Restorative proctocolectomy: an example of how surgery evolves in response to paradigm shifts in care.

AIM: Surgical technique constantly evolves in response to the pressure of progress. Ileal pouch anal anastomosis (IPAA) is a good example. We analysed the effect of changes in practice on the technique of IPAA and its outcomes. METHOD: Patients undergoing primary IPAA at this institution were divided into three groups by date of the IPAA: those operated from 1983 to 1993, from 1994 to 2004 and from 2005 to 2015. Demographics, patient comorbidity, surgical techniques, postoperative outcomes, pouch function and quality of life were analysed. RESULTS: In all, 4525 patients had a primary IPAA. With each decade, increasing numbers of surgeons were involved (decade I, 8; II, 16; III, 31), patients tended to be sicker (higher American Society of Anesthesiologists score) and three-staged pouches became more common. After an initial popularity of the S pouch, J pouches became dominant and a mucosectomy rate of 12% was standard. The laparoscopic technique blossomed in the last decade. 90-day postoperative morbidity by decade was 38.3% vs 50% vs 48% (P < 0.0001), but late morbidity decreased from 74.2% through 67.1% to 30% (P < 0.0001). Functional results improved, but quality of life scores did not. Pouch survival rate at 10 years was maintained (94% vs 95.2% vs 95.2%; P = 0.06). CONCLUSION: IPAA is still evolving. Despite new generations of surgeons, a more accurate diagnosis, appropriate staging and the laparoscopic technique have made IPAA a safer, more effective and enduring operation.

Risk factors associated with portomesenteric venous thrombosis in patients undergoing restorative proctocolectomy for medically refractory ulcerative colitis.

AIM: Data on risk factors for portomesenteric venous thrombosis (PMVT) following abdominal surgery for ulcerative colitis (UC) are limited. The aim of this study was to investigate factors associated with PMVT after surgical treatment for UC. METHOD: Patients who underwent restorative proctocolectomy (RPC) and ileal pouch-anal anastomosis (IPAA) including diverting ileostomy closure for medically refractory UC were identified from a prospectively maintained database. Patient-related, disease-related and treatment-related variables were collected. Univariable and multivariable analyses were performed to assess factors associated with PMVT. RESULTS: Of the 521 patients completing surgical treatment for UC between 2006 and 2012, symptomatic PMVT occurred in 36 (7%), which resulted in a significantly increased hospital stay (P < 0.001). Patients developing PMVT were younger (P = 0.014), had a lower preoperative albumin level (P = 0.037) and were more likely to have been taking steroids within 1 month before surgery (P = 0.006). The combined incidence of PMVT was comparable between patients having a three-stage and two-stage management (6% vs. 8%, P = 0.43), but the relative incidence of PMVT after RPC + IPAA was 8%, significantly higher than the 4% after total abdominal colectomy (TAC) (P = 0.005) and the 2% after subsequent completion proctectomy (CP) + IPAA (P = 0.038). Multivariate analysis confirmed that RPC + IPAA was associated with a significantly greater risk of PMVT than CP + IPAA (OR = 4.9, P = 0.003) or TAC (OR = 3.5, P = 0.011). Preoperative steroid use was an independent factor for PMVT (OR = 5.8, P = 0.006). CONCLUSION: Steroid use 1 month before surgery is associated with an increased risk of PMVT. A staged restorative proctocolectomy does not increase the overall incidence of PMVT.

Association between high visceral fat area and postoperative complications in patients with Crohn's disease following primary surgery.

