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Background: Up to 20% of patients with ileal pouch will develop pouch failure, ultimately requiring surgical reintervention. As a result of the complexity of reoperative pouch surgery, minimally invasive approaches were rarely utilized. In this series, we present the outcomes of the patients who underwent robotic-assisted pouch revision or excision to assess its feasibility and short-term results. Methods: All the patients affected by inflammatory bowel diseases and familial adenomatous polyposis who underwent robotic reoperative surgery of an existing ileal pouch were included. Results: Twenty-two patients were included; 54.6% were female. The average age at reoperation was 51 ± 16 years, with a mean body mass index of 26.1 ± 5.6 kg/m2. Fourteen (63.7%) had a diagnosis of ulcerative colitis at reoperation, and seven (31.8%) had Crohn's disease. The mean time to pouch reoperation was 12.8 ± 11.8 years. Seventeen (77.3%) patients underwent pouch excision, and five (22.7%) had pouch revision surgery. The mean operative time was 372 ± 131 min, and the estimated blood loss was 199 ± 196.7 ml. The conversion rate was 9.1%, the 30-day morbidity rate was 27.3% (with only one complication reaching Clavien–Dindo grade IIIB), and the mean length of stay was 5.8 ± 3.9 days. The readmission rate was 18.2%, the reoperation rate was 4.6%, and mortality was nihil. All patients in the pouch revisional group are stoma-free. Conclusion: Robotic reoperative pouch surgery in highly selected patients is technically feasible with acceptable outcomes. [ABSTRACT FROM AUTHOR]

Background: Obesity is a risk factor for failure of pouch surgery completion. However, little is known about the impact of obesity on short-term outcomes after minimally invasive (MIS) ileal pouch-anal anastomosis (IPAA). This study aimed to assess short-term postoperative outcomes in patients undergoing MIS total proctocolectomy (TPC) with IPAA in patients with and without obesity. Materials and methods: All adult patients (≥ 18 years old) who underwent MIS IPAA as reported in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant User Files 2007 to 2018 were included. Patients were divided according to their body mass index (BMI) into two groups (BMI ≥ 30 kg/m2 vs. BMI < 30 kg/m2). Baseline demographics, preoperative risk factors including comorbidities, American Society of Anesthesiologists Class, smoking, different preoperative laboratory parameters, and operation time were compared between the two groups. Propensity score matching (1:1) based on logistic regression with a caliber distance of 0.2 of the standard deviation of the logit of the propensity score was used to overcome biases due to different distributions of the covariates. Thirty-day postoperative complications including overall surgical and medical complications, surgical site infection (SSI), organ space infection, systemic sepsis, 30-day mortality, and length of stay were compared between both groups. Results: Initially, a total of 2158 patients (402 (18.6%) obese and 1756 (81.4%) nonobese patients) were identified. After 1:1 matching, 402 patients remained in each group. Patients with obesity had a higher risk of postoperative organ/space infection (12.9%; vs. 6.5%; p-value 0.002) compared to nonobese patients. There was no difference between the groups regarding the risk of postoperative sepsis, septic shock, need for blood transfusion, wound disruption, superficial SSI, deep SSI, respiratory, renal, major adverse cardiovascular events (myocardial infarction, stroke, cardiac arrest requiring cardiopulmonary resuscitation), venous thromboembolism, 30-day mortality, and length of stay. Conclusion: MIS IPAA can be safely performed in patients with obesity. However, patients with obesity have a 2-fold risk of organ space infection compared to patients without obesity. Loss of weight before MIS IPAA is recommended not only to allow for pouch creation but also to decrease organ space infections. [ABSTRACT FROM AUTHOR]

