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INTRODUCTION: Crohn's disease can present with complex surgical pathologies, posing a significant risk of morbidity and mortality for patients. The implementation of a loop ileostomy for selected patients may help minimize associated risks. METHODS: In this retrospective cohort study, we investigated the utilization of temporary fecal diversion through the creation of a loop ileostomy in Crohn's surgery. Closure of all ostomies involved a hand-sewn single-layer technique. We then conducted bivariate analysis on 30-day outcomes for closures, focusing on favorable recovery defined as the restoration of bowel continuity without the occurrence of two challenges in recovery: newly developed organ dysfunction or the necessity for reoperation. RESULTS: In total, 168 patients were included. The median age of the patients was 38 years (IQR 27-51). The most common indication for a loop ostomy was peritonitis (49%). After ileostomy closure, 163 patients (97%) achieved favorable recovery, while five encountered challenges; four (2.4%) underwent abdominal surgery, and one (0.6%) developed acute renal failure requiring dialysis. Two patients (1.2%) had a re-creation of ileostomy. Patients encountering challenges were older (56 [IQR 41-61] vs. 37 [IQR 27-50]; p 0.039) and more often required secondary intention wound healing (40% vs. 6.7%; p 0.049) and postoperative parenteral nutrition following their index surgery (83% vs. 26%; p 0.006). CONCLUSION: Selectively staging the Crohn's disease operations with a loop ileostomy is a reliable practice with low morbidity and high restoration rates of bowel continuity. Our hand-sewn single-layer technique proves effective in achieving successful surgical recovery.
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Doença de Crohn , Ileostomia , Humanos , Doença de Crohn/cirurgia , Doença de Crohn/complicações , Ileostomia/métodos , Ileostomia/efeitos adversos , Feminino , Masculino , Estudos Retrospectivos , Adulto , Pessoa de Meia-Idade , Resultado do Tratamento , Estudos de Coortes , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/epidemiologiaRESUMO
BACKGROUND: Ileal pouch anal anastomosis is the preferred method for restoration of intestinal continuity after proctocolectomy. Successful ileal pouch anal anastomosis requires adequate reach of the ileal mesentery to the pelvis. Reach issues are a common cause for intraoperative pouch abandonment; however, data regarding contemporary abandonment rates are rare and nonexistent in the revisional setting. METHODS: A retrospective review was conducted of consecutive ileal pouch anal anastomosis surgery at a single referral center. Both initial or "primary" pouches and revisional pouch surgery were included. RESULTS: In total, 447 attempts at pouch anal anastomosis were made, with an 1.6% overall rate of intraoperative abandonment. Pouch abandonment was attributed to inadequate mesenteric reach during 3 surgeries, desmoid tumors in 2 surgeries, and insufficient remaining small bowel in 2 surgeries. Twelve patients required lengthening maneuvers including 6 S pouches (1%) and 6 H pouches (1%). One half (49%) of operations were revisional ileal pouch anal anastomosis surgery. Overall, reach issues led to intraoperative abandonment in only 0.4% of attempted primary pouches and 1.0% of revisional surgeries. A preoperative diagnosis of familial adenomatous polyposis was associated with pouch abandonment (P < .001). CONCLUSION: Extremely low pouch abandonment rates as a result of mesenteric reach can be achieved even in the revisional setting at a high-volume center with institutional expertise. In the revisional setting, intra-abdominal desmoids or the potential for short gut affects pouch abandonment rates as much as reach issues.
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Bolsas Cólicas , Proctocolectomia Restauradora , Reoperação , Humanos , Estudos Retrospectivos , Feminino , Proctocolectomia Restauradora/métodos , Proctocolectomia Restauradora/efeitos adversos , Reoperação/estatística & dados numéricos , Masculino , Adulto , Pessoa de Meia-Idade , Adulto Jovem , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricosRESUMO
Objective: Analyze our long-term experience with a less-popularized but stalwart approach, the stapled end-to-side ileocolic anastomosis. Background: The choice of technical approach to ileocolic anastomosis after ileocecal resection for Crohn's disease affects surgical outcomes and recurrence. Yet, despite heterogeneous data from different anastomotic configurations, there remains no clear guidance as to the optimal technique. Methods: In a retrospective cohort design, patients undergoing ileocolic anastomosis in the setting of Crohn's disease between 2016 and 2021 at two institutions were identified. Patient characteristics and surgical outcomes in terms of recurrence (surgical, clinical, and endoscopic) were studied. Results: In total, 211 patients were included. Before surgery, 80% were exposed to at least 1 cycle of systemic steroids and 71% had at least 1 biologic agent; 60% exhibited penetrating disease and 38% developed an intra-abdominal abscess. After surgery, one anastomosis leaked (0.5%). Over 2.4 years of follow-up (IQR = 1.3-3.9), surgical recurrence was 0.9%. Two-year overall recurrence-free and endoscopic recurrence-free survivals were 74% and 85% (95% CI = 68-81 and 80-91), respectively. The adjusted hazard ratio of endoscopic recurrence was 3.0 (95% CI = 1.4-6.2) for males and 5.2 (1.2-22) for patients who received systemic steroids before the surgery. Conclusion: The stapled end-to-side anastomosis is an efficient, reliable, and reproducible approach to maintain bowel continuity after ileocecal resection with durable outcomes. Our outcomes demonstrate low rates of disease recurrence and stand favorably in comparison to other more technically complex or protracted anastomotic approaches. This anastomosis is an ideal reconstructive approach after ileocecal resection for Crohn's disease.