AIM: The aim of this study was to determine the association between visceral fat area (VFA) on CT and postoperative complications after primary surgery in patients with Crohn's disease (CD). METHOD: Inclusion criteria were patients with a confirmed diagnosis of CD who had preoperative abdominal CT scan. The areas of total fat, subcutaneous fat and visceral fat were measured using an established image-analysis method at the lumbar 3 (L3) level on CT cross-sectional images. Visceral obesity was defined as a visceral fat area (VFA) of ≥ 130 cm(2) . Clinical variables, intra-operative outcomes and postoperative courses within 30 days were analysed. RESULTS: A total of 164 patients met the inclusion criteria. Sixty-three (38.4%) patients had postoperative complications. The mean age of the patients with complications (the study group) was 40.4 ± 15.4 years and of those without complications (the control group) was 35.8 ± 12.9 years (P = 0.049). There were no differences in disease location and behaviour between patients with or without complications (P > 0.05). In multivariable analysis, VFA [odds ratio (OR) = 2.69; 95% confidence interval (CI): 1.09-6.62; P = 0.032] and corticosteroid use (OR = 2.86; 95% CI: 1.32-6.21; P = 0.008) were found to be associated with postoperative complications. Patients with visceral obesity had a significantly longer operative time (P = 0.012), more blood loss (P = 0.019), longer bowel resection length (P = 0.003), postoperative ileus (P = 0.039) and a greater number of complications overall (P < 0.001). CONCLUSION: High VFA was found to be associated with an increased risk for 30-day postoperative complications in patients with CD undergoing primary surgery.

Conversion in laparoscopic colorectal surgery: Are short-term outcomes worse than with open surgery?

BACKGROUND: The aim of the present study was to compare the perioperative outcomes in patients who underwent planned open colectomy to those who were converted to an open. METHODS: All patients who underwent elective colectomy were identified from the American College of Surgeons National Surgical Quality Improvement Program using procedure-targeted database (2012-2014). Patients were divided into two groups: open (planned) versus converted. Perioperative outcomes were compared. A logistic regression model was used to calculate the propensity of unplanned conversion as opposed to open surgery. RESULTS: There were 21,437 patients; 17,366 (81.0%) in the open group and 4071 (19.0%) in the converted group. Operative time was longer in the converted group (212 ± 99 vs. 182 ± 111 min, p < 0.001), and hospital stay was longer in the open group (10.5 ± 9.3 vs. 8.7 ± 7.7 days, p < 0.001). Difference in morbidity rate (37.6% open vs. 34.5% converted, p < 0.001) was no longer significant once confounders were adjusted. Specific complications were similar except for superficial surgical site infection (SSI) rate, which was significantly lower in open group (odds ratio 0.87, 95% confidence interval 0.76-0.97, p = 0.010). CONCLUSIONS: The current study showed that conversion of laparoscopic colectomy to an open approach was associated with slight increase in superficial SSI rate but shorter hospital stay compared to planned open.

Salvage surgery after failure of endoscopic balloon dilatation versus surgery first for ileocolonic anastomotic stricture due to recurrent Crohn's disease.

BACKGROUND: Both surgical resection and endoscopic balloon dilatation are treatment options for ileocolonic anastomotic stricture caused by recurrent Crohn's disease unresponsive to medications. Perioperative outcomes of salvage surgery owing to failed endoscopic balloon dilatation in comparison with performing surgery first for the same indication are unclear. METHODS: An analysis of a prospectively maintained Crohn's disease database was carried out to compare perioperative outcomes of patients who had surgery for failure of endoscopic balloon dilatation with outcomes in patients who underwent resection first for ileocolonic anastomotic stricture caused by recurrent Crohn's disease between 1997 and 2013. RESULTS: Of 194 patients, 114 (58·8 per cent) underwent surgery without previous endoscopic balloon dilatation. The remaining 80 patients had salvage surgery after one or more endoscopic balloon dilatations during a median treatment span of 14·5 months. Patients in the salvage surgery group had a significantly shorter length of anastomotic stricture (P < 0·001). Salvage surgery was associated with increased rates of stoma formation (P = 0·030), overall surgical-site infection (SSI) (P = 0·025) and organ/space SSI (P = 0·030). In multivariable analysis, preoperative endoscopic balloon dilatation was independently associated with both postoperative SSI (odds ratio 3·16, 95 per cent c.i. 1·01 to 9·84; P = 0·048) and stoma diversion (odds ratio 3·33, 1·14 to 9·78; P = 0·028). CONCLUSION: Salvage surgery after failure of endoscopic balloon dilatation is associated with increased adverse outcomes in comparison with surgery first. This should be discussed with patients being considered for endoscopic balloon dilatation for ileocolonic anastomotic stricture due to recurrent Crohn's disease.

Genotype-defined cancer risk in juvenile polyposis syndrome.

