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BACKGROUND: We recently described a cluster of symptoms known as twisted pouch syndrome that rarely affects patients with ileoanal pouches. Herein, we present a narrative review in which we describe the diagnosis, treatment, and prevention of twisted pouch syndrome, with a focus on a simple classification schema. METHODS: Diagnostic signs from endoscopic and radiological examinations, treatment, and prevention strategies are presented. RESULTS: Patients with twisted pouch syndrome suffer from a triad of obstructive symptoms, erratic bowel habits, and pain which may be severe, debilitating visceral pain, all in the setting of a mechanical pouch abnormality. Diagnostic modalities include imaging, careful pouchoscopy, functional testing, diagnostic laparoscopy or laparotomy, and recently 3-dimensional pouchography. Classification of twisted pouch syndrome is based on the location and degree of rotation of the pouch and its mesentery. Outlet twists may result when the distal pouch rotates >90° to 360° clockwise inadvertently during anastomosis; when only the distal most pouch is twisted, it results in an iris-like deformity of the pouch outlet, or when the distal half of the pouch is twisted, a mid-pouch stenosis and an hourglass-shaped pouch may result. Inlet twists are either a full 360° (mesentery posterior), unintentional 180° (mesentery anterior), or 90° counterclockwise twists. Both inlet and outlet twists are fixed deformities and may only be reduced by disconnecting the entire pouch from the anus. If they result in twisted pouch syndrome, a redo pouch procedure or pouch excision is required to reduce the twist; 90° counterclockwise twists may undergo pouch inlet transposition. Adhesive twists result when the pouch becomes fixed in the pelvis in an abnormal configuration, such as when the efferent limb becomes twisted underneath the afferent limb secondary to an occult tip of the J leak, and may be reduced by pelvic adhesiolysis with or without pouch revision. CONCLUSIONS: Pouches may rarely be inadvertently twisted during construction or twisted owing to adhesive disease or leaks. A high index of suspicion is needed to establish the diagnosis. We present a simple classification of twisted pouch syndrome that may aid in the prevention and recognition of these often difficult to diagnose postoperative complications.
In this article, we report a simple classification system for the mechanical pouch complication known as twisted pouch syndrome, including diagnostic signs from endoscopic and radiological examinations, treatment, and prevention strategies.
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The diagnosis of long rectal cuff syndrome may be considered in patients with persistent rectal bleeding after ileal pouchanal anastomosis. Pouch salvage with excision of residual rectum and conversion to an ileoanal anastomosis offers patients the chance to achieve stoma-free survival.
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BACKGROUND & AIMS: Perianal fistulizing Crohn's disease (PFCD)-associated anorectal and fistula cancers are rare but often devastating diagnoses. However, given the low incidence and consequent lack of data and clinical trials in the field, there is little to no guidance on screening and management of these cancers. To inform clinical practice, we developed consensus guidelines on PFCD-associated anorectal and fistula cancers by multidisciplinary experts from the international TOpClass consortium. METHODS: We conducted a systematic review by standard methodology, using the Newcastle-Ottawa Scale quality assessment tool. We subsequently developed consensus statements using a Delphi consensus approach. RESULTS: Of 561 articles identified, 110 were eligible, and 76 articles were included. The overall quality of evidence was low. The TOpClass consortium reached consensus on 6 structured statements addressing screening, risk assessment, and management of PFCD-associated anorectal and fistula cancers. Patients with long-standing (>10 years) PFCD should be considered at small but increased risk of developing perianal cancer, including squamous cell carcinoma of the anus and anorectal carcinoma. Risk factors for squamous cell carcinoma of the anus, notably human papilloma virus, should be considered. New, refractory, or progressive perianal symptoms should prompt evaluation for fistula cancer. There was no consensus on timing or frequency of screening in patients with asymptomatic perianal fistula. Multiple modalities may be required for diagnosis, including an examination under anesthesia with biopsy. Multidisciplinary team efforts were deemed central to the management of fistula cancers. CONCLUSIONS: Inflammatory bowel disease clinicians should be aware of the risk of PFCD-associated anorectal and fistula cancers in all patients with PFCD. The TOpClass consortium consensus statements outlined herein offer guidance in managing this challenging scenario.
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AIM: Recent evidence challenges the current standard of offering surgery to patients with ileocaecal Crohn's disease (CD) only when they present complications of the disease. The aim of this study was to compare short-term results of patients who underwent primary ileocaecal resection for either inflammatory (luminal disease, earlier in the disease course) or complicated phenotypes, hypothesizing that the latter would be associated with worse postoperative outcomes. METHOD: A retrospective, multicentre comparative analysis was performed including patients operated on for primary ileocaecal CD at 12 referral centres. Patients were divided into two groups according to indication of surgery for inflammatory (ICD) or complicated (CCD) phenotype. Short-term results were compared. RESULTS: A total of 2013 patients were included, with 291 (14.5%) in the ICD group. No differences were found between the groups in time from diagnosis to surgery. CCD patients had higher rates of low body mass index, anaemia (40.9% vs. 27%, p < 0.001) and low albumin (11.3% vs. 2.6%, p < 0.001). CCD patients had longer operations, lower rates of laparoscopic approach (84.3% vs. 93.1%, p = 0.001) and higher conversion rates (9.3% vs. 1.9%, p < 0.001). CCD patients had a longer hospital stay and higher postoperative complication rates (26.1% vs. 21.3%, p = 0.083). Anastomotic leakage and reoperations were also more frequent in this group. More patients in the CCD group required an extended bowel resection (14.1% vs. 8.3%, p: 0.017). In multivariate analysis, CCD was associated with prolonged surgery (OR 3.44, p = 0.001) and the requirement for multiple intraoperative procedures (OR 8.39, p = 0.030). CONCLUSION: Indication for surgery in patients who present with an inflammatory phenotype of CD was associated with better outcomes compared with patients operated on for complications of the disease. There was no difference between groups in time from diagnosis to surgery.
