Laparoscopic modified mesh rectopexy: medium-term results of a novel approach for external rectal prolapse.

AIM: Rectal prolapse is a common and significantly debilitating condition. Surgical correction is usually required. The two most common abdominal approaches are ventral mesh rectopexy and posterior suture rectopexy. Both may be complicated, respectively, by either mesh-related complications or significant postoperative constipation. We report the outcome of a novel rectopexy operation which combines aspects of both the aforementioned approaches, for the treatment of external rectal prolapse (ERP). METHOD: The technique involves laparoscopic partial posterior-lateral rectal mobilization of the rectum with posterior suture fixation to the sacral promontory and placement of an absorbable mesh in the rectovaginal space. Data were collected on postoperative complications, prolapse recurrence, mesh-related complications and the assessment of quality of life. RESULTS: Eighty patients underwent a modified mesh rectopexy for ERP. Seventy-seven were women. The median age was 67.5 years. Almost a third had undergone a previous rectal prolapse repair. Recurrences were seen in 11 (13.8%). No mesh-related complications were seen. Eleven patients reported postoperative constipation. CONCLUSION: The laparoscopic modified mesh rectopexy may be a safe and effective operation for the treatment of ERP.

Surgical management of complex ileocolonic Crohn's disease: a survey of IBD colorectal surgeons to assess variability in operative strategy.

INTRODUCTION: To explore the reported variability in the surgical management of ileocolonic Crohn' s disease and identify areas of standard practice, we present this study which aims to assess how different colorectal surgeons with a subspecialty interest in inflammatory bowel disease (IBD) surgery may act in different clinical scenarios of ileocolonic Crohn's disease. METHODS: Anonymous videos demonstrating the small bowel walkthrough and anonymised patients' clinical data, imaging and pathological findings were distributed to the surgeons using an electronic tool. Surgeons answered on operative strategy, bowel resections, management of small bowel mesentery, type of anastomosis and use of stomas. RESULTS: Eight small bowel walkthrough videos were registered and 12 assessors completed the survey with a questionnaire completion rate of 87.5%. There was 87.7% agreement in the need to perform an ileocolonic resection. However, the agreement for the need to perform associated surgical procedures such as strictureplasties or further bowel resections was only 57.4%. When an anastomosis was fashioned, the side to side configuration was the most commonly used. The preferred management of the mesentery was dissection close to the bowel. CONCLUSIONS: The decision on the main procedure to be performed had a high agreement amongst the different assessors, but the treatment of multifocal disease was highly controversial, with low agreement on the need for associated procedures to treat internal fistulae and the use of strictureplasties. At the same time, there was significant heterogeneity in the decision on when to anastomose and when to fashion an ileostomy.

Video-laparoscopic assessment of the small bowel in Crohn's disease: a comparative study to evaluate surgeons' inter-observer variability.

BACKGROUND: Assessment of the entire small bowel is advocated during Crohn's disease (CD) surgery, as intraoperative detection of new lesions may lead to change in the planned procedure. The aim of this study was to evaluate the inter-observer variability in the assessment of extent and severity of CD at the small bowel laparoscopic "walkthrough". METHODS: A survey on laparoscopic assessment of the small bowel in patients with CD, including items adapted from the MREnterography or ultrasound in Crohn's disease (METRIC) study and from the classification of severity of mesenteric disease was developed by an invited committee of colorectal surgeons. Anonymous laparoscopic videos demonstrating the small bowel "walkthrough" in ileocolonic resection for primary and recurrent CD were distributed to the committee members together with the anonymous survey. The primary outcome was the rate of inter-observer variability on assessment of strictures, dilatations, complications and severity of mesenteric inflammation. RESULTS: 12 assessors completed the survey on 8 small bowel walkthrough videos. The evaluation of the small bowel thickening and of the mesenteric fat wrapping were the most reliable assessments with an overall agreement of 87.1% (k = 0.31; 95% CI - 0.22, 0.84) and 82.7% (k = 0.35; 95% CI - 0.04, 0.73), respectively. The presence of strictures and pre-stenotic dilatation demonstrated agreement of 75.2% (k = 0.06: 95% CI - 0.33, 0.45) and 71.2% (k = 0.33; 95% CI 0.15, 0.51), respectively. Evaluation of fistulae had an overall agreement of 75.3%, while there was a significant variation in the evaluation of mild, moderate and severe mesenteric disease with overall agreement ranging from 33.3 to 100%. CONCLUSION: Laparoscopic assessment of the small bowel thickening and of the presence of mesenteric fat wrapping is reliable for the intraoperative evaluation of CD with high inter-rater agreement. There is significant heterogeneity in the assessment of the severity of the mesenteric disease involvement.

