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Ulcerative colitis (UC) requires surgical management in 20 to 30% of patients. Indications for surgery include medically refractory disease, dysplasia, cancer, and other complications of UC. Appropriate patient selection for timing and staging of surgery is paramount for optimal outcomes. Restorative proctocolectomy is the preferred standard of care and can afford many patients with excellent quality of life. There have been significant shifts in the treatment of UC-associated dysplasia, with less patients requiring surgery and more entering surveillance programs. There is ongoing controversy surrounding the management of UC-associated colorectal cancer and the techniques that should be used. This article reviews the most recent literature on the indications for elective and emergent surgical intervention for UC and the considerations behind the surgical options.

The aim of this study was to describe the surgical management, outcomes and risk of malignancy of presacral tailgut cysts.A retrospective analysis of all patients who underwent resection of tailgut cyst at Mayo Clinic in Arizona, Florida and Minnesota between 2008 and 2020 was performed. Demographics, presentation, evaluation, surgical approach, postoperative complications, pathology and recurrence rates were reviewed.Seventy-three patients were identified (81% female) with a mean age of 45 years. Thirty-nine patients (53%) were symptomatic, most commonly with pelvic pain (26 patients). Digital rectal examination identified a palpable mass in 68%. Mean tumour size was 6 cm. Resection was primarily performed through a posterior approach (77%, n = 56), followed by a transabdominal approach (18%, n = 13) and a combined approach (5%, n = 4). Six patients underwent a minimally invasive resection (laparoscopic/robotic). Coccygectomy or distal sacrectomy was performed in 41 patients (56%). Complete resection was achieved in 94% of patients. Thirty-day morbidity occurred in 18% and was most commonly wound related; there was no mortality. Malignancy was identified in six patients (8%). For the 30 patients with follow-up greater than 1 year, the median follow-up was 39 months (range 1.0-11.1 years). Local recurrence was identified in three patients and distant metastatic disease in one patient.The rate of malignancy in presacral tailgut cysts based on this current review was 8%. Overall recurrence was 5% at a median of 24 months.

Perioperative management entails the multiple substeps in the performance of major abdominal surgery that are considered relevant for an optimal outcome. The PG/CME symposium of the SSAT 2018 provided a set of key talks that the authors subsequently summarized in the respective subsections of this summary article. Highlights topics included oral antibiotics and mechanical bowel prep, surgical site infections, DVT prophylaxis, enhanced recovery after surgery (ERAS), and narcotic-sparing pain management.

Small bowel adenocarcinoma (SBA) remains a rare entity but occurs at increased frequency in the setting of chronic Crohn’s disease (CD). Our aim was to study the presentation, diagnosis and prognosis of SBA in patients undergoing surgery for CD at a single institution. We reviewed the medical records of all patients with CD complicated by adenocarcinoma of the small bowel from 2000 to 2017. Descriptive statistics and Kaplan–Meier overall survival estimates were calculated. In total, 22 patients (14 males) with CD (median duration of Crohn’s diagnosis 32 years) were diagnosed with SBA and underwent surgical resection (8 isolated small bowel resections, 12 ileocolic resections, and 2 total proctocolectomies). The median patient age at the time of diagnosis was 54 years (range 22–82 years). A total of 17 patients (77%) underwent cross-sectional CT imaging within 3 months of surgery, a cancer diagnosis was suggested in only one patient. In one other patient, SBA was diagnosed preoperatively on endoscopic biopsy of the terminal ileum. The remaining patients were operated on for obstruction (n = 17), abscess or fistulizing disease (n = 2), and sigmoid cancer (n = 1). For these 20 (90%) patients not suspected to have SBA on preoperative assessment, 5 (25%) were diagnosed intraoperatively on frozen section and 15 (75%) were unexpectedly diagnosed postoperatively on final pathology. T staging was characterized by more advanced tumors (T4: 59%, T3: 27%, T2: 9%, and T1: 5%). Nine patients (41%) had nodal involvement and five patients (23%) had hepatic and/or peritoneal carcinomatosis. The 1-, 3-, and 5-year survival estimates for our cohort were 84%, 30%, and 10%, respectively. Median survival was 30.5 months with median follow-up of 23 months (range 6–84 months). SBA in the setting of CD is most commonly found incidentally after surgical resection for benign indications. As such, any suspicious finding at the time of surgery in a patient with chronic CD should warrant careful investigation with frozen section and/or resection. Prognosis for CD complicated by SBA remains poor even in the modern era.

Laparoscopic sigmoidectomy is the preferred approach in the elective surgical management of diverticulitis. However, it is unclear if the benefits of laparoscopy persist when operative times are prolonged. We aimed to investigate if the recovery benefits associated with laparoscopy are retained when operative times are long. A retrospective review of a prospectively maintained database of patients who underwent elective laparoscopic sigmoidectomy from 2010–2015 at a single academic tertiary institution was performed. Operative times among laparoscopic completed cases were divided into quartiles, and patient outcomes were compared between the groups. A total of 466 patients (median age: 58 ± 11.6 years, 58% females) underwent sigmoidectomy: 430 completed laparoscopically and 36 (7.7%) converted. Median operative time in laparoscopically completed cases was 188 min (IQR 154–230). There were no differences in morbidity (P = 0.52) or readmission rates (P = 0.22) among the quartiles. The 2nd and 4th operative time quartiles were associated with significantly longer length of stay (LOS) when compared to the fastest quartile (P = 0.003 and P = 0.002, respectively), but there was no increase in LOS as operative times progressed between the 2nd, 3rd, and 4th quartiles. LOS after conversion was longer but did not reach statistical significance when compared to laparoscopically completed operations in the longest quartile (5.0 vs 6.5 days, P = 0.075) Our data do not support preemptive conversion of laparoscopic sigmoidectomy to avoid prolonged operative times. As long as progress is safely being made, surgeons are justified to continue pursuing laparoscopic completion.

The causes of chronic antibiotic refractory pouchitis (CARP) and pouch failure in inflammatory bowel disease (IBD) patients remain unknown. Our previous small study showed peripouch fat area measured by MRI was associated with pouchitis. To explore the relationship between peripouch fat area on CT imaging and pouch outcomes. This is a historical cohort study. Demographic, clinical, and radiographic data of IBD patients with abdominal CT scans after pouch surgery between 2002 and 2017 were collected. Peripouch fat areas and mesenteric peripouch fat areas were measured on CT images at the middle pouch level. A total of 435 IBD patients were included. Patients with higher peripouch fat areas had a higher prevalence of CARP. Univariate analyses demonstrated that long duration of the pouch, high weight or body mass index, the presence of primary sclerosing cholangitis or other autoimmune disorders, and greater peripouch fat area or mesenteric peripouch fat area were risk factors for CARP. Multivariable analyses demonstrated that the presence of primary sclerosing cholangitis or autoimmuned disorders, and greater peripouch fat area (odds ratio [OR] 1.031; 95% confidence interval [CI] 1.016–1.047, P