BACKGROUND: Germline mutations in SMAD4 and BMPR1A disrupt the transforming growth factor ß signal transduction pathway, and are associated with juvenile polyposis syndrome. The effect of genotype on the pattern of disease in this syndrome is unknown. This study evaluated the differential impact of SMAD4 and BMPR1A gene mutations on cancer risk and oncological phenotype in patients with juvenile polyposis syndrome. METHODS: Patients with juvenile polyposis syndrome and germline SMAD4 or BMPR1A mutations were identified from a prospectively maintained institutional registry. Medical records were reviewed and the clinical patterns of disease were analysed. RESULTS: Thirty-five patients had germline mutations in either BMPR1A (8 patients) or SMAD4 (27). Median follow-up was 11 years. Colonic phenotype was similar between patients with SMAD4 and BMPR1A mutations, whereas SMAD4 mutations were associated with larger polyp numbers (number of patients with 50 or more gastric polyps: 14 versus 0 respectively). The numbers of patients with rectal polyps was comparable between BMPR1A and SMAD4 mutation carriers (5 versus 17). No patient was diagnosed with cancer in the BMPR1A group, whereas four men with a SMAD4 mutation developed gastrointestinal (3) or extraintestinal (1) cancer. The gastrointestinal cancer risk in patients with juvenile polyposis syndrome and a SMAD4 mutation was 11 per cent (3 of 27). CONCLUSION: The SMAD4 genotype is associated with a more aggressive upper gastrointestinal malignancy risk in juvenile polyposis syndrome.

Factors affecting the fate of faecal diversion in patients with perianal Crohn's disease.

AIM: A study was carried out with the aim of identifying potential factors which might influence the fate of patients undergoing faecal diversion by stoma in perianal Crohn's disease. METHOD: Patients with severe perianal Crohn's disease undergoing faecal diversion between 1994 and 2012 were identified and the factors associated with stoma closure were assessed using univariate and multivariate analysis. RESULTS: Of 138 diverted patients, 30 (22%) achieved stoma closure, 45 (33%) had a stoma with the rectum left in situ and 63 (45%) underwent proctectomy with permanent stoma formation after a mean follow-up of 5.7 years. Univariate analysis demonstrated that synchronous colonic (P = 0.004) or rectal (P = 0.021) disease involvement and an increased frequency of loose seton placement (P = 0.001) adversely affected successful stoma closure rates. Multivariate analysis indicated a significant association between the inability to achieve stoma closure and persisting rectal involvement (OR 7.5, 95% CI 2.4-33.4), one or two placements of a loose seton (OR 3.3, 95% CI 1.4-8.8) and more than two placements (OR 6.9, 95% CI 1.2-132.5). No specific medical management was associated with an improved stoma closure rate, including biological agents when these were available (P = 0.25). CONCLUSION: The fate of temporary faecal diversion in patients with perianal Crohn's disease is adversely affected by aggressive disease characteristics. No particular treatment, including biological therapy, was associated with an improved outcome.

Neoadjuvant chemoradiation for rectal cancer is not associated with higher rates of thromboembolism.

AIM: Thromboembolism (TE) is a leading cause of death amongst cancer patients. The effect of neoadjuvant chemoradiotherapy (nCRT) on the risk of TE in rectal cancer patients is unknown. The aim of this study was to determine whether nCRT was associated with an increased risk of TE in patients with rectal cancer, either during therapy or with subsequent treatment. METHOD: This was a retrospective study from a prospectively maintained database at a tertiary referral centre. Participants included patients with rectal cancer treated between January 2000 and December 2013. The primary outcome was the rate of TE in patients with rectal cancer who had nCRT compared with those who did not. RESULTS: One hundred and seventy-one (7.8%) of 2181 rectal cancer patients developed TE. Patients who had nCRT did not have an increased incidence of TE compared with those who had surgery alone (81/946, 8.6% vs 94/1235, 7.6%, P = 0.42) after a median follow-up of 95 months. Ten (1.1%) of 946 patients who received nCRT developed TE during or immediately after nCRT. Most TE events occurred in the 30-day postoperative period (70 patients, 3.2%). CONCLUSION: The prevalence of TE in patients with rectal cancer was 7.8%, with most events occurring in within 30 days of surgery. Neoadjuvant chemoradiation was not associated with an increased risk of TE.

