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This study aimed to conduct a systematic literature review of small bowel adenocarcinoma (SBA) associated with small bowel Crohn’s disease (CD). A systematic literature review was conducted using MEDLINE, PubMed, Embase, CINAHL, Cochrane and Google Scholar databases. Data regarding demographics, presentation, diagnosis, treatment and survival were extracted. The review included articles that reported the location of SBA in the setting of CD and excluded articles that did not state the CD location and/or cancer type. We identified 218 patients diagnosed with SBA in the setting of small bowel Crohn’s disease. SBA should be in the differential diagnosis in patients with long-standing ileal CD presenting with small bowel obstruction, anaemia and perforation. SBA in the setting of CD presents diagnostic and treatment challenges; however, a high clinical index of suspicion may lead to early diagnosis and increased survival.

The robotic platform can overcome limitations of the laparoscopic approach, particularly in the facilitation of intracorporeal anastomosis creation. We aim to share our institutional experience with robotic ileocolic resection for Crohn's disease (CD) and compare it to a laparoscopic cohort. We identified patients who underwent ileocolic resection for CD with a purely robotic (R) or laparoscopic (L) approach between February 2015 and 2018. Chart review was performed and preoperative, intraoperative, and postoperative data was collected. A total of 47 patients with a mean age of 35.2 years old were identified and 61% were female. Seventy percent [n = 33, (23 females, 69.6%)] of the cases were performed robotically and 30% of the cases [n = 14, (6 females, 42.8%)] were performed laparoscopically. The groups were well matched for age, gender, BMI as well as disease related factors (CD duration; clinical classification and location), perioperative immunosuppression, and surgical history. Time to bowel function was shorter by about 1 day in the robotic group (R: 1.9 ± 0.88 days vs. L: 2.7 ± 0.8 days, p = 0.003). Mean operative time was longer in the robotic group by 51 min and this difference was significant (p = 0.03), however 30.3% of patients underwent ureteral stent placement, which can account for added time in robotic cases. There were less conversions in the robotic group [R: 1(4.3%) vs. L: 1(7%)], but this was not significant. There were no intraoperative complications in either group. Complication (L: 21.4% vs. R: 15.1%, p = 0.605) and reoperation rates (L: 0% vs. R: 3.03%, p = 0.429) were similar. Robotic ileocolic resection for Crohn's disease is as safe and feasible as the laparoscopic approach. This was accomplished with no leaks, major morbidity or mortality and comparable length of stay, with 1 day shorter return of bowel function, and with a lower overall complication rate. The robotic approach offers advantages in Crohn's disease which should be studied further in prospective studies.