Background Both saline and lactated Ringer’s solutions are commonly given to surgical patients. However, hyperchloremic acidosis consequent to saline administration may provoke complications. The authors therefore tested the primary hypothesis that a composite of in-hospital mortality and major postoperative complications is less common in patients given lactated Ringer’s solution than normal saline. Methods The authors conducted an alternating cohort controlled trial in which adults having colorectal and orthopedic surgery were given either lactated Ringer’s solution or normal saline in 2-week blocks between September 2015 and August 2018. The primary outcome was a composite of in-hospital mortality and major postoperative renal, respiratory, infectious, and hemorrhagic complications. The secondary outcome was postoperative acute kidney injury. Results Among 8,616 qualifying patients, 4,187 (49%) were assigned to lactated Ringer’s solution, and 4,429 (51%) were assigned to saline. Each group received a median 1.9 l of fluid. The primary composite of major complications was observed in 5.8% of lactated Ringer’s versus 6.1% of normal saline patients, with estimated average relative risk across the components of the composite of 1.16 (95% CI, 0.89 to 1.52; P = 0.261). The secondary outcome, postoperative acute kidney injury, Acute Kidney Injury Network stage I–III versus 0, occurred in 6.6% of lactated Ringer’s patients versus 6.2% of normal saline patients, with an estimated relative risk of 1.18 (99.3% CI, 0.99 to 1.41; P = 0.009, significance criterion of 0.007). Absolute differences between the treatment groups for each outcome were less than 0.5%, an amount that is not clinically meaningful. Conclusions In elective orthopedic and colorectal surgery patients, there was no clinically meaningful difference in postoperative complications with lactated Ringer’s or saline volume replacement. Clinicians can reasonably use either solution intraoperatively. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Pouch prolapse is a rare pouch complication which often leads to pouch failure in inflammatory bowel disease (IBD) patients. Its exact cause remains unknown. Floppy pouch complex (FPC) was defined as the presence of any one of the following pouch disorders: pouch prolapse, afferent limb syndrome (ALS), redundant loop, and pouch folding. We aimed to explore the role of peripouch fat area in the occurrence of pouch prolapse and FPC. Pouch patients with available pouchoscopy and abdominal CT scans who were followed up between 2011 and 2017 in Cleveland Clinic were reviewed. Peripouch fat was measured on CT images. Of the 93 included patients, 31 were females; 87 had J pouches and 6 had S pouches. The median duration of pouch was 8.0 (interquartile range [IQR] 5.0–16.5) years. A total of 18 cases (19.4%, 18/93) were identified as FPC, including 12 pouch prolapse, 5 ALS, 1 redundant loop, and 3 pouch folding. Patients with pouch prolapse had lower peripouch fat area (13.6 (9.3–18.5) vs. 27.6 (11.0–46.2)cm2, P = 0.022) than those without. Patients with FPC had lower peripouch fat area (15.4 (11.4–20.6) vs. 27.6 (11.0–46.9)cm2, P = 0.040) than those without. Univariate and multivariate analyses demonstrated that lower peripouch fat area, lower weight, and family history of IBD were independent predictors of pouch prolapse and FPC. A lower peripouch fat area was observed in inflammatory bowel disease patients with pouch prolapse and FPC. Longitudinal studies are needed to further elucidate the role of peripouch fat in the pathogenesis of pouch prolapse and FPC.

Malnutrition is a very common and often underrecognized condition among patients with inflammatory bowel diseases (IBD). This is most commonly due to increased nutritional requirements and gastrointestinal losses, along with reduced oral intake. Screening for malnutrition is an essential component of managing both inpatients and outpatients with IBD. Although enteral nutrition is the preferred route of supplementation, parenteral nutrition (PN) remains an important strategy and should be considered in certain situations, such as cases with short-bowel syndrome, high-output intestinal fistula, prolonged ileus, or small-bowel obstruction. Appropriate use of PN is critical in order to prevent associated complications. This review addresses the common indications for use of PN, the composition of PN, and the possible complications encountered with PN use, as well as scenarios of inappropriate PN use among patients with IBD. A clinical management algorithm for utilizing PN among patients with IBD is proposed in this review.Malnutrition is common and underrecognized among patients with inflammatory bowel diseases (IBD). Screening for malnutrition is an essential component of IBD management. Although enteral nutrition is the preferred route of supplementation, parenteral nutrition (PN) should be considered in certain situations. Appropriate use of PN is critical to prevent associated complications.

AIM The existing literature was updated, assessing the use of surgery in patients with ulcerative colitis in more recent years. METHODS This was a retrospective observational study identifying all patients with ulcerative colitis within the National Inpatient Sample, years 2009-2018. All patients with International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification diagnostic codes for ulcerative colitis were included. The primary outcome was the trend in total number of total abdominal colectomy, proctocolectomy and simultaneous versus delayed pouch construction. RESULTS A total of 1 184 711 ulcerative-colitis-related admissions were identified. An increase of 18.6% in the number of patients was observed, while the number of surgeries decreased. A total of 40 499 patients underwent total colectomy, annually decreasing from 5241 to 3185. The number of proctocolectomies without pouch decreased from 1191 to 530, while the number of patients undergoing pouch construction decreased from 2225 to 1284. The proportion of patients undergoing initial pouch at time of proctocolectomy decreased from 995 (45%) to 265 (21%), while the proportion of patients undergoing delayed pouch construction in 2018 was 79% (n = 1120). CONCLUSION Surgery use in ulcerative colitis has decreased in the last decade despite increasing numbers of hospital admissions in patients with this condition. While the overall proportion of patients undergoing pouch construction remained stable, the majority of patients were initially treated with total colectomy and their ileal pouches werre constructed in a delayed fashion.

It is unknown if ulcerative colitis (UC) duration has an impact on outcomes of ileal pouch anal anastomosis (IPAA). The aim of the study was to compare the long-term IPAA outcomes based on preoperative UC duration.All patients with pathologically confirmed UC who underwent IPAA were included from a prospectively maintained pouch database (1983-2017).Patient's cohort was stratified according to UC duration:5 years,5-10 years,10-20 years,20 years. UC duration was defined as time interval from date of preoperative diagnosis to colectomy date. The main outcome was Kaplan-Meier pouch survival. Secondary outcomes were pouch function and quality of life.Out of 4502 IPAAs (1983-2016), 2797 patients were included. Treated with biologics versus 12% with UC duration20 years were 41% patients with UC duration5 years. Treated with steroids compared to shortest (34%,p0.001) were 54% patients with the longest disease. A total of 65% of patients with shortest disease had IPAAs performed mostly in 3 stages. Anastomotic separation and pelvic sepsis were more prevalent among shortest compared to longest disease groups. Rates of pouch-targeted fistulas, anastomotic strictures, and pouchitis were highest in longest disease group. Pouch survival was similar between groups. Multivariate analysis did not show a significant association between UC duration and pouch failure [1.05(0.97-1.1), p = 0.23].Longer UC duration was associated with increased odds of pouchitis [1.2(1.1, 1.3), p0.001]. Biologics agents were shown to be protective against pouchitis.Preoperative UC duration does not increase pouch failure risk. Longer preoperative UC duration increases the pouchitis risk. Biologic agents and three-staged IPAA are protective against pouchitis and septic complications in long-term among patients with UC.

Diverticular disease is the leading cause of colovaginal fistulas. Surgery is challenging given the inflammatory process that makes dissection difficult. To date, studies are small and include fistula secondary to multiple etiologies.The objectives of this study were to examine surgical outcomes of diverticular colovaginal fistulas and to identify variables associated with successful closure.This was a retrospective study of a prospectively maintained clinical database.The study was conducted at a single tertiary referral center.Women with diverticular colovaginal fistulas, who underwent surgical repair with intent to close the fistula, were included.Repair of colovaginal fistula through minimally invasive or open techniques was involved.Successful closure of fistula, defined as resolution of symptoms and no stoma, was measured.Fifty-two patients underwent surgical treatment of diverticular colovaginal fistula, 23 (44%) of whom underwent a minimally invasive approach (conversion rate of 22%). Ostomy construction and omental pedicle flaps were used in 28 (54%) and 38 patients (73%). Surgery was successful in 47 patients (90%). Accounting for secondary operations, ultimate success and failure rates were 49 (94.0%) and 3 (5.7%). There was no difference in postoperative morbidity between the 2 groups (5 patients with Clavien-Dindo III/IV complications in the success group versus 2 patients in the failure group; 10.6% vs 40.0%; p = 0.44). Failure to achieve fistula closure was not associated with perioperative variables, age, BMI, diabetes mellitus, ASA grade, steroid use, previous abdominal surgery or hysterectomy, use of omentoplasty, or ostomy. Patients who failed were more likely to be smokers (60.0% vs 12.8%; p = 0.03).Limitations include the retrospective design and lack of power.Surgery is effective in achieving successful closure of diverticular colovaginal fistula. Smokers should be encouraged to stop before embarking on an elective repair. Although the use of fecal diversion and omental pedicle flaps did not correlate with success, they should be used when clinically appropriate. See Video Abstract at http://links.lww.com/DCR/A983. FÍSTULAS COLOVAGINALES DIVERTICULARES ¿QUÉ FACTORES CONTRIBUYEN AL ÉXITO DEL TRATAMIENTO QUIRÚRGICO?: La enfermedad diverticular es la causa principal de fístulas colovaginales. La cirugía es un reto dado el proceso inflamatorio que dificulta la disección. Hasta la fecha, los estudios son pequeños e incluyen fístulas secundarias a múltiples etiologías.1) Examinar los resultados quirúrgicos de las fístulas colovaginales diverticulares; 2) Identificar variables asociadas a un cierre exitoso. DISEÑO:: Estudio retrospectivo de una base de datos clínicos prospectivamente mantenida. CONFIGURACIÓN:: Centro de referencia superior.Mujeres con fístulas colovaginales diverticulares, que se sometieron a una reparación quirúrgica con la intención de cerrar la fístula.Reparación de la fístula colovaginal mediante técnicas mínimamente invasivas o abiertas.Cierre exitoso de la fístula definida como resolución de los síntomas y sin estoma.Cincuenta y dos pacientes se sometieron a tratamiento quirúrgico de la fístula colovaginal diverticular, 23 (44%) de los cuales se sometieron a un acceso mínimamente invasivo (tasa de conversión del 22%). La construcción de la ostomía y los pedículos omentales se utilizaron en 28 (54%) y 38 pacientes (73%), respectivamente. La cirugía fue exitosa en 47 pacientes (90%). Tomando en cuenta las operaciones secundarias, las tasas finales de éxito y fracaso fueron 49 (94.0%) y 3 (5.7%). No hubo diferencias en la morbilidad postoperatoria entre los dos grupos (5 pacientes con complicaciones de Clavien-Dindo III / IV en el grupo de éxito versus a 2 pacientes en el grupo de fracaso, 10.6% versus a 40.0%; p = 0.44). El fracaso para lograr el cierre de la fístula no se asoció con variables perioperatorios, edad, IMC, diabetes, grado ASA, uso de esteroides, cirugía abdominal previa o histerectomía, uso de omentoplastia u ostomía. Los pacientes que fracasaron eran más propensos a ser fumadores (60.0% versus a 12.8%; p = 0.03).Las limitaciones incluyen el diseño retrospectivo y la falta de poder.La cirugía es efectiva para lograr el cierre exitoso de la fístula colovaginal diverticular. Se debe aconsejar a los fumadores a parar de fumar antes de embarcarse en una reparación electiva. Mientras el uso de desviación fecal y pedículos omentales no se correlacionó con el éxito, deberían utilizarse cuando sea clínicamente apropiado. Consulte el Video del Resumen en http://links.lww.com/DCR/A983.