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Doença de Crohn , Íleo , Fenótipo , Complicações Pós-Operatórias , Humanos , Doença de Crohn/cirurgia , Doença de Crohn/complicações , Feminino , Estudos Retrospectivos , Masculino , Adulto , Resultado do Tratamento , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/epidemiologia , Pessoa de Meia-Idade , Íleo/cirurgia , Adulto Jovem , Ceco/cirurgia , Laparoscopia/métodos , Laparoscopia/estatística & dados numéricos , Laparoscopia/efeitos adversos , Duração da Cirurgia , Tempo de Internação/estatística & dados numéricos , Fatores de TempoRESUMO
PURPOSE: Limited data exist regarding the surgical outcomes of acute colonic pseudo-obstruction (ACPO), commonly referred to as Ogilvie syndrome, in modern clinical practice. The prevailing belief is that surgery should be avoided due to previously reported high mortality rates. We aimed to describe the surgical results of ACPO treated within our institution. METHODS: Our prospectively maintained colorectal surgery registry was queried for patients diagnosed with ACPO, who underwent surgery between 2009 and 2022. Postoperative complications were graded according to Clavien-Dindo (CD) classification. The primary outcome was postoperative mortality. RESULTS: A total of 32 patients who underwent surgery for ACPO were identified. Overall, nonoperative therapy was initially administered to 21 patients (65.6%). The surgeries performed included total abdominal colectomy (15, 43.1%), ascending colectomy with end ileostomy (8, 25%), transverse colostomy (5, 15.6%), ileostomy and transverse colostomy (3, 9.4%), and Hartmann's operation (1, 3.1%). Severe postoperative complications (CD grade 3 or 4) occurred in five patients (15.6%). No recurrence of ACPO was observed and no patient required reoperation. The average postoperative length of stay was 14.5 days, 30-day mortality was 6.3% (n = 2), and 90-day mortality was 15.6% (n = 5) due to complications of underlying comorbidities. CONCLUSIONS: Surgical treatment was effective for patients with ACPO refractory to medical therapy or presenting with acute complications. Although postoperative complications were frequent, both the 30- and 90-day mortality rates were lower than previously documented in the literature. Further investigations are warranted to determine the optimal surgical strategy, which may involve total or segmental colectomy, or diversion alone without resection.
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Colectomia , Pseudo-Obstrução do Colo , Complicações Pós-Operatórias , Humanos , Pseudo-Obstrução do Colo/cirurgia , Pseudo-Obstrução do Colo/mortalidade , Masculino , Feminino , Estudos Retrospectivos , Idoso , Pessoa de Meia-Idade , Colectomia/métodos , Complicações Pós-Operatórias/etiologia , Doença Aguda , Resultado do Tratamento , Adulto , Idoso de 80 Anos ou mais , Tempo de Internação , Sistema de RegistrosRESUMO
BACKGROUND: Medically refractory ulcerative colitis necessitates surgical intervention, with total abdominal colectomy with end ileostomy being a definitive treatment. The comparison between single-port and multiport laparoscopic surgery outcomes remains underexplored. OBJECTIVE: To compare the surgical outcomes of single-port versus multiport laparoscopic surgery in patients undergoing total abdominal colectomy with end ileostomy for medically refractory ulcerative colitis. DESIGN: A retrospective analysis comparing single-port to multiport surgery in patients with ulcerative colitis from 2010 to 2020. Patients were propensity score-matched 3:1 (multiport to single-port) on baseline characteristics. SETTINGS: Single-center academic hospital. PATIENTS: A total of 756 patients with medically refractory ulcerative colitis who underwent multiport vs single-port total abdominal colectomy with end ileostomy from 2010 to 2020 were included. MAIN OUTCOME MEASURES: Binary outcomes were compared using a multivariable logistic regression model, and a subset analysis was conducted for postoperative stump leak based on stump implantation during surgery. These metrics were compared between the single-port and multiport groups to assess the differences in surgical outcomes. RESULTS: The multiport and single-port groups included 642 and 114 patients, respectively. The matched cohort included 342 multiports and 114 single ports. We observed a statistically significant difference in mean operation time, with the single-port procedure taking 43 minutes less than the multiport laparoscopy. There were no significant differences between the 2 groups in postoperative stump leaks, postoperative ileus, stoma site complications, postoperative readmission within 30 days, postoperative reoperation within 30 days, and subsequent IPAA surgery. In the subset analysis, stump implantation was associated with a higher risk of stump leak in the multiport group. The single-port group had a shorter hospital stay. LIMITATIONS: Retrospective nature and being conducted at a single center. CONCLUSION: Single-incision laparoscopic total abdominal colectomy in the treatment of mucosal ulcerative colitis is a safe, effective, and efficient approach. In our cohort, single-incision laparoscopy has had shorter operation times and better overall length of stay compared with the multiport approach. Taking into account a less invasive approach, decreased abdominal trauma, and faster recovery, single-port surgery is a viable alternative to multiport surgery. See Video Abstract . UN ANLISIS EMPAREJADO POR PUNTUACIN DE PROPENSIN DE LA COLECTOMA ABDOMINAL TOTAL LAPAROSCPICA CON PUERTO NICO VERSUS PUERTO MLTIPLE CON ILEOSTOMA TERMINAL PARA LA COLITIS ULCEROSA MDICAMENTE REFRACTARIA: ANTECEDENTES:La colitis ulcerosa (CU) médicamente refractaria requiere una intervención quirúrgica, siendo la colectomía abdominal total con ileostomía terminal un tratamiento definitivo. La comparación entre los resultados de la cirugía laparoscópica con puerto único y con puerto múltiple aún no se ha explorado lo suficiente.OBJETIVO:Comparar los resultados quirúrgicos de la cirugía laparoscópica con puerto único versus con puerto múltiple en pacientes sometidos a colectomía abdominal total con ileostomía terminal para CU médicamente refractaria.DISEÑO:Un análisis retrospectivo que comparó la cirugía de puerto único con la de puerto múltiple en pacientes con CU de 2010 a 2020. Los pacientes fueron emparejados por puntuación de propensión 3:1 (puerto múltiple a puerto único) según las características iniciales.AJUSTES:Hospital académico unicentrico.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados binarios se compararon utilizando un modelo de regresión logística multivariable y se realizó un análisis de subconjunto para la fuga postoperatoria del muñón basado en la implantación del muñón durante la cirugía. Estas métricas se compararon entre los grupos de puerto único y de puerto múltiple para evaluar las diferencias en los resultados quirúrgicos.RESULTADOS:Los grupos de puerto único y multipuerto incluyeron 642 y 114 pacientes, respectivamente. La cohorte emparejada incluyó 342 puertos múltiples y 114 puertos únicos. Observamos una diferencia estadísticamente significativa en el tiempo medio de operación, ya que el procedimiento de puerto único duró 43 minutos menos que la laparoscopia de puerto múltiple. No hubo diferencias significativas entre los dos grupos en las fugas del muñón posoperatorio, el íleo posoperatorio, las complicaciones del sitio del estoma, el reingreso posoperatorio dentro de los 30 días, la reoperación posoperatoria dentro de los 30 días y la cirugía IPAA posterior. En el análisis de subconjunto, la implantación del muñón se asoció con un mayor riesgo de fuga del muñón en el grupo multipuerto. El grupo de puerto único tuvo una estancia hospitalaria más corta.LIMITACIONES:Carácter retrospectivo, realizándose en un único centro.CONCLUSIÓN:La colectomía abdominal total laparoscópica de incisión única en el tratamiento de la colitis ulcerosa mucosa es un enfoque seguro, eficaz y eficiente. En nuestra cohorte, en comparación con el abordaje multipuerto, la laparoscopia de incisión única ha mostrado tiempos de operación más cortos y una mejor duración total de la estancia hospitalaria. Teniendo en cuenta un enfoque menos invasivo, un menor traumatismo abdominal y una recuperación más rápida, la cirugía con puerto único es una alternativa viable a la cirugía con puertos múltiples. (Traducción-Dr. Mauricio Santamaria ).