Training in colorectal surgery in Europe and 20 years of the European Board of Surgical Qualification coloproctology examination.

AIM: Training in colorectal surgery across Europe is not yet standardized. The European Board of Surgical Qualification (EBSQ) coloproctology examination has been held annually since 1998. The aims of this study were to illustrate the current situation of coloproctology specialization in Europe and to analyse the EBSQ examinations held over the last 20 years. METHOD: A survey, focused on current training and education in colorectal surgery in Europe, was conducted among all national representatives of the European Society of Coloproctology (ESCP) in 2018. Candidate demographics (1998-2018) and the results of the EBSQ examination (2007-2018) were analysed. RESULTS: In Europe, there are currently 26 national colorectal societies, 27 national annual colorectal meetings, 16 national specialized training programmes and 13 national colorectal fellowships. Six countries have board certification in colorectal surgery and five a dedicated examination. During the last 20 years, 475 candidates from 29 countries, of whom 88 (19%) were women, passed the EBSQ examination. The pass rate was higher in younger applicants (< 42 years, P = 0.01). The success rate was higher for candidates with academic experience (more than five publications or presentations) and with an academic title (thesis) (P = 0.01). CONCLUSION: Colorectal surgical training is still not standardized in Europe, although efforts have been made to recognize colorectal surgery as an independent speciality. The number of holders of the EBSQ Diploma has increased over the years, demonstrating the acceptance of the examination among European surgeons. Young candidates with an academic profile are the most successful.

Comparison between high-resolution water-perfused anorectal manometry and THD® Anopress anal manometry: a prospective observational study.

AIM: Anorectal physiology tests provide a functional assessment of the anal canal. The aim of this study was to compare the results generated by standard high-resolution water-perfused manometry (WPM) with the newer THD® Anopress manometry system. METHOD: This was a prospective observational study. Conventional manometry was carried out using a water-perfused catheter with high-resolution manometry and compared with the Anopress system with air-filled catheters. All patients underwent the two procedures successively in a randomized order. Time to arrive at the resting pressure plateau, resting, squeeze, straining pressure and visual analogue scale (VAS) scores for pain were recorded. A qualitative analysis of the two devices was performed. RESULTS: Between 2016 and 2017, 60 patients were recruited. The time from insertion of the catheter to arriving at the resting pressure plateau was significantly lower with the Anopress compared with WPM: 12 s [interquartile range (IQR) 10-17 s] versus 100 s (IQR 67-121 s) (P < 0.001). A strong correlation between the manometric values of WPM and the Anopress was observed. Both procedures were well tolerated, although the VAS score for insertion of the WPM catheter was significantly higher. The Anopress was easier to use and more time-efficient than the WPM. CONCLUSION: The pressure values obtained with Anopress correlated well with those of conventional manometry. The Anopress has the advantage of being less time-consuming, user-friendly and better tolerated by patients.

Temporary faecal diversion in ileocolic resection for Crohn's disease: is there an impact on long-term surgical recurrence?

