Navigating Progress: Eight-Year Single-Center Experience With Minimally Invasive Proctectomy and Ileal Pouch-Anal Anastomosis.

BACKGROUND: Ileal pouch-anal anastomosis has become the gold standard for treating ulcerative colitis, familial adenomatous polyposis, and selected cases of Crohn's colitis. Robotic surgery promises improved postoperative outcomes and decreased length of stay. However, few studies have evaluated the benefits of robotic ileal pouch-anal anastomosis compared to laparoscopy. OBJECTIVE: To compare short-term 30-day postoperative outcomes of robotic versus laparoscopic proctectomy with ileal pouch-anal anastomosis and diverting loop ileostomy. DESIGN: Retrospective observational study from a single, high-volume center. SETTINGS: Mayo Clinic, Rochester, MN (tertiary referral center for inflammatory bowel disease). PATIENTS: All adult patients undergoing minimally invasive proctectomy with ileal pouch-anal anastomosis and DLI between January 2015 and April 2023. MAIN OUTCOME MEASURES: Thirty-day complications, hospital length of stay, estimated blood loss, conversion rate, 30-day readmission, and 30-day reoperation. RESULTS: Two hundred seventeen patients were included in the study; 107 underwent robotic proctectomy with ileal pouch-anal anastomosis and diverting loop ileostomy, while 110 had laparoscopic proctectomy with ileal pouch-anal anastomosis and diverting loop ileostomy. Operating time was significantly longer in the robotic group (263 ± 38 minutes versus 228 ± 75 minutes, p < 0.0001); estimated blood loss was lower in the robotic group (81.5 ± 77.7 ml vs. 126.8 ± 111.0 ml, p = 0.0006) as well as the number of conversions (0% versus 8.2%, p = 0.003). Patients in the robotic group received more intraoperative fluids (3099 ± 1140 ml versus 2472 ± 996 ml, p = 0.0001). However, there was no difference in length of stay, 30-day morbidity, 30-day readmission, 30-day reoperation, rate of diverting loop ileostomy closure at three months, and surgical ileal pouch-anal anastomosis complication rate after ileostomy closure. LIMITATIONS: Retrospective design, single-center study, potential bias due to the novelty of robotic approach, lack of long-term and quality-of-life outcomes. CONCLUSIONS: Robotic proctectomy with ileal pouch-anal anastomosis and diverting loop ileostomy may offer advantages in terms of estimated blood loss and conversion rate, while maintaining the benefits of minimally invasive surgery. Further research is needed to evaluate long-term outcomes. See Video Abstract.

Timing and Location of Venous Thromboembolisms After Surgery for Inflammatory Bowel Disease.

INTRODUCTION: Patients with inflammatory bowel disease are reported to be at elevated risk for postoperative venous thromboembolism (VTE). The rate and location of these VTE complications is unclear. METHODS: Patients with ulcerative colitis (UC) or Crohn's disease (CD) undergoing intestinal operations between January 2006 and March 2021 were identified from the medical record at a single institution. The overall incidence of VTEs and their anatomic location were determined to 90 days postoperatively. RESULTS: In 2716 operations in patients with UC, VTE prevalence was 1.95% at 1-30 days, 0.74% at 31-60 days, and 0.48% at 90 days (P < 0.0001). Seventy two percent of VTEs within the first 30 days were in the portomesenteric system, and this remained the location for the majority of VTE events at 31-60 and 61-90 days postoperatively. In the first 30 days, proctectomies had the highest incidence of VTEs (2.5%) in patients with UC. In 2921 operations in patients with CD, VTE prevalence was 1.43%, 0.55%, and 0.41% at 1-30 days, 31-60 days, and 61-90 days, respectively (P < 0.0001). Portomesenteric VTEs accounted for 31% of all VTEs within 30 days postoperatively. In the first 30 days, total abdominal colectomies had the highest incidence of VTEs (2.5%) in patients with CD. CONCLUSIONS: The majority of VTEs within 90 days of surgery for UC and Crohn's are diagnosed within the first 30 days. The risk of a VTE varies by the extent of the operation performed, with portomesenteric VTE representing a substantial proportion of events.

Robotic modified Sugarbaker technique for parastomal hernia repair: a standardized approach.

Parastomal hernia (PSH) is a prevalent long-term morbidity associated with stoma construction, and the optimal operative management remains uncertain. This study addresses the need for a standardized approach to symptomatic PSH repair, focusing on the robotic-assisted modified Sugarbaker technique with composite permanent mesh. The study, conducted in a high-volume colon and rectal surgery referral practice, outlines a systematic approach to patient selection, surgical procedures, and postoperative care. Preoperative evaluations include detailed medical and surgical histories, impact assessments of PSH, and oncological history reviews. The surgical technique involves the Da Vinci Xi™ robotic platform for adhesiolysis, hernia content reduction, stoma revision if needed, narrowing of the enlarged stoma trephine, lateralization of the stoma limb of bowel, and securing the mesh to the abdominal wall. Outcomes are reported for 102 patients undergoing robotic parastomal hernia repair from January 2021 to July 2023. Conversion to open surgery occurred in only one case (0.9%). Postoperative complications affected 39.2% of patients, with ileus being the most frequent (24.5%). Recurrence was observed in 5.8% of cases during an average follow-up of 10 months. In conclusion, parastomal hernia, a common complication post-stoma creation, demands surgical intervention. The robotic-assisted modified Sugarbaker repair technique, as outlined in this paper, offers promising results in terms of feasibility and outcomes.

Evolution of laparoscopic ileal pouch-anal anastomosis: impact of enhanced recovery program, medication changes, and staged approaches on outcomes.

BACKGROUND: Although laparoscopic Ileal pouch-anal anastomosis (IPAA) has become the gold standard in restorative proctocolectomy, surgical techniques have experienced minimal changes. In contrast, substantial shifts in perioperative care, marked by the enhanced recovery program (ERP), modifications in steroid use, and a shift to a 3-staged approach, have taken center stage. METHODS: Data extracted from our prospective IPAA database focused on the first 100 laparoscopic IPAA cases (historic group) and the latest 100 cases (modern group), aiming to measure the effect of these evolutions on postoperative outcomes. RESULTS: The historic IPAA group had more 2-staged procedures (92% proctocolectomy), whereas the modern group had a higher number of 3-staged procedures (86% proctectomy) (P < .001). Compared with patients in the modern group, patients in the historic group were more likely to be on steroids (5% vs 67%, respectively; P < .001) or immunomodulators (0% vs 31%, respectively; P < .001) at surgery. Compared with the historic group, the modern group had a shorter operative time (335.5 ± 78.4 vs 233.8 ± 81.6, respectively; P < .001) and length of stay (LOS; 5.4 ± 3.1 vs 4.2 ± 1.6 days, respectively; P < .001). Compared with the modern group, the historic group exhibited a higher 30-day morbidity rate (20% vs 33%, respectively; P = .04) and an elevated 30-day readmission rate (9% vs 21%, respectively; P = .02). Preoperative steroids use increased complications (odds ratio [OR], 3.4; P = .01), whereas 3-staged IPAA reduced complications (OR, 0.3; P = .03). ERP was identified as a factor that predicted shorter stays. CONCLUSION: Although ERP effectively reduced the LOS in IPAA surgery, it failed to reduce complications. Conversely, adopting a 3-staged IPAA approach proved beneficial in reducing morbidity, whereas preoperative steroid use increased complications.