Cancer in the Anal Transition Zone and Ileoanal Pouch following Surgery for Ulcerative Colitis.

Restorative proctocolectomy with ileal pouch-anal anastomosis remains the gold standard treatment for patients with ulcerative colitis who desire restoration of intestinal continuity. Despite a significant cancer risk reduction after surgical removal of the colon and rectum, dysplasia and cancers of the ileal pouch or anal transition zone still occur and are a risk even if an anal canal mucosectomy is performed. Surgical care and maintenance after ileoanal anastomosis must include consideration of malignant potential along with other commonly monitored variables such as bowel function and quality of life. Cancers and dysplasia of the ileal pouch are rare but sometimes difficult-to-manage sequelae of pouch surgery.

Effect of Incisional Negative Pressure Wound Therapy on Surgical Site Infections in High-Risk Reoperative Colorectal Surgery: A Randomized Controlled Trial.

BACKGROUND: Colorectal resections have relatively high rates of surgical site infections causing significant morbidity. Incisional negative pressure wound therapy was introduced to improve wound healing of closed surgical incisions and to prevent surgical site infections. OBJECTIVE: This randomized controlled trial aimed to investigate the effect of incisional NPWT on superficial surgical site infections in high-risk, open, reoperative colorectal surgery. DESIGN: This was a single-center randomized controlled trial conducted between July 2015-October 2020. Patients were randomly assigned to incisional negative pressure wound therapy or standard gauze dressing with a 1:1 ratio. A total of 298 patients were included. SETTINGS: This study was conducted at the colorectal surgery department of a tertiary-level hospital. PATIENTS: This study included patients older than 18 years who underwent elective reoperative open colorectal resections. Patients were excluded who had open surgery within the past 3 months, who had active surgical site infection, and who underwent laparoscopic procedures. MAIN OUTCOME MEASURES: The primary outcome was superficial surgical site infection within 30 days. Secondary outcomes were deep and organ-space surgical site infections within 7 days and 30 days, postoperative complications, and length of hospital stay. RESULTS: A total of 149 patients were included in each arm. The mean age was 51 years, and 49.5% were women. Demographics, preoperative comorbidities, and preoperative albumin levels were comparable between the groups. Overall, most surgeries were performed for IBD, and 77% of the patients had an ostomy fashioned during the surgery. No significant difference was found between the groups in 30-day superficial surgical site infection rate (14.1% in control versus 9.4% in incisional negative pressure wound therapy; p = 0.28). Deep and organ-space surgical site infections rates at 7 and 30 days were also comparable between the groups. Postoperative length of stay and complication rates (Clavien-Dindo grade) were also comparable between the groups. LIMITATIONS: The patient population included in the trial consisted of a selected group of high-risk patients. CONCLUSIONS: Incisional negative pressure wound therapy was not associated with reduced superficial surgical site infection or overall complication rates in patients undergoing high-risk reoperative colorectal resections. See Video Abstract at http://links.lww.com/DCR/B956 . EFECTO DE LA TERAPIA DE HERIDA INSICIONAL CON PRESIN NEGATIVA EN INFECCIONES DEL SITIO QUIRRGICO EN CIRUGA COLORRECTAL REOPERATORIA DE ALTO RIESGO UN ENSAYO CONTROLADO ALEATORIZADO: ANTECEDENTES:Las resecciones colorrectales tienen tasas relativamente altas de infecciones del sitio quirúrgico que causan una morbilidad significativa. La terapia de heridas incisionales con presión negativa se introdujo para mejorar la cicatrización de las heridas de incisiones quirúrgicas cerradas y para prevenir infecciones del sitio quirúrgico.OBJETIVO:El objetivo de este ensayo controlado y aleatorizado fue investigar el efecto de la terapia de herida incisional con presión negativa en infecciones superficiales del sitio quirúrgico en cirugía colorrectal re operatoria, abierta y de alto riesgo.DISEÑO:Ensayo controlado y aleatorizado de un solo centro entre julio de 2015 y octubre de 2020. Los pacientes fueron aleatorizados para recibir tratamiento para heridas incisionales con presión negativa o vendaje de gasa estándar en una proporción de 1:1. Se incluyeron un total de 298 pacientes.AJUSTE:Este estudio se realizó en el departamento de cirugía colorrectal de un hospital de tercer nivel.PACIENTES:Se incluyeron pacientes mayores de 18 años que se fueron sometidos a resecciones colorrectales abiertas, re operatorias y electivas. Se excluyeron aquellos pacientes que tuvieron cirugía abierta en los últimos 3 meses, con infección activa del sitio quirúrgico y que fueron sometidos a procedimientos laparoscópicos.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue infección superficial del sitio quirúrgico dentro de los 30 días. Los resultados secundarios fueron infecciones del sitio quirúrgico profundas y del espacio orgánico dentro de los 7 y 30 días, las complicaciones posoperatorias y la duración de la estancia hospitalaria.RESULTADOS:Se incluyeron un total de 149 pacientes en cada brazo. La edad media fue de 51 años y el 49,5% fueron mujeres. La demografía, las comorbilidades preoperatorias y los niveles de albúmina preoperatoria fueron comparables entre los grupos. En general, la mayoría de las cirugías fueron realizadas por enfermedad inflamatoria intestinal y al 77 % de los pacientes se les confecciono una ostomía durante la cirugía. No hubo diferencias significativas entre los grupos en la tasa de infección del sitio quirúrgico superficial a los 30 días (14,1 % en el control frente a 9,4 % en el tratamiento de herida incisional con presión negativa, p = 0,28). Las tasas de infecciones del sitio quirúrgico profundas y del espacio orgánico a los 7 y 30 días también fueron comparables entre los grupos. La duración de la estancia postoperatoria y las tasas de complicaciones (Clavien-Dindo Graduacion) también fueron comparables entre los grupos.LIMITACIONES:La población de pacientes incluida en el ensayo consistió en un grupo seleccionado de pacientes de alto riesgo.CONCLUSIONES:Video Resumen en http://links.lww.com/DCR/B956 . (Traducción-Dr. Osvaldo Gauto ).

