Long-term Outcomes Following Colectomy and Liver Transplantation for Inflammatory Bowel Disease with Primary Sclerosing Cholangitis.

OBJECTIVE: To investigate the long-term outcomes of patients with combined primary sclerosing cholangitis/inflammatory bowel disease (PSC-IBD) undergoing both liver transplantation (LT) and total abdominal colectomy (TAC). SUMMARY BACKGROUND DATA: The fraction of patients with PSC-IBD that require both LT and TAC is small, thereby limiting significant conclusions regarding long-term outcomes. METHODS: Adult and pediatric patients from nine centers from the US IBD Surgery Collaborative who underwent staged LT and TAC for PSC-IBD were included. Long-term outcomes, including survival, were assessed. RESULTS: Among 127 patients, 66 underwent TAC-before-LT, with a median time from TAC to LT of 7.9 yrs, while 61 underwent LT-before-TAC, with a median time from LT to TAC of 4.4 years. Median patient survival post TAC was significantly worse in those undergoing LT-before-TAC (16.0 yrs vs. 42.6 yrs, P=0.007), while post LT survival was not impacted by the order of TAC and LT (21.6 yrs vs. 22.0 yrs, P=0.81). Patients undergoing TAC for medically refractory disease had a higher incidence of recurrent PSC (rPSC) (P=0.02) and biliary complications (0.09) compared to those undergoing TAC for oncologic indications. Definitive TAC reconstruction with either end ileostomy or ileal-pouch anal anastomosis (IPAA) did not impact post-LT or post-TAC outcomes. CONCLUSIONS: Long term survival in PSC-IBD was contingent upon progression to LT and was not impacted by the need for TAC. PSC-IBD patients undergoing TAC for medically refractory disease had a higher incidence of rPSC and biliary complications. The use of IPAA in PSC-IBD was a viable alternative to end ileostomy.

Historical Perspectives: Malignancy in Crohn's Disease and Ulcerative Colitis.

While both Crohn' disease (CD) and ulcerative colitis (UC) are known to predispose patients to certain intestinal malignancies, the exact mechanism of carcinogenesis remains unknown and optimal screening guidelines have not been established. This article will explore the history of our understanding of intestinal malignancy in inflammatory bowel disease (IBD). To contextualize the medical community's difficulty in linking each condition to cancer, the first section will review the discovery of CD and UC. Next, we discuss early attempts to define IBD's relationship with small bowel adenocarcinoma and colorectal cancer. The article concludes with a review of each disease's surgical history and the ways in which certain procedures produced poor oncologic outcomes.

Predictive factors of first-time failure on the American Board of Colorectal Surgery certifying and qualifying examinations.

Objective: To discover if first-attempt failure of the American Board of Colon and Rectal Surgery (ABCRS) board examination is associated with surgical training or personal demographic characteristics. Methods: Current colon and rectal surgery program directors in the United States were contacted via email. Deidentified records of trainees from 2011 to 2019 were requested. Analysis was performed to identify associations between individual risk factors and failure on the ABCRS board examination on the first attempt. Results: Seven programs contributed data, totaling 67 trainees. The overall first-time pass rate was 88% (n = 59). Several variables demonstrated potential for association, including Colon and Rectal Surgery In-Training Examination (CARSITE) percentile (74.5 vs 68.0, P = 0.09), number of major cases in colorectal residency (245.0 vs 219.2, P = 0.16), >5 publications during colorectal residency (75.0% vs 25.0%, P = 0.19), and first-time passage of the American Board of Surgery certifying examination (92.5% vs 7.5%, P = 0.18). Conclusion: The ABCRS board examination is a high-stakes test, and training program factors may be predictive of failure. Although several factors showed potential for association, none reached statistical significance. Our hope is that by increasing our data set, we will identify statistically significant associations that can potentially benefit future trainees in colon and rectal surgery.

A local tumor microenvironment acquired super-enhancer induces an oncogenic driver in colorectal carcinoma.

Tumors exhibit enhancer reprogramming compared to normal tissue. The etiology is largely attributed to cell-intrinsic genomic alterations. Here, using freshly resected primary CRC tumors and patient-matched adjacent normal colon, we find divergent epigenetic landscapes between CRC tumors and cell lines. Intriguingly, this phenomenon extends to highly recurrent aberrant super-enhancers gained in CRC over normal. We find one such super-enhancer activated in epithelial cancer cells due to surrounding inflammation in the tumor microenvironment. We restore this super-enhancer and its expressed gene, PDZK1IP1, following treatment with cytokines or xenotransplantation into nude mice, thus demonstrating cell-extrinsic etiology. We demonstrate mechanistically that PDZK1IP1 enhances the reductive capacity CRC cancer cells via the pentose phosphate pathway. We show this activation enables efficient growth under oxidative conditions, challenging the previous notion that PDZK1IP1 acts as a tumor suppressor in CRC. Collectively, these observations highlight the significance of epigenomic profiling on primary specimens.