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Colectomia , Colite Ulcerativa , Ileostomia , Laparoscopia , Pontuação de Propensão , Humanos , Colite Ulcerativa/cirurgia , Masculino , Feminino , Ileostomia/métodos , Ileostomia/efeitos adversos , Laparoscopia/métodos , Colectomia/métodos , Estudos Retrospectivos , Adulto , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Duração da Cirurgia , Resultado do Tratamento , Tempo de Internação/estatística & dados numéricosRESUMO
BACKGROUND: Postoperative recurrence of Crohn's disease (CD) is common. While most patients undergo resection with undiverted anastomosis (UA), some individuals also have creation of an intended temporary diversion (ITD) with an ileostomy followed by ostomy takedown (OT) due to increased risk of anastomotic complications. We assessed the association of diversion with subsequent CD recurrence risk and the influence of biologic prophylaxis timing to prevent recurrence in this population. METHODS: This was a retrospective cohort study of CD patients who underwent ileocolic resection between 2009 and 2020 at a large quaternary health system. Patients were grouped by continuity status after index resection (primary anastomosis or ITD). The outcomes of the study were radiographic, endoscopic, and surgical recurrence as well as composite recurrence postoperatively (after OT in the ITD group). Propensity score-weighted matching was performed based on risk factors for diversion and recurrence. Multivariable regression and a Cox proportional hazards model adjusting for recurrence risk factors were used to assess association with outcomes. Subgroup analysis in the ITD group was performed to assess the impact of biologic timing relative to OT (no biologic, biologic before OT, after OT) on composite recurrence. RESULTS: A total of 793 CD patients were included (mean age 38 years, body mass index 23.7 kg/m2, 52% female, 23% active smoker, 50% penetrating disease). Primary anastomosis was performed in 67.5% (nâ =â 535) and ITD in 32.5% (nâ =â 258; 79% loop, 21% end) of patients. Diverted patients were more likely to have been males and to have had penetrating and perianal disease, prior biologic use, lower body mass index, and lower preoperative hemoglobin and albumin (all Pâ <â .01). After a median follow-up of 44 months, postoperative recurrence was identified in 83.3% patients (radiographic 40.4%, endoscopic 39.5%, surgical 13.3%). After propensity score matching and adjusting for recurrence risk factors, no significant differences were seen between continuity groups in radiographic (adjusted hazard ratio [aHR], 1.32; 95% confidence interval [CI], 0.91-1.91) or endoscopic recurrence (aHR, 1.196; 95% CI, 0.84-1.73), but an increased risk of surgical recurrence was noted in the ITD group (aHR, 1.61; 95% CI, 1.02-2.54). Most (56.1%) ITD patients started biologic prophylaxis after OT, 11.4% before OT, and 32.4% had no postoperative biologic prophylaxis. Biologic prophylaxis in ITD was associated with younger age (Pâ <â .001), perianal disease (Pâ =â .04), and prior biologic use (Pâ <â .001) but not in recurrence (Pâ =â .12). Despite higher rates of objective disease activity identified before OT, biologic exposure before OT was not associated with a significant reduction in composite post-OT recurrence compared with starting a biologic after OT (52% vs 70.7%; Pâ =â 0.09). CONCLUSIONS: Diversion of an ileocolic resection is not consistently associated with a risk of postoperative recurrence and should be performed when clinically appropriate. Patients requiring diversion at time of ileocolic resection are at high risk for recurrence, and biologic initiation prior to stoma reversal may be considered.
Diversion of an ileocolic resection is not consistently associated with a risk of postoperative recurrence and should be performed when clinically appropriate. Patients requiring diversion at time of ileocolic resection are high risk for recurrence, and biologic initiation prior to stoma reversal may be considered.