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 Modality of index IPAA creation may affect the results after redo IPAA surgery for IPAA failure. To our knowledge, there is no study evaluating the effects of modality of index IPAA creation on redo IPAA outcomes. Objective This study aimed to compare short- and long-term outcomes of transabdominal redo IPAA surgery for failed minimally invasive IPAA and open IPAA. Design This was a retrospective cohort study. Settings This investigation was based on a single-surgeon experience on redo IPAA. Patients Patients undergoing transabdominal redo IPAA for a failed minimally invasive IPAA and open IPAA between September 2007 and September 2017 were included. Main outcome measures Short-term complications and long-term outcomes were compared between 2 groups. Results A total of 42 patients with failed index minimally invasive IPAA were case matched with 42 failed index open IPAA counterparts. The interval between index IPAA and redo IPAA operations was shorter in patients who had minimally invasive IPAA (median, 28.5 vs 56.0 mo; p = 0.03). A long rectal stump (>2 cm) was more common after minimally invasive IPAA (26% vs 10%; p = 0.046). Redo IPAAs were constructed more commonly with staplers in the laparoscopy group compared with open counterparts (26% vs 10%; p = 0.046), and other intraoperative details were comparable. Although short-term morbidity was similar between 2 groups, abscess formation (7% vs 24%; p = 0.035) was more frequent in patients who had index IPAA with open technique. Functional outcomes were comparable. Redo IPAA survival for failed minimally invasive IPAA and open IPAA was comparable. Limitations This study was limited by its retrospective, nonrandomized nature and relatively low patient number. Conclusions A long rectal cuff after minimally invasive IPAA is a potential and preventable risk factor for failure. Due to its technical and patient-related complexity, handsewn anastomoses in redo IPAA are associated with increased risk of abscess formation. See Video Abstract at http://links.lww.com/DCR/B252. RESCATE DEL RESERVORIO ILEO-ANAL POR VIA TRANSABDOMINAL EN CASOS DE FUGA ANASTOMOTICA ENTRE ABORDAGE MINIMAMENTE INVASIVO Y ABORDAJE ABIERTO: ESTUDIO DE EMPAREJAMIENTO DE MUESTRAS Y CASOS: La creacion de modalidades e indices de Reservorios Ileo-Anales (RIA) pueden afectar los resultados despues de rehacer la cirugia de RIAs por fallas en el reservorio. Hasta donde sabemos, no hay ningun estudio que evalue los efectos de la modalidad de creacion de indices RIA en los resultados para el rescate del reservorio.Este estudio tuvo como objetivo comparar los resultados a corto y largo plazo de la cirugia transabdominal redo RIA en casos de fracaso por via minimamente invasiva (MI-RIA) o por la via abierta (A-RIA).Estudio de cohortes tipo retrospectivo.Investigacion basada en la experiencia de un solo cirujano en redo del Reservorio Ileo-Anal.Se incluyeron aquellos pacientes sometidos a re-operacion transabdominal y re-confeccion de un RIA por fallas en el MI-RIA y en el A-RIA durante un lapso de tiempo entre septiembre 2007 y septiembre 2017.Las complicaciones a corto plazo y los resultados a largo plazo se compararon entre los dos grupos.Un total de 42 pacientes con indice fallido de MI-RIA fueron emparejados con 42 homologos con indice fallido de A-RIA. El intervalo entre las operaciones de RIA y redo RIA fue mas corto en pacientes que tenian MI-RIA (mediana, 28,5 meses frente a 56 meses, p = 0,03). Un munon rectal largo (> 2 cm) fue mas comun despues de MI-RIA (26% vs 10%, p = 0.046). Redo RIAs se construyeron mas comunmente con engrampadoras en el grupo Minimalmente Invasivo en comparacion con la contraparte abiertas (26% vs 10%, p = 0.046). Aunque la morbilidad a corto plazo fue similar entre los dos grupos, la aparicion de abscesos (7% frente a 24%, p = 0.035) fue mas frecuente en pacientes que tenian RIA con tecnica abierta. Los resultados funcionales fueron comparables. La sobrevida de las redo RIAs para MI-RIA y A-RIA fallidas, tambien fue comparable.Este estudio estuvo limitado por su naturaleza retrospectiva, no aleatoria y el numero relativamente bajo de pacientes.Un munon rectal largo despues de MI-RIA es un factor de riesgo potencial y previsible para el fracaso. Debido a su complejidad tecnica y relacionada con el paciente, las anastomosis suturadas a mano en redo RIA estan asociadas con un mayor riesgo de formacion de abscesos. Consulte Video Resumen en http://links.lww.com/DCR/B252.

Hidradenitis suppurativa (HS) is a chronic, progressive inflammatory disease of the apocrine gland-bearing skin that typically affects the axillary, perianal, perineal, and inframammary regions. It causes open comedones (clogged hair follicle), tender subcutaneous papules, inflammatory nodules, abscesses, sinus tracts and scarring. The prevalence of HS is 0.1 to 4% worldwide; the mean age of onset is 20 to 24 years. Cigarette smoking and obesity are risk factors for HS. Dietary triggers include dairy products and highly refined simple carbohydrates. The anal region is the second most commonly involved area after the axilla; 30% to 50% of patients with HS have perianal lesions. A number of comorbid conditions are present in patients with HS including acne, inflammatory bowel diseases, spondyloarthropathy, genetic keratin disorders and squamous cell cancer. Management of the disease includes medical and surgical treatment. Local and small lesions can benefit from medical treatment but recurrence rates are high. Widespread disease is an indication for radical surgical excision with possible need for reconstruction.

