Blinded Intraoperative Quantitative Indocyanine Green Metrics Associate With Intestinal Margin Acceptance in Colorectal Surgery.

BACKGROUND: Indocyanine green is a useful tool in colorectal surgery. Quantitative values may enhance and standardize its application. OBJECTIVE: To determine whether quantitative indocyanine green metrics correlate with standard subjective indocyanine green perfusion assessment in acceptance or rejection of anastomotic margins. DESIGN: Prospective single-arm, single-institution cohort study. Surgeons viewed subjective indocyanine green images but were blinded to quantitative indocyanine green metrics. SETTING: Tertiary academic center. PATIENTS: Adults undergoing planned intestinal resection. MAIN OUTCOME MEASURES: Accepted perfusion and rejected perfusion of the intestinal margin were defined by the absence or presence of ischemia by subjective indocyanine green and gross inspection. The primary outcomes included quantitative indocyanine green values, maximum fluorescence, and time-to-maximum fluorescence in accepted compared to rejected perfusion. Secondary outcomes included maximum fluorescence and time-to-maximum fluorescence values in anastomotic leak. RESULTS: There were 89 perfusion assessments comprising 156 intestinal segments. Nine segments were subjectively assessed to have poor perfusion by visual inspection and subjective indocyanine green. Maximum fluorescence (% intensity) exhibited higher intensity in accepted perfusion (accepted perfusion 161% [82%-351%] vs rejected perfusion 63% [10%-76%]; p = 0.03). Similarly, time-to-maximum fluorescence (seconds) was earlier in accepted perfusion compared to rejected perfusion (10 seconds [1-40] vs 120 seconds [90-120]; p < 0.01). Increased BMI was associated with higher maximum fluorescence. Anastomotic leak did not correlate with maximum fluorescence or time-to-maximum fluorescence. LIMITATIONS: Small cohort study, not powered to measure the association between quantitative indocyanine green metrics and anastomotic leak. CONCLUSIONS: We demonstrated that blinded quantitative values reliably correlate with subjective indocyanine green perfusion assessment. Time-to-maximum intensity is an important metric in perfusion evaluation. Quantitative indocyanine green metrics may enhance intraoperative intestinal perfusion assessment. Future studies may attempt to correlate quantitative indocyanine green values with anastomotic leak. See Video Abstract . LAS MTRICAS CUANTITATIVAS INTRAOPERATORIAS CIEGAS DEL VERDE DE INDOCIANINA SE ASOCIAN CON LA ACEPTACIN DEL MARGEN INTESTINAL EN LA CIRUGA COLORRECTAL: ANTECEDENTES:El verde de indocianina es una herramienta útil en la cirugía colorrectal. Los valores cuantitativos pueden mejorar y estandarizar su aplicación.OBJETIVO:Determinar si las métricas cuantitativas de verde de indocianina se correlacionan con la evaluación subjetiva estándar de perfusión de verde de indocianina en la aceptación o rechazo de los márgenes anastomóticos.DISEÑO:Estudio de cohorte prospectivo de un solo brazo y de una sola institución. Los cirujanos vieron imágenes subjetivas de verde de indocianina, pero no conocían las métricas cuantitativas de verde de indocianina.AJUSTE:Centro académico terciario.PACIENTES:Adultos sometidos a resección intestinal planificada.PRINCIPALES MEDIDAS DE RESULTADO:La perfusión aceptada y la perfusión rechazada del margen intestinal se definieron por la ausencia o presencia de isquemia mediante verde de indocianina subjetiva y la inspección macroscópica. Los resultados primarios fueron los valores cuantitativos de verde de indocianina, la fluorescencia máxima y el tiempo hasta la fluorescencia máxima en la perfusión aceptada en comparación con la rechazada. Los resultados secundarios incluyeron la fluorescencia máxima y el tiempo hasta alcanzar los valores máximos de fluorescencia en la fuga anastomótica.RESULTADOS:Se realizaron 89 evaluaciones de perfusión, comprendiendo 156 segmentos intestinales. Se evaluó subjetivamente que 9 segmentos tenían mala perfusión mediante inspección visual y verde de indocianina subjetiva. La fluorescencia máxima (% de intensidad) mostró una mayor intensidad en la perfusión aceptada [Perfusión aceptada 161% (82-351) vs Perfusión rechazada 63% (10-76); p = 0,03]. De manera similar, el tiempo hasta la fluorescencia máxima (segundos) fue más temprano en la perfusión aceptada en comparación con la rechazada [10 s (1-40) frente a 120 s (90-120); p < 0,01]. Aumento del índice de masa corporal asociado con una fluorescencia máxima más alta. La fuga anastomótica no se correlacionó con la fluorescencia máxima ni con el tiempo hasta la fluorescencia máxima.LIMITACIONES:Estudio de cohorte pequeño, sin poder para medir la asociación entre las mediciones cuantitativas del verde de indocianina y la fuga anastomótica.CONCLUSIÓN:Demostramos que los valores cuantitativos ciegos se correlacionan de manera confiable con la evaluación subjetiva de la perfusión de verde de indocianina. El tiempo hasta la intensidad máxima es una métrica importante en la evaluación de la perfusión. Las métricas cuantitativas de verde de indocianina pueden mejorar la evaluación de la perfusión intestinal intraoperatoria. Los estudios futuros pueden intentar correlacionar los valores cuantitativos de verde de indocianina con la fuga anastomótica. (Traducción-Dr. Yolanda Colorado).

Risk Factors for Microscopic Disease Positivity at Ileocolic Resection Margins for Crohn's Disease.

INTRODUCTION: Interest in microscopic margin positivity during surgical resection of medical-refractory Crohn's disease has been renewed with multiple recent studies showing an association between microscopic margin positivity with disease recurrence. Our aim was to determine risk factors for microscopic margin disease positivity following ileocolic resection (ICR). MATERIALS AND METHODS: A prospectively-maintained database of patients with Crohn's disease undergoing ICR at a tertiary-referral center was queried. Margin positivity was defined as the presence of cryptitis, erosion, transmural inflammation with lymphoid aggregates, or architectural distortion at either ileal (proximal) or colonic (distal) margins. RESULTS: Amongst 584 patients, 97 patients had a positive microscopic margin (17%) of which 46% had a positive proximal margin, 17% had a positive distal margin, and 13% had both positive and distal margins. Using multivariable logistic regression analysis, index ICR was associated with less odds of positive margin (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.24-0.89, p=0.02), and granuloma presence was associated with increased odds (OR 2.26, 95% CI 1.23-4.21, p=0.01). CONCLUSION: We found that repeat ileocolic resection and granuloma presence were predictors of microscopic margin disease.

CORE-IBD: A Multidisciplinary International Consensus Initiative to Develop a Core Outcome Set for Randomized Controlled Trials in Inflammatory Bowel Disease.