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INTRODUCTION: Older adults with inflammatory bowel disease (IBD) are at higher risk for postoperative complications as compared to their younger counterparts; however, factors contributing to this are unknown. We assessed risk factors associated with adverse IBD-related surgical outcomes, evaluated trends in emergency surgery, and explored differential risks by age. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified adults ≥18 years of age who underwent an IBD-related intestinal resection from 2005 to 2019. Our primary outcome included a 30-day composite of mortality, readmission, reoperation, and/or major postoperative complication. RESULTS: Overall, 49,746 intestinal resections were performed with 9,390 (18.8%) occurring among older adults with IBD. Nearly 37% of older adults experienced an adverse outcome as compared to 28.1% among younger adults with IBD ( P < 0.01). Among all adults with IBD, the presence of preoperative sepsis (adjusted odds ratio [aOR], 2.08; 95% confidence interval [CI] 1.94-2.24), malnutrition (aOR, 1.22; 95% CI 1.14-1.31), dependent functional status (aOR, 6.92; 95% CI 4.36-11.57), and requiring emergency surgery (aOR, 1.50; 95% CI 1.38-1.64) increased the odds of an adverse postoperative outcome, with similar results observed when stratifying by age. Furthermore, 8.8% of surgeries among older adults were emergent, with no change observed over time ( P = 0.16). DISCUSSION: Preoperative factors contributing to the risk of an adverse surgical outcome are similar between younger and older individuals with IBD, and include elements such as malnutrition and functional status. Incorporating these measures into surgical decision-making can reduce surgical delays in older individuals at low risk and help target interventions in those at high risk, transforming care for thousands of older adults with IBD.
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Doenças Inflamatórias Intestinais , Desnutrição , Cirurgiões , Humanos , Estados Unidos/epidemiologia , Idoso , Melhoria de Qualidade , Fatores de Risco , Doenças Inflamatórias Intestinais/cirurgia , Doenças Inflamatórias Intestinais/complicações , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Desnutrição/complicações , Estudos RetrospectivosRESUMO
Restorative proctocolectomy with ileal pouch-anal anastomosis (RP/IPAA) is the procedure of choice for patients with ulcerative colitis (UC), some patients with colonic Crohn's disease (CD), and those with familial adenomatous polyposis (FAP); albeit, owing to its complexity, it should be performed by experienced professionals. RP/IPAA is the recommended surgical treatment for UC when the standard medical therapy is ineffective. This procedure has been demonstrated to provide patients with a good quality of life, such as in FAP patients with extensive disease in the rectum. The CD has been associated with higher rates of perianal involvement and disease recurrence, but some patients with CD limited to the large intestine and minimal perianal or ileal disease may also be considered for this operation. First, all patients undergo a detailed preoperative evaluation that includes a review of previous imaging, pathology, and colonoscopy findings, a perianal examination, an evaluation of the anorectal functions, mechanical bowel preparation, and prophylaxis against deep venous thrombosis and infectious complications. A staged approach is the most commonly preferred technique for RP/IPAA, which can be performed in 2 or 3 stages. The IPAA can be performed by laparoscopic, robotic, or open approach. The type of approach is determined based on the patient's condition, medication used, elective or emergency setting, and the surgeon's expertise level. A successful IPAA requires tension-free pouch anastomosis. The most common IPAA pouch types are the J or S pouches; alternatively, an H pouch may be created, which is mainly used in redo pouches. In experienced centers, > 95% of the patients become stoma-free in 10 years. IPAA is a complex procedure, and the complications after pouch surgery are pouchitis, pelvic sepsis, pouch failure, or anastomotic stricture. The majority of long-term complications can be prevented in such cases with a comprehensive preoperative evaluation and through the use of appropriate surgical techniques and postoperative care conducted at experienced centers. The techniques for performing RP/IPAA with their long-term outcomes have been reviewed in this article.
