Management, Functional Outcomes, and Quality of Life After Development of Pelvic Sepsis in Patients Undergoing Re-Do Ileal Pouch Anal Anastomosis.

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 ).

Operative, long-term and quality of life outcomes after salvage of failed re-do ileal pouch anal anastomosis.

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.

Handsewn Versus Stapled IPAA in Redo Setting: Indications, Patient Characteristics, Operative, Functional, and Quality-of-Life Outcomes.

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).

Transabdominal Pouch Salvage for Failed Minimally Invasive Versus Open IPAA: A Case-Matched Study.

BACKGROUND: Modality of index IPAA creation may affect the results after redo IPAA surgery for IPAA failure. To our knowledge, there is no study evaluating the effects of modality of index IPAA creation on redo IPAA outcomes. OBJECTIVE: This study aimed to compare short- and long-term outcomes of transabdominal redo IPAA surgery for failed minimally invasive IPAA and open IPAA. DESIGN: This was a retrospective cohort study. SETTINGS: This investigation was based on a single-surgeon experience on redo IPAA. PATIENTS: Patients undergoing transabdominal redo IPAA for a failed minimally invasive IPAA and open IPAA between September 2007 and September 2017 were included. MAIN OUTCOME MEASURES: Short-term complications and long-term outcomes were compared between 2 groups. RESULTS: A total of 42 patients with failed index minimally invasive IPAA were case matched with 42 failed index open IPAA counterparts. The interval between index IPAA and redo IPAA operations was shorter in patients who had minimally invasive IPAA (median, 28.5 vs 56.0 mo; p = 0.03). A long rectal stump (>2 cm) was more common after minimally invasive IPAA (26% vs 10%; p = 0.046). Redo IPAAs were constructed more commonly with staplers in the laparoscopy group compared with open counterparts (26% vs 10%; p = 0.046), and other intraoperative details were comparable. Although short-term morbidity was similar between 2 groups, abscess formation (7% vs 24%; p = 0.035) was more frequent in patients who had index IPAA with open technique. Functional outcomes were comparable. Redo IPAA survival for failed minimally invasive IPAA and open IPAA was comparable. LIMITATIONS: This study was limited by its retrospective, nonrandomized nature and relatively low patient number. CONCLUSIONS: A long rectal cuff after minimally invasive IPAA is a potential and preventable risk factor for failure. Due to its technical and patient-related complexity, handsewn anastomoses in redo IPAA are associated with increased risk of abscess formation. See Video Abstract at http://links.lww.com/DCR/B252. RESCATE DEL RESERVORIO ILEO-ANAL POR VIA TRANSABDOMINAL EN CASOS DE FUGA ANASTOMÓTICA ENTRE ABORDAGE MINIMAMENTE INVASIVO Y ABORDAJE ABIERTO: ESTUDIO DE EMPAREJAMIENTO DE MUESTRAS Y CASOS: La creación de modalidades e índices de Reservorios Ileo-Anales (RIA) pueden afectar los resultados después de rehacer la cirugía de RIAs por fallas en el reservorio. Hasta donde sabemos, no hay ningún estudio que evalúe los efectos de la modalidad de creación de índices RIA en los resultados para el rescate del reservorio.Este estudio tuvo como objetivo comparar los resultados a corto y largo plazo de la cirugía transabdominal redo RIA en casos de fracaso por via mínimamente invasiva (MI-RIA) o por la vía abierta (A-RIA).Estudio de cohortes tipo retrospectivo.Investigación basada en la experiencia de un solo cirujano en redo del Reservorio Ileo-Anal.Se incluyeron aquellos pacientes sometidos a re-operación transabdominal y re-confección de un RIA por fallas en el MI-RIA y en el A-RIA durante un lapso de tiempo entre septiembre 2007 y septiembre 2017.Las complicaciones a corto plazo y los resultados a largo plazo se compararon entre los dos grupos.Un total de 42 pacientes con índice fallido de MI-RIA fueron emparejados con 42 homólogos con índice fallido de A-RIA. El intervalo entre las operaciones de RIA y redo RIA fué más corto en pacientes que tenían MI-RIA (mediana, 28,5 meses frente a 56 meses, p = 0,03). Un muñón rectal largo (> 2 cm) fue más común después de MI-RIA (26% vs 10%, p = 0.046). Redo RIAs se construyeron más comúnmente con engrampadoras en el grupo Minimalmente Invasivo en comparación con la contraparte abiertas (26% vs 10%, p = 0.046). Aunque la morbilidad a corto plazo fue similar entre los dos grupos, la aparición de abscesos (7% frente a 24%, p = 0.035) fue más frecuente en pacientes que tenían RIA con técnica abierta. Los resultados funcionales fueron comparables. La sobrevida de las redo RIAs para MI-RIA y A-RIA fallidas, también fué comparable.Este estudio estuvo limitado por su naturaleza retrospectiva, no aleatoria y el número relativamente bajo de pacientes.Un muñon rectal largo después de MI-RIA es un factor de riesgo potencial y previsible para el fracaso. Debido a su complejidad técnica y relacionada con el paciente, las anastomosis suturadas a mano en redo RIA están asociadas con un mayor riesgo de formación de abscesos. Consulte Video Resumen en http://links.lww.com/DCR/B252.