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Background: Since 2009, inflammatory bowel disease (IBD) specialists have utilized "IBD LIVE," a weekly live video conference with a global audience, to discuss the multidisciplinary management of their most challenging cases. While most cases presented were confirmed IBD, a substantial number were diseases that mimic IBD. We have categorized all IBD LIVE cases and identified "IBD-mimics" with consequent clinical management implications. Methods: Cases have been recorded/archived since May 2018; we reviewed all 371 cases from May 2018-February 2023. IBD-mimics were analyzed/categorized according to their diagnostic and therapeutic workup. Results: Confirmed IBD cases made up 82.5% (306/371; 193 Crohn's disease, 107 ulcerative colitis, and 6 IBD-unclassified). Sixty-five (17.5%) cases were found to be mimics, most commonly medication-induced (nâ =â 8) or vasculitis (nâ =â 7). The evaluations that ultimately resulted in correct diagnosis included additional endoscopic biopsies (nâ =â 13, 21%), surgical exploration/pathology (nâ =â 10, 16.5%), biopsies from outside the GI tract (nâ =â 10, 16.5%), genetic/laboratory testing (nâ =â 8, 13%), extensive review of patient history (nâ =â 8, 13%), imaging (nâ =â 5, 8%), balloon enteroscopy (nâ =â 5, 8%), and capsule endoscopy (nâ =â 2, 3%). Twenty-five patients (25/65, 38%) were treated with biologics for presumed IBD, 5 of whom subsequently experienced adverse events requiring discontinuation of the biologic. Many patients were prescribed steroids, azathioprine, mercaptopurine, or methotrexate, and 3 were trialed on tofacitinib. Conclusions: The diverse presentation of IBD and IBD-mimics necessitates periodic consideration of the differential diagnosis, and reassessment of treatment in presumed IBD patients without appropriate clinical response. The substantial differences and often conflicting treatment approaches to IBD versus IBD-mimics directly impact the quality and cost of patient care.
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BACKGROUND: The long-term risk of pouch failure after restorative proctocolectomy with ileal-pouch anal anastomosis (IPAA) range from 5 and 15%. Salvage surgery for failing IPAA's may be achieved by disconnecting the IPAA and either repairing and re-using the existing pouch (REP) or constructing a neo-pouch (NEO). We aimed to evaluate whether there are differences in long-term functional pouch survival and functional outcomes between the REP group and the NEO group. We hypothesized patients undergoing REP have higher long-term pouch survival rates compared to patients who require NEO pouch construction. METHODS: Our prospectively maintained Pouch Registry was queried for patients who underwent a pouch salvage surgery with either pouch REP or NEO from 1988 - 2020. Patients who underwent pouch repair without disconnection from the anus were excluded. The primary endpoint was long-term pouch survival after redo pouch surgery. Secondary outcomes were patient reported quality of life and pouch function. RESULTS: Of 653 patients undergoing redo IPAA, 462 met inclusion criteria of transabdominal redo surgery with pouch reconnection: 243 (52.6%) had REP and 219 (47.4%) had NEO. Median age was 39 years and 59% were female. Median time between index and redo IPAA was 34 months for REP vs 54 months for NEO (p=0.002). The 5-year pouch survival after redo IPAA was similar between REP (79.5%) and NEO (76.8%) groups (p=0.4). Fewer patients in the REP group reported nighttime pad use (51.4% vs 68.2%, p=0.04). CONCLUSION: Pouch survival and functional outcomes after salvage surgery for failing ileoanal pouch was similar regardless of pouch salvage procedure. When performing redo pouch surgery, surgeons should not hesitate to construct a new pouch if indicated.
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BACKGROUND: Herein, we present a proof-of-concept study of 3-dimensional (3D) pouchography using virtual and printed 3D models of ileal pouch-anal anastomosis (IPAA) in patients with normal pouches and in cases of mechanical pouch complications. MATERIALS & METHODS: We performed a retrospective, descriptive case series of a convenience sample of 10 pouch patients with or without pouch dysfunction who had CT scans appropriate for segmentation were identified from our pouch registry. The steps involved in clinician-driven automated 3D reconstruction are presented. RESULTS: Three patients who underwent CT imaging and were found to have no primary pouch pathology, and seven patients with known pouch pathology identifiable with 3D reconstruction including pouch strictures, megapouch, pouch volvulus, and twisted pouches underwent 3D virtual modeling; one normal and one twisted pouch were 3D printed. We discovered that 3D pouchography reliably identified staple lines (pouch body, anorectal circular and transverse, and tip of J), the relationship between staple lines, and variations in pouch morphology, and pouch pathology. CONCLUSIONS: Three-dimensional reconstruction of IPAA morphology is highly feasible using readily available technology. In our practice, we have found 3D pouchography to be an extremely useful adjunct to diagnose various mechanical pouch complications and improve planning for pouch salvage strategies. Given its ease of use and helpfulness in understanding the pouch structure and function, we have started to routinely integrate 3D pouchography into our clinical pouch referral practice. Further study is needed to formally assess to value of this technique to aid in the diagnosis of pouch pathology.