Management of the Hostile Abdomen.

Caring for a patient with a hostile abdomen is one of the most challenging clinical situations one can encounter. It requires specialized technical skill coupled with bold but thoughtful decision-making to achieve good outcomes. An approach to the patient with a complex, hostile abdomen must be individualized to account for the patient's personal details. However, implementing an experienced-based algorithm to help make the difficult decisions required in this setting can be helpful, as evidence-based studies are few. The purpose of this review is to provide a structured, evidence, and experienced-based approach to the challenges that the surgeon encounters when faced with a patient with a hostile abdomen, and to discuss perioperative and intraoperative surgical strategies that can lead to most successful outcomes.

Don't Forget about the K-Pouch!

The continent ileostomy (CI) was popularized by Nils Kock as a means to provide fecal continence to patients, most commonly in those with ulcerative colitis, after proctocolectomy. Although the ileal pouch-anal anastomosis (IPAA) now represents the most common method to restore continence after total proctocolectomy, CI remains a suitable option for highly selected patients who are not candidates for IPAA or have uncorrectable IPAA dysfunction but still desire fecal continence. The CI has exhibited a fascinating and marked evolution over the past several decades, from the advent of the nipple-valve to a distinct pouch design, giving the so-inclined and so-trained colorectal surgeon a technique that provides the unique patient with another option to restore continence. The CI continues to offer a means for appropriately selected patients to achieve the highest possible quality of life (QOL) and functional status after total proctocolectomy.

Is Conversion of a Failed IPAA to a Continent Ileostomy a Risk Factor for Long-term Failure?