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Polipose Adenomatosa do Colo , Colite Ulcerativa , Pouchite , Proctocolectomia Restauradora , Humanos , Proctocolectomia Restauradora/efeitos adversos , Proctocolectomia Restauradora/métodos , Qualidade de Vida , Recidiva Local de Neoplasia/cirurgia , Anastomose Cirúrgica/efeitos adversos , Anastomose Cirúrgica/métodos , Pouchite/etiologia , Pouchite/cirurgia , Colite Ulcerativa/cirurgia , Colite Ulcerativa/complicações , Polipose Adenomatosa do Colo/cirurgia , Polipose Adenomatosa do Colo/complicaçõesRESUMO
PURPOSE: Given that ileal pouch-anal anastomosis (IPAA) surgery is a technically challenging and high-morbidity procedure, there are numerous pertinent imaging findings that need to be clearly and efficiently communicated to the IBD surgeons for essential patient management and surgical planning. Structured reporting has been increasingly used over the past decade throughout various radiology subspecialties to improve reporting clarity and completeness. We compare structured versus non-structured reporting of pelvic MRI for ileal pouch to evaluate for clarity and effectiveness. METHODS: 164 consecutive pelvic MRI's for ileal pouch evaluation, excluding subsequent exams for the same patient, acquired between 1/1/2019 and 7/31/2021 at one institution were included, before and after implementation (11/15/2020) of a structured reporting template, which was created with institutional IBD surgeons. Reports were assessed for the presence of 18 key features required for complete ileal pouch assessment: anastomosis (IPAA, tip of J, pouch body), cuff (length, cuffitis), pouch body (size, pouchitis, stricture), pouch inlet/pre-pouch ileum (stricture, inflammation, sharp angulation), pouch outlet (stricture), peripouch mesentery (position, mesentery twist), pelvic abscess, peri-anal fistula, pelvic lymph nodes, and skeletal abnormalities. Subgroup analysis was performed based on reader experience and divided into three categories: experienced (n = 2), other intra-institutional (n = 20), or affiliate site (n = 6). RESULTS: 57 (35%) structured and 107 (65%) non-structured pelvic MRI reports were reviewed. Structured reports contained 16.6 [SD:4.0] key features whereas non-structured reports contained 6.3 [SD:2.5] key features (p < .001). The largest improvement following template implementation was for reporting sharp angulation of the pouch inlet (91.2% vs. 0.9%, p < .001), tip of J suture line and pouch body anastomosis (both improved to 91.2% from 3.7%). Structured versus non-structured reports contained mean 17.7 versus 9.1 key features for experienced readers, 17.0 versus 5.9 for other intra-institutional readers, and 8.7 versus 5.3 for affiliate site readers. CONCLUSION: Structured reporting of pelvic MRI guides a systematic search pattern and comprehensive evaluation of ileal pouches, and therefore facilitates surgical planning and clinical management. This standardized reporting template can serve as baseline at other institutions for adaptation based on specific radiology and surgery preferences, fostering a collaborative environment between radiology and surgery, and ultimately improving patient care.
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Bolsas Cólicas , Doenças Inflamatórias Intestinais , Proctocolectomia Restauradora , Humanos , Constrição Patológica/cirurgia , Proctocolectomia Restauradora/métodos , Imageamento por Ressonância Magnética , Complicações Pós-OperatóriasRESUMO
A mechanical obstruction is not a physiological entity, and when it occurs within the 30-day postoperative period, it is called an early postoperative small bowel obstruction. Kinking of small bowel segments at the ileostomy outlet secondary to a distended bladder is an unusual source of early postoperative small bowel obstruction. A 36-year-old female underwent a redo J-Pouch surgery and creation of loop ileostomy after pouch failure related to recurrent small bowel obstruction and perianal fistulae. Her foley catheter was removed on postoperative day 3 and she passed a trial of void test. On postoperative day 6, the abdomen became progressively more distended. Computerized tomography (CT) imaging with IV contrast showed small bowel distension extending to the midline anterior to the urinary bladder where it demonstrated a narrowed lumen. These findings were thought to be the cause of small bowel obstruction at this level before the ileostomy. Immediately after CT, a foley catheter was applied with which 2 L of urine was removed, and consequently, gas and stool were observed in the ostomy soon thereafter. Although rare, urinary retention may cause intestinal obstruction, especially in the presence of a loop ileostomy in close proximity.
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BACKGROUND: Postoperative recurrence (POR) of Crohn's disease (CD) is common after surgical resection. We aimed to compare biologic type and timing for preventing POR in adult CD patients after ileocecal resection (ICR). METHODS: We performed a retrospective cohort study of CD patients who underwent an ICR at 2 medical centers. Recurrence was defined by endoscopy (≥ i2b Rutgeerts score) or radiography (active inflammation in neoterminal ileum) and stratified by type and timing of postoperative prophylactic biologic within 12 weeks following an ICR (none, tumor necrosis factor antagonists [anti-TNF], vedolizumab, and ustekinumab). RESULTS: We identified 1037 patients with CD who underwent an ICR. Of 278 (26%) who received postoperative prophylaxis, 80% were placed on an anti-TNF agent (n = 223) followed by ustekinumab (n = 28, 10%) and vedolizumab (n = 27, 10%). Prophylaxis was initiated in 35% within 4 weeks following an ICR and in 65% within 4 to 12 weeks. After adjusting for factors associated with POR, compared with no biologic prophylaxis, the initiation of an anti-TNF agent within 4 weeks following an ICR was associated with a reduction in POR (adjusted hazard ratio, 0.61; 95% CI, 0.40-0.93). Prophylaxis after 4 weeks following an ICR or with vedolizumab or ustekinumab was not associated with a reduction in POR compared with those who did not receive prophylaxis. CONCLUSION: Early initiation of an anti-TNF agent within 4 weeks following an ICR was associated with a reduction in POR. Vedolizumab or ustekinumab, at any time following surgery, was not associated with a reduction in POR, although sample size was limited.