Background Enhanced recovery pathways (ERPs) have been shown to reduce length of stay (LOS), complications, and costs after colorectal surgery; yet, little data exists regarding patients with inflammatory bowel disease (IBD). We hypothesized that implementation of ERP for IBD patients is associated with shorter LOS and improved economic outcomes. Methods An IRB-approved prospective clinical database was used to identify consecutive patients from 2015 to 2017. Patients were grouped as “pre-ERP” and “post-ERP” based on the date of implementation of a comprehensive ERP. Ileostomy closures, redo pouch operations, and outpatient operations were excluded. The relationship between ERP, LOS, and secondary outcomes was assessed using univariate and multivariate analysis. Results Overall, a total of 671 patients were included: 345 (51.4%) with Crohn’s disease (CD) and 326 (48.6%) with ulcerative colitis (UC). Of these, 425 were pre-ERP (63.4%), and 246 were post-ERP (36.6%). The groups did not differ in terms of age, gender, American Society of Anesthesiologist (ASA) scores, comorbidities, estimated blood loss, or ostomy construction. The post-ERP group had a significantly higher mean body mass index (BMI), more patients with CD, longer operative time, and more minimally invasive surgery (MIS; all P < 0.05). The post-ERP group had a significantly shorter LOS (6 vs 4.5 days, median), whereas mean hospital costs decreased by 15.7%. There was no difference in readmissions or complications. On multivariate analysis, MIS and ERP use were both associated with a shorter LOS. Conclusion Inflammatory bowel disease patients benefit from the use of ERP, demonstrating decreased LOS and costs without an increase in complications and readmissions. Enhanced recovery pathways should be routinely implemented in this often challenging patient population.

Endoscopic stricturotomy (ESt) is a novel technique in the treatment of anastomotic strictures in Crohn's disease (CD). The aim of this study was to compare the outcome of patients with ileocolonic anastomotic stricture treated with ESt versus ileocolonic resection (ICR).This historical cohort study included consecutive CD patients with ileocolonic anastomotic stricture treated with ESt or ICR from 2010 to 2017. The primary outcomes were surgery-free survival and postprocedural adverse events.Thirty-five patients treated with ESt and 147 patients treated with ICR were analyzed. Median follow-up was .8 years (interquartile range [IQR], .2-1.7) and 2.2 years (IQR, 1.2-4.4) in the ESt and ICR groups, respectively (P .001). Subsequent stricture-related surgery was needed in 4 patients (11.3%) receiving ESt and in 15 patients (10.2%) receiving ICR (P = .83). Kaplan-Meier analysis also showed no statistical difference regarding surgery-free survival between the 2 groups (P = .24). Procedure-related major adverse events were documented in 5 of 49 patients (10.2% per procedure) undergoing ESt and 47 patients (31.9%) undergoing ICR (P = .003). Risk factors for decreased surgery-free survival on multivariate analysis included preprocedural corticosteroids (hazard ratio [HR], 2.8; 95% confidence interval [CI], 1.0-8.1), multiple strictures (HR, 4.9; 95% CI, 1.7-14.2), and increased disease-related hospitalizations (HR, 4.0; 95% CI, 1.2-13.0).With the limitation of a shorter follow-up, ESt achieved comparable surgery-free survival with a decreased morbidity when compared with ICR.

Background and Aim The effects of vedolizumab [VEDO] exposure on perioperative outcomes following surgery for inflammatory bowel disease [IBD] remain controversial. The aim of our study was to compare postoperative morbidity of IBD surgery following treatment with VEDO vs other biologics or no biologics. Methods An institutional review board-approved, prospectively collected database was queried to identify all patients undergoing abdominal surgery for IBD between August 2012 and May 2017. The impact of VEDO within 12 weeks preoperatively on postoperative morbidity was initially assessed with univariate and multivariable analyses on all patients. A case-matched analysis was then carried out comparing patients exposed to VEDO vs other biologic agents, based on gender, age ± 5 years, diagnosis, date of surgery ± 2 years, and surgical procedure. Results Out of 980 patients, 141 received VEDO. The majority of patients [59%] underwent surgery involving end or diverting ostomy creation. The initial multivariate analysis conducted on all patients indicated that VEDO use was independently associated with increased overall morbidity [p Conclusions In a study population having a high rate of surgery involving ostomy creation, the exposure to preoperative VEDO was not associated with an increased morbidity rate when compared with other biologics.

Purpose This study aimed to determine one-year outcomes and the impact of various factors on the need for readmission and reoperation following abdominoperineal resection (APR). Method A multivariate logistic regression analysis was conducted to determine predictors of readmission and/or reoperation within one year of APR performed between January-2000 and December-2013. Results 536 patients were analyzed for whom the most common indication for surgery was rectal cancer(86.4%). Within one year of operation, 14.2% (n = 76) of patients have major (grade III/IV of Clavien-Dindo [CD]) and 26.1%(n = 140) of patients have minor complications (grade I/II of CD). Respective major and minor perineal wound complication(PWC) rates were 10.4% and 5.6%.Readmission and reoperation rates within 90 days following discharge were 25% and 8.8%, respectively. While PWC (n = 53,39.2%) and small bowel obstruction(n = 23,17%) were the most common causes of readmission within 90 days,PWC(n = 20,23.3%) and distant metastasis(n = 20,23.3%) were the main causes of long-term readmission(90-day to 1 year). Conclusion Perineal wound complications were the most common cause of readmission and reoperation within one year of APR. Well-coordinated efforts aimed at decreasing the perineal wound morbidity may impact the need for readmission and reoperation.

Pouch-vaginal fistula is a debilitating condition with no single best surgical treatment described. Closure of these fistulas can be incredibly difficult, and transanal, transabdominal, and transvaginal approaches have been reported with varying success rates. Recurrence is a major problem and could eventually result in repeat redo pouch or permanent diversion.The aim of our study was to investigate healing rates for procedures done for pouch-vaginal fistula closure.This is a retrospective analysis of a prospectively maintained database complemented by chart review.This study reports data of a tertiary referral center.Patients who underwent surgery for pouch-vaginal fistula from 2010 to 2017 were identified. Patients who underwent surgery with intent to close the fistula were included, and patients who had inadequate follow-up to verify fistula status were excluded.Patients included underwent surgery to close pouch-vaginal fistula.Success of the surgery was the main outcome measure. Success was defined as procedures with no reported recurrence of fistula on last follow-up.A total of 70 patients underwent surgery with an intent to close the pouch-vaginal fistula, 65 of whom had undergone index IPAA for ulcerative colitis, but 13 of these patients later had the diagnosis changed to Crohn's disease. Thirty-nine patients (56%) had a fistula originating from anal transition zone to dentate line to the vagina (not at the pouch anastomosis). In the total group of 70 patients, our successful closure rate was 39 (56%) of 70. Procedures with the highest success rates were perineal ileal pouch advancement flap and redo IPAA (61% and 69%).The retrospective nature and small number of cases are the limitations of the study.Although numerous procedures may be used in an attempt to close pouch-vaginal fistula, pouch advancement and redo pouch were the most successful in closing the fistula. See Video Abstract at http://links.lww.com/DCR/A841.