Hand-Crafted Endoluminal Vacuum-Assisted Drainage for Anastomotic Leak After IPAA.

INTRODUCTION: The vacuum-assisted drainage has many applications in managing complex wound healing. It quickens the recovery period by its hyperemic effect on the exposed zone, decreasing bacterial colonization, preventing tissue edema, and promoting granulation of the wound. However, its use in anastomotic leak after IPAA is scarcely studied, especially because a proprietary endoluminal vacuum-assisted closure system was removed from the US market. TECHNIQUE: We applied a hand-crafted endoluminal vacuum-assisted closure system using the existing standard wound vacuum-assisted closure supplies to 2 patients who developed an anastomotic leak with a presacral abscess after completion proctectomy with J-pouch construction. RESULTS: We changed the endoluminal vacuum-assisted closure drain every 2 to 3 days, and both patients had substantial improvements in their abscess cavity after the seventh and ninth applications. CONCLUSIONS: Anastomotic leak at the IPAA traditionally takes up to a year to heal, which causes a significant toll on the psychosocial life of the patient and delayed stoma closure. Therefore, we believe that facilitating the healing process by using our hand-crafted endoluminal vacuum-assisted closure drain might provide a great value to patients' quality of life.

Transabdominal re-do pouch surgery in pediatric patients for failed ileal pouch anal anastomosis: a case matched study.

PURPOSE: Data regarding safety and feasibility of re-do ileal pouch anal anastomosis (IPAA) for failed ileal pouch in children are limited. In this study, we compared the short- and long-term outcomes of re-do IPAA in pediatric and adult populations in a case-matched setting. METHODS: Between March 2007 and June 2017, pediatric patients undergoing a transabdominal re-do IPAA by single surgeon were reviewed and case matched with adult counterparts. Short- and long-term outcomes including complications, functional outcomes, and quality of life of the two groups were compared. RESULTS: 60 patients were included (pediatric, n = 30; adult, n = 30). Time between index IPAA and re-do IPAA was shorter in the pediatric group (30 ± 26 vs 86 ± 74 months, p = 0.001). In the pediatric population, the existing pouch was more commonly used to construct the re-do pouch (n = 19 vs n = 12, p = 0.07). There was a trend towards the presence of less postoperative complications in pediatric group (n = 13 vs n = 20, p = 0.07). There were no reoperations or mortality. Long-term pouch survival was comparable between two groups (p = 0.96). Six re-do IPAAs failed in the study period. CONCLUSION: Re-do IPAA is safe and feasible in pediatric population with failed IPAA and can be performed with similar short- and long-term outcomes compared to adults in experienced hands.

Restorative proctocolectomy with a handsewn IPAA: S-pouch or J-pouch?