BACKGROUND & AIMS: End points to determine the efficacy and safety of medical therapies for Crohn's disease (CD) and ulcerative colitis (UC) are evolving. Given the heterogeneity in current outcome measures, harmonizing end points in a core outcome set for randomized controlled trials is a priority for drug development in inflammatory bowel disease. METHODS: Candidate outcome domains and outcome measures were generated from systematic literature reviews and patient engagement surveys and interviews. An iterative Delphi process was conducted to establish consensus: panelists anonymously voted on items using a 9-point Likert scale, and feedback was incorporated between rounds to refine statements. Consensus meetings were held to ratify the outcome domains and core outcome measures. Stakeholders were recruited internationally, and included gastroenterologists, colorectal surgeons, methodologists, and clinical trialists. RESULTS: A total of 235 patients and 53 experts participated. Patient-reported outcomes, quality of life, endoscopy, biomarkers, and safety were considered core domains; histopathology was an additional domain for UC. In CD, there was consensus to use the 2-item patient-reported outcome (ie, abdominal pain and stool frequency), Crohn's Disease Activity Index, Simple Endoscopic Score for Crohn's Disease, C-reactive protein, fecal calprotectin, and co-primary end points of symptomatic remission and endoscopic response. In UC, there was consensus to use the 9-point Mayo Clinic Score, fecal urgency, Robarts Histopathology Index or Geboes Score, fecal calprotectin, and a composite primary end point including both symptomatic and endoscopic remission. Safety outcomes should be reported using the Medical Dictionary for Regulatory Activities. CONCLUSIONS: This multidisciplinary collaboration involving patients and clinical experts has produced the first core outcome set that can be applied to randomized controlled trials of CD and UC.

Prospective Randomized Trial of Immediate Postoperative Use of Regular Diet Versus Clear Liquid Diet in Major Colorectal Surgery.

BACKGROUND: Enhanced recovery protocols are becoming standard practice after major colorectal surgery. An increasing body of evidence suggests that early feeding should be encouraged; however, whether a clear liquid diet or solid diet should be given immediately after surgery is undetermined. OBJECTIVE: Evaluate whether regular diet was superior to clear liquid diet beginning on postoperative day 0 after major colorectal surgery. DESIGN: Superiority trial design. SETTING: Urban tertiary center. PATIENTS: Consecutive patients undergoing abdominal colorectal surgery from September 2017 to June 2018. INTERVENTIONS: Eligible patients received either 1) clear liquid diet on postoperative day 0 with advancement to regular diet on postoperative day 1 or 2) regular diet on postoperative day 0 and continuing for the duration of patients' recovery. MAIN OUTCOME MEASURES: The primary end point was diet tolerance, defined by the absence of vomiting by postoperative day 2. RESULTS: A total of 105 patients were randomly assigned with 53 in the clear liquid diet group and 52 in the regular diet group. All randomly assigned patients were included in the analysis. The rate of diet tolerance by postoperative day 2 was similar between groups. Rates of ileus, antiemetic usage, narcotic usage, time to return of bowel function, and pain/nausea/bloating scores were similar between the 2 groups. Significantly more patients in the clear liquid diet group (91%) tolerated their diet than did the regular diet group (71%) on postoperative day 0 ( p = 0.01). LIMITATIONS: Diet tolerance was only monitored during inpatient stay. The rate of postoperative ileus was difficult to capture as its clinical definition encompassed a wide range of symptoms. CONCLUSIONS: Regular diet immediately after abdominal colorectal surgery was not superior to a clear liquid diet with respect to diet tolerance by postoperative day 2. Furthermore, starting regular diet on postoperative day 0 was not associated with any outcome benefits compared to clear liquid diet. ENSAYO PROSPECTIVO ALEATORIZADO SOBRE EL USO POSTOPERATORIO INMEDIATO DE UNA DIETA NORMAL VERSUS UNA DIETA DE LQUIDOS CLAROS EN CIRUGAS MAYORES COLORRECTALES: ANTECEDENTES:Los protocolos de recuperación mejorada se están convirtiendo en una práctica estandarizada tras una cirugía mayor colorrectal. La creciente evidencia sugiere la alimentación temprana debe ser estimulada, sin embargo, no se ha determinado si se debe administrar una dieta de líquidos claros o una dieta sólida inmediatamente después de la cirugía.OBJETIVO:Evaluar si la dieta regular fue superior a la dieta de líquidos claros a partir del día cero del postoperatorio tras una cirugía mayor colorrectal.DISEÑO:Diseño de prueba de superioridad.AJUSTE:Centro terciario urbano.PACIENTES:Pacientes consecutivos sometidos a cirugía abdominal colorrectal desde septiembre de 2017 hasta junio de 2018INTERVENCIONES:Los pacientes elegibles recibieron ya sea 1) dieta de líquidos claros en el día 0 del postoperatorio con avance a la dieta regular en el día 1 del postoperatorio o 2) dieta regular en el día 0 del postoperatorio y continuaron durante la recuperación de los pacientes.PRINCIPALES MEDIDAS DE RESULTADO:El criterio principal de valoración fue la tolerancia a la dieta, definida por la ausencia de vómitos en el segundo día posoperatorio.RESULTADOS:Un total de 105 pacientes fueron aleatorizados con 53 en el grupo de dieta de líquidos claros y 52 en el grupo de dieta regular. Todos los pacientes aleatorizados fueron incluidos en el análisis. La tasa de tolerancia a la dieta en el segundo día postoperatorio fue similar entre los grupos. Las tasas de íleo, del uso de antieméticos, del uso de narcóticos, del tiempo de recuperación de la función intestinal y puntajes de dolor/náuseas/distensión abdominal fueron similares entre los dos grupos. Significativamente más pacientes en el grupo de dieta de líquidos claros (91%) toleraron su dieta comparada al grupo de dieta regular (71%) en el día postoperatorio 0 ( p = 0,01).LIMITACIONES:La tolerancia a la dieta solo fue monitorizada durante la estadía hospitalaria. La tasa de íleo postoperatorio fue difícil de registrar debido a que su definición clínica abarcaba una amplia variedad de síntomas.CONCLUSIONES:La dieta regular inmediatamente después de la cirugía abdominal colorrectal no fue superior a una dieta de líquidos claros con respecto a la tolerancia de la dieta en el día 2 del postoperatorio. Además, comenzar una dieta regular el día cero del postoperatorio no se asoció con ningún beneficio en los resultados en comparación con la dieta de líquidos claros. (Traducción-Dr. Osvaldo Gauto ).

Efficacy of Anal Sphincter Division During Fistulotomy in Anal Fissure-Associated Fistula.