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BACKGROUND: Segmental colectomy in ulcerative colitis is performed in select patients who may be at increased risk for postoperative morbidity. OBJECTIVE: To identify patients with ulcerative colitis who underwent segmental colectomy and assess their postoperative and long-term outcomes. DESIGN: Retrospective case series. SETTING: A tertiary care IBD center. PATIENTS: Patients with ulcerative colitis who underwent surgery between 1995 and 2022. INTERVENTION: Segmental colectomy. MAIN OUTCOME MEASURES: Postoperative complications, early and late colitis, metachronous cancer development, completion proctocolectomy-free survival rates, and stoma at follow-up. RESULTS: Fifty-five patients were included (20 [36.4%] women; age 67.8 (57.4-77.1) years at surgery; BMI 27.7 (24.2-31.1) kg/m 2 ; median follow-up 37.3 months). Thirty-two patients (58.2%) had ASA score of 3, 48 (87.3%) had at least 1 comorbidity, and 48 (87.3%) had Mayo endoscopic subscores of 0 to 1. Patients underwent right hemicolectomy (n = 28; 50.9%), sigmoidectomy (n = 17; 30.9%), left hemicolectomy (6; 10.9%), low anterior resection (n = 2; 3.6%), or a nonanatomic resection (n = 2; 3.6%) for endoscopically unresectable polyps (n = 21; 38.2%), colorectal cancer (n = 15; 27.3%), symptomatic diverticular disease (n = 13; 23.6%), and stricture (n = 6; 10.9%). Postoperative complications occurred in 16 patients (29.1%; n = 7 [12.7%] Clavien-Dindo class III-V). Early and late postoperative colitis rates were 9.1% and 14.5%, respectively. Metachronous cancer developed in 1 patient. Four patients (7.3%) underwent subsequent completion proctocolectomy with ileostomy. Six patients (10.9%) had a stoma at follow-up. Two- and 5-year completion proctocolectomy-free survival rates were 91% and 88%, respectively. LIMITATIONS: Retrospective study and small sample size. CONCLUSIONS: Segmental colectomy in ulcerative colitis is associated with low postoperative complication rates, symptomatic early colitis and late colitis rates, metachronous cancer development, and the need for subsequent completion proctocolectomy. Therefore, it can be safe to consider select patients, such as the elderly with quiescent colitis and other indications, for colectomy. See Video Abstract . COLECTOMA SEGMENTARIA EN LA COLITIS ULCEROSA: ANTECEDENTES:La colectomía segmentaria en la colitis ulcerosa se realiza en pacientes seleccionados que pueden tener un mayor riesgo de morbilidad posoperatoria.OBJETIVO:Identificar pacientes con colitis ulcerosa sometidos a colectomía segmentaria y evaluar sus resultados postoperatorios y a largo plazo.DISEÑO:Serie de casos retrospectivos.AMBIENTE:Un centro de atención terciaria para enfermedades inflamatorias intestinales.PACIENTES:Pacientes con colitis ulcerosa intervenidos quirúrgicamente entre 1995 y 2022.INTERVENCIÓN(S):Colectomía segmentaria.PRINCIPALES MEDIDAS DE RESULTADO:Complicaciones postoperatorias, colitis temprana y tardía, desarrollo de cáncer metacrónico, tasas de supervivencia sin proctocolectomía completa y estoma en el seguimiento.RESULTADOS:Se incluyeron cincuenta y cinco pacientes [20 (36,4%) mujeres; 67,8 (57,4-77,1) años de edad al momento de la cirugía; índice de masa corporal 27,7 (24,2-31,1) kg/m2; mediana de seguimiento 37,3 meses]. La puntuación ASA fue III en 32 (58,2%) pacientes, 48 (87,3%) tenían al menos una comorbilidad y 48 (87,3%) tenían una subpuntuación endoscópica de Mayo de 0-1. Los pacientes fueron sometidos a hemicolectomía derecha (28, 50,9%), sigmoidectomía (17, 30,9%), hemicolectomía izquierda (6, 10,9%), resección anterior baja (2, 3,6%) o resección no anatómica (2, 3,6%) para; pólipos irresecables endoscópicamente (21, 38,2%), cáncer colorrectal (15, 27,3%), enfermedad diverticular sintomática (13, 23,6%) y estenosis (6, 10,9%). Se produjeron complicaciones postoperatorias en 16 (29,1%) pacientes [7 (12,7%) Clavien-Dindo Clase III-V]. Las tasas de colitis posoperatoria temprana y tardía fueron del 9,1% y el 14,5%, respectivamente. Un paciente desarrolló cáncer metacrónico. A 4 (7,3%) pacientes se les realizó posteriormente proctocolectomía completa con ileostomía. Seis (10,9%) pacientes tenían estoma en el seguimiento. Las tasas de supervivencia sin proctocolectomía completa a dos y cinco años fueron del 91% y 88%, respectivamente.LIMITACIONES:Estudio retrospectivo, tamaño de muestra pequeño.CONCLUSIONES:La colectomía segmentaria en la colitis ulcerosa se asocia con bajas tasas de complicaciones postoperatorias, tasas de colitis sintomática temprana y tasas de colitis tardía, desarrollo de cáncer metacrónico y la necesidad de una posterior proctocolectomía completa. Por lo tanto, puede ser seguro considerar pacientes seleccionados, como los ancianos con colitis inactiva y otras indicaciones de colectomía. (Traducción-Dr. Yolanda Colorado ).
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Colectomia , Colite Ulcerativa , Complicações Pós-Operatórias , Humanos , Colite Ulcerativa/cirurgia , Feminino , Masculino , Colectomia/métodos , Estudos Retrospectivos , Pessoa de Meia-Idade , Idoso , Complicações Pós-Operatórias/epidemiologia , Resultado do Tratamento , Segunda Neoplasia Primária/epidemiologiaRESUMO
BACKGROUND: A colosplenic fistula (CsF) is an extremely rare complication. Its diagnosis and management remain poorly understood, owing to its infrequent incidence. Our objective was to systematically review the etiology, clinical features, diagnosis, management, and prognosis to help clinicians gain a better understanding of this unusual complication and provide aid if it is to be encountered. METHODS: A systematic review of studies reporting CsF diagnosis in Ovid MEDLINE, Ovid EMBASE, Scopus, Web of Science, and Wiley Cochrane Library from 1946 to June 2022. Additionally, a retrospective review of four cases at our institution were included. Cases were evaluated for patient characteristics (age, sex, and comorbidities), CsF characteristics including causes, symptoms at presentation, diagnosis approach, management approach, pathology findings, intraoperative complications, postoperative complications, 30-day mortality, and prognosis were collected. RESULTS: Thirty patients with CsFs were analyzed, including four cases at our institution and 26 single-case reports. Most of the patients were male (70%), with a median age of 56 years. The most common etiologies were colonic lymphoma (30%) and colorectal carcinoma (17%). Computed tomography (CT) was commonly used for diagnosis (90%). Approximately 87% of patients underwent a surgical intervention, most commonly segmental resection (81%) of the affected colon and splenectomy (77%). Nineteen patients were initially managed surgically, and 12 patients were initially managed nonoperatively. However, 11 of the nonoperative patients ultimately required surgery due to unresolved symptoms. The rate of postoperative complications was (17%). Symptoms resolved with surgical intervention in 25 (83%) patients. Only one patient (3%) had had postoperative mortality. CONCLUSIONS: Our review of 30 cases worldwide is the largest in literature. CsFs are predominantly complications of neoplastic processes. CsF may be successfully and safely treated with splenectomy and resection of the affected colon, with a low rate of postoperative complications.