Postoperative recurrence of Crohn's disease is common after ileocecal resection. In this dual-center study, early initiation of an anti-TNF agent within 4 weeks following an ileocecal resection was associated with a reduction in postoperative recurrence of Crohn's disease.
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Doença de Crohn , Adulto , Humanos , Doença de Crohn/tratamento farmacológico , Doença de Crohn/cirurgia , Inibidores do Fator de Necrose Tumoral/uso terapêutico , Estudos Retrospectivos , Ceco/cirurgia , Ustekinumab/uso terapêutico , Necrose/tratamento farmacológico , RecidivaRESUMO
PURPOSE: The aim of this study was to evaluate the diagnostic performance of preoperative cross-sectional imaging findings using the SAR-AGA definitions in Crohn's disease (CD) patients who underwent ileocolic resection (ICR) with and without surgically complex ileocolic CD (CIC-CD). METHODS: 69 CD patients [38 men; mean (± SD) age: 40.6 (16.2) years] who underwent ICR were retrospectively classified by surgical complexity by a colorectal surgeon using operative findings. CIC-CD was defined as ileal CD, not confined to the distal ileum. Two radiologists retrospectively evaluated the preoperative imaging for the presence and type of penetrating disease, stricture, or probable stricture using the SAR-AGA consensus definitions. The diagnostic performance of preoperative imaging findings was compared for patients with and without CIC-CD. Estimated blood loss (EBL), operative time (OT), conversion to open surgery, diversion, and length of hospital stay (LOS) were compared. RESULTS: 60.9% had CIC-CD and 79.7% underwent primary ICR. Penetrating disease was more common in patients with than without CIC-CD (76.2% vs. 40.7%, p = 0.0048) and similar among primary versus redo ICR (p = 0.12). Patients with CIC-CD had more complex fistulas (59.5% vs. 11.1%; p < 0.0001) and fewer simple fistulas (2.4% vs. 18.5%; p = 0.03) than those without. Mesenteric findings (abscess, inflammatory mass) were more frequent in patients with (35.7%) than without (0%) (p = 0.0002) CIC-CD. Stricture and probable stricture were similar (p = 0.59). CIC-CD patients had greater EBL (178 cc vs. 57 cc, p = 0.006), conversion rates (30% vs. 0%, p = 0.0026), and diversion (80% vs. 52%, p = 0.04). CONCLUSION: Complex fistula, mesenteric abscess, or inflammatory mass defined by the SAR-AGA guidelines suggests CIC-CD. ICR for CIC-CD had greater EBL, conversion to open surgery, and diversion.
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Doença de Crohn , Laparoscopia , Masculino , Humanos , Adulto , Doença de Crohn/diagnóstico por imagem , Doença de Crohn/cirurgia , Estudos Retrospectivos , Constrição Patológica/diagnóstico por imagem , Constrição Patológica/cirurgia , Abscesso , Laparoscopia/métodosRESUMO
Colorectal cancer is the third most common cancer in Turkey. The current guidelines do not provide sufficient information to cover all aspects of the management of rectal cancer. Although treatment has been standardized in terms of the basic principles of neoadjuvant, surgical, and adjuvant therapy, uncertainties in the management of rectal cancer may lead to significant differences in clinical practice. In order to clarify these uncertainties, a consensus program was constructed with the participation of the physicians from the Acibadem Mehmet Ali Aydinlar and Koç Universities. This program included the physicians from the departments of general surgery, gastroenterology, pathology, radiology, nuclear medicine, medical oncology, radiation oncology, and medical genetics. The gray zones in the management of rectal cancer were determined by reviewing the evidence-based data and current guidelines before the meeting. Topics to be discussed consisted of diagnosis, staging, surgical treatment for the primary disease, use of neoadjuvant and adjuvant treatment, management of recurrent disease, screening, follow-up, and genetic counseling. All those topics were discussed under supervision of a presenter and a chair with active participation of related physicians. The consensus text was structured by centralizing the decisions based on the existing data.