AIM: Temporary faecal diversion after ileocolic resection (ICR) for Crohn's disease reduces postoperative anastomotic complications in high-risk patients. The aim of this study was to assess if this approach also reduces long-term surgical recurrence. METHOD: This was a multicentre retrospective review of prospectively maintained databases. Patient demographics, medical and surgical details were collected by three specialist centres. All patients had undergone an ICR between 2000 and 2012. The primary end-point was surgical recurrence. RESULTS: Three hundred and twelve patients (80%) underwent an ICR without covering ileostomy (one stage). Seventy-seven (20%) had undergone an ICR with end ileostomy/double-barrel ileostomy/enterocolostomy followed by closure (two stage). The median follow-up was 105 months [interquartile range (IQR) 76-136 months]. The median time to ileostomy closure was 9 months (IQR 5-12 months). There was no significant difference in surgical recurrence between the one- and two-stage groups (18% vs 16%, P = 0.94). We noted that smokers (20% vs 34%, P = 0.01) and patients with penetrating disease (28% vs 52%, P < 0.01) were more likely to be defunctioned. A reduced recurrence rate was observed in the small high-risk group of patients who were smokers with penetrating disease behaviour treated with a two-stage strategy (0/10 vs 4/7, P = 0.12). CONCLUSION: Despite having higher baseline risk factors, the results in terms of rate of surgical recurrence over 9 years are similar for patients having a two-stage compared with a one-stage procedure.

Incisional hernia and enterocutaneous fistula in patients with chronic intestinal failure: prevalence and risk factors in a cohort of patients referred to a tertiary centre.

AIM: This study aims to determine the prevalence of incisional hernia (IH) and enterocutaneous fistula (ECF) in patients with intestinal failure (IF) referred to a tertiary centre and to identify factors associated with their development. METHOD: A retrospective case note review was undertaken of a prospectively maintained database of all patients on home parenteral nutrition between 2011 and 2016 at a UK tertiary referral centre for IF. Risk factors were identified using binary logistic regression. RESULTS: The database search identified 447 patients, of whom 349 (78.1%) had surgery prior to developing IF. Eighty-one (23.2%) patients had an IH and 123 (35.2%) had an ECF at the time of referral. Of these, 51 (14.6%) had both IH and ECF. IH was associated with a high body mass index (P = 0.05), a history of a major surgical complication resulting in IF (P = 0.01), previous emergency surgery (P = 0.04), increasing number of operations (P = 0.02) and surgical site infection (SSI; P = 0.01). ECF was associated with complications relating to earlier surgery. (P ≤ .001), previous treatment with an open abdomen (P = 0.03), SSI (P = 0.001), intra-abdominal collection (P ≤ 0.001) and anastomotic leak (P = 0.02). CONCLUSION: In this series, patients with IF had a prevalence of IH which was more than double that expected following elective laparotomy (about 10%) and one in three had an ECF. Risk factors for IH and ECF are discussed.

Management of early pouch-related septic complications in ulcerative colitis: a systematic review.

AIM: It is well established that ileo-anal pouch-related septic complications (PRSC) increase the risk of pouch failure. There are a number of publications that describe the management of early PRSC in ulcerative colitis (UC) in small series. This article aims to systematically review and summarize the relevant current data on this subject and provide an algorithm for the management of early PRSC. METHOD: A systematic review was undertaken in accordance with PRISMA guidelines. Studies published between 2000 and 2017 describing the clinical management of PRSC in patients with UC within 30 days of primary ileo-anal pouch surgery were included. A qualitative analysis was undertaken due to the heterogeneity and quality of studies included. RESULTS: A total of 1157 abstracts and 266 full text articles were screened. Twelve studies were included for analysis involving a total of 207 patients. The studies described a range of techniques including image-guided, endoscopic, surgical and endocavitational vacuum methods. Based on the evidence from these studies, an algorithm was created to guide the management of early PRSC. CONCLUSION: The results of this review suggest that although successful salvage of early PRSC is improving there is little information available relating to methods of salvage and outcomes. Novel techniques may offer an increased chance of salvage but comparative studies with longer follow-up are required.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease.