BACKGROUND: A subset of chronic anal fissures beget focal infection, leading to concomitant fistula. The optimal management of fissure-associated fistula is unknown. OBJECTIVE: This study aimed to characterize healing rates and effects of fistulotomy in fissure-associated fistula. DESIGN: Retrospective study. SETTING: Urban tertiary center. PATIENTS: Adults who underwent fistulotomy for a fistula associated with a chronic anal fissure were included in the study. However, those with Crohn's disease, a history of lateral internal sphincterotomy, and a fistula not amenable to fistulotomy were excluded. INTERVENTIONS: Patients were managed with fistulotomy. Fissures were otherwise managed conservatively with a step-up approach. MAIN OUTCOME MEASURES: The primary end point was healing, defined as resolution of symptoms and both fistula and fissure wounds within 1 year. Subgroup analysis compared those who underwent subcutaneous fistulotomy (group A) with those who underwent fistulotomy involving anal sphincter fibers (group B). RESULTS: Twenty-four of 38 patients (63%) healed with a median overall follow-up of 6.6 months (4.2-14.1). The overall median time to healing was 4.4 months (2.2-6.0). No clinical or pathologic factors predicted healing. In subgroup analysis, overall subcutaneous fistulotomy healing rates were nonstatically lower at 46% (6/13) compared to fistulotomy involving anal sphincter fibers at 72% (18/25; p = 0.16). There was no difference in time to healing (subcutaneous fistulotomy, 6.7 mo [5.2-8.4] vs fistulotomy involving sphincter, 5.1 mo [2.1-7.0]; p = 0.36). LIMITATIONS: The limitations include treatment bias, with increased utilization of chemical sphincter-relaxing agents in those who did not heal. Findings are not applicable to complex fistulas, Crohn's disease, or atypical fissures. CONCLUSIONS: Patients presenting with chronic fissure and associated subcutaneous, intersphincteric, or low transphincteric fistula are successfully managed with fistulotomy. Patients with a subcutaneous fistula tract exhibited nonstatistically significantly lower rates of healing. See Video Abstract at http://links.lww.com/DCR/C145 . EFICACIA DE LA DIVISIN ESFINTRICA DURANTE LA FISTULOTOMA EN CASOS DE FSTULA ASOCIADA A FISURA ANAL: ANTECEDENTES: Ciertos subgrupos de fisuras anales crónicas ocasionan infección localizada, induciendo la aparición de una fístula anal concomitante. Se desconoce el manejo óptimo de la fístula concomitante a una fisura anal.OBJETIVO: Se trata de caracterizar las tasas de curación y el efecto de la fistulotomía en el tratamiento de la fístula concomitante a la fisura anal.DISEÑO: Estudio retrospectivo.EMPLAZAMIENTO: Centro terciario urbano.PACIENTES: Adultos sometidos a fistulotomía por una fístula concomitante a una fisura anal crónica. Se excluyeron la enfermedad de Crohn, el antecedente de una esfinterotomía lateral interna y las fístulas no susceptibles de fistulotomía.INTERVENCIONES: Los pacientes fueron manejados con una fistulotomía clasica. Por lo demás, las fisuras se trataron de forma conservadora con un enfoque médico escalonado.PRINCIPALES MEDIDAS DE RESULTADO: El criterio principal de valoración fué la cura definitiva, determinada como la resolución completa de los síntomas y de las heridas tanto de la fístula como de la fisura en el plazo de un año. El análisis de los subgrupos comparó los que se sometieron a una fistulotomía subcutánea (grupo A) versus una fistulotomía que involucró las fibras del esfínter anal interno (grupo B).RESULTADOS: 24/38 pacientes (63%) curaron con una mediana de seguimiento global de 6,6 meses (4,2-14,1). El tiempo medio general de curación fue de 4,4 meses (2,2-6,0). Ningún factor clínico o patológico predijo la cura. En el análisis de subgrupos, las tasas generales de cura de la fistulotomía subcutánea no fueron estadísticamente más bajas de 46 % (6/13) comparados con la fistulotomía que involucró las fibras del esfínter anal interno en 72 % (18/25; p = 0,16). No hubo diferencia en el tiempo de cicatrización [fistulotomía subcutánea 6,7 meses (5,2-8,4) conparada a la fistulotomía y esfínterotomía parcial interna a 5,1 meses (2,1-7,0); p = 0,36].LIMITACIONES: Sesgo del tratamiento, con mayor utilización de agentes químicos relajantes de la musculatura esfínteriana en aquellos pacientes que no sanaron. No aplicable a fístulas complejas, enfermedad de Crohn o fisuras atípicas.CONCLUSIÓNES: Los pacientes que presentan fisura crónica y fístula subcutánea, inter-esfintérica o trans-esfintérica baja concomitante se manejan con éxito con una fistulotomía. Los pacientes con un trayecto de fístula subcutánea exhibieron tasas de curación más bajas y no estadísticamente significativas. Consulte Video Resumen en http://links.lww.com/DCR/C145 . (Traducción-Dr. Xavier Delgadillo ).

Preoperative CT Indices Predict Nonreach Before IPAA.