BACKGROUND: A continent ileostomy may be offered to patients in hopes of avoiding permanent ileostomy. Data on the outcomes of continent ileostomy patients with a history of a failed IPAA are limited. OBJECTIVE: This study aimed to assess whether a history of previous failed IPAA had an effect on continent ileostomy survival and the long-term outcomes. DESIGN: This was a retrospective cohort study. SETTINGS: This investigation took place in a high-volume, specialized colorectal surgery department. PATIENTS: Patients who underwent continent ileostomy construction after IPAA failure between 1982 and 2013 were evaluated and compared with patients who have no history of IPAA surgery. MAIN OUTCOME MEASURES: Functional outcomes and long-term complications were compared. RESULTS: A total of 67 patients fulfilled the case-matching criteria and were included in the analysis. Requirement of major (52% vs 61%; p = 0.756) and minor (15% vs 19%; p = 0.492) revisions were comparable between patients who had continent ileostomy after a failed IPAA and those who had continent ileostomy without having a previous restorative procedure. Intubations per day (5 vs 5; p = 0.804) and per night (1 vs 1; p = 0.700) were similar in both groups. Our data show no clear relationship between failure of continent ileostomy and history of failed IPAA (p = 0.638). The most common cause of continent ileostomy failure was enterocutaneous/enteroenteric fistula (n = 14). Six patients died during the study period because of other causes unrelated to continent ileostomy. LIMITATIONS: This study was limited by its retrospective and nonrandomized nature. CONCLUSIONS: Converting a failed IPAA to a continent ileostomy did not worsen continent ileostomy outcomes in this selected group of patients. When a redo IPAA is not feasible, continent ileostomy can be offered as an alternative to conventional end ileostomy in highly motivated patients. See Video Abstract at http://links.lww.com/DCR/A803.

Outcomes of Endoscopic Balloon Dilation vs Surgical Resection for Primary Ileocolic Strictures in Patients With Crohn's Disease.

BACKGROUND & AIMS: Few studies have compared endoscopic balloon dilation (EBD) with ileocolic resection (ICR) in the treatment of primary ileocolic strictures in patients with Crohn's disease (CD). METHODS: We performed a retrospective study to compare postprocedure morbidity and surgery-free survival among 258 patients with primary stricturing ileo(colic) CD (B2, L1, or L3) initially treated with primary EBD (n = 117) or ICR (n = 258) from 2000 through 2016. Patients with penetrating disease were excluded from the study. We performed multivariate analyses to evaluate factors associated with surgery-free survival. RESULTS: Postprocedural complications occurred in 4.7% of patients treated with EBD and salvage surgery was required in 44.4% of patients. Factors associated with reduced surgery-free survival among patients who underwent EBD included increased stricture length (hazard ratio, 2.0; 95% CI, 1.3-3.3), ileocolonic vs ileal disease (hazard ratio, 10.9; 95% CI, 2.6-45.4), and decreased interval between EBD procedures (hazard ratio, 1.2; 95% CI, 1.1-1.4). There were no significant differences in sex, age, race, or CD duration between EBD and ICR groups. Patients treated with ICR were associated with more common postoperative adverse events (32.2%; P < .0001), but a reduced need for secondary surgery (21.7%; P < .0001) and significantly longer surgery-free survival (11.1 ± 0.6 vs 5.4 ± 0.6 y; P < .001). CONCLUSIONS: In this retrospective study, we found that although EBD is initially successful with minimal adverse events, there is a high frequency of salvage surgery. Initial ICR is associated with a higher morbidity but a longer surgery-free interval. The risks and benefits should be balanced in selecting treatments for individual patients.

Case-Matched Comparison of Long-Term Functional and Quality of Life Outcomes Following Laparoscopic Versus Open Ileal Pouch-Anal Anastomosis.