AIM: There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. METHODS: Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines. RESULTS: All aspects of surgical care for IBD have been included along with 157 recommendations for management. CONCLUSION: These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Technical variations and feasibility of transanal ileal pouch-anal anastomosis for ulcerative colitis and inflammatory bowel disease unclassified across continents.

PURPOSE: Initial reports of transanal ileal pouch-anal anastomosis (taIPAA) suggest safety and feasibility compared with transabdominal IPAA. The purpose of this study was to evaluate differences in technique and results of taIPAA in three centers performing taIPAA across two continents. METHODS: Prospective IPAA registries from three institutions in the US and Europe were queried for patients undergoing taIPAA. Demographic, preoperative, intraoperative, and postoperative data were compiled into a single database and evaluated. RESULTS: Sixty-two patients (median age 38 years; range 16-68 years, 43 (69%) male) underwent taIPAA in the three centers (USA 24, UK 23, Italy 15). Most patients had had a subtotal colectomy before taIPAA [n = 55 (89%)]. Median surgical time was 266 min (range 180-576 min) and blood loss 100 ml (range 10-500 ml). Technical variations across the three institutions included proctectomy plane of dissection (intramesorectal or total mesorectal excision plane), specimen extraction site (future ileostomy site vs. anus), ileo-anal anastomosis technique (stapled vs. hand sewn) and use of fluorescence angiography. Despite technical differences, anastomotic leak rates (5/62; 8%) and overall complications (18/62; 29%) were acceptable across the three centers. CONCLUSIONS: This is the first collaborative report showing safety and feasibility of taIPAA. Despite technical variations, outcomes are similar across centers. A large multi-institutional, international IPAA collaborative is needed to compare technical factors and outcomes.

Sexual dysfunction following rectal cancer surgery.

INTRODUCTION: Sexual and urological problems after surgery for rectal cancer are common, multifactorial, inadequately discussed, and untreated. The urogenital function is dependent on dual autonomic sympathetic and parasympathetic innervation, and four key danger zones exist that are at risk for nerve damage during colorectal surgery: one of these sites is in the abdomen and three are in the pelvis. The aim of this study is to systematically review the epidemiology of sexual dysfunction following rectal cancer surgery, to describe the anatomical basis of autonomic nerve-preserving techniques, and to explore the scientific evidence available to support the laparoscopic or robotic approach over open surgery. METHODS: According to the PRISMA guidelines, a comprehensive literature search of studies evaluating sexual function in patients undergoing rectal surgery for cancer was performed in Medline, Scopus, Web of Science, Embase, and Cochrane Central Register of controlled trials. RESULTS: An increasing number of studies assessing the incidence and prevalence of sexual dysfunction following multimodality treatment for rectal cancer has been published over the last 30 years. Significant heterogeneity in the prevalence of sexual dysfunction is reported in the literature, with rates between 5 and 90%. CONCLUSIONS: There is no evidence to date in favor of any surgical approach (open vs laparoscopic vs robotic). Standardized diagnostic tools should be routinely used to prospectively assess sexual function in patients undergoing rectal surgery.

Complex abdominal wall reconstruction in the setting of active infection and contamination: a systematic review of hernia and fistula recurrence rates.