Long-term outcomes after circular stapled hemorrhoidopexy versus Ferguson hemorrhoidectomy.

BACKGROUND: We aimed to compare long-term outcomes and quality of life in patients undergoing circular stapled hemorrhoidopexy to those who had Ferguson hemorrhoidectomy. METHODS: Patients who underwent Ferguson hemorrhoidectomy and circular stapled hemorrhoidopexy between 2000 and 2010 were reviewed. Long-term follow-up was assessed with questionnaires. RESULTS: Two hundred seventeen patients completed the questionnaires. Mean follow-up was longer in the Ferguson hemorrhoidectomy subgroups (7.7 ± 3.4 vs. 6.3 ± 2.9 years, p = 0.003). Long-term need for additional surgical or medical treatment was similar in the Ferguson hemorrhoidectomy and circular stapled hemorrhoidopexy groups (3 vs. 5%, p = 0.47 and 3% in both groups, p > 0.99, respectively). Eighty-one percentage of Ferguson hemorrhoidectomy and 83% of circular stapled hemorrhoidopexy patients stated that they would undergo hemorrhoid surgery again if needed (p = 0.86). The symptoms were greatly improved in the majority of patients (p = 0.06), and there was no difference between the groups as regards long-term anorectal pain (p = 0.16). The Cleveland global quality of life, fecal incontinence severity index, and fecal incontinence quality of life scores were similar (p > 0.05). CONCLUSIONS: This is one of the longest follow-up studies comparing the outcomes after circular stapled hemorrhoidopexy and Ferguson hemorrhoidectomy. Patient satisfaction, resolution of symptoms, quality of life, and functional outcome appear similar after circular stapled hemorrhoidopexy and Ferguson hemorrhoidectomy in long term.

Laparoscopic versus open fecal diversion: does laparoscopy offer better outcomes in short term?

BACKGROUND: Laparoscopic fecal diversion is performed in patients with complicated colon and rectal diseases. We aim to compare operative and short-term outcomes between laparoscopic and open fecal diversion. METHODS: After obtaining institutional review board approval, patients undergoing laparoscopic or open fecal diversion between February 2010 and September 2012 were reviewed. A straight comparison of the open and laparoscopic groups was made initially; then, patients who underwent laparoscopic fecal diversion were case-matched with open counterparts based on stoma type and primary diagnosis. RESULTS: While body mass index (BMI) was higher in the laparoscopy group (p = 0.04), American Society of Anesthesiologists (ASA) score (p = 0.33) and gender (p = 0.74) were comparable between the study groups in the straight comparison. In the case-matched analysis, type of prior operations (p > 0.05), age (p = 0.79), gender (p > 0.99), BMI (p = 0.1), and ASA (p = 0.25) score were comparable between the groups. Open surgery was associated with increased estimated blood loss (p = 0.01), longer hospital stay (p = 0.0002), higher postoperative ileus (p = 0.03), and higher readmission rates (p = 0.002). CONCLUSIONS: Considering the short-term benefits as regards postoperative recovery and morbidity, fecal diversions should be performed laparoscopically when feasible.

Venous thromboembolism in colorectal surgery: skip SCIP or comply?

BACKGROUND: The Surgical Care Improvement Project (SCIP) includes recommendations for mechanical and pharmacologic venous thromboembolism (VTE) prophylaxis after colorectal surgery. Compliance with these recommendations is publicly reported and included in current pay for performance plans. Presently, there is limited evidence to support compliance with these recommendations. AIM: To determine the incidence of venous thromboembolic events in colorectal surgery patients who did or did not receive the recommended pharmacologic prophylaxis. METHODS: We performed a retrospective analysis of prospectively accrued data from a single-center, tertiary care, colorectal surgery department. The main outcome measure was the occurrence of venous thromboembolic events and the need for blood transfusion after surgery. RESULTS: Of 674 patients, 613(91%) received the recommended pharmacologic VTE prophylaxis and 61 (9%) did not. Diagnosis, patient variables, and type of surgery performed were similar in each group while operative time was increased in the compliant group (251 vs. 194 min, p < 0.05). In the compliant and noncompliant groups, the incidence of extremity deep venous thrombosis was 2.8 and 8.2% (p = 0.04), the incidence of pulmonary embolus 1.1 and 3.3% (p = 0.19), the incidence of portomesenteric venous thrombosis 2.6 and 4.9% (p = 0.38), and the incidence of any VTE 5.4 and 13.1% (p = 0.02), respectively. The use of perioperative red blood cell transfusions in the two groups was 9.1 and 14.8%, p = 0.17. In the subgroup analysis of open cases, there were no statistical differences in the occurrence of any type or combination of VTE. CONCLUSIONS: Compliance with SCIP recommendations for pharmacologic VTE prophylaxis decreased the incidence of VTE after colorectal surgery with no increase in the use of perioperative transfusion. Colorectal surgeons who elect to skip these recommendations may jeopardize both the reputational score and financial reimbursement of their hospital and may put their patients at unnecessary risk for a preventable postoperative complication.