BACKGROUND: Laparoscopic ileal pouch-anal anastomosis (IPAA) is associated with recovery benefits when compared with open IPAA. There is limited data on long-term quality of life and functional outcomes, which this study aimed to assess. METHODS: An IRB-approved, prospectively maintained database was queried to identify patients undergoing laparoscopic IPAA (L), case-matched with open IPAA (O) based on age ± 5 years, gender, body mass index (BMI) ± 5 kg/m2, diagnosis, date of surgery ± 3 years, stapled/handsewn anastomosis, omission of diverting loop ileostomy and length of follow-up ± 3 years. We assessed functional results, dietary, social, work, sexual restrictions and the Cleveland Clinic global quality of life score (CGQoL) at 1, 2, 3, 4, 5 and 10 years postoperatively. Functional outcomes were assessed based on number of stools (day/night) and seepage protection use (day/night). Variables were evaluated with Kaplan-Meier survival curves, uni- and multivariable analyses. RESULTS: Out of 4595 IPAAs, 529 patients underwent L, of whom 404 patients were well matched 1:1 to an equivalent number of O based on all criteria. Median follow-ups were 2 (0.5-17.8) versus 2.4 (0.5-22.2) years in L versus O, respectively (p = 0.18). L was associated with significantly decreased number of stools at night and less frequent pad usage at 1 year, both during the day and at night. Functional outcomes became similar during further follow-up. L was also associated with improved overall CGQoL, and energy scores at 1 year postoperatively, and decreased social restrictions for 1-2 years. There were no significant differences in quality of health, dietary, work or sexual restrictions. Laparoscopy was not associated with increased risk of pouch failure (p = 0.07) or significantly different causes of pouch failure when compared to O. CONCLUSIONS: Laparoscopic and open IPAA are associated with equivalent long-term functional outcomes, quality of life and pouch survival rates. Laparoscopic technique is associated with temporary benefits lasting 1 or 2 years.

Long-term Outcomes After Continent Ileostomy Creation in Patients With Crohn's Disease.

BACKGROUND: Patients with Crohn's disease have a higher failure rate after ileal pouch surgery compared with their counterparts with ulcerative colitis. OBJECTIVE: We hypothesized that risk of continent ileostomy failure can be stratified based on the timing of Crohn's disease diagnosis and aimed to assess long-term outcomes. DESIGN: This was a retrospective cohort study. SETTINGS: The investigation took place in a high-volume, specialized colorectal surgery department. PATIENTS: Patients with Crohn's disease who underwent continent ileostomy surgery between 1978 and 2013 were evaluated. MAIN OUTCOME MEASURES: Functional outcomes, postoperative complications, requirement of revision surgery, and continent ileostomy failure were analyzed. RESULTS: There were 48 patients (14 male patients) with a median age of 33 years at the time of continent ileostomy creation. Crohn's disease diagnosis was before continent ileostomy (intentional) in 15 or made in a delayed fashion at a median 4 years after continent ileostomy in 33 patients. Median follow-up was 19 years (range, 1-33 y) after index continent ileostomy creation. Major and minor revisions were performed in 40 (83%) and 13 patients (27%). Complications were fistula (n = 20), pouchitis (n = 16), valve slippage (n = 15), hernia (n = 9), afferent limb stricture (n = 9), difficult intubation (n = 8), incontinence (n = 7), bowel obstruction (n = 7), valve stricture (n = 5), leakage (n = 4), bleeding (n = 3), and valve prolapse (n = 3). Median Cleveland global quality-of-life score was 0.8. Continent ileostomy failure occurred in 22 patients (46%). Based on Kaplan-Meier estimates, continent ileostomy survival was 48 % (95% CI, 33%-63%) at 20 years. Continent ileostomy failure was similar regardless of timing of diagnosis of Crohn's disease (p = 0.533). LIMITATIONS: This study was limited by its retrospective and nonrandomized nature. CONCLUSIONS: Outcomes of continent ileostomy in patients with Crohn's disease are poor, regardless of the timing of diagnosis. Very careful consideration should be given by both the surgeon and the patient before undertaking this procedure in patients with Crohn's disease. See Video Abstract at http://links.lww.com/DCR/A327.

Radiation-Induced Problems in Colorectal Surgery.

Radiotherapy not only plays a pivotal role in the cancer care pathways of many patients with pelvic malignancies, but can also lead to significant injury of normal tissue in the radiation field (pelvic radiation disease) that is sometimes as challenging to treat as the neoplasms themselves. Acute symptoms are usually self-limited and respond to medical therapy. Chronic symptoms often require operative intervention that is made hazardous by hostile surgical planes and unforgiving tissues. Management of these challenging patients is best guided by the utmost caution and humility.

Serrated Polyps and Serrated Polyposis Syndrome.