AIM: Minimal evidence exists to guide surgeons on the risk of complications when performing abdominal wall reconstruction (AWR) in the presence of active infection, contamination or enterocutaneous fistula. This study aims to establish the outcomes of contaminated complex AWR. METHOD: Analysis was conducted according to PRISMA guidelines. Systematic search of the MEDLINE, EMBASE and Pubmed databases was performed. Studies reporting exclusively on single-staged repair of contaminated complex AWR were included. Pooled data were analysed to establish rates of complications. RESULTS: Sixteen studies were included, consisting of 601 contaminated complex AWRs, of which 233 included concurrent enterocutaneous fistula repair. The average follow-up period was 26.7 months. There were 146 (24.3%) reported hernia recurrences. When stratified by repair method, suture repair alone had the lowest rate of recurrence (14.2%), followed by nonabsorbable synthetic mesh reinforcement (21.2%), biological mesh (25.8%) and absorbable synthetic mesh (53.1%). Hernia recurrence was higher when fascial closure was not achieved. Of the 233 enterocutaneous fistula repairs, fistula recurrence was seen in 24 patients (10.3%). Suture repair alone had the lowest rate of recurrence (1.6%), followed by nonbiological mesh (10.3%) and biological mesh reinforcement (12%). Forty-six per cent of patients were reported as having a wound-related complication and the mortality rate was 2.5%. CONCLUSION: It is feasible to perform simultaneous enterocutaneous fistula repair and AWR as rates of recurrent fistula are comparable with series describing enterocutaneous fistula repair alone. Hernias recurred in nearly a quarter of cases. This analysis is limited by a lack of comparative data and variability of outcome reporting.

Major Complex Abdominal Wall Repair in Contaminated Fields with Use of a Non-cross-linked Biologic Mesh: A Dual-Institutional Experience.

BACKGROUND: Data on the use of biologic mesh in abdominal wall repair in complex cases remain sparse. Aim of this study was to evaluate a non-cross-linked porcine acellular dermal matrix for repair of complex contaminated abdominal wall defects. METHODS: Retrospective observational cohort study of consecutive patients undergoing abdominal wall repair with use of Strattice™ Reconstructive Tissue Matrix (LifeCell Corporation, Oxford, UK) between January 2011 and February 2015 at two National Intestinal Failure Units. RESULTS: Eighty patients were identified. Indications for abdominal wall repair included enterocutaneous fistula takedown (n = 50), infected synthetic mesh removal (n = 9), restoration of continuity or creation of a stoma with concomitant ventral hernia repair (n = 12), and others (n = 9). The median defect area was 143.0 cm2 (interquartile range or IQR 70.0-256.0 cm2). All had a grade III or IV hernia. Component separation technique (CST) was performed in 54 patients (68%). Complete fascial closure was not possible despite CST and biologic mesh-assisted traction (bridged repair) in 20 patients (25%). In-hospital mortality was 1%. Thirty-six patients (45%) developed a wound infection. None required mesh removal. Of 76 patients with a median clinical follow-up of 7 months (IQR 4-15) available for analysis, 10 patients (13%) developed a hernia recurrence, of whom 3 had undergone bridged repairs. Seven patients developed a postoperative (recurrent) fistula (9%). CONCLUSION: Repair of challenging and contaminated abdominal wall defects can be done effectively with non-cross-linked biologic mesh and component separation technique without the need for mesh removal despite wound infections.

Short-term efficacy and safety of three novel sphincter-sparing techniques for anal fistulae: a systematic review.

BACKGROUND: The surgical treatment of complex anal fistulae, particularly those involving a significant portion of the anal sphincter in which fistulotomy would compromise continence, is challenging. Video-assisted anal fistula treatment (VAAFT), fistula tract laser closure (FiLaC™) and over-the-scope clip (OTSC®) proctology system are all novel sphincter-sparing techniques targeted at healing anal fistulae. In this study, all published articles on these techniques were reviewed to determine efficacy, feasibility and safety. METHODS: A systematic search of major databases was performed using defined terms. All studies reporting on experience of these techniques were included and outcomes (fistula healing and safety) evaluated. RESULTS: Eighteen studies (VAAFT-12, FiLaC™-3, OTSC®-3) including 1245 patients were analysed. All were case series, and outcomes were heterogeneous with follow-up ranging from 6 to 69 months and short-term (< 1 year) healing rates of 64-100%. Morbidity was low with only minor complications reported. There was one report of minor incontinence following the first reported study of FiLaC™, and this was treated successfully at 6 months with rubber band ligation of hypertrophied prolapsed mucosa. There are inconsistencies in the technique in studies of VAAFT and FiLaC™. CONCLUSIONS: All three techniques appear to be safe and feasible options in the management of anal fistulae, and short-term healing rates are acceptable with no sustained effect on continence. There is, however, a paucity of robust data with long-term outcomes. These techniques are thus welcome additions; however, their long-term place in the colorectal surgeon's armamentarium, whether diagnostic or therapeutic, remains uncertain.