Comparison of hospital costs for single-port and conventional laparoscopic colorectal resection: a case-matched study.

BACKGROUND: Whether single-port laparoscopic (SPL) colorectal resection is cost-effective in comparison to conventional laparoscopy remains unclear. The aim of this study is to compare hospital costs for single-port versus conventional laparoscopic colorectal resections. METHODS: Patients with available cost data who underwent (SPL) colorectal resection between December 2007 and December 2010 were matched with conventional (multiport) laparoscopic (CL) counterparts for age, gender, American Society of Anesthesiologists score, body mass index, operation type and year of surgery. Patients who underwent hand-assisted laparoscopic surgery were not included in the study. Direct hospital costs for the two groups were compared. RESULTS: There were 90 patients in the SPL group and 90 patients in the CL group. Age (p = 0.79), gender (p = 0.88), body mass index (p = 0.82), American Society of Anesthesiologists score (p = 1) and diagnosis (p = 0.85) were similar in both groups. Operation type (p = 1), estimated blood loss (p = 0.17) and length of hospital stay (p = 0.06) were comparable between the groups. Operation time was significantly shorter in the SPL group (p < 0.001), thus anesthesia cost was significantly lower in this group (p = 0.003). Total costs (p = 0.5), operating room (p = 0.65), nursing (p = 0.13), pharmacy (p = 0.6), radiology (p = 0.27), professional (p = 0.38) and pathology/laboratory (p = 0.46) costs were similar between the two groups. CONCLUSIONS: Single-port laparoscopic colorectal resection can be performed with comparable hospital costs to conventional multiport laparoscopy.

Key factors associated with postoperative complications in patients undergoing colorectal surgery.

BACKGROUND: Surgical outcomes are determined by complex interactions among a variety of factors including patient characteristics, diagnosis, and type of procedure. OBJECTIVE: The aim of this study was to prioritize the effect and relative importance of the surgeon (in terms of identity of a surgeon and surgeon volume), patient characteristics, and the intraoperative details on complications of colorectal surgery including readmission, reoperation, sepsis, anastomotic leak, small-bowel obstruction, surgical site infection, abscess, need for transfusion, and portal and deep vein thrombosis. DESIGN: This study uses a novel classification methodology to measure the influence of various risk factors on postoperative complications in a large outcomes database. METHODS: Using prospectively collected information from the departmental outcomes database from 2010 to 2011, we examined the records of 3552 patients who underwent colorectal surgery. Instead of traditional statistical methods, we used a family of 7000 bootstrap classification models to examine and quantify the impact of various factors on the most common serious surgical complications. For each complication, an ensemble of multivariate classification models was designed to determine the relative importance of potential factors that may influence outcomes of surgery. This is a new technique for analyzing outcomes data that produces more accurate results and a more reliable ranking of study variables in order of their importance in producing complications. PATIENTS: Patients who underwent colorectal surgery in 2010 and 2011 were included. SETTINGS: This study was conducted at a tertiary referral department at a major medical center. MAIN OUTCOME: Postoperative complications were the primary outcomes measured. RESULTS: Factors sorted themselves into 2 groups: a highly important group (operative time, BMI, age, identity of the surgeon, type of surgery) and a group of low importance (sex, comorbidity, laparoscopy, and emergency). ASA score and diagnosis were of intermediate importance. The outcomes most influenced by variations in the highly important factors included readmission, transfusion, surgical site infection, and abscesses. LIMITATIONS: This study was limited by the use of data from a single tertiary referral department at a major medical center. CONCLUSIONS: Body mass index, operative time, and the surgeon who performed the operation are the 3 most important factors influencing readmission rates, rates of transfusions, and surgical site infection. Identification of these contributing factors can help minimize complications.