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Neoplasias Retais , Terapia Combinada , Consenso , Humanos , Oncologia , Terapia Neoadjuvante , Estadiamento de Neoplasias , Neoplasias Retais/patologia , Neoplasias Retais/terapiaRESUMO
AIM: Approximately 20%-40% of the patients with re-do ileal pouch anal anastomosis (IPAA) experience pouch failure. Salvage surgery can be attempted in this patient group with severe aversion to permanent ileostomy. The literature regarding secondary IPAA revision after re-do IPAA failure is scarce. METHODS: All patients who underwent a secondary IPAA revision after re-do IPAA failure between September 2016 and July 2021 in a single centre were included. Short- and long-term outcomes and quality of life in this patient group are reported. RESULTS: Ten patients who had secondary IPAA revision for re-do IPAA failure were included. All patients had ulcerative colitis. Nine of these patients had pelvic sepsis and one patient had a mechanical issue. Mucosectomy and handsewn anastomosis was performed in nine patients. The existing pouch was salvaged in six patients and four patients had pouch excision and re-creation. Two patients had postoperative pelvic sepsis. Pouch retention rate was 78% in a median of 28 months. None of the patients had short-gut syndrome. The procedure was associated with good quality of life (median Cleveland Global Quality of Life Index 0.8). All patients would undergo the same surgery if needed. CONCLUSION: Secondary IPAA revision after a failed re-do IPAA can be an option in patients with severe aversion to permanent ileostomy if re-do IPAA fails and it is associated with good outcomes. This patient group should be carefully evaluated and referred to specialized centres if required.
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Colite Ulcerativa , Bolsas Cólicas , Proctocolectomia Restauradora , Sepse , Colite Ulcerativa/cirurgia , Bolsas Cólicas/efeitos adversos , Humanos , Ileostomia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Proctocolectomia Restauradora/efeitos adversos , Proctocolectomia Restauradora/métodos , Qualidade de Vida , Reoperação/métodos , Sepse/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: The data on management and outcomes of pelvic sepsis after re-do IPAA are scarce. OBJECTIVE: The aim of this study is to report our management algorithm of pelvic sepsis in the setting of re-do IPAA and compare functional outcomes and quality of life after successful management of pelvic sepsis with a no sepsis control group. DESIGN: This is a retrospective cohort study. SETTINGS: This investigation is based on a single academic practice group experience on re-do IPAA. PATIENTS: Patients who underwent re-do IPAA for ileal pouch failure between September 2016 and September 2020 were included in the study. MAIN OUTCOME MEASURES: Management of pelvic sepsis was reported. Functional outcomes, restrictions, and quality-of-life scores were compared between the sepsis and no sepsis groups. RESULTS: One-hundred ten patients were included in our study, of whom 25 (22.7%) developed pelvic sepsis. Twenty-three patients presented with pelvic sepsis before ileostomy closure, and 2 patients presented with pelvic sepsis after ileostomy closure. There were 6 pouch failures in the study period due to pelvic sepsis. Our management was successful in 79% of the patients with median follow-up of 26 months. Treatments included interventional radiology abscess drainage (n = 7), IV antibiotics alone (n = 5), interventional radiology drainage and mushroom catheter placement (n = 1), mushroom catheter placement (n = 1), and endoluminal vacuum-assisted closure (n = 1). Average number of bowel movements, urgency, incontinence, pad use, and seepage were comparable between the pelvic sepsis and no pelvic sepsis groups ( p > 0.05). Lifestyle alterations, Cleveland Global Quality of Life scores, and happiness with the results of the surgery were similar ( p > 0.05). LIMITATIONS: This study is limited by its low study power and limited follow-up time. CONCLUSIONS: Pelvic sepsis is common after re-do IPAA, and management varies according to the location and size of the abscess/sinus. If detected early, our management strategy was associated with high pouch salvage rates. See Video Abstract at http://links.lww.com/DCR/B823 . MANEJO, RESULTADOS FUNCIONALES Y CALIDAD DE VIDA DESPUS DEL DESARROLLO DE SEPSIS PLVICA EN PACIENTES SOMETIDAS A RECONFECCIN DE ANASTOMOSIS ANAL CON BOLSA ILEAL: ANTECEDENTES:Los datos sobre el tratamiento y los resultados de la sepsis pélvica después de reconfección de anastomosis anal, de la bolsa ileal son escasos.OBJETIVO:El objetivo de este estudio es informar nuestro algoritmo de manejo de la sepsis pélvica en el contexto de reconfección de anastomosis anal de la bolsa ileal y comparar los resultados funcionales y la calidad de vida después del manejo exitoso de la sepsis pélvica con un grupo de control sin sepsis.DISEÑO:Este es un estudio de cohorte retrospectivo.AJUSTES:Esta investigación se basa en una experiencia de un solo grupo de práctica académica sobre reconfección de IPAA.PACIENTES:Se incluyeron en el estudio pacientes que se sometieron a una nueva anastomosis anal, del reservorio ileal por falla del reservorio ileal entre el 09/2016 y el 09/2020.PRINCIPALES MEDIDAS DE RESULTADO:Se informó el manejo de la sepsis pélvica. Los resultados funcionales, las restricciones y las puntuaciones de calidad de vida, se compararon entre los grupos con sepsis y sin sepsis.RESULTADOS:Se incluyeron 110 pacientes en nuestro estudio, de los cuales 25 (22,7) desarrollaron sepsis pélvica. Veintitrés pacientes presentaron sepsis pélvica antes del cierre de la ileostomía y 2 pacientes presentaron sepsis pélvica después del cierre de la ileostomía. Hubo 6 fallas de la bolsa en el período de estudio debido a sepsis pélvica. Nuestro manejo fue exitoso en el 79% de los pacientes con una mediana de seguimiento de 26 meses. Los tratamientos incluyeron drenaje de abscesos IR (n = 7), antibióticos intravenosos solos (n = 5), drenaje IR y colocación de catéter en forma de hongo (n = 1), colocación de catéter en forma de hongo (n = 1) y cierre endoluminal asistido por vacío (n = 1). El número promedio de evacuaciones intestinales, urgencia, incontinencia, uso de almohadillas y filtraciones fueron comparables entre los grupos con sepsis pélvica y sin sepsis pélvica ( p > 0,05). Las alteraciones del estilo de vida, las puntuaciones de la Calidad de vida global de Cleveland y la felicidad con los resultados de la cirugía fueron similares ( p > 0,05).LIMITACIONES:Este estudio está limitado por su bajo poder de estudio y su tiempo de seguimiento limitado.CONCLUSIONES:La sepsis pélvica es común después de la reconfección de anastomosis anal de la bolsa ileal y el manejo varía según la ubicación y el tamaño del absceso / seno. Si se detecta temprano, nuestra estrategia de manejo se asoció con altas tasas de recuperación de la bolsa. Consulte Video Resumen en http://links.lww.com/DCR/B823 . (Traducción-Dr. Mauricio Santamaria ).