BACKGROUND: IPAA aims to restore continence to patients after total proctocolectomy. However, some patients have inadequate small-bowel mesenteric length to achieve reconstruction. No preoperative risk stratification tools of native anatomy exist. OBJECTIVE: We report CT-guided measurements of anatomic landmarks to predict nonreach before IPAA. DESIGN: This is a single-institution retrospective analysis of a prospective database. SETTING: This study was conducted at Cedars-Sinai between January 2007 and December 2021. PATIENTS: Patients with IBD undergoing a 2- or 3-stage IPAA with a preoperative abdominal CT using either an enterography protocol or IV contrast sufficient to visualize mesenteric vasculature were included in the study. CT mesenteric indices were assessed, including total length (representing length required for the pouch to reach the anal canal), mesenteric length (inherent length of small-bowel mesentery), and mobilization length (the difference between total length and mesenteric length). MAIN OUTCOME MEASURES: The primary outcome was IPAA nonreach. The secondary outcomes were association of clinical variables and CT mesenteric indices. RESULTS: Six of 59 patients (10%) experienced nonreach. Mobilization length was longer in the nonreach group by 5.8 cm ( p = 0.01), and mesenteric length was shorter by 3.5 cm ( p = 0.04). Mobilization length ≥17 cm provided 100% sensitivity and 69% specificity (OR 1.46, area under the curve 0.84, p = 0.004) for nonreach. Similarly, a mesenteric length <14.6 cm demonstrated 100% sensitivity and 49% specificity for IPAA nonreach (area under the curve 0.75, p = 0.03). LIMITATIONS: The retrospective nature of the study precluded a standardized imaging protocol. External validation will be required because of the small sample size. CONCLUSIONS: CT-based measurements of length, specifically mesenteric and mobilization length, predict nonreach before IPAA. This method is noninvasive, readily available, and may be useful for preoperative patient counseling and operative planning. See Video Abstract at http://links.lww.com/DCR/C140 . LOS NDICES DE TOMOGRAFA COMPUTARIZADA PREOPERATORIA PREDICEN LA AUSENCIA DE ALCANCE ANTES DE LA ANASTOMOSIS DEL RESERVORIO ILEALANAL: ANTECEDENTES:La anastomosis del reservorio ileoanal tiene como objetivo restaurar la continencia en los pacientes después de una proctocolectomía total. Sin embargo, algunos pacientes tienen una longitud mesentérica del intestino delgado inadecuada para lograr la reconstrucción. No existen herramientas de estratificación del riesgo preoperatorio de la anatomía nativa.OBJETIVO:Informamos mediciones guiadas por tomografía computarizada de puntos de referencia anatómicos para predecir la falta de alcance antes de la anastomosis ileoanal con reservorio.DISEÑO:Este es un análisis retrospectivo de una sola institución de una base de datos prospectiva.AJUSTE:Este estudio se realizó en Cedars-Sinai entre Enero de 2007 y Diciembre de 2021.PACIENTES:Pacientes con enfermedad inflamatoria intestinal que se someten a una anastomosis anal con reservorio ileal en 2 o 3 etapas con una tomografía computarizada abdominal preoperatoria utilizando un protocolo de enterografía o contraste intravenoso suficiente para visualizar la vasculatura mesentérica. Se evaluaron los índices mesentéricos de tomografía computarizada, incluida la longitud total (que representa la longitud requerida para que la bolsa alcance el canal anal), la longitud mesentérica (longitud inherente del mesenterio del intestino delgado) y la longitud de movilización (la diferencia entre la longitud total y la longitud mesentérica).PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue falta de alcance de la anastomosis del reservorio ileoanal. Los resultados secundarios fueron la asociación de variables clínicas y los índices mesentéricos de tomografía computarizada.RESULTADOS:Seis de 59 (10%) pacientes experimentaron falta de alcance. La longitud de movilización fue mayor en el grupo sin alcance en 5,8 cm ( p = 0,01) y la longitud mesentérica fue menor en 3,5 cm ( p = 0,04). La longitud de movilización ≥17 cm proporcionó una sensibilidad del 100% y una especificidad del 69% (OR 1,46, AUC 0,84, p = 0,004) para la falta de alcance. De manera similar, una longitud mesentérica <14,6 cm demostró una sensibilidad del 100% y una especificidad del 49% para la falta de alcance de la anastomosis del reservorio ileoanal (AUC 0,75, p = 0,03).LIMITACIONES:La naturaleza retrospectiva del estudio impidió un protocolo de imágenes estandarizado. Se requerirá una validación externa debido al pequeño tamaño de la muestra.CONCLUSIONES:Las mediciones de longitud basadas en tomografía computarizada, específicamente la longitud mesentérica y de movilización, predicen la falta de alcance antes de la anastomosis anal con bolsa ileo. Este método no es invasivo, está fácilmente disponible y puede ser útil para el asesoramiento preoperatorio del paciente y la planificación quirúrgica. Consulte el Video Resumen en https://links.lww.com/DCR/C140 . (Traducción-Dr. Yesenia Rojas-Khalil ).

High Complication Rate After Early Ileostomy Closure: Early Termination of the Short Versus Long Interval to Loop Ileostomy Reversal After Pouch Surgery Randomized Trial.

BACKGROUND: In patients with ulcerative colitis who undergo IPAA, a diverting ileostomy is used to diminish the severity of anastomotic complications. Typically, the ileostomy is closed after an interval of 2 to 4 months. The safety of earlier closure of the ileostomy after pouch surgery is unknown. OBJECTIVE: This study aimed to compare postoperative outcomes in patients randomly assigned to early (7-12 days) or late (≥8 weeks) ileostomy closure after ileal pouch construction. DESIGN: This was a multicenter, prospective randomized trial. SETTING: The study was conducted at colorectal surgical units at select United States hospitals. PATIENTS: Adults with ulcerative colitis who underwent 2- or 3-stage proctocolectomy with IPAA were included. MAIN OUTCOME MEASURES: The primary outcomes included Comprehensive Complication Index at 30 days after ileostomy closure. The secondary outcomes included complications, severe complications, reoperations, and readmissions within 30 days of ileostomy closure. RESULTS: The trial was stopped after interim analysis because of a high rate of complications after early ileostomy closure. Among 36 patients analyzed, 1 patient (3%) had unplanned proctectomy with end-ileostomy. Of the remaining 35 patients, 28 patients (80%) were clinically eligible for early closure and underwent radiologic assessment. There were 3 radiologic failures. Of the 25 remaining patients, 22 patients (88%) were randomly assigned to early closure (n = 10) or late closure (n = 12), and 3 patients were excluded. Median Comprehensive Complication Index was 14.8 (0-54) and 0 (0-23) after early and late closure (p = 0.02). One or more complications occurred in 7 patients (70%) after early closure and in 2 patients (17%) after late closure (p = 0.01)' and complications were severe in 3 patients (30%) after early closure and 0 patients after late closure (p = 0.04). Reoperation was required in 1 patient (10%) and 0 patients (p = 0.26) after early closure and readmission was required in 7 patients (70%) and 1 patient (8%) after late closure (p = 0.003). LIMITATIONS: This study was limited by early study closure and selection bias. CONCLUSIONS: Early closure of a diverting ileostomy in patients with ulcerative colitis who underwent IPAA is associated with an unacceptably high rate of complications. See Video Abstract at http://links.lww.com/DCR/C68. ALTA TASA DE COMPLICACIONES DESPUS DEL CIERRE PRECOZ DE LA ILEOSTOMA TERMINACIN TEMPRANA DEL ENSAYO ALEATORIZADO DE INTERVALO CORTO VERSUS LARGO PARA LA REVERSIN DE LA ILEOSTOMA EN ASA DESPUS DE LA CIRUGA DE RESERVORIO ILEAL: ANTECEDENTES:En los pacientes con colitis ulcerosa que se someten a una anastomosis del reservorio ileoanal, se utiliza una ileostomía de derivación para disminuir la gravedad de las complicaciones de la anastomosis. Por lo general, la ileostomía se cierra después de un intervalo de 2 a 4 meses. Se desconoce la seguridad del cierre más temprano de la ileostomía después de la cirugía de reservorio.OBJETIVO:Comparar los resultados posoperatorios en pacientes asignados al azar al cierre temprano (7-12 días) o tardío (≥ 8 semanas) de la ileostomía después de la construcción de un reservorio ileal.DISEÑO:Este fue un ensayo aleatorizado prospectivo multicéntrico.ESCENARIO:El estudio se realizó en unidades quirúrgicas colorrectales en hospitales seleccionados de los Estados Unidos.PACIENTES:Se incluyeron adultos con colitis ulcerosa que se sometieron a proctocolectomía en 2 o 3 tiempos con anastomosis ileoanal con reservorio.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios incluyeron el Índice Integral de Complicaciones a los 30 días después del cierre de la ileostomía. Los resultados secundarios incluyeron complicaciones, complicaciones graves, reoperaciones y readmisiones dentro de los 30 días posteriores al cierre de la ileostomía.RESULTADOS:El ensayo se detuvo después del análisis interino debido a una alta tasa de complicaciones después del cierre temprano de la ileostomía. Entre los 36 pacientes analizados, 1 (3%) tuvo una proctectomía no planificada con ileostomía terminal. De los 35 pacientes restantes, 28 (80%) fueron clínicamente elegibles para el cierre temprano y se sometieron a una evaluación radiológica. Hubo 3 fracasos radiológicos. De los 25 pacientes restantes, 22 (88 %) se asignaron al azar a cierre temprano (n = 10) o tardío (n = 12) y 3 fueron excluidos. La mediana del Índice Integral de Complicaciones fue de 14,8 (0-54) y 0 (0-23) después del cierre temprano y tardío (p = 0,02). Una o más complicaciones ocurrieron en 7 pacientes (70%) después del cierre temprano y 2 (17%) pacientes después del cierre tardío (p = 0,01) y fueron graves en 3 (30%) y 0 pacientes, respectivamente (p = 0,04). Requirieron reintervención en 1 (10%) y 0 (p = 0,26) y reingreso en 7 (70%) y 1 (8%) pacientes (p = 0,003).LIMITACIONES:Este estudio estuvo limitado por el cierre temprano del estudio; sesgo de selección.CONCLUSIONES:El cierre temprano de una ileostomía de derivación en pacientes con colitis ulcerosa con anastomosis de reservorio ileoanal se asocia con una tasa inaceptablemente alta de complicaciones. Consulte Video Resumen en http://links.lww.com/DCR/C68. (Traducción-Dr. Felipe Bellolio).