Rationale: The aim of this study was to identify temporal readmission patterns according to baseline disease categories to provide opportunities for targeted interventions. Methods: Retrospective analysis of consecutive adult (≥18 years) patients who underwent elective colorectal resections (2011‐2017) at Mayo Clinic Rochester, MN. A prospective administrative database including patient demographics, procedure characteristics, discharge information and specifics on 30‐day readmissions (to index facility) including timing and reasons was utilized. The ICD‐9 codes were regrouped into the main pathologies Cancer, Crohn's disease (CD)/chronic ulcerative colitis (CUC), and diverticular disease. Results: In total, 521 (7.2%) out of 7245 patients undergoing inpatient colorectal surgery were readmitted. In all increments of time from discharge (0‐2 days: 31.3% of all readmissions, 3‐7 days: 32.4% of all readmissions, 8‐14 days: 18% of all readmissions, and 15‐30 days: 18.3% of all readmissions), reasons for readmission differed significantly (all P < 0.001). Across all disease categories, early readmissions (within 2 days of discharge) were most likely due to ileus/obstruction (53.4% of early readmissions), whereas with 42.5%, infection was the most common cause for late readmissions (>7 days). Patients with home discharge were more likely to be readmitted earlier within the 30‐day observation period (P = 0.099), whereas patients with a longer length of index hospital stay (>7 days) were readmitted later (P = 0.080). Conclusions: Reasons for readmission appear to be universal across different disease categories. Targeted educational and collaborative measures may help to mitigate the burden of hospital readmissions to index facilities. [ABSTRACT FROM AUTHOR]

Background Proctocolectomy with ileal pouch–anal anastomosis (IPAA) is the surgical procedure of choice for medically refractory ulcerative colitis and familial adenomatous polyposis. While rare, a pouch volvulus can occur. We aimed to determine the frequency, presentation, and management approach of pouch volvulus in patients with IPAA. Methods A systematic search of published literature was performed by a medical reference librarian on 10 August 2018 and two independent reviewers identified relevant publications, extracted data, and assessed the methodological quality based on a validated tool. A retrospective review of the Mayo Clinic electronic medical records identified one case of pouch volvulus between January 2008 and August 2018. Results The frequency of pouch volvulus from one large published study reporting long-term outcomes of IPAA was 0.18% (3/1,700). A total of 22 patients (18 ulcerative colitis) were included (median age 32 years, 73% females). Median time to volvulus after IPAA was 36 months while median interval to volvulus diagnosis from symptom onset was 24 hours. Abdominal pain was the most commonly reported symptom (76%). The diagnosis was made primarily by abdominal computed tomography (13/17 patients, 76%). Endoscopic treatment was successful in 1 of 11 patients (9%). Surgery was performed in 20 patients and pouch-pexy and pouch excision were the most frequent surgical operations. A redo IPAA was performed in five patients (25%). Conclusion Pouch volvulus is a rare but serious complication of IPAA and should be suspected even in the absence of obstruction symptoms. Endoscopic treatment often fails and surgery is effective when performed early. [ABSTRACT FROM AUTHOR]