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Bolsas Cólicas , Proctocolectomia Restauradora , Abscesso , Bolsas Cólicas/efeitos adversos , Humanos , Proctocolectomia Restauradora/efeitos adversos , Proctocolectomia Restauradora/métodos , Qualidade de Vida , Estudos RetrospectivosRESUMO
BACKGROUND: Salvage of the existing ileal pouch is favored during re-do ileal pouch anal anastomosis if the pouch is not damaged after pelvic dissection and there are no other mechanical reasons that may necessitate construction of a new pouch. Excision of the existing pouch may be associated with some concerns for short-bowel syndrome and poor functional outcomes. This study aimed to report indications and compare functional and quality of life outcomes of new pouch creation versus salvage of the existing pouch during re-do ileal pouch anal anastomosis. METHODS: Patients who underwent re-do ileal pouch anal anastomosis between September 2016 and June 2020 were included. The reasons for pouch excision and new pouch creation were reported. Perioperative, functional outcomes and quality of life were compared between patients who had creation of a new pouch versus salvage of existing pouch. RESULTS: A total of 105 patients with re-do ileal pouch anal anastomosis (new pouch, n = 63) were included. Most common indications for a new pouch creation were chronic pelvic infection that compromised the integrity and viability of the existing pouch (n = 32) and small pouch (n = 21). No patient developed short-bowel syndrome. The number of bowel movements, daily restrictions and Cleveland Global Quality of Life score scores were similar between 2 groups. Day-time seepage, day-time and night-time pad usage were more common after new pouch creation. Two-year pouch survival rates were comparable (new pouch: 92% versus existing pouch: 85%, P = .31). CONCLUSION: New pouch creation can be safely performed at the time of re-do ileal pouch anal anastomosis. It provides acceptable functional and quality of life outcomes if existing pouch salvage is not feasible.
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Bolsas Cólicas , Proctocolectomia Restauradora , Qualidade de Vida , Reoperação , Adulto , Doença Crônica , Bolsas Cólicas/efeitos adversos , Feminino , Humanos , Masculino , Infecção Pélvica/complicações , Complicações Pós-Operatórias , Proctocolectomia Restauradora/efeitos adversos , Proctocolectomia Restauradora/métodos , Síndrome do Intestino Curto , Resultado do TratamentoRESUMO
Pelvic sepsis is a dreadful complication after ileal pouch creation. It is mostly treated conservatively, and the ileal pouch can be salvaged if sepsis is detected and treated in a timely manner. Even under the best circumstances, pelvic sepsis is often associated with poor functional outcomes. If pelvic sepsis becomes chronic, it could lead to pouch failure. Redo ileal pouch-anal anastomosis (IPAA) is a viable option in the setting of chronic pelvic sepsis to preserve gastrointestinal continuity in motivated patients. It is associated with similar surgical morbidity, acceptable functional outcomes, and good quality of life. Patients should be involved in the decision-making process after ileal pouch failure. In the setting of ileal pouch failure, surgeons with limited experience may not be comfortable offering patients redo IPAA. Redo IPAA requires subspecialization and patients with ileal pouch failure should be treated at specialized high-volume centers.