Feasibility of opioid-free surgery for inflammatory bowel disease.

AIM: Patients undergoing colorectal surgery or those with inflammatory bowel disease (IBD) are particularly at risk for opioid-related complications and progression to long-term opioid dependence. The aim of this work is to explore the real-world possibility of perioperative opioid avoidance in colorectal surgery and IBD. METHOD: We conducted a retrospective analysis of patients aggregated from two prospective studies on multimodal postoperative pain control conducted at a single tertiary referral centre. All patients underwent major colorectal surgery with bowel resection. Patients with chronic preoperative opioid use were excluded. Opioid use was measured in oral morphine equivalents (OME) each postoperative day (POD) and cumulatively for the first 72 h. RESULTS: Our cohort of 209 patients included 148 (71%) with IBD and 61 (29%) non-IBD patients. IBD patients required significantly more opioids cumulatively over the first 72 postoperative hours compared with non-IBD patients [median OME 77 mg (interquartile range 33-148 mg) vs. 4 mg (interquartile range 17-82 mg), respectively; p = 0.001]. Five percent of IBD patients achieved opioid-free postoperative pain control during the entire 72 h postoperative period compared with 12% of non-IBD patients. Only 7% of IBD patients avoided opioid use on POD 1 compared with 20% of non-IBD patients (p = 0.02); however the number of IBD patients increased to 16% on POD 2 then 40% on POD 3, closely resembling the non-IBD cohort at 49% (p = 0.22). CONCLUSION: In the era of modern enhanced recovery protocols and minimally invasive techniques, we show that early postoperative opioid avoidance is feasible in a limited number of IBD patients after colorectal surgery.

A Single-Center Experience of Transanal Proctectomy With IPAA for IBD.

BACKGROUND: Restorative proctocolectomy with IPAA is the standard procedure in ulcerative colitis patients with medical refractory disease or dysplasia and select patients with IBD unclassified or Crohn's disease. A variety of minimally invasive techniques have become increasingly utilized, including the transanal IPAA. Unfortunately, despite its growing popularity, there is a lack of high-quality data for the transanal approach. OBJECTIVE: The aim of this study was to investigate clinical outcomes, including complication rates, during our initial experience with the transanal approach. DESIGN: The study design was a single-center prospective case series. SETTINGS: The study was conducted at a tertiary referral center. PATIENTS: The study included patients with ulcerative colitis, IBD unclassified, and Crohn's disease undergoing 2- or 3-stage restorative proctocolectomy with IPAA. INTERVENTIONS: Consecutive patients after November 2016 undergoing restorative proctocolectomy with transanal approach were compared with a historic cohort of patients who underwent an open approach before October 2016. MAIN OUTCOME MEASURES: The primary outcome measure was early and late anastomotic leak rates during our learning curve. Secondary outcomes included postoperative clinical measures. RESULTS: The study group consisted of 100 open and 65 transanal approach patients. Median (interquartile range) estimated blood loss was lower with the transanal approach (100 [50-150] vs 150 [100-250] mL; p = 0.007), and hospital stay was lower in the transanal group by 2 days ( p < 0.001). There was a significantly higher rate of anastomotic leaks with the transanal approach compared with the open approach (n = 7 [11%] vs n = 2 [2%] respectively; p = 0.03). There were fewer, but statistically insignificant, anastomotic complications in the third tertile, which was later in our learning curve. LIMITATIONS: The study was nonrandomized with consecutive assignment, introducing possible selection and chronology biases. CONCLUSION: Restorative proctocolectomy with the transanal approach was associated with lower blood loss and shorter hospital stay but a significantly higher anastomotic leak rate. The transanal minimally invasive approach for pouch surgery offers some advantages but carries a steep learning curve. See Video Abstract at http://links.lww.com/DCR/B842 . EXPERIENCIA DE UN SOLO CENTRO DE PROCTECTOMA TRANSANAL CON ANASTOMOSIS ILEOANAL CON RESERVORIO ILEAL PARA ENFERMEDAD INFLAMATORIA INTESTINAL: ANTECEDENTES:La proctocolectomía restaurativa con anastomosis ileoanal con reservorio ileal es el procedimiento estándar en pacientes con colitis ulcerativa con enfermedad médica refractaria o displasia y pacientes seleccionados con enfermedad inflamatoria intestinal no clasificada o enfermedad de Crohn. Se ha utilizado cada vez más una variedad de técnicas mínimamente invasivas, incluido el enfoque de anastomosis ileoanal con reservorio ileal transanal. Desafortunadamente, a pesar de su creciente popularidad, hay falta de datos de alta calidad para el enfoque transanal.OBJETIVO:Investigar los resultados clínicos, incluidas las tasas de complicaciones, durante nuestra experiencia inicial con el enfoque transanal.DISEÑO:Serie de casos prospectivos de un solo centro.AJUSTES:Centro de referencia terciario.PACIENTES:Pacientes con ulcerativa, enfermedad inflamatoria intestinal no clasificada y enfermedad de Crohn sometidos a proctocolectomía restaurativa de 2 o 3 etapas con anastomosis ileoanal con reservorio ileal.INTERVENCIONES:Pacientes consecutivos después de noviembre del 2016 sometidos a proctocolectomía restaurativa con abordaje transanal fueron comparados con una cohorte histórica que se sometieron a un abordaje abierto antes de octubre del 2016.PRINCIPALES MEDIDAS DE RESULTADO:La principal medida de resultado fueron las tasas de fuga anastomótica temprana y tardía durante nuestra curva de aprendizaje. Los resultados secundarios incluyeron medidas clínicas postoperatorias.RESULTADOS:El grupo de estudio estuvo formado por 100 pacientes con abordaje abierto y 65 por vía transanal. La media de pérdida sanguínea estimada fue menor con el abordaje transanal (100 [50-150] vs 150 [100-250] mL; p = 0.007) y la estancia hospitalaria fue menor en el grupo transanal por 2 días ( p < 0.001). Hubo una tasa significativamente mayor de fugas anastomóticas con el abordaje transanal en comparación con el abordaje abierto (n = 7 [11%] vs n = 2 [2%] respectivamente, p = 0.03). Hubo menos complicaciones anastomóticas, pero estadísticamente insignificantes, en el tercer tercil, posterior en nuestra curva de aprendizaje.LIMITACIONES:Estudio no randomizado con asignación consecutiva que presenta posibles sesgos de selección y cronología.CONCLUSIÓNES:La proctocolectomía restaurativa con abordaje transanal se asoció a una menor pérdida sanguínea y estancia hospitalaria más corta, pero con una tasa de fuga anastomótica significativamente mayor. El abordaje transanal mínimamente invasivo para cirugía de reservorio ofrece algunas ventajas, pero conlleva a una curva de aprendizaje pronunciada. Consulte Video Resumen en http://links.lww.com/DCR/B842 . (Traducción- Dr. Francisco M. Abarca-Rendon ).