Background and Aims Patients with Crohn’s disease undergoing ileocolectomy and primary anastomosis are often at increased risk of anastomotic leak. We aimed to determine whether diverting ileostomy was protective against anastomotic leak after ileocolic resection for Crohn’s disease using a large international registry. Methods We analysed the National Surgical Quality Improvement Program Colectomy Module from 2012 to 2016. Multivariable logistic regression analysis and propensity-score matching were used to identify independent risk factors for leak, and to test the hypothesis that diverting ileostomy was protective against anastomotic leakage. Results A total of 4172 [92%] patients underwent primary anastomosis, and 365 [8%] underwent anastomosis plus ileostomy. The leak rates in the two groups were 4.5% and 2.7%, [p = 0.12], respectively. Multivariate analysis indicated ileostomy omission, emergency surgery, smoking, inpatient status, wound classification 3 or 4, weight loss, steroid use, and prolonged operative time were independently associated with leak. Patients with 0–6 risk factors had leak rates of 1.6%, 2.7%, 4.3%, 6.7%, 8.8%, 11.5%, and 14.3% [p ≤ 0.001], respectively. Following propensity-score matching, ileostomy reduced the risk of leak rate by 55% [p = 0.005]. Patients with primary anastomosis who leaked most frequently required reoperation [57.8%], but anastomosis plus ileostomy patients who leaked most frequently were managed by percutaneous drainage [70%], p = 0.04. Conclusions After ileocolic resection for Crohn’s disease, anastomotic leak may be predicted by simple addition of risk factors. We found that diverting ileostomy mitigated against leak, reducing both the leak rate and the likelihood of unplanned reoperations. Faecal diversion should be considered when ≥3 risk factors are present.

The purpose of this study was to determine the impact of the incision used for specimen extraction on wound infection during laparoscopic colorectal surgery.All patients undergoing elective laparoscopic colorectal resection in a single specialized department from 2000 to 2011 were identified from a prospectively maintained institutional database. Specific extraction-sites and other relevant factors associated with wound infection rates were evaluated with univariate and multivariate analyses.2801 patients underwent specimen extraction through infra-umbilical midline (N = 657), RLQ/LLQ (N = 388), stoma site (N = 58), periumbilical midline (N = 629), Pfannenstiel (N = 789) and converted midline (N = 280). The overall wound infection rate was 10% and was highest in converted midline (14.6%) and Pfannenstiel (11.4%) incisions, while the lowest rate was associated with RLQ/LLQ (N = 13, 3.3%). Independent factors associated with wound infection were increased BMI (p 0.001), extraction site location (p = 0.006), surgical procedure (p = 0.020, particularly left-sided colectomy and total proctocolectomy), diagnosis (p 0.001, particularly sigmoid diverticulitis and inflammatory bowel disease), intraabdominal adhesions (p = 0.033) and intrabdominal rather than pelvic procedure (p = 0.005).A RLQ/LLQ extraction site is associated with the most reduced risk of wound infection in laparoscopic colorectal surgery.

Mechanical complications of the ileal pouch can be created or acquired. This chapter describes the common and clinically relevant mechanical complications of ileal pouch operations. Diagnostic and therapeutic recommendations are provided.

The prognostic association between mesorectal grading and oncological outcome in patients undergoing resection for rectal adenocarcinoma is controversial. The aim of this retrospective chart review was to determine the individual impact of mesorectal grading on rectal cancer outcomes.We compared oncological outcomes in patients with complete, near-complete and incomplete mesorectum who underwent rectal excision with curative intent from 2009 to 2014 for Stage cI-III rectal adenocarcinoma. We also assessed the independent association of mesorectal grading and oncological outcome using multivariate models including other relevant variables.Out of 505 patients (339 men, median age of 60 years), 347 (69%) underwent a restorative procedure. There were 452 (89.5%), 33 (6.5%) and 20 (4%) patients with a complete, near-complete and incomplete mesorectum, respectively. Local recurrence was seen in 2.4% (n = 12) patients after a mean follow-up of 3.1 ± 1.7 years. Unadjusted 3-year Kaplan-Meier analysis by mesorectal grade showed decreased rates of overall, disease-free and cancer-specific survival and increased rates of overall and distant recurrence with a near-complete mesorectum, while local recurrence was increased in cases of an incomplete mesorectum (all P 0.05). On multivariate analyses, a near-complete mesorectum was independently associated with decreased cancer-specific survival (hazard ratio 0.26, 95% CI 0.1-0.7; P = 0.007). There were no associations between mesorectal grading and overall survival, disease-free survival, overall recurrence or distant recurrence (all P 0.05).Mesorectal grading is independently associated with oncological outcome. It provides unique information for optimizing surgical quality in rectal cancer.

The association between preoperative use of monoclonal antibodies in inflammatory bowel disease (IBD) patients and postoperative complications is controversial, especially for the latest approved biologics, ustekinumab and vedolizumab, where data is limited. We hypothesized that ustekinumab-treated patients would have a similar overall postoperative complication rate as vedolizumab-treated patients. The aim of this study was to compare postoperative complications in patients receiving preoperative ustekinumab vs. vedolizumab. We queried our IRB-approved prospective database to identify Crohn’s patients who underwent colorectal surgery and pretreatment with ustekinumab or vedolizumab within 12 weeks of surgery. Ustekinumab-treated patients were matched to vedolizumab-treated patients based on sex, age ± 5 years, date of operation ± 3 years, and type of surgery. Paired univariate analysis and conditional logistic regression of the matched pairs were performed. Our primary outcome was the short-term postoperative complication rate. Secondary outcomes included infectious complications, readmission, reoperation, and length of stay. A total of 103 patients with Crohn’s disease (CD) met the inclusion criteria (mean age 38.7 ± 13.4 years; male 51.2%). Overall, 30 patients received preoperative ustekinumab and 73 vedolizumab. In the univariate analysis, vedolizumab-treated patients had a higher postoperative complication rate (p = 0.009) and ileus rate (p = 0.015). After matching, 26 matched pairs were compared and logistic regression models demonstrated no significant difference in the primary outcome. For our limited experience, the choice of preoperative biologic treatment between ustekinumab and vedolizumab should not be influenced by fear of surgical complications.

Background There is controversy regarding the postoperative outcomes in Crohn’s disease [CD] patients exposed to vedolizumab [VDZ] or ustekinumab [UST]. We aimed to describe our surgical outcomes in patients who underwent minimally invasive ileocolonic resection [MIS-ICR] for CD who had preoperative biologic therapy. Methods All consecutive adult patients who had MIS-ICR for CD between 2014 and 2021 at our institution were included. Patients were divided into four groups: VDZ, UST, anti-tumour necrosis factor [anti-TNF], and no biologic group. Timing between the last dose of biologics and surgery was per surgeon’s discretion. The primary outcome was intra-abdominal septic complications. Secondary outcomes included all 30-day complications. Results A total of 274 patients were identified. Of these, 113 [41.2%] patients had received anti-TNF, 52 [19%] had received UST, and 19 [7%] had received VDZ. There was no difference between the four groups regarding baseline risk factors. There was no difference between the four groups regarding intra-abdominal septic complications [4.4% for no biologic, 5.3% for anti-TNF, 5.8% for UST, and 5.3% for VDZ; p = 0.987], surgical site infection rate, overall 30-day morbidity, overall 30-day readmission, overall surgical and medical complications, urinary tract infection, pulmonary infections, or length of stay. Those results were consistent after a subgroup analysis based on complexity of the disease. Conclusions This retrospective analysis demonstrates an equivalent postoperative safety profile for patients treated with preoperative anti-TNF, VDZ, or UST versus no biologic therapy within 3 months of MIS-ICR for Crohn’s disease. Preoperative biologic therapy may not increase complications after minimally invasive ileocolonic resection in Crohn’s disease. Further studies with larger sample sizes are needed to confirm results.