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Colite Ulcerativa , Bolsas Cólicas , Proctocolectomia Restauradora , Sepse , Colite Ulcerativa/cirurgia , Bolsas Cólicas/efeitos adversos , Humanos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Proctocolectomia Restauradora/efeitos adversos , Qualidade de Vida , Reoperação , Sepse/etiologia , Resultado do TratamentoAssuntos
Doença de Crohn/cirurgia , Doenças do Íleo/cirurgia , Obstrução Intestinal/cirurgia , Proctocolectomia Restauradora , Adulto , Colite Ulcerativa/tratamento farmacológico , Colite Ulcerativa/cirurgia , Doença de Crohn/complicações , Doença de Crohn/diagnóstico , Feminino , Humanos , Doenças do Íleo/etiologia , Obstrução Intestinal/etiologia , Proctocolectomia Restauradora/efeitos adversos , Terapia de Salvação/métodosRESUMO
BACKGROUND: The impact of the type of anastomosis on the outcomes of redo IPAA is unknown. OBJECTIVE: The aim of this study is to assess the indications, perioperative outcomes, and functional outcomes in patients undergoing stapled vs handsewn redo IPAA. DESIGN: This is a retrospective cohort study. SETTINGS: This investigation is based on a single academic practice group experience with redo IPAA. PATIENTS: Patients who underwent redo IPAA for ileal pouch failure between September 2016 and May 2020 were included in the study. MAIN OUTCOME MEASURES: Indications, perioperative outcomes, functional outcomes, restrictions, and quality-of-life scores were compared between stapled and handsewn groups. RESULTS: A total of 105 patients underwent redo IPAA for ileal pouch failure of whom 76 (72%) had handsewn and 29 (28%) had stapled reanastomosis. The interval between the index and redo IPAA was shorter in stapled redo IPAA (median (interquartile range), Stapled: 3 years (1-4) vs handsewn: 7 years (3-17), p < 0.001). Handsewn anastomosis was more commonly used after pelvic sepsis (handsewn: n = 57 (76%) vs stapled: n = 13 (45%), p = 0.002). Overall postoperative morbidity was similar between the 2 groups (handsewn: n = 38 (50%) vs stapled: n = 16 (55%), p = 0.635). The number of bowel movements, pad use, daily restrictions, and Cleveland Global Quality of Life scores were similar between stapled and handsewn groups. Although daytime seepage was more common after handsewn anastomosis (handsewn, n = 20 (44%) vs stapled, n = 3 (14%), p = 0.013), nighttime seepage was similar in both groups. Pouch survival rates were comparable: 88% vs 92% (p > 0.05). LIMITATIONS: This study is limited by its low study power and limited follow-up time. CONCLUSIONS: Patients who had pelvic sepsis after their index IPAA required handsewn anastomosis at higher rates than other redo cases. Although handsewn anastomosis is a more complex procedure, it is associated with morbidity, functional outcomes, and quality-of-life scores similar to stapled anastomosis for redo IPAA. See Video Abstract at http://links.lww.com/DCR/B580. RECONSTRUCCIN DE ANASTOMOSIS ILEONAL CON RESERVORIO ILEAL CON SUTURA MANUAL VERSUS ANASTOMOSIS CON ENGRAPADO INDICACIONES, CARACTERSTICAS DEL PACIENTE, RESULTADOS OPERATORIOS, FUNCIONALES Y DE CALIDAD DE VIDA: ANTECEDENTES:Se desconoce el impacto en los resultados del tipo de anastomosis se rehace una anastomosis ileonal con reservorio ileal (IPAA).OBJETIVO:El propósito de este estudio es evaluar las indicaciones, resultados perioperatorios y funcionales en pacientes sometidos a una reconstrucción IPAA con engrapado vs sutura manual.DISEÑO:Este es un estudio de cohorte retrospectivo.ENTORNO CLINICO:Esta investigación se basa en la experiencia de un solo grupo de práctica académica sobre reconstrucción IPAA.PACIENTES:Se incluyeron en el estudio pacientes que fueron sometidos a una reconstrucción de IPAA por falla del reservorio ileal entre septiembre del 2016 hasta mayo del 2020.PRINCIPALES MEDIDAS DE VALORACION:se compararon indicaciones, resultados perioperatorios, funcionales, restricciones y puntuaciones de calidad de vida entre los grupos de engrapado y sutura manual.RESULTADOS:Un total de 105 pacientes fueron sometidos a una reconstrucción de IPAA por falla del reservorio ileal, de los cuales 76 (72%) fueron reanastomosis con sutura manual y 29 (28%) con engrapado. El intervalo entre la cirugía inicial y la reintervención de IPAA fue más corto en la reconstrucción de IPAA con engrapado [mediana (IQR), engrapado: 3 años (1-4) vs con sutura manual: 7 años (3-17), p <0,001]. La anastomosis con sutura manual se realizo con mayor frecuencia después de sepsis pélvica [sutura manual: n = 57 (76%) vs engrapado: n = 13 (45%), p = 0,002]. La morbilidad postoperatoria total fue similar entre los dos grupos [sutura manual: n = 38 (50%) vs engrapado: n = 16 (55%), p = 0,635]. El número de evacuaciones intestinales, el uso de paños protectores, restricciones diarias y puntuaciones en CGQL fueron similares entre los grupos de engrapado y sutura manual. Si bien el manchado por la mañana fue más común después de la anastomosis con sutura manual [sutura manual, n = 20 (44%) vs engrapado, n = 3 (14%), p = 0.013], el manchado por la noche fue similar en ambos grupos. Las tasas de sobrevida con reservorio fueron comparables; 88% vs 92% respectivamente (p> 0,05).LIMITACIONES:Este estudio está limitado por su bajo poder de estudio y su tiempo de seguimiento limitado.CONCLUSIONES:Los pacientes que tuvieron sepsis pélvica después de su primer IPAA, requirieron anastomosis con sutura manual en un porcentaje más alto que otros procedimientos de reintervención. Si bien es cierto, la anastomosis con sutura manual es un procedimiento mucho más complejo; este se asoció a una morbilidad, resultados funcionales y puntuaciones de calidad de vida similares en comparación a la anastomosis con engrapado cuando se rehace la IPAA. Consulte Video Resumen en http://links.lww.com/DCR/B580. (Traducción- Dr. Francisco M. Abarca-Rendon).