Colorectal serrated polyps are intermediate lesions in the serrated neoplastic pathway, which account for up to 30% of colorectal cancers. This pathway is biologically distinct from the adenoma-to-carcinoma sequence, with associated cancers exhibiting mutations in the BRAF oncogene, DNA promoter hypermethylation, and microsatellite instability. An evolving understanding of these unique lesions has led to the development of a more accurate classification, improved endoscopic identification, and tailored clinical management guidelines. This article reviews serrated polyps and serrated polyposis syndrome.

Transabdominal Redo Ileal Pouch Surgery for Failed Restorative Proctocolectomy: Lessons Learned Over 500 Patients.

OBJECTIVES: The purpose of this study was to report our large, single-center experience of transabdominal ileal pouch-anal anastomoses (IPAA) redo surgery for a failed initial IPAA. BACKGROUND: IPAA fail from 3% to 15% of the times, mainly due to technical or inflammatory conditions. There is limited information about the surgical, functional, and quality-of-life (QOL) outcomes of redo surgery for failed IPAA, especially in large series of patients. METHODS: Patients undergoing transabdominal redo surgery for failed IPAA between 1983 and 2014 were evaluated. Primary endpoints were morbidity of the surgery, the proportion of patients with a functioning pouch, frequency of defecation and incidence of incontinence, and the patients' perception of QOL. RESULTS: There were 502 (43% males) patients with a median age of 38 years and median body mass index 24 kg/m at the time of revision surgery. A new pouch was created in 41% of patients whereas 59% had their original pouch revised and retained. Postoperative mortality was 0% and morbidity was 53%. The short-term anastomotic leak rate was 8%. At a median follow-up of 7 years after redo surgery, 101 (n = 20%) patients had redo IPAA failure. Pelvic sepsis developing after redo ileal pouch surgery was the primary indicator of pouch failure (hazard ratio, 3.691; 95% confidence interval, 2.411-5.699; P < 0.0001). Overall functional outcomes and QOL scores were acceptable. CONCLUSIONS: Patients with a failed ileoanal pouch may be offered redo pouch surgery with a high likelihood of success in terms of function and QOL.

Laparoscopy mitigates adverse oncological effects of delayed adjuvant chemotherapy for colon cancer.

BACKGROUND: Delaying initiation of adjuvant chemotherapy more than 8 weeks after surgical resection for colorectal cancer adversely affects overall patient survival. The effect of a laparoscopic surgical approach on initiation of chemotherapy has not been studied. The goal of this study was to determine if a laparoscopic approach to colon cancer resection affects the timing of adjuvant chemotherapy and outcomes. METHODS: Patients who underwent curative surgery for stage II or III colon cancer and received adjuvant chemotherapy between 2003 and 2010 were identified from a prospectively maintained database. Patients were categorized according to surgical approach: open or laparoscopic. Patient demographics, clinicopathologic variables, postoperative complications, time from surgery to initiation of chemotherapy, and long-term oncologic outcomes were compared. RESULTS: Age, gender, ASA class, BMI, tumor stage, and postoperative complications were similar for laparoscopic and open cases, while length of stay was 2 days shorter for laparoscopic cases (5.4 vs 7.6 days, p < 0.01). The proportion of patients who received adjuvant chemotherapy more than 8 weeks after surgery did not differ between the groups (35.6 % open vs 38.7 % laparoscopic, p = 0.77). In the open group, delay in chemotherapy after surgery was associated with decreased disease-free and overall survival (p = 0.01, 0.01, respectively). However, delay in chemotherapy more than 8 weeks did not affect disease-free or overall survival in the laparoscopy group (p = 0.93, 0.51, respectively). CONCLUSIONS: The benefits of quicker recovery after laparoscopic surgery did not translate into earlier initiation of adjuvant chemotherapy in this retrospective study. However, a laparoscopic approach negated the inferior oncologic outcomes of patients who received delayed initiation of chemotherapy.

Does laparoscopy reduce splenic injuries during colorectal resections? An assessment from the ACS-NSQIP database.