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Esplenopatias , Humanos , Esplenopatias/cirurgia , Esplenopatias/diagnóstico , Esplenopatias/terapia , Masculino , Feminino , Pessoa de Meia-Idade , Fístula Intestinal/cirurgia , Fístula Intestinal/diagnóstico , Esplenectomia , Adulto , Idoso , Complicações Pós-Operatórias , Doenças do Colo/cirurgia , Doenças do Colo/diagnóstico , Doenças do Colo/terapia , Tomografia Computadorizada por Raios XRESUMO
AIM: Restorative proctocolectomy with transabdominal ileal pouch-anal anastomosis (abd-IPAA) has become the standard surgical treatment for medically refractory ulcerative colitis (UC). However, it requires a technically difficult distal anorectal dissection and anastomosis due to the bony confines of the deep pelvis. To address these challenges, the transanal IPAA approach (ta-IPAA) was developed. This novel approach may offer increased visibility and range of motion compared with abd-IPAA, although its postoperative benefits remain unclear. The aim of this work was to perform a systematic review and meta-analysis to compare and inform the frequency of postoperative outcomes between ta-IPAA and abd-IPAA for patients with UC. METHOD: Several databases were searched from inception until May 2022 for studies reporting postoperative outcomes of patients undergoing ta-IPAA. Reviewers, working independently and in duplicate, evaluated studies for inclusion and graded the risk of bias. Odds ratios (OR), mean differences (MD) and prevalence ratio (PR) and their corresponding 95% confidence intervals (CIs) were calculated using random-effects models. Sensitivity analysis was performed. RESULTS: Ten retrospective studies comprising 284 patients with ta-IPAA were included. Total mesorectal excision was performed in 61.8% of cases and close rectal dissection in 27.9%. There was no difference in the odds of Clavien-Dindo (CD) I-II complications, CD III-IV and anastomotic leak (OR 0.96, 95% CI 0.27-3.40; OR 1.18, 95% CI 0.65-2.16; OR 1.37, 95% CI 0.58-3.23; respectively) between ta-IPAA and abd-IPAA. The ta-IPAA pooled CD I-II complication rate was 18% (95% CI 5%-35%) and for CD III-IV 10% (95% CI 5%-17%), and the anastomotic leak rate was 6% (95% CI 2%-10%). There were no deaths reported. CONCLUSIONS: This meta-analysis compared the novel ta-IPAA procedure with abd-IPAA and found no difference in postoperative outcomes. While the need for randomized controlled trails and comparison of functional outcomes between both approaches remains, this evidence should assist colorectal surgeons to decide if ta-IPAA is a viable alternative.
Assuntos
Colite Ulcerativa , Complicações Pós-Operatórias , Proctocolectomia Restauradora , Humanos , Proctocolectomia Restauradora/métodos , Proctocolectomia Restauradora/efeitos adversos , Colite Ulcerativa/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Resultado do Tratamento , Bolsas Cólicas/efeitos adversos , Canal Anal/cirurgia , Feminino , Masculino , Adulto , Estudos Retrospectivos , Pessoa de Meia-Idade , Anastomose Cirúrgica/métodos , Anastomose Cirúrgica/efeitos adversos , Fístula Anastomótica/etiologia , Fístula Anastomótica/epidemiologia , Cirurgia Endoscópica Transanal/métodos , Cirurgia Endoscópica Transanal/efeitos adversos , Doenças Inflamatórias Intestinais/cirurgiaRESUMO
BACKGROUND: Ileal pouch-anal anastomosis is a technically demanding procedure with many potential complications. Rediversion with an ileostomy is often the first step in pouch salvage; however, it may not be clear if an individual patient will undergo subsequent pouch salvage surgery. We aimed to describe the indications and short- and long-term outcomes of rediversion in our pouch registry. METHODS: We queried our institutional pouch registry for patients who underwent index 2- or 3-stage IPAA and subsequent rediversion at our institution between 1985 and 2022. Pouches constructed elsewhere, rediverted elsewhere, or those patients who underwent pouch salvage/excision without prior rediversion were excluded. Patients were selected for pouch salvage according to the surgeon's discretion. RESULTS: Overall, 177 patients (3.4% of 5207 index pouches) were rediverted. At index pouch, median patient age was 32 years and 50.8% were women. Diagnoses included ulcerative colitis (86.4%), indeterminate colitis (6.2%), familial adenomatous polyposis (4.0%), and others (3.4%). Median time from prior ileostomy closure to rediversion was 7.2 years. Indications for rediversion were inflammatory in 98 (55.4%) and noninflammatory in 79 (44.6%) patients. After rediversion, 52% underwent pouch salvage, 30% had no further surgery, and 18.1% underwent pouch excision. The 5-year pouch survival rates for inflammatory and noninflammatory indications were 71.5% and 94.5%, respectively (Pâ =â .02). CONCLUSION: Rediversion of ileoanal pouches is a safe initial strategy to manage failing pouches and is a useful first step in pouch salvage in many patients. Subsequent salvage surgery for noninflammatory indications had a significantly higher pouch salvage rate than those rediverted for inflammatory complications.
Rediversion with an ileostomy was a safe, useful first step in pouch salvage, and subsequent salvage surgery for noninflammatory indications had a significantly higher pouch salvage rate than those rediverted for inflammatory complications.
RESUMO
ABTRACT: BACKGROUND: When constructing an ileal pouch-anal anastomosis (IPAA), the rectal cuff should ideally be 1-2 cm long to avoid subsequent complications. METHODS: We identified patients from our IBD center who underwent redo IPAA for a long rectal cuff. Long rectal cuff syndrome (LRCS) was defined as a symptomatic rectal cuff ≥ 4 cm. RESULTS: Forty patients met the inclusion criteria: 42.5% female, median age at redo surgery 42.5 years. The presentation was ulcerative proctitis in 77.5% of the cases and outlet obstruction in 22.5%. The index pouch was laparoscopically performed in 18 patients (45%). The median rectal cuff length was 6 cm. The pouch was repaired in 16 (40%) cases, whereas 24 (60%) required the creation of a neo-pouch. At the final pathology, the rectal cuff showed chronic active colitis in 38 (90%) cases. After a median follow-up of 34.5 (IQR 12-109) months, pouch failure occurred in 9 (22.5%) cases. The pouch survival rate was 78% at 3 years. Data on the quality of life were available for 11 (27.5%) patients at a median of 75 months after redo surgery. The median QoL score (0-1) was 0.7 (0.4-0.9). CONCLUSION: LRCS, a potentially avoidable complication, presents uniformly with symptoms of ulcerative proctitis or stricture. Redo IPAA was restorative for the majority.
