant chemotherapy for patients with rectal cancer who undergo curative surgery who have been rendered node-negative by neoadjuvant chemoradiation.

Background Diagnosis and management of leak from the tip of the J-pouch after IPAA has not been systematically studied. Objective The aim of this study is to report our experience in the diagnosis and management of these leaks following primary IPAA. Design This study is a retrospective review of prospectively gathered data. Settings Data were obtained from a prospectively maintained single-institution pelvic pouch database. Patients Included in this study were patients with a leak from the tip of the J-pouch after primary IPAA. Main outcome measures The main measures of outcomes after salvage surgery were pouch failure, pouch function, and quality of life. Results There were 27 (14 male) patients. Median age was 37 years (range, 20-73). Underlying disease in these patients was ulcerative colitis in 22 patients. Predominant symptoms were abdominal pain (n = 15) and fever (n = 5). Twenty patients had either a pelvic abscess detected by CT or MRI or a leak demonstrated at gastrografin enema or pouchoscopy. In 6 patients, the diagnosis was only made at salvage surgery. In 1 patient, the leak-associated abscess was detected during emergent laparotomy for acute peritonitis before salvage surgery. Of 27 patients, 1 had successful CT-guided drainage without the need for further surgery. Another patient had pouch resection with end ileostomy. Salvage surgery was performed in 25 patients by means of pouch repair (n = 23) and new pouch creation (n = 2); 8 patients had a repeat anastomosis. Median time from primary IPAA to salvage surgery was 0.9 years (0.13-9.8). Twenty-four patients with salvage surgery have a functioning pouch after a mean follow-up of 3.2 ± 1.9 years. Limitations : The study was limited by its retrospective nature. Conclusions Leak from the tip of the J-pouch is indolent and diagnosis can be difficult. Satisfactory outcomes in terms of pouch retention may be expected after appropriate surgical management.

The recovery benefits of laparoscopy are traditionally believed to minimize the initial negative impact of surgery on early postoperative quality of life (QOL). We evaluate whether laparoscopic colectomy leads to recovery of QOL early after surgery and evaluate factors associated with the change in QOL.Preoperative and early postoperative QOL data (SF-36) were prospectively accrued for patients undergoing laparoscopic colorectal resection (LCR) (2002-2009). Changes in postoperative QOL from preoperative values and effects of patient, disease, operation and postoperative outcomes on these changes were evaluated.One hundred and sixty-six patients (female = 86) underwent LCR for cancer (n = 79), Crohn's disease (n = 24), diverticulitis (n = 38), and ulcerative colitis (n = 25) with complete SF-36 scores. Median age was 56.9 (range: 15-91) years, mean body mass index 27.4 ± 6.2 kg/m(2) with American Society of Anesthesiologists (ASA) class being II in 94 patients. Median operative time was 152.5 (range: 50-358) min; mean length of stay (LOS) 4.5 ± 3.3 days. At 4 weeks, the postoperative SF-36 physical component scale (PCS) continued to be lower than the preoperative PCS (41.8 ± 8.8 vs. 47.1 ± 9.4, P0.001), while the postoperative SF-36 mental component scale (MCS) was similar to the preoperative MCS (45.6 ± 10.2 vs. 46.1 ± 11.9, P = 0.17). Gender, age, operation, LOS, surgeon, ASA, BMI, complications, and readmission were not associated with a change in QOL from preoperative values. Cancer as an indication for surgery was associated with less improvement of MCS and PCS (P = 0.024 and 0.004, respectively).Although patients who undergo LCR may have clinical evidence of healing at 4 weeks after surgery, QOL does not return to the preoperative level. This finding may help develop evidence-based recommendations pertaining to timing of return to full activity.

Background: Distal small bowel obstruction following ileal pouch-anal anastomosis (IPAA) can occur secondary to acute angulation or prolapse of the afferent limb at the pouch inlet, namely, afferent limb syndrome (ALS). The aim of this study is to report our experience in diagnosis and management of ALS in patients with IPAA. Methods: All patients with ALS after IPAA were identified from prospectively maintained databases. Demographic, clinical, endoscopic, and radiographic features together with its management and outcome were studied. Results: Eighteen patients (12 female) were included. The mean age was 35.6 ± 14.3 years. Most patients presented with intermittent obstructive symptoms. Fifteen patients were diagnosed by pouch endoscopy with features of angulation of the pouch inlet and difficulty in intubating the afferent limb; 12 patients had kinking or narrowing of the pouch inlet identified with abdominal imaging. The median follow-up was 1.3 (range, 0.14–16.1) years. Nine patients underwent empiric balloon dilatation of the afferent limb/pouch inlet. Of nine, four needed repeat dilatations. One patient with repeat dilatation ultimately had pouch excision; another has been scheduled for surgery after failed repeat dilatations. Eight patients underwent surgery, resection of angulated bowel (n = 3), pouchopexy (n = 2), pouch mobilization with small bowel fixation (n = 1), and pouch excision (n = 2). One patient without symptoms did not receive any therapy despite the finding of ALS on pouchoscopy. Conclusions: ALS was characterized by clinical presentation of partial small bowel obstruction, which can be diagnosed by careful pouchoscopy and/or abdominal imaging. Endoscopic or surgical intervention is often needed and surgical therapy appears to be more definitive. (Inflamm Bowel Dis 2011;)