Patients undergoing colon resection for Crohn’s disease are at risk of developing postoperative complications. The aim of this study is to identify factors associated with short-term (30-day) morbidity in patients undergoing colon resection for Crohn’s disease from a national database. Patients who underwent colon resection for Crohn’s disease in 2015 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The groups were classified based on presence of postoperative 30-day complications. The overall morbidity was calculated by including patients who had at least one postoperative complication. Demographics, preoperative, and operative factors were assessed and compared between the two groups. Further multivariate logistic regression analysis was conducted. A total of 1643 patients met the inclusion criteria [mean age of 41.2 (± 15.5) years, 871 (53%) female]. Sixty percent (n = 993) of the procedures were performed laparoscopically and 128 (12.8%) cases were converted to open. Ninety-five patients (5%) underwent emergent resections. Thirty percent (n = 507) of patients had at least one postoperative complication within 30 days of surgery. Ileus (16%), transfusion (7%), and organ-space surgical site infection (6%) were the most common morbidities. Independent risk factors for postoperative morbidity were male gender (p = 0.01), open surgery (p = 0.002), preoperative severe anemia (p = 0.001), and preoperative weight loss (p = 0.04). Approximately one third of the patients who undergo colon resection for Crohn’s disease experience postoperative complications. Preoperative optimization of nutrition and anemia may improve outcomes. Laparoscopic technique appears to be the preferred surgical treatment option for resection when feasible.

Midgut malrotation is a congenital anomaly that usually occurs during infancy. The most common type is the “classic” form, which is defined as complete failure of rotation of both proximal (duodenojejunal limb) and distal (cecocolic) small bowel loops (nonrotation). Delayed diagnosis of midgut malrotation anomalies may lead to progression to catastrophic complications including volvulus and ischemic necrosis. Ladd’s procedure is the standard of care. We aimed to report a brief case of a midgut nonrotation in an adult male patient.

The aim of this study was to evaluate the impact of various factors on 30-day postoperative morbidity in patients who underwent colorectal surgery (CRS) for colovesical fistula (CVF) in the elective and emergency settings. Patients who underwent CRS for CVF between 2005 and 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program database by using current procedural terminology codes. Demographics, perioperative, and operative factors were assessed and compared between two groups classified according to the presence or absence of postoperative complications. Five hundred twelve patients met the inclusion criteria [mean age of 61.4 (±14.7) years, female 214 (42%)]. Etiology of fistula was diverticulitis [N = 438 (85.5%)], colon cancer [N = 39 (7.6%)], and Crohn’s disease [N = 35 (6.8%)]. One hundred fifty-two procedures (29.7%) were performed laparoscopically. In 186 patients (36%), no bladder intervention was performed. One hundred forty-nine patients (29.1%) had at least one postoperative complication. Patients who developed complication were older (P =