Assuntos
Colite , Doenças Inflamatórias Intestinais , Proctite , Proctocolectomia Restauradora , Humanos , Feminino , Adulto , Masculino , Qualidade de Vida , Proctocolectomia Restauradora/efeitos adversos , Síndrome , Proctite/etiologia , Proctite/cirurgiaRESUMO
AIM: Ileorectal anastomosis (IRA) following total abdominal colectomy (TAC) allows for resortation of bowel continuity but prior studies have reported rates of anastomotic leak (AL) to be as high as 23%. We aimed to report rates of AL and complications in a large cohort of patients undergoing IRA. We hypothesized that AL rates were lower than previously reported and that selective use of diverting loop ileostomy (DLI) is associated with decreased AL rates. METHOD: Patients undergoing TAC or end-ileostomy reversal with IRA, with or without DLI, between 1980 and 2021 were identified from a prospectively maintained institutional database and retrospectively analysed. Redo IRA cases were excluded. Short-term (30-day) surgical outcomes were collected using our database. AL was defined using a combination of imaging and, in the case of return to the operating room, intraoperative findings. RESULTS: Of 823 patients in the study cohort, DLI was performed in 27% and performed more frequently for constipation and inflammatory bowel disease. The overall AL rate was 3% (1% and 4% in those with and without DLI, respectively) and diversion was found to be protective against leak (OR 0.28, 95% CI 0.08-0.94, p = 0.04). However, patients undergoing diversion had a higher overall rate of postoperative complications (51% vs. 36%, p < 0.001) including superficial wound infection, urinary tract infection, dehydration, blood transfusion and portomesenteric venous thrombosis (all p < 0.04). CONCLUSION: Our study represents the largest series of patients undergoing IRA reported to date and demonstrates an AL rate of 3%. While IRA appears to be a viable surgical option for diverse indications, our study underscores the importance of careful patient selection and thoughtful consideration of staging the anastomosis and temporary faecal diversion when necessary.
Assuntos
Anastomose Cirúrgica , Fístula Anastomótica , Colectomia , Ileostomia , Íleo , Reto , Humanos , Feminino , Masculino , Anastomose Cirúrgica/métodos , Anastomose Cirúrgica/efeitos adversos , Estudos Retrospectivos , Pessoa de Meia-Idade , Reto/cirurgia , Fístula Anastomótica/etiologia , Fístula Anastomótica/epidemiologia , Ileostomia/métodos , Ileostomia/efeitos adversos , Colectomia/métodos , Colectomia/efeitos adversos , Íleo/cirurgia , Idoso , Adulto , Resultado do Tratamento , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologiaRESUMO
BACKGROUND: Ileal pouch-anal anastomosis (IPAA) is considered the preferred restorative surgical procedure for patients with ulcerative colitis and familial adenomatous polyposis requiring proctocolectomy. Unfortunately, postoperative leaks remain a complication with potentially significant ramifications. This study aimed to provide a comprehensive description of the evaluation, management, and outcomes of leaks after primary IPAA procedures. METHODS: Between 1995 and 2022, a total of 4058 primary IPAA procedures were performed at Cleveland Clinic. From a prospectively maintained pouch registry, we retrospectively reviewed the data of 237 patients who presented to the pouch center for management. Of these, 114 (3%) had undergone the index IPAA procedure at our clinic (de novo cases), whereas 123 patients had their index IPAA performed elsewhere. Data were missing for 43 patients, resulting in a final cohort of 194 patients. RESULTS: Our cohort had an average age of 41 years (range, 16-76) at the time of leak diagnosis. Overall, 55.2% were males, average body mass index was 24.4 kg/m2, and pain was the most prevalent presenting symptom (61.8%), followed by fever (34%). Leaks were confirmed through diagnostic testing in 141 cases, whereas 27.3% were detected intraoperatively. The most common initial diagnoses were pelvic abscess (47.4%) and enteric fistulas (26.8%), including cutaneous (9.8%), vaginal (7.2%), and bladder fistulas (3.1%). By location, leaks occurred at the tip of the "J" (52.6%), at the pouch-anal anastomotic site (35%), and in the body of the pouch (12.4%). A nonoperative management approach was initially attempted in 49.5% of cases, including antibiotic therapy, drainage, endoclip, and endo-sponge, with a success rate of 18.5%. Surgery was eventually required in 81.4% of patients, including (1) sutured or stapled pouch repair (52.5%), with diversion performed in 87.9% of these cases either before or during the salvage surgery; (2) pouch excision with neo-IPAA (22.7%), including 9 patients from the first group; and (3) pouch disconnection, repair, and reanastomosis (9.3%). Pouch failure occurred in 8.4%, with either pouch excision (11.1%) or permanent diversion (4.5%). Ultimately, 12.4% of patients (24 of 194) required permanent diversion, with all necessitating pouch excision. In the 30-day follow-up after salvage surgery, short-term complications arose in 38.7% of patients. The most common complications observed were ileus, pelvic abscess/sepsis, and fever. CONCLUSION: Leaks after primary IPAA procedures represent an infrequent, yet challenging, complication. Despite attempts at nonoperative management, the success rate is limited. Salvage surgery is associated with a high pouch retention rate, underscoring its importance in the management of post-IPAA leaks.