Background: Ileal pouch anal anastomosis (IPAA) is associated with a high 30-day hospital readmission rate. Risk factors and etiology of readmission remain poorly defined. We sought to determine the 30-day hospital readmission rate following IPAA at a high-volume center and identify any modifiable perioperative factors.Methods: A retrospective review of all patients undergoing two- or three-stage IPAA for chronic ulcerative colitis at our institution between 2002 and 2013 was performed. Analysis was performed on rate of readmission, readmission diagnosis, intervention performed upon readmission, and risk factors for readmission.Results: Thirty-day primary and secondary readmission rates after IPAA were 20.3% (n = 185) and 2.1% (n = 19), respectively. The leading etiologies for readmission included partial small bowel obstruction/ileus (n = 52, 21.9%), pelvic sepsis (n = 43, 18.1%), dehydration (n = 42, 17.7%), and venous thromboembolism (n = 31, 13.1%). While the majority of readmissions were managed medically (n = 119, 65.4%), 19.2% (n = 35) required radiologic intervention and 15.3% (n = 28) required a return to the operating room. On univariate analysis, younger age (p = 0.03) and female sex (p = 0.04) had a significantly increased risk of readmission. On multivariable analysis, BMI ≥ 30 (OR 0.51; 95% CI, 0.25-0.97, p = 0.04) was protective of readmission.Conclusions: Thirty-day hospital readmission following IPAA remains a common problem. Preventable etiologies of readmission include dehydration and venous thromboembolism (VTE). Future quality improvement efforts should focus on education regarding stoma output and extended VTE prophylaxis to decrease hospital readmission rates following IPAA. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic ileal pouch-anal anastomosis (L-IPAA) has been increasingly adopted over the last decade due to short-term patient-related benefits. Several studies have shown L-IPAA to be equivalent to open IPAA in terms of safety and short-term outcomes. However, few L-IPAA studies have examined long-term functional outcomes. We aimed to evaluate the long-term functional outcomes of L-IPAA as compared to open IPAA.Methods: A previous case-matched cohort study at our institution compared short-term outcomes between L-IPAA and open IPAA from 1998 to 2004. For this study, we selected all patients from this case-matched cohort study with chronic ulcerative colitis (CUC) who had follow-up functional data of greater than 1 year. Functional data was obtained through prospective surveys, which were sent annually to all IPAA patients postoperatively.Results: One hundred and forty-nine patients (58 L-IPAA, 91 open IPAA) with a median 8-year duration of follow-up were identified. There were no differences in demographics and long-term surgical outcomes between groups. Stapled anastomosis was more common in the laparoscopic group (91.4 versus 54.9%, p < 0.001). Stool frequency during daytime (>6 stools, L-IPAA 32.8%, open 49.4%, p = 0.048) and nighttime (>2 stools, L-IPAA 13.8%, open 30.6%; p = 0.024) was significantly lower in the L-IPAA group. Ability to differentiate gas from stool was not different (p = 0.13). Rate of complete continence was similar in L-IPAA and open groups (L-IPAA 36.2%, open 21.8%, p = 0.060). There was no difference in use of medication to control stools, perianal skin irritation, voiding difficulty, sexual problems, and occupational change between groups. Subgroup analysis to evaluate for any group differences attributable to anastomotic technique demonstrated only that stapled anastomoses lead to more perianal skin irritation in the L-IPAA group (L-IPAA = 60.4% versus open IPAA = 38.8%; p = 0.031).Conclusion: Overall, L-IPAA has comparable functional results to the open approach with slightly lower daytime and nighttime stool frequency. This difference may be attributed to a greater number of stapled anastomoses performed in the laparoscopic cohort. [ABSTRACT FROM AUTHOR]

The present large scale study aimed to assess the prevalence and consequences of malnutrition, based on clinical assessment (body mass index and preoperative weight loss) and severe hypoalbuminemia (<3.1 g/L), in a representative US cohort undergoing IBD surgery. The American College of Surgeons National Quality improvement program (ACS-NSQIP) Public User Files (PUF) between 2005 and 2018 were assessed. A total of 25,431 patients were identified. Of those, 6560 (25.8%) patients had severe hypoalbuminemia, 380 (1.5%) patients met ESPEN 2 criteria (≥10% weight loss over 6 months PLUS BMI < 20 kg/m2 in patients <70 years OR BMI < 22 kg/m2 in patients ≥70 years), and 671 (2.6%) patients met both criteria (severe hypoalbuminemia and ESPEN 2). Patients who presented with malnutrition according to any of the three definitions had higher rates of overall, minor, major, surgical, and medical complications, longer LOS, higher mortality and higher rates of readmission and reoperation. The simple clinical assessment of malnutrition based on BMI and weight loss only, considerably underestimates its true prevalence of up to 50% in surgical IBD patients and calls for dedicated nutritional assessment. [ABSTRACT FROM AUTHOR]