BACKGROUND: The efferent limb on the S-pouch fits well into the anal canal while the body of the pouch lies on the levators. In contrast, the blunt end of a J-pouch may be distorted as it is forced into the muscular tube of the stripped anus. OBJECTIVE: The aim of this study is to compare the clinical outcomes and quality of life between patients with S- and J-pouches with a handsewn IPAA. DESIGN: This study was retrospective. SETTING: This study was conducted at a high-volume tertiary referral center. PATIENTS: Patients undergoing a primary handsewn IPAA from 1983 to 2012 were identified. MAIN OUTCOMES MEASURES: Demographics, operative details, functional outcomes, and quality of life were abstracted. RESULTS: A total of 502 patients, including 169 patients with an S-pouch (33.7%) and 333 patients with J-pouch (66.3%), met our inclusion criteria; 55.8% (n = 280) were men. Mean age at pouch construction was 37.8 ± 12.5 years. Patients with an S-pouch were younger (p = 0.004) and had a higher BMI (p = 0.035) at pouch surgery. There was no significant difference between patients with S- or J-pouches in other demographics. The frequencies of short-term complications in the 2 groups were similar (p > 0.05), but pouch fistula or sinus (p = 0.047), pelvic sepsis (p = 0.044), postoperative partial small-bowel obstruction (p = 0.003), or postoperative pouch-related hospitalization (p = 0.021) occurred in fewer patients with an S-pouch. At a median follow-up of 12.2 (range, 4.3-20.1) years, patients with an S-pouch were found to have fewer bowel movements (p < 0.001), less frequent pad use (p = 0.001), and a lower fecal incontinence severity index score (p = 0.015). The pouch failed in 62 patients (12.4%), but neither univariate nor multivariate analysis showed a significant association with pouch configuration. LIMITATIONS: The use of data from a single tertiary referral center was a limitation of this study. CONCLUSION: We recommend using an S-pouch when constructing an IPAA with a handsewn technique.

Is adjuvant chemotherapy really needed after curative surgery for rectal cancer patients who are node-negative after neoadjuvant chemoradiotherapy?

PURPOSE: Adjuvant chemotherapy is currently offered, as standard, after curative resection for patients with rectal cancer who receive neoadjuvant chemoradiation (NCRT). We postulate that adjuvant chemotherapy adds minimal oncologic benefit for patients who undergo total mesorectal excision who are node-negative after neoadjuvant chemoradiation. METHODS: From a prospective, institutional cancer database, rectal cancer patients who completed neoadjuvant chemoradiation and curative surgery (2000-2008) and were node-negative on final pathology were identified. Patient, tumor, treatment characteristics, and oncologic outcomes were compared for patients who completed intended adjuvant chemotherapy (group chemo) or did not receive any chemotherapy (group no-chemo). RESULTS: Chemo (n=58) and no-chemo (n=70) patients had similar age (P=0.13), gender (P=0.67), body mass index (P=0.46), American Society of Anesthesiologists class (P=0.67), preoperative tumor stage (P=0.16), type of surgery (P=0.76), and postoperative complications. The no-chemo group had greater complete pathologic response (n=34, 48.6% vs. n=14, 24.1%). After prolonged follow-up, local recurrence (P=1), disease-free survival (P=0.41), and overall survival (P=0.52) were similar. Oncologic benefits of adjuvant chemotherapy were especially questionable for patients with complete pathologic response (chemo vs. no-chemo, local recurrence at 5 years: 0 vs. 2.9%, P>0.99), disease-free (79.1% vs. 88%, P=0.51), and overall survival (90.9% vs. 95.2%, P=0.41). CONCLUSIONS: These results question the routine use of adjuvant chemotherapy for patients with rectal cancer who undergo curative surgery who have been rendered node-negative by neoadjuvant chemoradiation.

Permanent ostomy after ileoanal pouch failure: pouch in situ or pouch excision?