Assuntos
Fístula Anastomótica , Colite Ulcerativa , Bolsas Cólicas , Proctocolectomia Restauradora , Humanos , Feminino , Masculino , Adulto , Proctocolectomia Restauradora/efeitos adversos , Proctocolectomia Restauradora/métodos , Pessoa de Meia-Idade , Fístula Anastomótica/etiologia , Fístula Anastomótica/cirurgia , Fístula Anastomótica/diagnóstico , Fístula Anastomótica/terapia , Estudos Retrospectivos , Bolsas Cólicas/efeitos adversos , Adulto Jovem , Adolescente , Colite Ulcerativa/cirurgia , Idoso , Fístula Intestinal/etiologia , Fístula Intestinal/cirurgia , Reoperação/estatística & dados numéricos , Reoperação/métodos , Polipose Adenomatosa do Colo/cirurgia , Fístula da Bexiga Urinária/cirurgia , Fístula da Bexiga Urinária/etiologia , Fístula Vaginal/cirurgia , Fístula Vaginal/etiologia , Fístula Urinária/etiologia , Fístula Urinária/cirurgia , Febre/etiologiaRESUMO
BACKGROUND: A complete total mesorectal excision is the criterion standard in curative rectal cancer surgery. Ensuring quality is challenging in a narrow pelvis, and obesity amplifies technical difficulties. Pelvimetry is the measurement of pelvic dimensions, but its role in gauging preoperatively the difficulty of proctectomy is largely unexplored. OBJECTIVE: To determine pelvic structural factors associated with incomplete total mesorectal excision after curative proctectomy and build a predictive model for total mesorectal excision quality. DESIGN: Retrospective cohort study. SETTING: A quaternary referral center database of patients diagnosed with rectal adenocarcinoma (2009-2017). PATIENTS: Curative-intent proctectomy for rectal adenocarcinoma. INTERVENTIONS: All radiological measurements were obtained from preoperative CT images using validated imaging processing software tools. Completeness of total mesorectal excision was obtained from histology reports. MAIN OUTCOME MEASURES: Ability of radiological pelvimetry and obesity measurements to predict total mesorectal excision quality. RESULTS: Of the 410 cases meeting inclusion criteria, 362 underwent a complete total mesorectal excision (88%). Multivariable regression identified a deeper sacral curve (per 100 mm 2 [OR: 1.14; 95% CI, 1.06-1.23; p < 0.001]) and a greater transverse distance of the pelvic outlet (per 10 mm [OR:1.41, 95% CI, 1.08-1.84; p = 0.012]) to be independently associated with incomplete total mesorectal excision. An increased area of the pelvic inlet (per 10 cm 2 [OR: 0.85; 95% CI, 0.75-0.97; p = 0.02) was associated with a higher rate of complete mesorectal excision. No difference in visceral obesity ratio and visceral obesity (ratio >0.4 vs <0.4) between BMI (<30 vs ≥30) and sex was identified. A model was built to predict mesorectal quality using the following variables: depth of sacral curve, area of pelvic inlet, and transverse distance of the pelvic outlet. LIMITATIONS: Retrospective analysis is not controlled for the choice of surgical approach. CONCLUSIONS: Pelvimetry predicts total mesorectal excision quality in rectal cancer surgery and can alert surgeons preoperatively to cases of unusual difficulty. This predictive model may contribute to treatment strategy and aid in the comparison of outcomes between traditional and novel techniques of total mesorectal excision. See Video Abstract . USO DE MEDICIONES DE PELVIMETRA Y OBESIDAD VISCERAL BASADAS EN TC PARA PREDECIR LA CALIDAD DE TME EN PACIENTES SOMETIDOS A CIRUGA DE CNCER DE RECTO: ANTECEDENTES:Una escisión mesorrectal total y completa es el estándar de oro en la cirugía curativa del cáncer de recto. Garantizar la calidad es un desafío en una pelvis estrecha y la obesidad amplifica las dificultades técnicas. La pelvimetría es la medición de las dimensiones pélvicas, pero su papel para medir la dificultad preoperatoria de la proctectomía está en gran medida inexplorado.OBJETIVO:Determinar los factores estructurales pélvicos asociados con la escisión mesorrectal total incompleta después de una proctectomía curativa y construir un modelo predictivo para la calidad de la escisión mesorrectal total.DISEÑO:Estudio de cohorte retrospectivo.ÁMBITO:Base de datos de un centro de referencia cuaternario de pacientes diagnosticados con adenocarcinoma de recto (2009-2017).PACIENTES:Proctectomía con intención curativa para adenocarcinoma de recto.INTERVENCIONES:Todas las mediciones radiológicas se obtuvieron a partir de imágenes de TC preoperatorias utilizando herramientas de software de procesamiento de imágenes validadas. La integridad de la escisión mesorrectal total se obtuvo a partir de informes histológicos.PRINCIPALES MEDIDAS DE VALORACIÓN:Capacidad de la pelvimetría radiológica y las mediciones de obesidad para predecir la calidad total de la escisión mesorrectal.RESULTADOS:De los 410 casos que cumplieron los criterios de inclusión, 362 tuvieron una escisión mesorrectal total completa (88%). Una regresión multivariable identificó una curva sacra más profunda (por 100 mm2); OR:1,14,[IC95%:1,06-1,23,p<0,001], y mayor distancia transversal de salida pélvica (por 10mm); OR:1,41, [IC 95%:1,08-1,84,p=0,012] como asociación independiente con escisión mesorrectal total incompleta. Un área aumentada de entrada pélvica (por 10 cm2); OR:0,85, [IC95%:0,75-0,97,p=0,02] se asoció con una mayor tasa de escisión mesorrectal completa. No se identificaron diferencias en la proporción de obesidad visceral y la obesidad visceral (proporción>0,4 vs.<0,4) entre el índice de masa corporal (<30 vs.>=30) o el sexo. Se construyó un modelo para predecir la calidad mesorrectal utilizando variables: profundidad de la curva sacra, área de la entrada pélvica y distancia transversal de la salida pélvica.LIMITACIONES:Análisis retrospectivo no controlado por la elección del abordaje quirúrgico.CONCLUSIONES:La pelvimetría predice la calidad de la escisión mesorrectal total en la cirugía del cáncer de recto y puede alertar a los cirujanos preoperatoriamente sobre casos de dificultad inusual. Este modelo predictivo puede contribuir a la estrategia de tratamiento y ayudar en la comparación de resultados entre técnicas tradicionales y novedosas de escisión mesorrectal total. (Traducción- Dr. Ingrid Melo).