The role of the defaecating pouchogram in the assessment of evacuation difficulty after restorative proctocolectomy and pouch-anal anastomosis.

AIM: Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) is the most frequently performed operation for intractable ulcerative colitis (UC) and for many patients with familial adenomatous polyposis (FAP). It can be complicated by a functional evacuation difficulty, which is not well understood. We aimed to evaluate the role of defaecating pouchography in an attempt to assess the mechanism of evacuation difficulty in pouch patients. METHOD: All RPC patients who had had a defaecating pouchogram for evacuation difficulty at one hospital between 2006 and 2014 were retrospectively reviewed. The findings and features were correlated with the symptoms. Demographic, clinical and radiological variables were analysed. RESULTS: Eighty-seven [55 (63%) female] patients aged 47.6 ± 12.5 years (mean standard ± SD) were identified. Thirty-five had a mechanical outlet obstruction and 52 had no identified mechanical cause to explain the evacuation difficulty. The mean age of these 52 [33 (63%) female] patients was 48.2 ± 13 years. Of these 52 patients, significantly more used anti-diarrhoeal medication (P = 0.029), complained of a high frequency of defaecation (P = 0.005), experienced a longer time to the initiation of defaecation (P = 0.049) and underwent pouchoscopy (P = 0.003). Biofeedback appeared to improve the symptoms in 7 of 16 patients with a nonmechanical defaecatory difficulty. The most common findings on defaecating pouchography included residual barium of more than 33% after an attempted evacuation (46%, n = 24), slow evacuation (35%, n = 18) and mucosal irregularity (33%, n = 17). Correlation between radiological features and symptoms showed a statistically significant relationship between straining, anal pain, incontinence and urgency with patterns of anismus or pelvic floor descent or weakness seen on the defaecating pouchogram. Symptoms of incomplete evacuation, difficulty in the initiation of defaecation, high defaecatory frequency and abdominal pain were not correlated with the radiological features of the pouchogram. CONCLUSION: Defaecating pouchography may be useful for identifying anismus and pelvic floor disorders in pouch patients who have symptoms of straining, anal pain or incontinence. In patients with a high frequency of defaecation and abdominal pain it does not provide clinically meaningful information. Patients who complain of straining, incontinence, anal pain or urgency and have anismus or pelvic floor disorders may benefit from behavioural therapy.

Initial experience of restorative proctocolectomy for ulcerative colitis by transanal total mesorectal rectal excision and single-incision abdominal laparoscopic surgery.

AIM: Laparoscopic surgery is well established for colon cancer, with defined benefits. Use of laparoscopy for the performance of restorative proctocolectomy (RPC) with ileoanal anastomosis is more controversial. Technical aspects include difficult dissection of the distal rectum and a potentially increased risk of anastomotic leakage through multiple firings of the stapler. In an attempt to overcome these difficulties we have used the technique of transanal rectal excision to perform the proctectomy. This paper describes the technique, which is combined with an abdominal approach using a single-incision platform (SIP). METHOD: Data were collected prospectively for consecutive operations between May 2013 and October 2015, including all cases of restorative proctocolectomy with ileoanal pouch anastomosis performed laparoscopically. Only patients having a transanal total mesorectal excision (TaTME) assisted by SIP were included. The indication for RPC was ulcerative colitis (UC) refractory to medical treatment. RESULTS: The procedure was performed on 16 patients with a median age of 46 (26-70) years. The male:female ratio was 5:3 and the median hospital stay was 6 (3-20) days. The median operation time was 247 (185-470) min and the overall conversion rate to open surgery was 18.7%. The 30-day surgical complication rate was 37.5% (Clavien-Dindo 1 in four patients, 2 in one patient and 3 in one patient). One patient developed anastomotic leakage 2 weeks postoperatively. CONCLUSION: This initial study has demonstrated the feasibility and safety of TaTME combined with SIP when performing RPC with ileal pouch-anal anastomosis for UC.