Ileocolic resection (ICR) is the most common surgical procedure in Crohn disease (CD). There are many surgical techniques for performing ICRs and subsequent anastomoses. Recurrence of CD after ICR is common, often clinically silent, and thus requires monitoring including periodic use of endoscopy to detect early active disease. There is emerging evidence that surgical approaches may influence CD recurrence. This review explores the various surgical considerations, the data behind each decision, and how these techniques influence subsequent endoscopic surveillance.

BACKGROUND In selected patients with ulcerative colitis and pelvic pouch failure, redo pouch is an option. However, it is unknown whether selected patients with Crohn's disease should be offered a chance to avoid permanent diversion after failure of IPAA. OBJECTIVE The objective was to compare the outcomes of redo pouch for ulcerative colitis and Crohn's disease. DESIGN This was a retrospective analysis of a prospectively maintained pouch database (1983-2017). SETTINGS The setting was the Cleveland Clinic. PATIENTS This study included patients who underwent redo pouch with a primary surgical specimen diagnosis of ulcerative or Crohn's colitis at the time of initial pouch. MAIN OUTCOME MEASURES Pouch failure was defined as either pouch excision or indefinite pouch diversion. Patient characteristics, perioperative and functional outcomes, pouch survival, and quality of life were compared according to the diagnosis. RESULTS Of 422 patients, 392 had ulcerative colitis and 30 had Crohn's disease. Age and sex were comparable. The most common indications for redo pouch included anastomotic separation and fistulas (220 (56.1%) in ulcerative colitis and 21 (70%) in Crohn's disease). The majority of redo pouches required mucosectomy with handsewn anastomosis (310 (79%) in ulcerative colitis and 30 (100%) in Crohn's disease; p = 0.23). A new pouch was constructed in 160 patients (41%) with ulcerative colitis and repair of old pouch in 231 patients (59%) compared with 25 (83%) in Crohn's disease, who had creation of new pouch; only in 5 (17%) was the old pouch re-anastomosed. Stool frequency, seepage, and fecal urgency were comparable between groups. Cumulative 5-year pouch survival was longer in ulcerative colitis versus Crohn's disease (88% vs 55%; p = 0.008). Major causes of redo failure in Crohn's disease were pouch fistulas and/or strictures occurring after ileostomy closure. These were more common in Crohn's disease than in ulcerative colitis (p < 0.001). LIMITATIONS This was a retrospective design. CONCLUSIONS Redo pouch can be offered to selected patients with colonic Crohn's disease diagnosed at the time of their primary pouch. See Video Abstract at http://links.lww.com/DCR/B206. REHACER LA ANASTOMOSIS ILEOANAL CON RESERVORIO DESPUeS DE UN RESERVORIO ILEAL FALLIDO EN PACIENTES CON ENFERMEDAD DE CROHN: ?VALE LA PENA INTENTARLO?: En pacientes seleccionados con colitis ulcerativa y falla del reservorio pelvico, rehacer el reservorio es una opcion. Sin embargo, se desconoce si en los pacientes seleccionados con enfermedad de Crohn se deberia ofrecer la oportunidad de evitar la derivacion permanente despues de la falla de la anastomosis ileoanal con reservorio ileal.El objetivo fue comparar los resultados de reservorios re-hechos en colitis ulcerosa y la enfermedad de Crohn.El escenario fue la Cleveland Clinic.Analisis retrospectivo de una base de datos de reservorios ileales mantenida prospectivamente (1983-2017).Este estudio incluyo a pacientes que se sometieron a cirugia para rehacer el reservorio ileal con un diagnostico en el especimen quirurgico primario de colitis ulcerosa o de Crohn en el momento del reservorio inicial.La falla del reservorio se definio como la escision del reservorio o la derivacion indefinida del reservorio. Las caracteristicas del paciente, los resultados perioperatorios y funcionales, la supervivencia del reservorio y la calidad de vida se compararon de acuerdo con el diagnostico.De 422 pacientes, 392 tenian colitis ulcerativa y 30 tenian enfermedad de Crohn. La edad y el genero fueron comparables. Las indicaciones mas comunes para rehacer el reservorio incluyeron dehiscencia anastomotica y fistulas [220 (56,1%) en colitis ulcerosa y 21 (70%) en la enfermedad de Crohn]. La mayoria de los reservorios rehechos requirieron mucosectomia con anastomosis manual [310 (79%) en colitis ulcerosa y 30 (100%) en la enfermedad de Crohn, p = 0.23]. Se construyo un nuevo reservorio en 160 (41%) pacientes con colitis ulcerativa y se reparo el reservorio antiguo en 231 (59%) pacientes, en comparacion con 25 (83%) en la enfermedad de Crohn, que requirieron creacion de un nuevo reservorio, y solo 5 (17%) donde el reservorio antiguo se volvio a anastomosar. La frecuencia de las evacuaciones, el manchado fecal y la urgencia fecal fueron comparables entre grupos. La supervivencia acumulada del reservorio a 5 anos fue mayor en la colitis ulcerativa frente a la enfermedad de Crohn (88% frente a 55%, p = 0.008). Las principales causas de falla del reservorio rehecho en la enfermedad de Crohn fueron las fistulas del reservorio y / o las estenosis que ocurrieron despues del cierre de ileostomia. Estas fueron mas comunes en la enfermedad de Crohn que en la colitis ulcerativa (p

Background Risk factors for pouch survival may or may not have a linear relationship with pouch loss over time. Conditional survival is a method to describe these nonlinear time-to-event relationships by reporting the expected survival at various time points. Objective The aim of this study was to calculate conditional pouch survival based on occurrence of risk factors for pouch loss. Design This was a retrospective study from an institutional database. Settings The study was conducted at the Cleveland Clinic Foundation. Patients Patients with ulcerative or indeterminate colitis who underwent index IPAA construction between 1986 and 2016 were included. Main outcome measures Patients were stratified based on postoperative anastomotic leak, abscess, or fistula occurrence. The Kaplan-Meier method with conditional survival was used to estimate overall and cause-specific survival at 10 years. Results A total of 3468 patients underwent IPAA during the study period. The overall 10-year pouch survival rate was 0.94 (95% CI, 0.93-0.95), and after 1 year the conditional pouch survival increased to 0.95 (95% CI, 0.94-0.96), after 3 years to 0.97 (95% CI, 0.96-0.98), and after 5 years to 0.98 (95% CI, 0.98-0.99). A total of 122 patients (3.5%) developed anastomotic leak, and the 10-year IPAA survival in patients with leak was 0.85 (95% CI, 0.77-0.93). In this group, after 1 year of pouch survival, the conditional pouch survival increased to 0.89 (95% CI, 0.82-0.96) and after 3 years to 0.98 (95% CI, 0.94-1.00). A similar pattern was seen for IPAA with postoperative abscess. The conditional survival curve was stable over time for patients with a fistula. Limitations This was a retrospective, single-institution study. Conclusions Overall conditional pouch survival improved over time for patients with postoperative anastomotic leak and abscess. These novel findings can be useful to counsel patients regarding expectations for long-term pouch survival even if they develop leaks and abscesses. See Video Abstract at http://links.lww.com/DCR/B217. SUPERVIVENCIA CONDICIONAL DESPUES DE ANASTOMOSIS CON BOLSA ILEO ANAL, PARA COLITIS ULCERATIVA E INDETERMINADA: ?LA SOBREVIDA DE LA BOLSA A LARGO PLAZO, MEJORA O EMPEORA CON EL TIEMPO?: Los factores de riesgo para la sobrevida de la bolsa, pueden o no tener una relacion lineal con la perdida de la bolsa y con el tiempo. La supervivencia condicional es un metodo para describir estas relaciones no lineales de tiempo, hasta el evento informando la supervivencia esperada en varios puntos de tiempo.El objetivo de este estudio fue calcular la supervivencia condicional de la bolsa, en funcion de aparicion de factores de riesgo para la perdida de bolsa.Estudio retrospectivo de una base de datos institucional.Cleveland Clinic Foundation.Pacientes con colitis ulcerativa o indeterminada, sometidos a una anastomosis de bolsa ileo anal, de 1986 a 2016.Los pacientes fueron estratificados en funcion de la fuga anastomotica postoperatoria, absceso o aparicion de fistula. El metodo de Kaplan Meier con supervivencia condicional, se utilizo para estimar la supervivencia general y la causa especifica a los 10 anos.Un total de 3.468 pacientes fueron sometidos a anastomosis ileal con bolsa anal durante el periodo de estudio. La tasa de supervivencia global de la bolsa a 10 anos, fue de 0,94 (0,93 a 0,95), y despues de 1 ano, la supervivencia condicional de la bolsa aumento a 0,95 (0,94 a 0,96), despues de 3 anos a 0,97 (0,96 a 0,98) y despues de 5 anos a 0.98 (0.98 - 0.99). Un total de 122 (3,5%) pacientes desarrollaron fuga anastomotica, y la supervivencia de la anastomosis de bolsa ileo anal a 10 anos en pacientes con fuga fue de 0,85 (IC del 95%: 0,77 a 0,93). En este grupo, despues de 1 ano de supervivencia de la bolsa, la supervivencia condicional de la bolsa aumento a 0,89 (IC del 95%: 0,82 a 0,96), y despues de 3 anos a 0,98 (IC del 95%: 0,94 a 1). Se observo un patron similar para la anastomosis de bolsa ileo anal con absceso postoperatorio. La curva de supervivencia condicional fue estable en el tiempo para los pacientes con una fistula.Estudio retrospectivo, de una sola institucion.La supervivencia condicional global de la bolsa, mejoro con el tiempo para pacientes con fuga anastomotica postoperatoria y absceso. Estos nuevos hallazgos pueden ser utiles para aconsejar a los pacientes con respecto a las expectativas de supervivencia de la bolsa a largo plazo, incluso si desarrollan fugas y abscesos. Consulte Video Resumen http://links.lww.com/DCR/B217. (Traduccion-Dr Fidel Ruiz Healy).