This study was designed to compare short-term outcomes after laparoscopic ileal pouch-anal anastomosis with those of open ileal pouch-anal anastomosis in patients with both sclerosing cholangitis and ulcerative colitis. Sixteen patients with sclerosing cholangitis and ulcerative colitis undergoing laparoscopic ileal pouch-anal anastomosis were matched with 16 open ileal pouch control subjects by sex, American Society of Anesthesiologists’ score, age, and body mass index. Operative mortality was zero. Operative time was longer in the laparoscopic group (500 ± 125.8 vs. 381.8 ± 60.9 minutes, P = 0.03). Thirty-day complications were not significantly different between groups (laparoscopic 25 percent vs. open 43.7 percent, P = 0.26). Length of stay was significantly shorter in the laparoscopic group (5.3 ± 1.3 days vs. 9.9 ± 3.3 days open, P < 0.001). Average return of gastrointestinal function was 2.5 days in the laparoscopic group and 4.8 days in the open group ( P = 0.001). Time to soft diet was three days in the laparoscopic group and six days in the open group ( P < 0.001). All patients were alive and all pouches were intact at last follow-up. Laparoscopic ileal pouch-anal anastomosis is feasible with apparent safety in patients with primary sclerosing cholangitis, resulting in shorter duration of hospital stay and quicker return of gastrointestinal function compared with the open procedure with no difference in perioperative complications, reoperations, and readmissions. [ABSTRACT FROM AUTHOR]

This study was designed to compare self-reported sexual function, body image, and quality of life outcomes among ulcerative colitis patients undergoing laparoscopic or open ileal pouch-anal anastomosis. Between 1978 and 2004, 100 laparoscopic and 189 open operations were performed in patients who were identified from a previously published cohort. Patients were surveyed one year after operation to evaluate sexual function, body image, and quality of life. A total of 125 of 289 patients (43 percent) returned completed surveys. There were no significant differences in terms of demographics, complications, or long-term functional outcomes between those who completed the surveys and those who did not. There were no clinical differences in results between laparoscopic and open patients using the three survey instruments. Orgasmic function scores were lower in men who underwent laparoscopic ileal pouch-anal anastomosis ( P < 0.05) compared with open ileal pouch-anal anastomosis. Overall, sexual function scores were equal to or better than normal values for men but were lower in women. Finally, overall body image and quality of life scores were above the means published for the United States. After ileal pouch-anal anastomosis, men and women reported excellent body image and high cosmetic and quality of life scores regardless of operative approach. Female sexual function was more adversely affected after ileal pouch-anal anastomosis than was male sexual function. [ABSTRACT FROM AUTHOR]

Laparoscopic surgery of the colon has become an established method for the resection of both benign and malignant disease. Complex laparoscopic colon resections were once stigmatized due to their longer operating times and inherent technical difficulty. However, technological innovations and increased surgical experience with laparoscopy have advanced the field of complex laparoscopic surgery, including ileal pouch-anal anastomosis (IPAA) procedure, with safe feasible results. When these operations are broken down in a stepwise fashion, the complexity of the laparoscopic IPAA procedure becomes simplified, allowing one to effectively reproduce this operation. The systematic laparoscopic steps outlined establish a simple, reproducible approach to a laparoscopic IPAA procedure for ulcerative colitis patients. This approach to laparoscopic IPAA provides one with a viable approach to this complex operation. [ABSTRACT FROM AUTHOR]

PURPOSE: Functional outcomes in laparoscopic-assisted ileal pouch-anal anastomosis have been incompletely studied. More than one-year follow-up has rarely been reported in these patients. This study was designed to assess operative, functional, and quality of life outcomes in patients with ulcerative colitis or familial adenomatous polyposis a minimum of one year after. METHODS: Thirty-three laparoscopic-assisted ileal pouch-anal anastomosis and 33 open ileal pouch-anal anastomosis patients, with a median of 13 months and minimum of 12 months follow-up, were identified from a prospective, laparoscopic database. Functional outcome was prospectively assessed by using a standardized survey. These cohorts were matched by individual patient for year of surgery, age, gender, body mass index, and indication. RESULTS: Median age was 27 years (open) and 28 years (laparoscopic). There were 27 females and 6 males in each group. All operations occurred between 1999 and 2001. Median body mass index was 22.3 (open) and 21.7 (laparoscopic) groups. There were no significant differences in diagnosis, use of diversion, and anastomotic technique. Postoperative morbidity occurred in 6 percent of the laparoscopic cases and 12 percent of the open cases. Functional outcome after a minimum of one year revealed equivalent median day and median nocturnal number of stools of six to seven and one to two respectively. Consistency of stool, medication usage, and continence were no different between groups. Daytime and nocturnal incontinence was similar. Quality of life in regard to social, home life, family, travel, sports, recreation, and sex life were equivalent. CONCLUSIONS: The function and quality of life outcomes for patients undergoing laparoscopic-assisted ileal pouch-anal anastomosis seem to be equivalent to our open experience. Laparoscopic-assisted ileal pouch-anal anastomosis offers selected patients a safe, feasible, and durable alternative. [ABSTRACT FROM AUTHOR]