Concomitant colonic disease (Montreal L3) and re-resectional surgery are predictors of clinical recurrence following ileocolonic resection for Crohn's disease.

AIM: Ileocolonic resection is reserved for patients with moderate to severe Crohn's disease. Postoperative clinical recurrence can occur in up to 55% of patients within 5 years. Predicting the risk of recurrence is key in deciding upon appropriate treatment strategies. This study aims to determine the incidence of postoperative clinical recurrence and predictors of recurrence in a specialist institution. METHOD: The clinical case records of 142 patients who underwent either a one-stage or two-stage procedure for ileocolonic Crohn's disease from 1 January 2005 to 31 December 2010 were reviewed. Preoperative, perioperative and postoperative variables were extracted. Postoperative clinical recurrence was defined as an initiation or change in medical treatment for recurrent symptoms with endoscopic or radiological evidence of active disease. Time to clinical recurrence was measured in months after surgery. Univariate and multivariate analyses were performed. RESULTS: Over the 6-year period, follow-up data were obtained on 142 patients over a median of 28.5 months. Clinical recurrence was demonstrated in 59 (41.5%) patients. The proportion of patients with clinical recurrence at 5 years was 48.2%. Predictors of recurrence included a re-resection for recurrent disease [hazard ratio (HR) 1.9; 95% CI 1.1-3.3; P = 0.02] and ileocolonic disease (HR 1.7; 95% CI 1.0-2.9; P = 0.05). CONCLUSION: Identifying the predictors for postoperative clinical recurrence is important for determining the postoperative strategy. This study provides a unique perspective on the incidence of recurrence and associated predictors from the perspective of a specialist unit.

Mortality after acute primary mesenteric infarction: a systematic review and meta-analysis of observational studies.

AIM: The primary aim of this study was to determine whether the in-hospital mortality for acute mesenteric infarction has reduced in the last decade. The secondary aim was to determine if there was a statistical difference in mortality between patients having acute primary mesenteric infarction due to different causes. METHOD: A literature search was performed of PubMed, Ovid (Embase) and Google Scholar databases. Studies on acute mesenteric infarction of primary vascular pathology were included for pooled analyses while studies that had reported comparative mortality between arterial, venous and non-occlusive mesenteric infarction (NOMI) were included in meta-analyses. Their quality was assessed using the National Institute for Health and Care Excellence assessment scale. Odds ratios (ORs) of mortality were calculated using a Mantel-Haenszel random effect model. RESULTS: The total number of patients was 4527 and the male/female ratio was 1912/2247. The pooled in-hospital mortality was 63%. There was no significant reduction of in-hospital mortality rate in the last decade (P = 0.78). There was a significant difference in in-hospital mortality between acute arterial mesenteric infarction (73.9%) compared with acute venous mesenteric infarction (41.7%) [OR 3.47, confidence interval (CI) 2.43-4.96, P < 0.001] and NOMI (68.5%) compared with acute venous mesenteric infarction (44.2%) (OR 3.2, CI 1.83-5.6, P < 0.001). There was no difference in mortality between acute arterial mesenteric infarction and NOMI (OR 1.08, CI 0.57-2.03, P = 0.82). CONCLUSION: In-hospital mortality rate has not changed in the last decade. Patients with arterial mesenteric infarction or with NOMI are over three times more likely to die during the first hospital admission compared with those with venous mesenteric infarction.