The causes of chronic antibiotic refractory pouchitis (CARP) and pouch failure in inflammatory bowel disease (IBD) patients remain unknown. Our previous small study showed peripouch fat area measured by MRI was associated with pouchitis.To explore the relationship between peripouch fat area on CT imaging and pouch outcomes.This is a historical cohort study. Demographic, clinical, and radiographic data of IBD patients with abdominal CT scans after pouch surgery between 2002 and 2017 were collected. Peripouch fat areas and mesenteric peripouch fat areas were measured on CT images at the middle pouch level.A total of 435 IBD patients were included. Patients with higher peripouch fat areas had a higher prevalence of CARP. Univariate analyses demonstrated that long duration of the pouch, high weight or body mass index, the presence of primary sclerosing cholangitis or other autoimmune disorders, and greater peripouch fat area or mesenteric peripouch fat area were risk factors for CARP. Multivariable analyses demonstrated that the presence of primary sclerosing cholangitis or autoimmuned disorders, and greater peripouch fat area (odds ratio [OR] 1.031; 95% confidence interval [CI] 1.016-1.047, P 0.001) or mesenteric peripouch fat area were independent risk factors for CARP. Of the 435 patients, 139 (32.0%) had two or more CT scans. Multivariable Cox proportional hazard analyses showed that "peripouch fat area increase ≥ 15%" (OR 3.808, 95%CI 1.703-8.517, P = 0.001) was an independent predictor of pouch failure.A great peripouch fat area measured on CT image is associated with a higher prevalence of CARP, and the accumulation of peripouch fat is a risk factor for pouch failure. The assessment of peripouch fat may be used to monitor the disease course of the ileal pouch.

Background The structures of the mesentery including adipose tissue, nerves, and lymphatics play an important role in the pathogenesis and disease progression of Crohn’s disease (CD). Conventional surgical resection for CD usually does not involve resecting the mesentery en bloc with the specimen. This contrasts with complete mesocolic excision (CME) in colorectal cancer, which involves radical resection of the mesentery. Preliminary evidence from smaller studies suggests that applying the principle of mesocolic excision to CD surgery may reduce the risk of postoperative recurrence. This randomized controlled trial is designed to test whether applying the principles of mesocolic excision to CD results in reduced postoperative recurrence. It also aims to evaluate intra- and postoperative morbidity between the two approaches. Methods This international, multicenter, randomized controlled trial will randomize patients (n = 116) scheduled to undergo primary ileocolic resection to either receive extensive mesenteric excision (EME) or conventional ileocolic resection with limited mesenteric excision (LME). Five sites will recruit patients in three countries. In the EME group, the mesentery is resected following CME, while avoiding the root region, i.e., 1 cm from the root of the ileocolic artery and vein. In the LME group, the mesentery is retained, i.e., “close shave” or Discussion If mesocolic excision in CD reduces postoperative disease recurrence and does not increase morbidity, this trial has the potential to change practice and reduce recurrence of CD after surgical resection. Trial registration Clinical Trials.gov, ID: NCT03769922. Registered on February 27, 2019.

Background Restorative total proctocolectomy with IPAA may not be feasible in some patients because of technical intraoperative limitations. Objective This study aimed to assess preoperative predictors for intraoperative IPAA and review management. Design This is a retrospective review. Setting This study was conducted at Cleveland Clinic between January 2010 and May 2018. Patients Patients ≥18 years of age who underwent ileoanal pouch surgery were included. Patients with successful pouch creation as planned were grouped as "successful IPAA creation." Operative reports of patients who underwent alternative procedures were reviewed to identify cases when the pouch was preoperatively planned but intraoperatively abandoned (IPAA-abandoned group). Multivariate logistic regression models were developed to determine predictors of intraoperative pouch abandonment. We also reviewed the management of patients in whom the initial pouch creation failed. Main outcome measures The primary outcomes measured were preoperative predictors for intraoperative ileoanal pouch abandonment. Results A total of 1438 patients were offered an ileoanal pouch; 21 (1.5%) experienced pouch abandonment due to inadequate reach (n = 17) and other technical reasons (n = 4). These patients underwent alternative procedures such as end or loop ileostomy with/without proctectomy. Multivariate logistic regression analysis indicated male sex (OR, 6.021; 95% CI, 1.540-23.534), BMI (OR, 1.217; 95% CI, 1.114-1.329), and a 2-stage procedure (OR, 14.510; 95% CI, 4.123-51.064) as independent factors associated with intraoperative abandonment of pouch creation. Alternative procedures were total proctocolectomy with end ileostomy (n = 14) and total abdominal colectomy with end ileostomy without proctectomy (n = 7). Ultimately, pouch creation was achieved in 6 of 21 patients after a median interval of 8.8 (range, 4.1-34.8) months. All patients had intentional weight loss before a reattempt and total abdominal colectomy with end ileostomy without proctectomy as their initial procedure. Limitations This study was limited by its retrospective nature. Conclusions Ileoanal pouch abandonment is rare and can be mitigated by initial total abdominal colectomy and weight loss. Male, obese patients are at a higher risk of failure. Intraoperative assessment of ileoanal pouch feasibility should occur before rectal dissection. See Video Abstract at http://links.lww.com/DCR/B156. PREDICCION MULTIVARIANTE DEL ABANDONO INTRAOPERATORIO DE LA ANASTOMOSIS ANAL CON BOLSA ILEAL: La proctocolectomia total restaurativa con anastomosis de bolsa ileoanal puede no ser posible en algunos pacientes debido a limitaciones tecnicas intraoperatorias.Evaluar los predictores preoperatorios para el abandono intraoperatorio de la bolsa ileoanal y revisar el manejo.Revision retrospectiva.Cleveland Clinic entre Enero de 2010 y mayo de 2018.Pacientes > 18 anos que se sometieron a cirugia de bolsa ileoanal. Los pacientes con una creacion exitosa de la bolsa segun lo planeado se agruparon como "creacion exitosa de anastomosis de bolsa ileoanal". Se revisaron los informes operativos de los pacientes que se sometieron a procedimientos alternativos para identificar los casos en que la bolsa se planifico preoperatoriamente pero se abandono intraoperatoriamente (grupo de "anastomosis anal de bolsa ileoanal abandonada"). Se desarrollaron modelos de regresion logistica multivariante para determinar los predictores del abandono intraoperatorio de la bolsa. Tambien revisamos el manejo de pacientes que fallaron en la creacion inicial de la bolsa.Predictores preoperatorios para el abandono intraoperatorio de la bolsa ileoanal.A un total de 1438 pacientes se les ofrecio una bolsa ileoanal; 21 (1.5%) experimentaron abandono de la bolsa debido a un alcance inadecuado (n = 17) y otras razones tecnicas (n = 4). Estos pacientes se sometieron a procedimientos alternativos como ileostomia final o de asa con / sin proctectomia. El analisis de regresion logistica multivariante indico genero masculino (OR, 6.021; IC 95%, 1.540-23.534), indice de masa corporal (OR, 1.217; IC 95%, 1.114-1.329) y procedimiento en 2 etapas (OR, 14.510; IC 95%, 4.123-51.064) como factores independientes asociados con el abandono intraoperatorio de la creacion de la bolsa. Los procedimientos alternativos fueron la proctocolectomia total con ileostomia final (n = 14) y la colectomia abdominal total con ileostomia final sin proctectomia (n = 7). Finalmente, la creacion de la bolsa se logro en 6/21 pacientes despues de un intervalo medio de 8.8 (rango, 4.1-34.8) meses. Todos los pacientes tuvieron perdida de peso intencional antes de la reintenta y colectomia abdominal total con ileostomia final sin proctectomia como procedimiento inicial.Naturaleza retrospectiva.El abandono de la bolsa ileoanal es raro y puede mitigarse mediante la colectomia abdominal total inicial y la perdida de peso. Los pacientes masculinos y obesos tienen un mayor riesgo de fracaso. La evaluacion intraoperatoria de la viabilidad de la bolsa ileoanal debe ocurrir antes de la diseccion rectal. Consulte Video Resumen en http://links.lww.com/DCR/B156. (Traduccion-Dr. Yesenia Rojas-Kahlil).