Assuntos
Anastomose Cirúrgica/métodos , Bolsas Cólicas/efeitos adversos , Reoperação , Adulto , Estudos de Coortes , Feminino , Humanos , Masculino , Qualidade de Vida , Estudos Retrospectivos , Sepse/cirurgia , Grampeamento CirúrgicoRESUMO
While current neoadjuvant protocols have proven benefits on local control for majority of patients with locally advanced rectal cancer, there are certain clinical conditions that require future advances for improving the outcomes. Total neoadjuvant therapy incorporates systemic chemotherapy planned within standard neoadjuvant protocols either before or after radiotherapy for locally advanced rectal cancer as a whole. Enhanced compliance with planned oncological therapy, tumour downstaging, administration of chemotherapy at the earliest time in the disease course to help assessing chemosensitivity are the proposed benefits of total neoadjuvant therapy in patients with locally advanced rectal cancer. Patient selection criteria for administration of total neoadjuvant therapy in the recent guidelines are unclear. Since current literature is inconclusive for the optimal sequence and type of radiotherapy and chemotherapy, premature incorporation of total neoadjuvant therapy for all locally advanced rectal cancers may result in overtreatment and subsequently toxicity. This article aims to discuss the current literature and to propose a future perspective by considering real-life scenarios reflecting patients' needs for treatment of locally advanced rectal cancer.
Assuntos
Terapia Neoadjuvante , Neoplasias Retais , Protocolos de Quimioterapia Combinada Antineoplásica , Quimiorradioterapia , Humanos , Estadiamento de Neoplasias , Neoplasias Retais/patologia , Reto/patologia , Resultado do TratamentoRESUMO
Objectives: Taurolidine is a bicyclic molecule produced by the natural amino acid taurine. Antibacterial, antiendotoxic and cytoprotective effects of taurolidine have been shown experimentally. Data on the effects of taurolidine on oxidative stress and hepatic regeneration are limited. The aim of the study was to evaluate the effect of taurolidine on hepatic regeneration and oxidative stress in rats undergoing partial hepatectomy. Material and Methods: Forty adult, male Wistar Albino rats were randomly divided into four equal groups: sham (S) group (n= 10), post-sham opera- tion taurolidine administered (ST) group (n= 10), partial hepatectomy (H) group (n= 10) and post-partial hepatectomy taurolidine administered (HT) group (n= 10). 100 mg/kg/day taurolidine was administered for seven days. Blood and liver tissue samples were collected on postoperative day seven. Liver tissue malondialdehyde, glutathione and Cu-Zn superoxide dismutase activity (SOD) were measured to assess oxidative stress. Binuclear hepato- cyte and Ki-67 antigen levels were measured to evaluate hepatic regeneration. Results: There was no difference between the groups for malondialdehyde, Cu-Zn superoxide dismutase and glutathione levels (p> 0.05). Binuclear nuclei levels were comparable between the H and HT groups (p= 0.06), while taurolidine decreased binuclear hepatocyte levels in the sham operated groups (p= 0.02). Taurolidine application decreased Ki-67 levels after partial hepatectomy (p= 0.001). Conclusion: Taurolidine may cause anti-regenerative effects after partial hepatectomy without causing oxidative damage.
RESUMO
Ileal pouch-anal anastomosis (IPAA) surgery is the reference standard surgical procedure for treatment of ulcerative colitis and most patients with familial adenomatous polyposis. This procedure allows preservation of fecal continence and gastrointestinal continuity. However, it is associated with a wide variety of complications, which often have nonspecific and overlapping clinical presentations, making imaging an important part of workup for pouch dysfunction. The purpose of this article is to propose structured reporting templates for MRI and water-soluble contrast enema (WSCE), based on our referral pouch center's experience, in patients who have undergone IPAA surgery. We review salient surgical technique, pouch anatomy, and imaging protocols, with an emphasis on a systematic search pattern for evaluation of ileal pouch complications using proposed structured reporting templates for MRI and WSCE.