Appropriateness of Medical and Surgical Treatments for Chronic Pouchitis Using RAND/UCLA Appropriateness Methodology.

BACKGROUND AND AIMS: The treatment of chronic pouchitis remains a challenge due to the paucity of high-quality studies. We aimed to provide guidance for clinicians on the appropriateness of medical and surgical treatments in chronic pouchitis. METHODS: Appropriateness of medical and surgical treatments in patients with chronic pouchitis was considered in 16 scenarios incorporating presence/absence of four variables: pouchitis symptoms, response to antibiotics, significant prepouch ileitis, and Crohn's disease (CD)-like complications (i.e., stricture or fistula). Appropriateness of permanent ileostomy in patients refractory to medical treatments was considered in eight additional scenarios. Using the RAND/UCLA appropriateness method, international IBD expert panelists rated appropriateness of treatments in each scenario on a 1-9 scale. RESULTS: Chronic antibiotic therapy was rated appropriate only in asymptomatic antibiotic-dependent patients with no CD-like complications and inappropriate in all other scenarios. Ileal-release budesonide was rated appropriate in 6/16 scenarios including patients with significant prepouch ileitis but no CD-like complications. Probiotics were considered either inappropriate (14/16) or uncertain (2/16). Biologic therapy was considered appropriate in most scenarios (14/16) and uncertain in situations where significant prepouch ileitis or CD-like complications were absent (2/16). In patients who are refractory to all medications, permanent ileostomy was considered appropriate in all scenarios (7/8) except in asymptomatic patients with no CD-like complications. CONCLUSIONS: In the presence of significant prepouch ileitis or CD-like complications, chronic antibiotics and probiotics are inappropriate. Biologics are appropriate in all patients except in asymptomatic patients with no evidence of complications. Permanent ileostomy is appropriate in most medically refractory patients.

IPAA in Known Preoperative Crohn's Disease: A Systematic Review.

BACKGROUND: Crohn's disease is a relative contraindication to IPAA due to perceived increased rates of pouch failure. OBJECTIVE: This study aimed to determine pouch functional outcomes and failure rates in patients with a known preoperative diagnosis of Crohn's disease. DATA SOURCES: A database search was performed in Ovid Medline In-Process & Other NonIndexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, and Ovid Cochrane Database of Systematic Reviews. STUDY SELECTION: The published human studies that reported short-term postoperative outcomes and/or long-term outcomes following IPAA in adult (≥18 years of age) Crohn's disease populations were selected. INTERVENTION: Ileal pouch anal anastomoses were constructed in patients who had Crohn's disease diagnosed preoperatively or through proctocolectomy pathology. MAIN OUTCOMES MEASURES: The primary outcomes measured were long-term functional outcomes (to maximal date of follow-up) and the pouch failure rate. RESULTS: Of 7019 records reviewed, 6 full articles were included in the analysis. Rates of pelvic sepsis, small-bowel obstruction, pouchitis, anal stricture, and chronic sinus tract were 13%, 3%, 31%, 18%, and 28%. Rates of incontinence, urgency, pad usage in the day, pad usage at night, and need for antidiarrheals were 24%, 21%, 19%, 20%, and 28%, and mean 24-hour stool frequency was 6.3 bowel movements at a mean 69 months of follow-up. The overall pouch failure rate was 15%; no risk factors for pouch failure were identified. LIMITATIONS: This investigation was limited by the small number of studies with significant study heterogeneity. CONCLUSION: In patients with known preoperative Crohn's disease, IPAA construction is feasible with functional outcomes equivalent to patients with ulcerative colitis, but, even in highly selected patients with Crohn's disease, pouch failure rates remain higher than in patients with ulcerative colitis.

A Prospective Randomized Trial of Surgeon-Administered Intraoperative Transversus Abdominis Plane Block With Bupivacaine Against Liposomal Bupivacaine: The TINGLE Trial.