BACKGROUND: Nearly half of all incidental splenectomies caused by iatrogenic splenic injury occur during colorectal surgery. This study evaluates factors associated with incidental splenic procedures during colorectal surgery and their impact on short-term outcomes using a nationwide database. METHODS: Patients who underwent colorectal resections between 2005 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program database according to Current Procedural Terminology codes. Patients were classified into two groups based on whether they underwent a concurrent incidental splenic procedure at the time of the colorectal procedure. All splenic procedures except a preoperatively intended splenectomy performed in conjunction with colon or rectal resections were considered as incidental. Perioperative and short-term (30 day) outcomes were compared between the groups. RESULTS: In total, 93633 patients who underwent colon and/or rectal resection were identified. Among these, 215 patients had incidental splenic procedures (153 open splenectomy, 17 laparoscopic splenectomy, 36 splenorraphy, and 9 partial splenectomy). Open colorectal resections were associated with a significantly increased likelihood of incidental splenic procedures (OR 6.58, p < 0.001) compared to laparoscopic surgery. Incidental splenic procedures were associated with increased length of total hospital stay (OR 1.25, p < 0.001), mechanical ventilation dependency (OR 1.62, p = 0.02), transfusion requirement (OR: 3.84, p < 0.001), re-operation requirement (OR 1.7, p = 0.005), and sepsis (OR: 2.03, p = 0.001). Short-term advantages of splenic salvage (splenorraphy or partial splenectomy) included shorter length of total hospital stay (p = 0.001) and decreased need for re-operation (p < 0.001). CONCLUSIONS: Incidental splenic procedures during colorectal resections are associated with worse short-term outcomes. Use of the laparoscopic technique decreases the need for incidental splenic procedures.

Frequency, manifestations and management of bezoars in ileal pouches

Background and Aim To evaluate the frequency, diagnosis and management of ileal pouch bezoars. Methods Patients diagnosed with ileal pouch bezoars at the P ouch C enter at Cleveland Clinic from 2002 to 2013 were included. Demographic, clinical and endoscopic features, management and outcomes were evaluated. Results Twelve patients with ileal pouch bezoars were enrolled, including five (0.4%) of 1390 patients with J ­pouch and seven (13.0%) of 54 with continent ileostomy (P < 0.001). Males accounted for 25% (n = 3) of the cohort. Mean age at time of detection was 61.5 ± 10.3 years. Of the 12 patients, six (50.0%) had phytobezoars, four (33.3%) had lithobezoars, one (8.3%) had pharmacobezoar and one (8.3%) had a retained­J ackson­P ratt drain. Median number of harvested bezoars was one (range: 1­224), and mean diameter was 4.0 ± 2.4 cm. Bezoars were located at the pouch body in eight (66.7%) patients, pouch inlet in two (16.7%), pouch­anal anastomosis in one (8.3%) and efferent limb in one (8.3%). Ten patients (83.3%) were symptomatic, including seven (58.3%) with partial bowel obstructive symptoms. Eleven patients (91.7%) were initially managed with endoscopic treatment including basket, R othN et® , mechanical lithotripsy T ripod and snares. After a median of one (1­3) endoscopic therapy, bezoars were successfully removed in seven patients (58.3%). Surgical intervention was required in the remaining five patients (41.7%). Conclusions Ileal pouch bezoars appeared to be more frequently encountered in patients with continent ileostomies than in those with J ­pouches. Endoscopic management seemed to be effective in some patients, whereas surgical intervention was needed in others.

Extraintestinal Manifestations and Family History of Inflammatory Bowel Disease Increase the Risk of Pouchitis in a State-Level Epidemiology Study.

