Preoperative hypoalbuminemia is associated with adverse outcomes after ileoanal pouch surgery.

BACKGROUND: This study examines the association between preoperative albumin and ileoanal pouch (IPAA) outcomes and the utility of serum albumin in the decision to perform a staged IPAA with an initial subtotal colectomy. METHODS: From 2001-2009, patients were identified from an institutional pouch database and albumin values were extracted from the clinic data repository. Hypoalbuminemic (albumin <3.5 g/dL) patients were compared with patients with normal albumin. The primary outcome was pouch failure. Secondary outcomes were anastomotic leak, length of stay, function, and quality of life after pouch surgery. RESULTS: Out of 405 patients, 34 were hypoalbuminemic pre-IPAA. Pre-IPAA hypoalbuminemia was associated with pouch failure (P = 0.004). Pre-IPAA hypoalbuminemia was an independent predictor of anastomotic leak (P = 0.017). Pre-IPAA hypoalbuminemia was an independent predictor of prolonged length of stay (LOS) (P < 0.001). Hypoalbuminemic patients who underwent index total proctocolectomy (TPC) with IPAA vs. subtotal colectomy (STC) and delayed IPAA had increased perioperative transfusion (P = 0.03) and median LOS at IPAA (P = 0.002). CONCLUSIONS: Preoperative serum albumin is an easily available, inexpensive marker in risk stratifying patients undergoing ileoanal pouch surgery. Serum albumin may provide an objective indicator in supporting the decision to undertake a subtotal colectomy as a first step rather than total proctocolectomy with immediate pouch creation.

Contemporary surgical management for ileosigmoid fistulas in Crohn's disease.

BACKGROUND: Current diagnostic modalities and surgical treatments for ileosigmoid fistulas (ISF) in Crohn's disease (CD) are not well characterized. METHODS: ISF patients operated during 2000-2007 in a prospectively collected CD surgery database were included. Disease extent, diagnostic studies, medications, and smoking status were retrospectively reviewed. RESULTS: One hundred four CD patients with ISF (median age 37) underwent ileocolic resection (75 open, 29 laparoscopic). Sigmoid colon was treated with primary repair (26), segmental resection (71), and subtotal colectomy (7). Thirty-eight patients required additional surgery for CD manifestations (ileovesical fistula (11), enterocutaneous fistula (11), and synchronous small bowel disease (22)). Overall sensitivity of studies for ISF detection was 63% (66/104) (colonoscopy 35% (31/89), CT scan 41% (31/76), fluoroscopy 53% (31/58)). Stoma diversion (53 patients, 51%) occurred more with open surgery (81% vs. 63%, p = 0.04), intraoperative ureteral stents (28% vs. 2%, p < 0.0001), additional small bowel procedures (42% vs. 18%, p = 0.008), longer overall length of stay (10 vs. 6 days, p < 0.0001), preoperative steroid use > or =20 mg prednisone (40% vs. 18%, p = 0.02), and preoperative albumin < or =3.5 gm/dl (43% vs. 22%, p = 0.02). Mortality was nil. Overall morbidity was 37% with anastomotic leak 4%. Neither was affected by stoma diversion, laparoscopy use, or sigmoid colon treatment. CONCLUSIONS: While most ISF in CD are found preoperatively, some are still incidental surgical findings. Sigmoid resection and primary repair have comparable morbidity if appropriately individualized. Laparoscopic treatment is acceptable in select cases without added morbidity.

Use of infliximab within 3 months of ileocolonic resection is associated with adverse postoperative outcomes in Crohn's patients.

BACKGROUND: Few studies have evaluated preoperative infliximab use and postoperative outcomes in Crohn's patients. Our aim was to evaluate 30-day postoperative outcomes for Crohn's patients treated with infliximab within 3 months prior to ileocolonic resection. METHODS: The study is a retrospective evaluation of data for patients undergoing ileocolonic resection after 1998 from a prospective Crohn's disease database. Patient characteristics and 30-day complications were compared for patients treated with infliximab within 3 months before surgery and an infliximab naïve group. The infliximab group was also compared with non-infliximab patients undergoing ileocolonic surgery before 1998. RESULTS: Sixty of 389 Crohn's patients undergoing ileocolonic resection received infliximab. The infliximab and non-infliximab groups had similar characteristics, preoperative risk factors, and surgical procedure. However, steroid use was higher (p < 0.05) in the non-infliximab group while concurrent immunosuppressive use was higher (p < 0.001) in the infliximab group. Multivariate analysis showed infliximab use to be associated with 30-day postoperative readmission (p = 0.045), sepsis (p = 0.027), and intraabdominal abscess (p = 0.005). The presence of diverting stoma (n = 17) in the infliximab group was associated with lower risk of sepsis (0% vs. 27.9%, p = 0.013). Similar results were noted when the infliximab group was compared to the pre-infliximab patients. CONCLUSIONS: Infliximab use within 3 months before surgery is associated with increased postoperative sepsis, abscess, and readmissions in Crohn's patients. Diverting stoma may protect against these complications.