Review of nomenclature in colonic surgery--proposal of a standardised nomenclature based on mesocolic anatomy.

The standardisation of the surgical management of rectal cancer has been facilitated by adoption of an anatomic surgical nomenclature. Thus, "total mesorectal excision" substituted "anterior resection" or "proctosigmoidectomy" and implies resection of both rectum and mesorectum. Similar trends towards standardisation of colonic surgery are ongoing, yet there remains a heterogeneity of terminology utilised (eg, "right hemicolectomy", "ileocolic resection", and "total mesocolic excision"). Recent descriptions of mesocolic anatomy provide an opportunity to standardise colonic resection according to a more precise and informative anatomic nomenclature. This article aims to firstly emphasise the central importance of the mesocolon and from this propose a related nomenclature for resectional colonic surgery. Introduction of a standardised nomenclature for colonic resection is a necessary step towards standardisation of colonic surgery in general.

Single-port laparoscopic colectomy.

Single-port laparoscopy (SPL) for colorectal surgery was first described for a right hemicolectomy in 2008. Since then, technology and experience have advanced, and SPL is now reported for a variety of colorectal procedures. Multiple case series and reports have demonstrated the adequate safety of SPL, but there are few reports of a measurable benefit of the technique. SPL is a difficult procedure to learn, it may have relatively high costs, and it is more difficult to perform as well as more physically and mentally taxing on the surgeon. Despite the difficulty and potentially increased cost, SPL suits colorectal patients well as they commonly have a stoma or extraction site adequate in size for a single port. There are cosmetic advantages to this technique, but they apply to a small subset of patients requiring colorectal surgery. There are many tips to incorporate SPL into practice successfully, but the procedure requires patience and experience. As surgeons become more facile with this technique, a group that derives a clear benefit beyond cosmesis will arise, likely a subset of reoperative patients requiring fecal diversion. The accompanying video demonstrates, step by step, the authors' technique of total proctocolectomy and ileo-anal pouch using a single-port device.

Prognostic modeling of preoperative risk factors of pouch failure.

BACKGROUND: The prospect of pouch failure needs to be considered when evaluating the management strategy for patients who may be candidates for an ileo anal pouch. An ability to predict the likelihood and timing of failure preoperatively may influence surgical decision making. OBJECTIVE: The aim of this study was to define a preoperative prognostic model for ileoanal pouch failure. DESIGN: A novel random forest methodology was used to evaluate the prognostic significance of 21 preoperative potential risk factors for pouch failure. A forest of 3000 random survival trees was grown to estimate pouch failure for each patient and to identify important risk factors that maximize survival prediction. SETTINGS: This study took place at a tertiary referral department at a major academic medical center. PATIENTS: Patients undergoing an ileoanal pouch at this institution between 1983 and 2008 were included. MAIN OUTCOME MEASURES: The primary outcome measured was pouch survival. RESULTS: Between 1983 and 2008, 3754 patients underwent ileoanal pouch. Type of resection (total proctocolectomy vs completion proctectomy), type of anastomosis (stapled vs mucosectomy), patient diagnosis (mucosal ulcerative colitis and others vs Crohn's disease) and diagnosis of diabetes had the strongest effect on pouch survival. Predicted survival was worse for completion proctectomy (HR, 1.44; 95% CI, 1.08-1.93), Crohn's disease (HR, 2.37; 95% CI, 1.48-3.79), handsewn anastomosis (HR, 1.72; 95% CI, 1.23-2.42), and diabetes (HR, 2.31; 95% CI, 1.25-4.24). Pouch survival was worse for the oldest group of patients. LIMITATIONS: This study was limited by its retrospective nature. CONCLUSION: Random forest techniques applied to a large number of patients undergoing the ileoanal pouch identify factors associated with pouch failure. Attention directed at these factors may improve outcomes for these patients.