BACKGROUND: The risks and benefits of pouch excision and end ileostomy creation when compared to the alternative option of a permanent diversion with the pouch left in situ when restoration of intestinal continuity is not pursued for patients who develop pouch failure after IPAA have not been well characterized. OBJECTIVE: This study aimed to compare the early and long-term outcomes after permanent diversion with the pouch left in situ vs pouch excision with end ileostomy creation for pouch failure. DESIGN: This study is a retrospective review of prospectively gathered data. SETTINGS: This investigation was conducted at a tertiary center. PATIENTS: Patients with pouch failure who underwent a permanent ileostomy with the pouch left in situ and those who underwent pouch excision were included in the study. MAIN OUTCOME MEASURES: The primary outcomes measured were the perioperative outcomes and quality of life using the pouch and Short Form 12 questionnaires. RESULTS: One hundred thirty-six patients with pouch failure underwent either pouch left in situ (n = 31) or pouch excision (n = 105). Age (p = 0.72), sex (p = 0.72), ASA score (p = 0.22), BMI (p = 0.83), disease duration (p = 0.74), time to surgery for pouch failure (p = 0.053), diagnosis at pouch failure (p = 0.18), and follow-up (p = 0.76) were similar. The predominant reason for pouch failure was septic complications in 15 (48.4%) patients in the pouch left in situ group and 39 (37.1%) patients in the pouch excision group (p = 0.3). Thirty-day complications, including prolonged ileus (p = 0.59), pelvic abscess (p = 1.0), wound infection (p = 1.0), and bowel obstruction (p = 1.0), were similar. At the most recent follow-up (median, 9.9 y), quality of life (p = 0.005) and health (p = 0.008), current energy level (p = 0.026), Cleveland Global Quality of Life score (p = 0.005), and Short Form 12 mental (p = 0.004) and physical (p = 0.014) component scales were significantly higher after pouch excision than after pouch left in situ. Urinary and sexual function was similar between the groups. Anal pain (n = 4) and seepage with pad use (n = 8) were the predominant concerns of the pouch left in situ group on long-term follow-up. None of the 18 patients with pouch in situ, for whom information relating to long-term pouch surveillance was available, developed dysplasia or cancer. LIMITATIONS: This study was limited by its retrospective nature. CONCLUSIONS: Although technically more challenging, pouch excision, rather than pouch left in situ, is the preferable option for patients who develop pouch failure and are not candidates for restoration of intestinal continuity. Because pouch left in situ was not associated with neoplasia, this option is a reasonable intermediate or long-term alternative when pouch excision is not feasible or advisable.

Indications, functional and quality of life outcomes of new pouch creation during re-do ileal pouch anal anastomosis: A comparative study with existing pouch salvage.

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.

Ileal Pouch Excision can Be Performed With Similar Outcomes in Obese Patients Compared to Nonobese Counterparts: An Assessment From American College of Surgeons National Surgical Quality Improvement Program.

BACKGROUND: Failed pouches may tend to be managed with only a loop ileostomy in obese patients due to some safety concerns. The effect of obesity on ileal pouch excision outcomes is poorly studied. In our study, we aimed to assess the short-term outcomes after ileal pouch excision in obese patients compared to their nonobese counterparts. METHODS: The patients who underwent pouch excision between 2005 and 2017 were included using ACS-NSQIP participant user files. The operative outcomes were compared between obese (BMI ≥30 kg/m2) and nonobese (BMI<30 kg/m2) groups. RESULTS: There were 507 pouch excision patients included of which eighty (15.7%) of them were obese. Physical status of the obese patients tended to be worse (ASA>3, 56.3 vs 42.9%, P = .027). There were more patients who had diabetes mellitus (DM) and hypertension (HT) in the obese group (26.3% vs. 11.2%, P = .015; 11.3 vs. 4.4%, P < .001, respectively). Operative time was similar between 2 groups (mean ± SD, 275 ± 111 vs. 252±111 minutes, P = .084). Deep incisional SSI was more commonly observed in the obese group (7.5 vs 2.8%, P = .038). In multivariate analysis, only deep incisional SSI was found to be independently associated with obesity (OR: 2.79, 95% CI: 1.02-7.67). Obese patients were readmitted more frequently than nonobese counterparts (28.3 vs 16%, P = .035). The length of hospital stay was comparable [median (IQR), 7 (4-13.5) vs. 7 (5-11) days, P = .942]. CONCLUSION: Ileal pouch excision can be performed in obese patients with largely similar outcomes compared to their nonobese counterparts although obesity is associated with a higher rate of deep space infection.