Both saline and lactated Ringer's solutions are commonly given to surgical patients. However, hyperchloremic acidosis consequent to saline administration may provoke complications. The authors therefore tested the primary hypothesis that a composite of in-hospital mortality and major postoperative complications is less common in patients given lactated Ringer's solution than normal saline.The authors conducted an alternating cohort controlled trial in which adults having colorectal and orthopedic surgery were given either lactated Ringer's solution or normal saline in 2-week blocks between September 2015 and August 2018. The primary outcome was a composite of in-hospital mortality and major postoperative renal, respiratory, infectious, and hemorrhagic complications. The secondary outcome was postoperative acute kidney injury.Among 8,616 qualifying patients, 4,187 (49%) were assigned to lactated Ringer's solution, and 4,429 (51%) were assigned to saline. Each group received a median 1.9 l of fluid. The primary composite of major complications was observed in 5.8% of lactated Ringer's versus 6.1% of normal saline patients, with estimated average relative risk across the components of the composite of 1.16 (95% CI, 0.89 to 1.52; P = 0.261). The secondary outcome, postoperative acute kidney injury, Acute Kidney Injury Network stage I-III versus 0, occurred in 6.6% of lactated Ringer's patients versus 6.2% of normal saline patients, with an estimated relative risk of 1.18 (99.3% CI, 0.99 to 1.41; P = 0.009, significance criterion of 0.007). Absolute differences between the treatment groups for each outcome were less than 0.5%, an amount that is not clinically meaningful.In elective orthopedic and colorectal surgery patients, there was no clinically meaningful difference in postoperative complications with lactated Ringer's or saline volume replacement. Clinicians can reasonably use either solution intraoperatively.

Background Hypotension compromises local tissue perfusion, thereby reducing tissue oxygenation. Hypotension might thus be expected to promote infection. Hypotension on surgical wards, while usually less severe than intraoperative hypotension, is common and often prolonged. In this retrospective cohort study, we tested the hypotheses that there is an association between surgical site infections and low postoperative time-weighted average mean arterial pressure and/or postoperative minimum mean arterial pressure. Methods We considered patients who had colorectal surgery lasting ≥1 hour at the Cleveland Clinic between 2009 and 2013. We defined blood pressure exposures as time-weighted average (primary) and minimum mean arterial pressure (secondary) within 72 hours after surgery. We assessed associations between continuous blood pressure exposures with a composite of deep and superficial surgical site infection using separate severity-weighted average relative effect generalized estimating equations models, each using an unstructured correlation structure and adjusting for potentially confounding variables. Results A total of 5896 patients were eligible for analysis. Time-weighted mean arterial pressure and surgical site infection were not significantly associated, with an estimated odds ratio (95% CI) of 1.03 (0.99-1.08) for a 5-mm Hg decrease (P = .16). However, there was a significant inverse association between minimum postoperative mean arterial pressure and infection, with an estimated odds ratio of 1.08 (1.03-1.12) per 5-mm Hg decrease (P = .001). Conclusions Postoperative time-weighted mean arterial pressure was not associated with surgical site infection, but lowest postoperative mean arterial pressure was. Whether the relationship is causal remains to be determined.

Splenic injury can occur during colorectal surgery especially in cases, where the splenic flexure is mobilized. The aim of this study was to analyze whether the operative approach (laparoscopic vs. open) was associated with an increased risk for splenic injury during colorectal surgery and to compare the outcomes of different management options. All accidental injuries that occurred during colorectal resections performed in our department between January 2010 and June 2013 were identified from an administrative database. All patients with iatrogenic splenic injuries were classified into two groups according to the operative approach. Only procedures that required splenic flexure mobilization were included. Splenic injury management options and outcomes were compared. There were 2336 colorectal resections (1520 open, 816 laparoscopic) performed during the study period. There were 25 (1.1%) iatrogenic splenic injuries. 23 out of 25 splenic injuries occurred during open colorectal surgery. Overall, 16 (64%) patients were managed with topical hemostatic methods, 5 (20%) with splenectomy, and 4 (16%) with splenorrhaphy. It was possible to salvage the spleen in both laparoscopic patients. The laparoscopic approach was associated with a lower splenic injury rate (0.25% vs. 1.5%, p = 0.005) and a lower need for splenectomy/splenorrhaphy (p = 0.03). Our data suggest that laparoscopic colorectal surgery may be associated with a lower risk of iatrogenic splenic injury, and that most splenic injuries can be managed with spleen-preserving approaches.

The role of omentoplasty in the prevention of anastomotic leak (AL) in colorectal surgery is controversial. The aim of this study was to evaluate the impact of omentoplasty on AL and septic complications after low pelvic anastomosis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The ACS-NSQIP database was queried for patients who underwent segmental colectomy with low pelvic anastomosis by using 2012 targeted colectomy participant use data file. Patients were divided into two groups according to omentoplasty versus no-omentoplasty formation. AL and surgical site infections (SSIs) within postoperative 30 days were compared between the groups. A total of 2891 patients (1447 [50.1%] males) with a mean age of 60.2 ± 13.0 years met the inclusion criteria. There were 86 (2.9%) and 2805 (97.1%) patients in the omentoplasty and no-omentoplasty group, respectively. In the multivariate analysis, omentoplasty neither reduced AL (p = 0.83; OR = 0.88, 95% CI, 0.21–2.44) nor organ/space SSIs (p = 0.08; OR = 2.14, 95% CI, 0.91–4.41). Also, this technique did not play any role in reducing AL and organ/space SSI rates regardless of diversion with the exception of its association with higher organ/space SSIs in patients without diverting stoma (9.2% vs 3.8%, p = 0.04). No differences were detected between the groups with respect to the management strategies for AL (p = 0.22). Omentoplasty did not decrease AL and septic complications after low pelvic anastomosis and had no impact on the postoperative management of AL.

Few studies have compared endoscopic balloon dilation (EBD) with ileocolic resection (ICR) in the treatment of primary ileocolic strictures in patients with Crohn's disease (CD).We performed a retrospective study to compare postprocedure morbidity and surgery-free survival among 258 patients with primary stricturing ileo(colic) CD (B2, L1, or L3) initially treated with primary EBD (n = 117) or ICR (n = 258) from 2000 through 2016. Patients with penetrating disease were excluded from the study. We performed multivariate analyses to evaluate factors associated with surgery-free survival.Postprocedural complications occurred in 4.7% of patients treated with EBD and salvage surgery was required in 44.4% of patients. Factors associated with reduced surgery-free survival among patients who underwent EBD included increased stricture length (hazard ratio, 2.0; 95% CI, 1.3-3.3), ileocolonic vs ileal disease (hazard ratio, 10.9; 95% CI, 2.6-45.4), and decreased interval between EBD procedures (hazard ratio, 1.2; 95% CI, 1.1-1.4). There were no significant differences in sex, age, race, or CD duration between EBD and ICR groups. Patients treated with ICR were associated with more common postoperative adverse events (32.2%; P.0001), but a reduced need for secondary surgery (21.7%; P.0001) and significantly longer surgery-free survival (11.1 ± 0.6 vs 5.4 ± 0.6 y; P.001).In this retrospective study, we found that although EBD is initially successful with minimal adverse events, there is a high frequency of salvage surgery. Initial ICR is associated with a higher morbidity but a longer surgery-free interval. The risks and benefits should be balanced in selecting treatments for individual patients.