It has been established that patients undergoing subtotal colectomy for UC benefit from a minimally invasive approach, despite the longer operating times associated with laparoscopic surgery when compared to open surgery (Andersson and Soderholm in Dig Dis 27(3):335–340, 2009; Telem et al. in Surg Endosc 24(7):1616–1620, 2010; Wu et al. in Int J Colorectal Dis 25(8):949–957, 2010). Our objective is to present our early experience with urgent robotic subtotal colectomy (RSTC) and compare them to a matched cohort of patients who underwent urgent laparoscopic subtotal colectomy (LSTC). A prospectively maintained institutional database was queried. Six RSTC patients and 13 LSTC patients were identified from 2015 to 2017. There was no difference in ASA score, body mass index, preoperative steroid use, c. difficile infection, or inflammatory markers between the groups. All patients in the robotic group and eight patients in the laparoscopic group received preoperative biologics. Neither group had intraoperative complications, open conversions, or 30-day mortality recorded. Robotic STC took 29 min longer (323.0 vs. 294.0 min, p = 0.3). There was no significant difference in blood loss between the two groups (80 ml vs. 75 ml p = 0.9). There were six postoperative complications (46%) in the laparoscopic group and 1 (20%) in the robotic group. Of these 23% (3/13) for LSTC and 0% (0/5) for RSTC were Grade III or higher. Two laparoscopic and 0 robotic patients required reoperation. The RSTC group had earlier stoma function (1.4 ± 0.8 days vs. 2 ± 1.3 days) and shorter LOS (3.4 ± 2 vs. 4.6 ± 3.2) than the LSTC group, but these did not reach statistical significance. In conclusion, urgent robotic subtotal colectomy for UC is safe and offers technical advantages.

OBJECTIVE The aim of this study is to identify the association between early postoperative troponin elevations and outcomes after major colorectal surgery. BACKGROUND Myocardial infarction is the leading cause of death after noncardiac surgery. Most postoperative myocardial infarctions are clinically silent, and asymptomatic troponin elevations have the same early mortality as symptomatic infarctions. METHODS Patients over the age of 45, undergoing major colorectal surgery from March 2015 to January 2016, were identified. Plasma troponin T concentrations were prospectively collected within 24 and 48 hours after surgery. Characteristics, evaluations, management, and outcomes of patients with elevated troponin concentrations were analyzed. Mortality within the follow-up period was the primary end point. RESULTS A total of 1020 patients were screened with postoperative troponin concentrations. Fifty patients had troponin concentrations >0.01 ng/mL. Patients rarely (16%) had ischemic symptoms. Cardiology was consulted for 23 patients and started on medical therapy. Seventeen of these patients were alive at follow-up. Ten patients (20%) with troponin concentrations >0.01 ng/mL died within the follow-up period, 7 of which had concentrations ≥0.03 ng/mL. CONCLUSIONS Most postoperative myocardial injury is asymptomatic and may only be detected by routine troponin screening. Elevated troponin concentrations after colorectal surgery may facilitate identifying patients at postoperative risk and prompt appropriate testing. Early intervention in select patients may lead to potential reduction of mortality after major colorectal surgery.

Aim Abdominal salvage surgery for a failed ileal pouch-anal anastomosis (IPAA) is safe and feasible in experienced hands. When salvaging an ileal pouch or creating a new J, S or W-pouch may not be feasible, construction of an H-pouch may be the final option. This study reports a single colorectal surgeon's experience on H-pouch anal anastomosis in patients referred with a failed ileal pouch. Method Patients undergoing transabdominal salvage surgery with H-pouch formation for a failed pouch from February 2012 to May 2016 were evaluated. Results Five patients were identified with a mean age of 46 (22-63) years. The pathologic diagnosis was mucosal ulcerative colitis (MUC) in all patients. Three patients had an initial traditional 2-stage J-pouch creation and two patients had an initial 3-stage approach. Median time to redo pouch surgery after index IPAA creation was 99 (11-158) months. One patient required excision of the pouch and 2 patients had a complication within 30 days of surgery. Conclusion The H-pouch is a good alternative for a failed IPAA when another type of reservoir is not an option. This article is protected by copyright. All rights reserved.

Multiple multicentered randomized clinical trials confirming the safety, efficacy and benefits of laparoscopy have arguably made minimally invasive surgery the new standard of care for colon resection. Both European and American multicenter randomized clinical trials (RTC) demonstrate improved short-term and comparable long-term outcomes with laparoscopic versus open colon resection [1–7].

Initially laparoscopic surgery for Crohn's disease was not attempted especially in cases with extensive inflammation, thickened mesentery and adhesions. With the benefit of laparoscopy and greater surgical experience, the laparoscopic approach has been increasingly used for fistulising Crohn's disease. This article is protected by copyright. All rights reserved.