Management of leak from the tip of the "J" in ileal pouch-anal anastomosis.

BACKGROUND: Diagnosis and management of leak from the tip of the J-pouch after IPAA has not been systematically studied. OBJECTIVE: The aim of this study is to report our experience in the diagnosis and management of these leaks following primary IPAA. DESIGN: This study is a retrospective review of prospectively gathered data. SETTINGS: Data were obtained from a prospectively maintained single-institution pelvic pouch database. PATIENTS: Included in this study were patients with a leak from the tip of the J-pouch after primary IPAA. MAIN OUTCOME MEASURES: The main measures of outcomes after salvage surgery were pouch failure, pouch function, and quality of life. RESULTS: There were 27 (14 male) patients. Median age was 37 years (range, 20-73). Underlying disease in these patients was ulcerative colitis in 22 patients. Predominant symptoms were abdominal pain (n = 15) and fever (n = 5). Twenty patients had either a pelvic abscess detected by CT or MRI or a leak demonstrated at gastrografin enema or pouchoscopy. In 6 patients, the diagnosis was only made at salvage surgery. In 1 patient, the leak-associated abscess was detected during emergent laparotomy for acute peritonitis before salvage surgery. Of 27 patients, 1 had successful CT-guided drainage without the need for further surgery. Another patient had pouch resection with end ileostomy. Salvage surgery was performed in 25 patients by means of pouch repair (n = 23) and new pouch creation (n = 2); 8 patients had a repeat anastomosis. Median time from primary IPAA to salvage surgery was 0.9 years (0.13-9.8). Twenty-four patients with salvage surgery have a functioning pouch after a mean follow-up of 3.2 ± 1.9 years. LIMITATIONS: : The study was limited by its retrospective nature. CONCLUSIONS: Leak from the tip of the J-pouch is indolent and diagnosis can be difficult. Satisfactory outcomes in terms of pouch retention may be expected after appropriate surgical management.

Single-port laparoscopic total proctocolectomy with ileal pouch-anal anastomosis: initial operative experience.

BACKGROUND: Single-port laparoscopic surgery (SPLS) has been used in urologic, gynecologic, general, and colorectal surgery. We herein report our experience with the use of SPLS for total proctocolectomy with ileal pouch-anal anastomosis (RP/IPAA). METHODS: All patients who underwent a RP/IPAA using SPLS between June and September 2009 were identified from a prospectively maintained laparoscopic database. All procedures were performed with the use of a 5-mm Olympus EndoEye™ and traditional laparoscopic instruments via a SILS™ port placed at the planned ileostomy site. RESULTS: There were five patients (3 male) included in the study. Median age was 43 years (range=13-47 years). Median body mass index was 20.66 kg/m2 (range=14.63-25.97 kg/m2). Diagnoses included ulcerative colitis (n=4) and familial adenomatous polyposis (n=1). Median ASA score was 2 (range=1-3). Median operative time was 153 min (range=132-278 min). Median estimated blood loss was 100 ml (range=50-200 ml). There were no conversions to either a conventional laparoscopic or an open procedure. Median time to return of bowel function was 2 days. Median length of stay was 4 days (range=3-6 days). Postoperative complications included two patients with partial small-bowel obstructions. Both resolved with conservative management. All patients had their ileostomies closed. CONCLUSION: RP/IPAA using SPLS is a safe technique. Additional studies are needed to compare SPLS to conventional laparoscopy and open surgery with respect to operative times, convalescence, and outcomes.

Does the learning curve during laparoscopic colectomy adversely affect costs?