Laparoscopic ileal pouch–anal anastomosis (IPAA) is associated with recovery benefits when compared with open IPAA. There is limited data on long-term quality of life and functional outcomes, which this study aimed to assess. An IRB-approved, prospectively maintained database was queried to identify patients undergoing laparoscopic IPAA (L), case-matched with open IPAA (O) based on age ± 5 years, gender, body mass index (BMI) ± 5 kg/m2, diagnosis, date of surgery ± 3 years, stapled/handsewn anastomosis, omission of diverting loop ileostomy and length of follow-up ± 3 years. We assessed functional results, dietary, social, work, sexual restrictions and the Cleveland Clinic global quality of life score (CGQoL) at 1, 2, 3, 4, 5 and 10 years postoperatively. Functional outcomes were assessed based on number of stools (day/night) and seepage protection use (day/night). Variables were evaluated with Kaplan–Meier survival curves, uni- and multivariable analyses. Out of 4595 IPAAs, 529 patients underwent L, of whom 404 patients were well matched 1:1 to an equivalent number of O based on all criteria. Median follow-ups were 2 (0.5–17.8) versus 2.4 (0.5–22.2) years in L versus O, respectively (p = 0.18). L was associated with significantly decreased number of stools at night and less frequent pad usage at 1 year, both during the day and at night. Functional outcomes became similar during further follow-up. L was also associated with improved overall CGQoL, and energy scores at 1 year postoperatively, and decreased social restrictions for 1–2 years. There were no significant differences in quality of health, dietary, work or sexual restrictions. Laparoscopy was not associated with increased risk of pouch failure (p = 0.07) or significantly different causes of pouch failure when compared to O. Laparoscopic and open IPAA are associated with equivalent long-term functional outcomes, quality of life and pouch survival rates. Laparoscopic technique is associated with temporary benefits lasting 1 or 2 years.

Intestinal obstruction is a leading cause of patient mortality and the most common reason for emergent operation in colorectal surgery. The influence of inter-hospital transfer on patients' outcomes varies greatly in different diseases. We aimed to compare the surgical outcomes and medical costs between transferred and directly admitted patients diagnosed with intestinal obstruction in an American tertiary referral center.All intestinal obstruction patients operated in Cleveland Clinic from Jan 2012 to Dec 2016 were collected from a prospectively maintained database. Preoperative characteristics; surgical outcomes, including intraoperative complication, postoperative complication, readmission, reoperation, and postoperative 30-day mortality; and medical cost were collected. All parameters were compared between two groups before and after propensity score match. Multivariate logistic analysis was used to explore risk factors of surgical outcomes.A total of 576 patients were included, with 75 in the transferred group and 501 in the directly admitted group. Before match, the transferred patients had longer waiting interval from admission to surgery (p 0.001), more contaminated or infected wounds (p = 0.02), different surgical procedures (p = 0.02), and similar surgical outcomes and total medical cost (all p 0.05), compared with the directly admitted group. Multivariate analysis showed that inter-hospital transfer was not an independent predictor of any surgical outcome. After matching to balance the preoperative characteristics between two groups, no significant differences were identified in all surgical outcomes and total medical cost between two groups (all p 0.05).Compared with directly admitted patients, transferred intestinal obstruction patients are associated with similar surgical outcomes and similar medical costs.

Porto-mesenteric venous thrombosis (PMVT) is an uncommon but serious complication. Data on the risk factors for PMVT following total colectomy with ileorectal anastomosis or end ileostomy (TC/IRA or EI) is limited. This study aimed to evaluate the factors associated with PMVT after TC/IRA or EI.Patients who underwent elective TC/IRA or EI between January 2010 and December 2014 were identified from institutional database. Patients who had CT proven PMVT within 30 days of surgery were included in the PMVT positive group. Demographics and perioperative/postoperative 30-day outcomes were compared between groups.Out of 832 patients, 34 patients (4.1%) were diagnosed with PMVT. PMVT positive group were younger (35.8vs.41 years, p = 0.03). Postoperative organ-space surgical site infection (17.6% vs. 4.8%, p = 0.007), deep venous thrombosis (8.8%vs.1.5%, p = 0.02), ileus (38.2%vs.20.8%, p = 0.018), and readmission (50.0%vs.12.7%, p 0.001) were more common in patients with PMVT, who also had longer hospital stay (8.5vs.6 days, p = 0.002).PMVT after TC/IRA or EI may occur in non-IBD patients. PMVT should be included in differential diagnosis after TC/IRA or EI in patients with intraabdominal infection or ileus, especially in younger patients.

Surgical site infections are the most common hospital-acquired infection after colorectal surgery, increasing morbidity, mortality, and hospital costs.The purpose of this study was to investigate the impact of preventive measures on colorectal surgical site infection rates in a high-volume institution that performs inherent high-risk procedures.This was a prospective cohort study.The study was conducted at a high-volume, specialized colorectal surgery department.The Prospective Surgical Site Infection Prevention Bundle Project included 14 preoperative, intraoperative, and postoperative measures to reduce surgical site infection occurrence after colorectal surgery. Surgical site infections within 30 days of the index operation were examined for patients during the 1-year period after the surgical site infection prevention bundle was implemented. The data collection and outcomes for this period were compared with the year immediately before the implementation of bundle elements. All of the patients who underwent elective colorectal surgery by a total of 17 surgeons were included. The following procedures were excluded from the analysis to obtain a homogeneous patient population: ileostomy closure and anorectal and enterocutaneous fistula repair.Surgical site infection occurring within 30 days of the index operation was measured. Surgical site infection-related outcomes after implementation of the bundle (bundle February 2014 to February 2015) were compared with same period a year before the implementation of bundle elements (prebundle February 2013 to February 2014).Between 2013 and 2015, 2250 abdominal colorectal surgical procedures were performed, including 986 (43.8%) during the prebundle period and 1264 (56.2%) after the bundle project. Patient characteristics and comorbidities were similar in both periods. Compliance with preventive measures ranged between 75% and 99% during the bundle period. The overall surgical site infection rate decreased from 11.8% prebundle to 6.6% at the bundle period (P0.001). Although a decrease for all types of surgical site infections was observed after the bundle implementation, a significant reduction was achieved in the organ-space subgroup (5.5%-1.7%; P0.001).We were unable to predict the specific contributions the constituent bundle interventions made to the surgical site infection reduction.The prospective Surgical Site Infection Prevention Bundle Project resulted in a substantial decline in surgical site infection rates in our department. Collaborative and enduring efforts among multiple providers are critical to achieve a sustained reduction See Video Abstract at http://links.lww.com/DCR/A438.

A total of 27 pouch patients with inflammatory bowel diseases, who underwent pelvic MRI-DIXON and CT scan within one year, were included. Peripouch fat areas were measured at the middle height level of pouch (AreaM) and the highest level of pouch (AreaH). Our results demonstrated that measurements of perianal fat thickness, AreaM and AreaH based on MRI image were accurate and reproducible (correlation efficiency(r): intraobserver: 0.984–0.991; interobserver: 0.969–0.971; all P

The aim of the present study was to create a unique risk adjustment model for surgical site infection (SSI) in patients who underwent colorectal surgery (CRS) at the Cleveland Clinic (CC) with inherent high risk factors by using a nationwide database. The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients who underwent CRS between 2005 and 2010. Initially, CC cases were identified from all NSQIP data according to case identifier and separated from the other NSQIP centers. Demographics, comorbidities, and outcomes were compared. Logistic regression analyses were used to assess the association between SSI and center-related factors. A total of 70,536 patients met the inclusion criteria and underwent CRS, 1090 patients (1.5%) at the CC and 69,446 patients (98.5%) at other centers. Male gender, work-relative value unit, diagnosis of inflammatory bowel disease, pouch formation, open surgery, steroid use, and preoperative radiotherapy rates were significantly higher in the CC cases. Overall morbidity and individual postoperative complication rates were found to be similar in the CC and other centers except for the following: organ-space SSI and sepsis rates (higher in the CC cases); and pneumonia and ventilator dependency rates (higher in the other centers). After covariate adjustment, the estimated degree of difference between the CC and other institutions with respect to organ-space SSI was reduced (OR 1.38, 95% CI 1.08–1.77). The unique risk adjustment strategy may provide center-specific comprehensive analysis, especially for hospitals that perform inherently high-risk procedures. Higher surgical complexity may be the reason for increased SSI rates in the NSQIP at tertiary care centers.