BACKGROUND: Transversus abdominis plane blocks are increasingly used to achieve opioid-sparing analgesia after colorectal surgery. Traditionally, bupivacaine was the long-acting analgesic of choice, but the addition of dexamethasone and/or epinephrine to bupivacaine may extend block duration. Liposomal bupivacaine has also been suggested to achieve an extended analgesia duration of 72 hours but is significantly more expensive. OBJECTIVE: The purpose of this study was to compare pain control between laparoscopic transversus abdominis plane blocks using liposomal bupivacaine versus bupivacaine with epinephrine and dexamethasone. DESIGN: This was a parallel-group, single-institution, randomized clinical trial. SETTINGS: The study was conducted at a single tertiary medical center. PATIENTS: Consecutive patients between October 2018 to October 2019, ages 18 to 90 years, undergoing minimally invasive colorectal surgery with multimodal analgesia were included. INTERVENTIONS: Patients were randomly assigned 1:1 to receive a laparoscopic transversus abdominis plane block with liposomal bupivacaine or bupivacaine with epinephrine and dexamethasone. MAIN OUTCOME MEASURES: The primary outcome was total oral morphine equivalents administered in the first 48 hours postoperatively. Secondary outcomes included pain scores, time to ambulation and solid diet, hospital length of stay, and complications. RESULTS: A total of 102 patients (50 men) with a median age of 42 years (interquartile range, 29-60 y) consented and were randomly assigned. The primary end point, total oral morphine equivalents administered in the first 48 hours, was not significantly different between the liposomal bupivacaine group (median = 69 mg) and the bupivacaine with epinephrine and dexamethasone group (median = 47 mg; difference in medians = 22 mg, (95% CI, -17 to 49 mg); p = 0.60). There were no significant differences in pain scores, time to ambulation, time to diet tolerance, time to bowel movement, length of stay, overall complications, or readmission rate between groups. There were no treatment-related adverse outcomes. LIMITATIONS: This study was not placebo controlled or blinded. CONCLUSIONS: This first randomized trial comparing laparoscopic transversus abdominis plane block with liposomal bupivacaine or bupivacaine with epinephrine and dexamethasone showed that a liposomal bupivacaine block does not provide superior or extended analgesia in the era of standardized multimodal analgesia protocols.See Video Abstract at http://links.lww.com/DCR/B533. ESTUDIO PROSPECTIVO Y RANDOMIZADO DE BLOQUEO DEL PLANO MUSCULAR TRANSVERSO DEL ABDOMEN REALIZADO POR EL CIRUJANO CON BUPIVACANA VERSUS BUPIVACANA LIPOSOMAL ESTUDIO TINGLE: ANTECEDENTES:El bloqueo anestésico del plano muscular transverso del abdomen se utiliza cada vez más para lograr una analgesia con menos consumo de opioides después de cirugía colorrectal. Tradicionalmente, la Bupivacaína era el analgésico de acción prolongada de elección, pero al agregarse Dexametasona y/o Adrenalina a la Bupivacaína se puede prolongar la duración del bloqueo. También se ha propuesto que la Bupivacaína liposomal logra una duración prolongada de la analgesia de 72 horas, pero es significativamente más cara.OBJETIVO:Comparar el control del dolor entre bloqueo laparoscópico del plano de los transversos del abdomen usando Bupivacaína liposomal versus Bupivacaína con Adrenalina y Dexametasona.DISEÑO:Estudio clínico prospectivo y randomizado de una sola institución en grupos paralelos.AJUSTE:Centro médico terciario único.PACIENTES:Todos aquellos pacientes entre 18 y 90 años sometidos a cirugía colorrectal mínimamente invasiva con analgesia multimodal, entre octubre de 2018 a octubre de 2019 incluidos de manera consecutiva.INTERVENCIONES:Los pacientes fueron seleccionados aleatoriamente 1:1 para recibir un bloqueo laparoscópico del plano de los transversos del abdomen con Bupivacaína liposomal o Bupivacaína con Adrenalina y Dexametasona.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue el total de equivalentes de morfina oral administradas en las primeras 48 horas después de la operación. Los resultados secundarios incluyeron puntuaciones de dolor, inicio de dieta sólida, tiempo de inicio a la deambulación, la estadía hospitalaria y las complicaciones.RESULTADOS:Un total de 102 pacientes (50 hombres) con una mediana de edad de 42 años (IQR 29-60) fueron incluidos aleatoriamente. El criterio de valoración principal, equivalentes de morfina oral total administrada en las primeras 48 horas, no fue significativamente diferente entre el grupo de Bupivacaína liposomal (mediana = 69 mg) y el grupo de Bupivacaína con Adrenalina y Dexametasona (mediana = 47 mg; diferencia en medianas = 22 mg, IC del 95% [-17] - 49 mg, p = 0,60). No hubo diferencias significativas en las puntuaciones de dolor, tiempo de inicio a la deambulación, el tiempo de tolerancia a la dieta sólida, el tiempo hasta el primer evacuado intestinal, la duración de la estadía hospitalaria, las complicaciones generales o la tasa de readmisión entre los grupos. No hubo resultados adversos relacionados con el tratamiento.LIMITACIONES:Este estudio no fue controlado con placebo ni de manera cegada.CONCLUSIONES:Este primer estudio prospectivo y randomizado que comparó el bloqueo del plano de los músculos transversos del abdomen por vía laparoscópica, utilizando Bupivacaína liposomal o Bupivacaína con Adrenalina y Dexametasona, demostró que el bloqueo de Bupivacaína liposomal no proporciona ni mejor analgesia ni un efecto mas prolongado.Consulte Video Resumen en http://links.lww.com/DCR/B533.

Perioperative safety of tofacitinib in surgical ulcerative colitis patients.

AIM: The literature regarding monoclonal antibodies and increased postoperative complications in inflammatory bowel disease remains controversial. There have been no studies investigating tofacitinib. The aim of this work was to determine preoperative exposure to the small-molecule inhibitor tofacitinib and postoperative outcomes. METHOD: We conducted a retrospective review of all adult patients exposed to tofacitinib within 4 weeks of total abdominal colectomy for medically refractory ulcerative colitis between 1 January 2018 and 1 September 2020 at four inflammatory bowel disease referral centres. Data collected included patient demographics and 90-day postoperative morbidity, readmission and reoperation rates. RESULTS: Fifty-three patients (32 men, 60%) with ulcerative colitis underwent a total abdominal colectomy (n = 50 laparoscopic, 94%) for medically refractory disease. Previous exposure to monoclonal antibodies included infliximab (n = 34), adalimumab (n = 35), certolizumab pegol (n = 5), vedolizumab (n = 33) and ustekinumab (n = 10). Twenty-seven (51%) patients were on concurrent prednisone at a median daily dose of 30 mg by mouth (range 5-60 mg). There were no postoperative deaths. Ninety-day postoperative complications included ileus (n = 7, 13.2%), superficial surgical site infection (n = 4, 7.5%), intra-abdominal abscess (n = 2, 3.8%) and venous thromboembolism (VTE) (n = 7, 13.2%). Locations of VTE included portomesenteric venous thrombus (n = 4), internal iliac vein (n = 2) and pulmonary embolism (n = 1). Nine (17%) patients were readmitted to hospital and five (9%) patients had a reoperation. CONCLUSION: Mirroring the recently issued US Food and Drug Administration black box warning of an increased risk of VTE in medically treated ulcerative colitis patients taking tofacitinib, preoperative tofacitinib exposure may present an increased risk of postoperative VTE events. Consideration should be given for prolonged VTE prophylaxis on hospital discharge.