BACKGROUND: This study aimed to investigate whether the learning curve during laparoscopic colectomy is associated with increased costs compared with the procedure after the learning curve has been achieved. METHODS: The direct costs for patients undergoing laparoscopic colectomy during the learning curve (group A) and after the attainment of proficiency by two colorectal surgeons performing the procedure (group B) between 2001 and 2007 were compared. The learning curve was defined as the first 40 laparoscopic colectomy cases for each surgeon. The distribution of cases for the surgeons ensured that cost-related differences were not influenced by lead time bias of cases performed during the learning curve. RESULTS: The study involved 80 group A and 74 group B patients. Groups A and B were similar in terms of age (P = 0.7), gender (P = 0.5), American Society of Anesthesiologists (ASA) score (P = 0.5), body mass index (P = 0.3), diagnosis (P = 0.8), previous abdominal surgery (P = 0.07), and comorbidity (P = 0.4). The two groups also were similar with regard to performance of anastomosis (P = 0.2) or resection (P = 0.6), conversion to open surgery (P = 0.7), postoperative morbidity (P = 0.6), readmission (P = 0.1), reoperation rate (P = 0.6), and hospital length of stay (P = 0.6). The operation time was significantly longer for group A (P = 0.01). The total direct costs (P = 0.7) and the operating room (P = 0.6), nursing (P = 0.7), pharmacy (P = 0.9), radiology (P = 1), and professional (P = 0.051) costs were however similar between the two groups. CONCLUSIONS: As expected, laparoscopic colectomy during the learning curve period is associated with prolonged operating time. Concerns pertaining to increased conversions, complications, and direct costs during this period were not substantiated in this study.

Laparoscopic versus open colectomy for patients with American Society of Anesthesiology (ASA) classifications 3 and 4: the minimally invasive approach is associated with significantly quicker recovery and reduced costs.

BACKGROUND: Conceivably, the benefits of earlier recovery associated with a minimally invasive technique used in laparoscopic colectomy (LC) may be amplified for patients with comorbid disease. The dearth of evidence supporting the safety of laparoscopy for these patients led to a comparison of outcomes between LC and open colectomy (OC) for patients with American Society of Anesthesiology (ASA) classifications 3 and 4. METHODS: Data for all ASA 3 and 4 patients who underwent elective LC were reviewed from a prospectively maintained laparoscopic database. The patients who underwent LC were matched with OC patients by age, gender, diagnosis, year, and type of surgery. Estimated blood loss, operation time, time to return of bowel function, length of hospital stay, readmission rate, and 30-day complication and mortality rates were compared using chi-square, Fisher's exact, and Wilcoxon tests as appropriate. A p value <0.05 was considered statistically significant. RESULTS: In this study, 231 LCs were matched with 231 OCs. The median age of the patients was 68 years, and 234 (51%) of the patients were male. There were 44 (19%) conversions from LC to OC. More patients in the OC group had undergone previous major laparotomy (5 vs. 15%; p < 0.001). Estimated blood loss, return of bowel function, length of hospital stay, and total direct costs were decreased in the LC group. Wound infection was significantly greater with OC (p = 0.02). When patients with previous major laparotomy were excluded, the two groups had similar overall morbidity. The other benefits of LC, however, persisted. CONCLUSION: The findings show that LC is a safe option for patients with a high ASA classification. The LC approach is associated with faster postoperative recovery, lower morbidity rates, and lower hospital costs than the OC approach.

Can laparoscopic ileocolic resection be performed with comparable safety to open surgery for regional enteritis: data from National Surgical Quality Improvement Program.

Laparoscopic ileocolic resection is feasible for Crohn's disease but few studies adjust for the various preoperative, intraoperative, and postoperative variables that may confound comparisons with open surgery. The aim of this study is to compare outcomes after laparoscopic (LICR) and open ileocolic resection (OICR) performed for regional enteritis using National Surgical Quality Improvement Program (NSQIP) data. Retrospective evaluation of data prospectively accrued into the NSQIP database for patients undergoing ileocolic resection for Crohn's by LICR and OICR was performed. LICR (n = 104) and OICR (n = 203) groups had similar age (P = 0.1), body mass index (P = 0.9), smoking history (P = 0.6), steroid use (P = 0.7), diabetes (P = 0.3), serum albumin (P = 0.07), and American Society of Anesthesiologists class (P = 0.13). LICR group had more female patients (P = 0.005). Complications including surgical site infections (P = 0.5), wound dehiscence (P = 1), pneumonia (P = 0.1), deep vein thrombosis (P = 0.3), pulmonary embolism (P = 1), urinary infection (P = 0.1), and return to the operating room (P = 0.2) were similar. LICR had shorter length of hospital stay than OICR (P < 0.001). In current practice, as observed with the NSQIP data, LICR, performed by experienced surgeons, is comparable in safety to OICR and is associated with a shorter hospital stay.