Hypothesis Functional outcome and quality of life in older patients (>55 years) undergoing ileal pouch–anal anastomosis (IPAA) for ulcerative colitis or familial adenomatous polyposis have been incompletely studied. Our aim was to update our understanding on how the age of the patient at the time of surgery influences functional outcome and quality of life after IPAA. Methods From January 1, 1981, to December 31, 2000, two thousand two patients who underwent IPAA were studied. Patients were grouped by age at operation: 45 years or younger (n = 1688), between 46 and 55 years (n = 249), and older than 55 years (n = 65). Mean age was 33.5 years. Postoperative complications, function, and quality of life were assessed with a questionnaire administered annually. Results Follow-up for patients older than 55 years was a mean ± SD of 8.1 ± 4.8 years. Overall, follow-up was a mean of 10.1 ± 5.7 years. The pouch failure rate for patients older than 55 years was 1.6% at 10 years. No statistically significant difference in pouch failure between age groups was observed. Overall, frequent daytime and nighttime incontinence, respectively, occurred in 5.6% and 13.3% of the patients at 10 years. Incontinence was more common in older patients (P = .002 at 3 years). Quality of life as assessed by social activities, work, travel, sexual activity, family relationships, and sports and recreation was not significantly different among age groups. Most patients felt that their condition had improved or that they had no restrictions after IPAA. Conclusions Postoperative complications after surgery seem to be unrelated to age at the time of surgery. Although incontinence may occur more frequently in older patients, IPAA does not adversely affect quality of life in patients older than 55 years. [ABSTRACT FROM AUTHOR]

Background: Total proctocolectomy and ileal pouch anal anastomosis (IPAA) is the preferred operation for patients with chronic ulcerative colitis (CUC) refractory to medical therapy. Infliximab (IFX), an antitumor necrosis factor−α antibody, has demonstrated efficacy in medical management of CUC. The aim of this study is to determine if IFX before IPAA impacts short-term outcomes. Study Design: A prospective institutional database was retrospectively reviewed for short-term complications after IPAA for CUC. Postoperative outcomes were compared between patients who received pre-IPAA IFX and those who did not. Results: Between 2002 and 2005, 47 patients received IFX before IPAA, and 254 patients received none. There were no gender (p = 0.16) or body mass index (p = 0.07) differences between groups. IFX patients were younger than non-IFX patients (mean age 28.1 to 39.3 years) (p < 0.001). In IFX patients, 70% were receiving preoperative IFX, azathioprine, and corticosteroids. Mortality was nil. Overall surgical morbidity was similar: 61.7% and 48.8%, IFX and non-IFX, respectively (p = 0.10). Anastomotic leaks (p = 0.02), pouch-specific (p = 0.01) and infectious (p < 0.01) complications were more common in IFX patients. Multivariable analysis revealed IFX as the only factor independently associated with infectious complications (odds ratio [OR] = 3.5; CI, 1.6−7.5). In a separate analysis, incorporating age, high-dose corticosteroids, azathioprine, and severity of colitis, IFX remained significantly associated with infectious complications (OR = 2.7; CI, 1.1−6.7). Conclusions: CUC patients treated with IFX before IPAA have substantially increased the odds of postoperative pouch-related and infectious complications. Additional prospective studies are required to determine if IFX alone or other factors contribute to the observed increases in infectious complications. [Copyright &y& Elsevier]