Antitumour necrosis factor therapy is associated with de novo Crohn's disease after ileal pouch-anal anastomosis.

AIM: Tumour necrosis factor inhibitors (TNFi) have revolutionized the management of moderate to severe ulcerative colitis (UC) since their approval for UC in 2005. However, many patients ultimately require surgery with ileal pouch-anal anastomosis (IPAA). Development of de novo Crohn's disease (CD) following IPAA is an increasingly common and devastating complication, sometimes progressing to pouch failure. The aim of this study was to evaluate the association of preoperative TNFi exposure and the development of de novo CD after IPAA. METHOD: A prospective single-centre inflammatory bowel disease (IBD) registry was searched for consecutive patients with UC undergoing IPAA during a 25-year period ending July 2018. Patients with preoperative CD or IBD-unclassified were excluded. De novo CD was diagnosed upon endoscopic evidence of five or more mucosal ulcers proximal to the ileal pouch any time after surgery and/or pouch fistula occurring more than three months after ileostomy closure. RESULTS: The study cohort consisted of 400 patients with a median follow-up of 44.0 (IQR 11-113) months. Sixty-two (16%) patients developed de novo CD 28.0 (IQR 6-67) months following ileostomy closure. Survival analysis of TNFi era patients revealed a significant increase in de novo CD risk in those with preoperative TNFi exposure. Multivariable proportional hazards modelling revealed two independent predictors for de novo CD development: older age was protective (HR 0.89 per 5-year increase; P = 0.009) and preoperative TNFi exposure was hazardous (HR 2.10; P = 0.011). CONCLUSION: This prospective study is the first to suggest an association between preoperative TNFi exposure and the development of de novo CD.

Colectomy with Permanent End Ileostomy Is More Cost-Effective than Ileal Pouch-Anal Anastomosis for Crohn's Colitis.

BACKGROUND: Much of the economic burden of Crohn's disease (CD) is related to surgery. Twenty percent of patients with CD have isolated colonic disease. While permanent end ileostomy (EI) is generally the procedure of choice for patients with refractory CD colitis, single-center experiences suggest that restorative proctocolectomy (IPAA) is durable in select patients. AIMS: We assessed the cost-effectiveness of total colectomy with permanent EI versus IPAA in medically refractory colonic CD. METHODS: We used a lifetime Markov model with 6-month cycles to simulate quality-adjusted life years (QALYs) and cost. In each of the EI and IPAA strategies, patients could transition between multiple health states. One-way and multivariable sensitivity analysis and tornado analysis were performed to identify thresholds for factors influencing cost-effectiveness. RESULTS: IPAA was more effective than EI surgery with an incremental cost-effectiveness ratio of $70,715 per QALY gained. We identified the following variables of importance in our model: (1) the cost of the EI surgery, (2) the cost of infliximab, and (3) the cost of gastroenterology ambulatory visit and labs. Threshold analysis revealed that if the costs associated with EI surgery exceeded $20,167 or if the utility of IPAA with CD remission without medical therapy exceeded 0.37, IPAA became the more cost-effective strategy. CONCLUSIONS: In patients with medically refractory CD isolated to the colon, colectomy with permanent EI is more cost-effective than IPAA unless the costs associated with the EI surgery exceed $20,167 or if the utility associated with IPAA and CD remission exceeds 0.37.

A prospective evaluation of the ligation of the intersphincteric tract procedure for complex anal fistula in patients with Crohn's disease.

OBJECTIVE: To evaluate 2- and 12-month outcomes after ligation of the intersphincteric fistula tract (LIFT) in Crohn's disease (CD). BACKGROUND: Surgical approaches to perianal fistulas in CD are frequently ineffective and hampered by concerns over adequate wound healing and sphincter injury. The efficacy of LIFT in CD patients is unknown. METHODS: Consecutive cases of CD patients with transsphincteric fistulas were prospectively analyzed. Fistula healing and 2 validated quality-of-life indices were assessed. RESULTS: Fifteen CD patients (9 women; mean age = 34.8 years) were identified. Location of the fistula was lateral (n = 10; 67%) or midline (n = 5; 33%). LIFT site healing was seen in 9 patients (60%) at 2-month follow-up. No patient developed fecal incontinence. LIFT site healing was seen in 8 of the 12 patients (67%) with complete 12-month follow-up. Significant factors for long-term LIFT site healing were lateral versus midline location (P = 0.02) and longer mean fistula length (P = 0.02). Patients who had successful operations significantly improved both their mean Wexner Perianal Crohn's Disease Activity Index and McMaster Perianal Crohn's Disease Activity Index quality-of-life scores at 2-month follow-up (14.0-3.8, P = 0.001, and 10.4-1.8, P = 0.0001, respectively). CONCLUSIONS: CD-associated anal fistulas may be treated with LIFT. This surgical procedure is a safe, outpatient procedure that minimizes both perianal wound creation and sphincter injury.

Impact of postoperative telemedicine visit versus in-person visit on patient satisfaction: A randomized clinical trial.

BACKGROUND: Although telemedicine use has increased dramatically during the COVID-19 pandemic and beyond, the impact of telemedicine versus in-person postoperative visits on patient satisfaction has not been studied prospectively. We hypothesized that telemedicine visits would be noninferior to in-person visits in terms of postoperative colorectal surgery patient satisfaction. METHODS: We conducted a randomized trial of consecutive adult patients undergoing transabdominal colorectal surgery from September 2020 to February 2021. Eligible participants were randomized 1:1 to either receive a telemedicine visit (Arm T) or an in-person visit (Arm I) for their first postoperative appointment. Subsequently, participants in Arm T completed a second postoperative visit in person, and participants in Arm I completed a second postoperative visit via telemedicine. All participants completed a patient satisfaction survey electronically within 24 hours after each postoperative visit. The primary endpoint was total patient satisfaction score. Secondary endpoints included patient-reported safety score, length of visit, and willingness of patients to recommend the practice to their peers. Fisher's exact test, χ2 analysis, and Student's t test were used to compare outcomes. RESULTS: A total of 46 patients were analyzed with 23 each in Arm T and Arm I. The mean age of our study cohort was 50.6 (standard deviation 17.7) years and 52% were female. No significant differences were found between groups in terms of baseline characteristics. With respect to our primary endpoint of total satisfaction score, patient satisfaction scores in Arm T were non-inferior to those in Arm I. Similarly, there was no significant difference in satisfaction scores after the second postoperative visit when the visit types were reversed. We did not find any significant differences between groups in terms of our secondary endpoints. CONCLUSION: Postoperative telemedicine visits were a safe and time-efficient option that maintained high patient satisfaction compared with in-person postoperative visits.