This study aimed to investigate whether the learning curve during laparoscopic colectomy is associated with increased costs compared with the procedure after the learning curve has been achieved. The direct costs for patients undergoing laparoscopic colectomy during the learning curve (group A) and after the attainment of proficiency by two colorectal surgeons performing the procedure (group B) between 2001 and 2007 were compared. The learning curve was defined as the first 40 laparoscopic colectomy cases for each surgeon. The distribution of cases for the surgeons ensured that cost-related differences were not influenced by lead time bias of cases performed during the learning curve. The study involved 80 group A and 74 group B patients. Groups A and B were similar in terms of age (P = 0.7), gender (P = 0.5), American Society of Anesthesiologists (ASA) score (P = 0.5), body mass index (P = 0.3), diagnosis (P = 0.8), previous abdominal surgery (P = 0.07), and comorbidity (P = 0.4). The two groups also were similar with regard to performance of anastomosis (P = 0.2) or resection (P = 0.6), conversion to open surgery (P = 0.7), postoperative morbidity (P = 0.6), readmission (P = 0.1), reoperation rate (P = 0.6), and hospital length of stay (P = 0.6). The operation time was significantly longer for group A (P = 0.01). The total direct costs (P = 0.7) and the operating room (P = 0.6), nursing (P = 0.7), pharmacy (P = 0.9), radiology (P = 1), and professional (P = 0.051) costs were however similar between the two groups. As expected, laparoscopic colectomy during the learning curve period is associated with prolonged operating time. Concerns pertaining to increased conversions, complications, and direct costs during this period were not substantiated in this study.

The aim of this study was to compare outcomes after primary hand-sewn versus stapled ileal pouch-anal anastomosis (IPAA).Patients undergoing a primary IPAA (1983-2007) were identified from a prospective pelvic pouch database. Differences between group A (hand-sewn) and group B (stapled) for pre-operative and peri-operative factors, complications, functional outcomes, and quality of life (QOL) were investigated.Of 3,382 patients with a primary IPAA, 3,109 were included. Median follow-up was 7.1 years (0.1-24). Mean age was 37.9 +/- 13.2 years. Overall, 1,741 patients (56%) were male. Group A (n = 474) and group B (n = 2635) had similar age (P = .28), sex (P = .8), albumin level (P = .74), prior colectomy (P = .98), and use of steroids (P = .1). Group A had a greater use of ileostomy (P = .001) and a longer duration of stay (P.001). Group B had a greater body mass index (P.001) and J-pouch (Por = .001). Wound infection (P = .42) and pouchitis (P = .59) were similar. Anastomotic stricture (P = .002), septic complications (P = .019), bowel obstruction (P = .027), and pouch failure (P.001) were greater in group A. At most recent follow-up, bowel frequency (P = .74) and rate of urgency were similar (P = .71). A greater proportion of patients in group A described incontinence (P.001), seepage (P.001), pad usage (P.001), dietary (P.001), social (P.001), and work restrictions (P = .025). The Cleveland Global QOL score (P = .018) was greater in group B.Patients undergoing a stapled IPAA had better outcomes and QOL than those undergoing a hand-sewn IPAA.

Purpose Laparoscopy is the approach of choice for the majority of colorectal disorders that require a minimally invasive abdominal operation. As the emphasis on minimizing the technique continues, natural orifice surgery is quickly evolving. The authors utilized an embryologic natural orifice, the umbilicus, as sole access to the abdomen to perform a colorectal procedure. Herein, we present our initial experience of single-port laparoscopic colorectal surgery using a Uni-X™ Single-Port Access Laparoscopic System (Pnavel Systems, Morganville, New Jersey, USA) with a multi-channel cannula and specially designed curved laparoscopic instrumentation. Method The abdomen was approached through a 3.5 cm incision via the umbilicus and a single-port access device was utilized to perform a right hemicolectomy on a patient with an unresectable caecal polyp and a body mass index of 35. Ligation of the ileocolic artery was done with a LigaSure Device™ (Covidien Ltd, Norwalk, Connecticut, USA), and was followed by colonic mobilization, extraction and extracorporeal ileocolic anastomosis. Results The total operative time was 115 min with minimal blood loss. Hospital stay was 4 days with no undue sequelae. Conclusion Single-port laparoscopic surgery may allow common colorectal laparoscopic operations to be performed entirely through the patient’s umbilicus and enable an essentially scarless procedure. Additional experience and continued investigation are warranted.