Repeat pouch surgery by the abdominal approach safely salvages failed ileal pelvic pouch.

PURPOSE: : This study evaluated outcomes of patients with abdominal salvage operations for failed ileal pouch-anal anastomosis. METHODS: : Patients undergoing laparotomy for ileoanal pouch salvage were reviewed from a prospectively maintained pouch database and records. RESULTS: : From 1983 to 2007, 241 abdominal reconstructions were performed. The median follow-up was 5 years (range, 0.04-20.8). Diagnoses before primary ileal pouch-anal anastomosis were ulcerative colitis in 187, familial adenomatous polyposis in 22, indeterminate colitis in 20, Crohn's disease in 9, and other in 3. The most common indications for salvage were fistula (n = 67), leak (n = 65), stricture (n = 42) pouch dysfunction (n = 40), pelvic abscess (n = 25). Seventy-one cases had a new pouch constructed. One hundred and seventy cases had the original pouch salvaged. Twenty-nine cases had either pouch excision or ileostomy without pouch excision the result of failure after reconstruction. To assess functional results and quality of life, patients with reconstruction were matched to those with a primary ileal pouch-anal anastomosis. Significantly higher proportions of patients with reconstruction reported seepage during daytime (P = 0.002), at night (P = 0.015), and daytime pad usage (P = 0.02). Other parameters and quality of life were similar between groups. CONCLUSIONS: : Repeat abdominal surgery was a good alternative for pouch failure. Functional and quality of life outcomes were encouraging.

Outcome of salvage surgery for ileal pouches referred with a diagnosis of Crohn's disease.

INTRODUCTION: Technical complications after ileal pouch-anal anastomosis may be mislabeled as Crohn's disease. The purpose of our study is to evaluate the presentation, treatment, and outcomes of patients with a potential misdiagnosis of Crohn's disease who have undergone redo ileal pouch-anal anastomosis. METHODS: We evaluated a historical cohort of patients, initially referred from outside institutions with a diagnosis of Crohn's disease of the pouch, who subsequently had redo ileal pouch-anal anastomosis (redo pouch or pouch revision for pouch failure) at our institution. With the use of validated questionnaires, the functional outcomes and quality of life of this cohort were compared with a control group of patients who underwent primary ileal pouch-anal anastomosis to assess whether a change in the diagnosis from Crohn's disease to technical complications was appropriate. RESULTS: Thirty-three patients underwent a redo pouch procedure for a previous diagnosis of Crohn's disease of the pouch. Precolectomy diagnosis included ulcerative colitis (31 patients) and indeterminate colitis (2 patients). Findings on our further evaluation and subsequent indications for repeat pouch surgery included pouch fistula (20 patients), pelvic sepsis or anastomotic leak (17 patients), stricture (4 patients), refractory pouchitis (2 patients), long exit conduit (1 patient), and retained rectal stump (1 patient). All patients had medical treatment for Crohn's disease before referral. Median time between primary and redo pouch was 2.1 years (interquartile range, 1.8-4.9). Median follow-up was 1.7 years (interquartile range, 1.0-3.5). Pouch retention rate was 84.8%. Five patients (15.2%) had pouch failure. Seven patients (21.2%) ultimately had pathology consistent with Crohn's disease. Comparison of the redo pouch and control groups revealed that functional outcomes and quality of life were similar between groups. CONCLUSION: Patients identified as having Crohn's disease need to be carefully reevaluated because some of these patients may actually have surgery-associated complications and can have a favorable long-term outcome after redo ileal pouch-anal anastomosis.