INTRODUCTION: Our understanding of the epidemiology of inflammatory conditions of the pouch and effectiveness of treatment is largely based on selected populations. We created a state-level registry to evaluate the incidence of pouchitis and the effectiveness of treatments used in an initial episode of pouchitis. METHODS: In a state-level retrospective cohort of all patients undergoing proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis between January 1, 2018, and December 31, 2020, we evaluated the incidence of pouchitis and compared the proportion of patients developing recurrent pouchitis and chronic antibiotic-dependent pouchitis according to initial antibiotic therapy. RESULTS: A total of 177 patients underwent surgery with 49 (28%) developing pouchitis within the 12 months after the final stage of IPAA. Patients with extraintestinal manifestations of inflammatory bowel disease (IBD) were significantly more likely to develop pouchitis within the first 12 months after IPAA (adjusted odds ratio 2.45, 95% confidence interval 1.03-5.81) after adjusting for family history of IBD (adjusted odds ratio 3.50, 95% 1.50-8.18). When comparing the proportion of patients who developed recurrent pouchitis or chronic antibiotic-dependent pouchitis with those who experienced an isolated episode of pouchitis, there were no significant differences among the initial antibiotic regimens used. DISCUSSION: In a state-level examination of outcomes after IPAA for ulcerative colitis, patients with extraintestinal manifestations of IBD were more likely to develop pouchitis; however, the initial antibiotic regimen chosen did not seem to affect long-term outcomes.

Stapled End-To-Side Ileocolic Anastomosis in Crohn's Disease: Old Dog, Reliable Tricks? A Retrospective Two-Center Cohort Study.

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.

Consequences of anastomotic leak after restorative proctectomy for cancer: effect on long-term function and quality of life.

BACKGROUND: Long-term consequences of anastomotic leak after restorative proctectomy for rectal cancer, in terms of bowel function and quality of life, have been poorly delineated. OBJECTIVE: The purpose of this study is to evaluate the impact of anastomotic leak, when intestinal continuity can still be maintained, on bowel function and quality of life in patients undergoing rectal cancer resection with low colorectal or coloanal anastomoses. DESIGN: From 1980 to 2010, 864 patients undergoing restorative resection for rectal cancers were identified from a prospective cancer database. Anastomotic leak detected by a combination of clinical, radiographic, and operative means was diagnosed in 52 (6%) patients. MAIN OUTCOME MEASURES: Patients with anastomotic leak were compared with those without anastomotic leak for functional outcomes and quality of life at 1 year and most recent follow-up (mean 3.2 years) by using Short-Form 36 questionnaires (physical and mental component scales) and the Fecal Incontinence Severity Index. RESULTS: American Society of Anesthesiologists' class (p = 0.48), cancer stage (p = 0.39), and the use of neoadjuvant therapy (p = 0.4) were similar in the 2 groups. Patients with anastomotic leak were younger (56 years vs 61 years; p = 0.007), more likely to be male (82% vs 64%; p = 0.008), and more likely to have undergone proximal diversion at proctectomy (51.9% vs 26.6%; p = 0.001). One year after proctectomy, patients with anastomotic leak had worse physical and mental component scores (p = 0.01), more frequent daytime (p = 0.001) and nighttime bowel movements (p = 0.03), and worse control of solid stool (p = 0.01) in comparison with those without an anastomotic leak. At most recent follow-up (leak, 3.3 years vs no leak, 2.4 years), patients with an anastomotic leak reported worse mental component scores and increased use of perineal pads. CONCLUSION: Anastomotic leak after restorative resection for rectal cancer leads to early adverse consequences on bowel function and quality of life even when anastomotic continuity can be maintained. These findings may help counsel patients and clinicians regarding anticipated outcomes over the long term.

Simulation in Surgical Resident Education: A Porcine Hemostasis and Laparoscopic Model.

The steep learning curve associated with learning laparoscopic techniques and limited training opportunities represents a challenge to general surgery resident training. The objective of this study was to use a live porcine model to improve surgical training in laparoscopic technique and management of bleeding. Nineteen general surgery residents (ranging from PGY 3 to 5) completed the porcine simulation and completed pre-lab and post-lab questionnaires. The institution's industry partner served as sponsors and educators on hemostatic agents and energy devices. Residents had a significant increase in confidence with laparoscopic techniques and the management of hemostasis (P = .01 and P = .008, respectively). Residents agreed and then strongly agreed that a porcine model was suitable to simulate laparoscopic and hemostatic techniques, but there was no significant change between pre- and post-lab opinions. This study demonstrates that a porcine lab is an effective model for surgical resident education and increases resident confidence.