A 25 year experience of perineal hernia repair.

PURPOSE: Though perineal hernias remain rare, the incidence is reportedly rising. Secondary to the historical rarity, optimal method of repair and outcomes after repair remain poorly understood. Therefore, we reviewed the past 25 years of our institutional experience with perineal hernia repair. METHODS: A retrospective review of an institution-maintained database was conducted from January 1, 1994 to January 31, 2018 for patients undergoing perineal hernia repair. Data were collected on patient characteristics, operative technique, and post-operative outcomes. RESULTS: Twenty-one patients (n = 12 male) underwent perineal hernia repair in the study period with two-thirds of the operations occurring in the most recent 7 years (since January 1, 2011). The median time to repair was 13 months (range 2-127) after index operation. The approach was transabdominal in nine, perineal in nine, and combined in three. Mesh, a tissue flap, or a combination of these was used in 19 of the cases and 6 additional abdominal wall hernias were repaired concurrently. Post-operative complications consisted of superficial surgical-site infection (n = 2), infected seroma (n = 1), and a missed enterotomy (n = 1). Follow-up ranged from 0 to 112 months (median 2 months) and only one recurrence was noted. CONCLUSION: Presentation for repair of perineal hernia has increased at our instituion over the past 2 decades. Outcomes did not differ between the three repair approaches and the choice of mesh or tissue-based repair. Surgeons should base these decisions on hernia complexity and local tissue conditions.

Short-term postoperative outcomes following robotic versus laparoscopic ileal pouch-anal anastomosis are equivalent.

BACKGROUND: Minimally invasive approaches have become the standard of care for ileal pouch-anal anastomoses (IPAA). There are few reports comparing outcomes following a laparoscopic versus robotic approach. Our aim was to determine if there were any differences in the 30-day postoperative outcomes following IPAA performed laparoscopically versus robotically. METHODS: A retrospective chart review of all laparoscopic and robotic IPAA performed between January 1, 2015 and June 30, 2018 was carried out. Patients included were adult patients who underwent a proctectomy and IPAA utilizing either a laparoscopic or robotic approach. Data collected included patient demographics, operative variables, and 30-day postoperative outcomes. RESULTS: A total of 132 patients had a minimally invasive IPAA; 58 were performed laparoscopically and 74 robotically. Less than half the patients were female (n = 55; 41.7%) with a median age of 37 years (range 18-68 years). The majority of patients had a diagnosis of ulcerative colitis (n = 103; 78.0%) with medically refractory disease (n = 87; 65.9%). A greater proportion of patients in the laparoscopic cohort had a prolonged length of stay (n = 27; 46.6% versus n = 18; 24.3%; p < 0.001) and a two-stage approach (n = 56; 96.6% versus n = 37; 50%; p < 0.001), but there were no differences in the rates between the laparoscopic versus robotic cohorts of superficial surgical site infection (6.9% versus 6.8%; p = 0.99), peripouch abscess (15.5% versus 6.8%; p = 0.11), anastomotic leak (6.9% versus 2.7%; p = 0.21), pelvic abscess (15.5% versus 6.8%; p = 0.11), and pelvic sepsis (15.5% versus 6.8%; p = 0.11), readmission (24.1% versus 17.6%; p = 0.35) or reoperation (6.9% versus 5.4%; p = 0.72). On multivariable analysis, only male sex remained predictive of prolonged length of stay, and a robotic approach trended toward a decreased rate of prolonged length of stay. CONCLUSIONS: Laparoscopic and robotic IPAA have equivalent postoperative morbidity underscoring the safety of the continued expansion of the robotic platform for pouch surgery.

Does external beam radiation therapy to the pelvis portend worse ileal pouch outcomes? An international multi-institution collaborative study.

AIM: Short-term morbidity and long-term functional outcome of patients with an ileal pouch-anal anastomosis (IPAA) exposed to pelvic external beam radiation therapy (EBRT) remains unknown. We report the largest series to date regarding the effects of pelvic EBRT on: (i) 30-day postoperative outcomes; and (ii) long-term functional outcome following IPAA. METHOD: A retrospective chart review was conducted of patients who received EBRT before or after IPAA between 1980 and 2017 across three international inflammatory bowel disease referral centres. RESULTS: Nineteen patients were included. Indications for EBRT were rectal adenocarcinoma (n = 13), prostate adenocarcinoma (n = 4) or anal squamous cell carcinoma (ASCC) (n = 2). EBRT was given prior to IPAA in 12 (63%) patients and after IPAA in seven (37%). In EBRT before IPAA, patients had a median of 5 (range: 4-8) daytime bowel movements, 1 (range: 0-5) night-time bowel movement, no daytime incontinence, and only one patient used pads at a median follow up of 25 (range: 11-163) months; one patient underwent pouch excision 15 months after IPAA. In EBRT after IPAA, patients reported a median of 8 (range: 5-10) daytime and 2 (range: 0-5) night-time bowel movements, 80% had either daytime or night-time incontinence and 80% used pads at a median follow up of 90 (range: 25-315) months. CONCLUSION: Pelvic EBRT administered prior to IPAA is associated with acceptable long-term function outcome. However, when pelvic EBRT is given to an IPAA in situ, most patients experience poor long-term pouch function without pouch failure.

Postoperative outcomes in vedolizumab-treated Crohn's disease patients undergoing major abdominal operations.

BACKGROUND: Up to 80% of patients with Crohn's disease require an abdominal operation in their lifetime. As the use of vedolizumab is increasing for the treatment of Crohn's disease, it is important to understand its potential association with post-operative complications. AIM: We sought to compare 30-day postoperative infectious complication rate among vedolizumab-treated Crohn's disease patients vs those who had received TNFα inhibitors or no biologic therapy. METHODS: A retrospective review of all Crohn's disease patients who received vedolizumab within 12 weeks of a major abdominal or pelvic operation was performed. Two control cohorts consisted of Crohn's disease patients treated with TNFα inhibitors or no biologic therapy. RESULTS: One hundred Crohn's disease patients received vedolizumab within 12 weeks of an abdominal operation. Vedolizumab-treated patients underwent an equivalent rate of laparoscopic surgery (P = .25), had fewer anastomoses performed (P = .0002), and had equally frequent diversion in the setting of anastomoses (P = .47). Thirty-two vedolizumab-treated patients experienced postoperative infectious complications (32%), 26 of which were surgical site infections (26%). The vedolizumab-treated group experienced no difference in nonsurgical site infections (6% vs 5% anti-TNFα and 2% nonbiologic; P = .34), but significantly higher rates of surgical site infections (26% vs 8% and 11%; P < .001). On univariate and multivariate analysis, exposure to vedolizumab remained a significant predictor of postoperative surgical site infection (P < .001 and P = .002). CONCLUSIONS: Twenty-six per cent of Crohn's disease patients who received vedolizumab within 12 weeks prior to a major abdominal operation experienced a 30-day postoperative surgical site infection, significantly higher than that of patients receiving TNFα inhibitors or no biologic therapy. Vedolizumab within 12 weeks of surgery remained a predictor of 30-day postoperative surgical site infection on multivariable analysis. While vedolizumab-treated Crohn's disease patients may be a sicker cohort of patients, it is important to consider these findings with regard to preoperative counselling, operative timing and primary closure of wounds.