Early versus delayed ileocolic resection for complicated Crohn's disease: is "cooling off" necessary?

BACKGROUND: Ileal Crohn's disease (CD) complicated by intraabdominal abscess, phlegmon, fistula, and/or microperforation is commonly treated with antibiotics, bowel rest, and percutaneous drainage followed by interval ileocolic resection (ICR). This "cool off" strategy is intended to facilitate the safe completion of a one-stage resection using a minimally invasive approach and minimize perioperative complications. There is limited data evaluating the benefits of delayed versus early resection. METHODS: A retrospective review of a prospectively maintained inflammatory bowel disease (IBD) database at a tertiary center was queried from 2013-2020 to identify patients who underwent ICR for complicated ileal CD confirmed on preoperative imaging. ICR cohorts were classified as early (≤ 7 days) vs delayed (> 7 days) based on the interval from diagnostic imaging to surgery. Operative approach and 30-day postoperative morbidity were analyzed. RESULTS: Out of 474 patients who underwent ICR over the 7-year period, 112 patients had complicated ileal CD including 99 patients (88%) with intraabdominal abscess. Early ICR was performed in 52 patients (46%) at a median of 3 days (IQR 2, 5) from diagnostic imaging. Delayed ICR was performed in 60 patients (54%) following a median "cool off" period of 23 days of non-operative treatment (IQR 14, 44), including preoperative percutaneous abscess drainage in 17 patients (28%). A higher proportion of patients with intraabdominal abscess underwent delayed vs early ICR (57% vs 43%, p = 0.19). Overall, there were no significant differences in the rate of laparoscopy (96% vs 90%), conversion to open surgery (12% vs 17%), rates of extended bowel resection (8% vs 13%), additional concurrent procedures (44% vs 52%), or fecal diversion (10% vs 2%) in the early vs delayed ICR groups. The median postoperative length of stay was 5 days in both groups with an overall 25% vs 17% (p = 0.39) 30-day postoperative complication rate and a 6% vs 5% 30-day readmission rate in early vs delayed ICR groups, respectively. Overall median follow-up time was 14.3 months (IQR 1.2, 24.1) with no difference in the rate of subsequent CD-related intestinal resection (4% vs 5%) between the two groups. CONCLUSIONS: In this contemporary series, at a high-volume tertiary referral center, a "cool off" delayed resectional approach was not found to reduce perioperative complications in patients undergoing ICR for complicated ileal Crohn's disease. Laparoscopic ICR can be performed within one week of diagnosis with low rates of conversion and postoperative complications.

Better characterization of operation for ulcerative colitis through the National surgical quality improvement program: A 2-year audit of NSQIP-IBD.

INTRODUCTION: There is little consensus of quality measurements for restorative proctocolectomy with ileal pouch-anal anastomosis(RPC-IPAA) performed for ulcerative colitis(UC). The National Surgical Quality Improvement Program(NSQIP) cannot accurately classify RPC-IPAA staged approaches. We formed an IBD-surgery registry that added IBD-specific variables to NSQIP to study these staged approaches in greater detail. METHODS: We queried our validated database of IBD surgeries across 11 sites in the US from March 2017 to March 2019, containing general NSQIP and IBD-specific perioperative variables. We classified cases into delayed versus immediate pouch construction and looked for independent predictors of pouch delay and postoperative Clavien-Dindo complication severity. RESULTS: 430 patients received index surgery or completed pouches. Among completed pouches, 46(28%) and 118(72%) were immediate and delayed pouches, respectively. Significant predictors for delayed pouch surgery included higher UC surgery volume(p = 0.01) and absence of colonic dysplasia(p = 0.04). Delayed pouch formation did not significantly predict complication severity. CONCLUSIONS: Our data allows improved classification of complex operations. Curating disease-specific variables allows for better analysis of predictors of delayed versus immediate pouch construction and postoperative complication severity. SHORT SUMMARY: We applied our previously validated novel NSIP-IBD database for classifying complex, multi-stage surgical approaches for UC to a degree that was not possible prior to our collaborative effort. From this, we describe predictive factors for delayed pouch formation in UC RPC-IPAA with the largest multicenter effort to date.

Abdominal Emergencies in Inflammatory Bowel Disease.

Although improved medical therapies have been associated with decreased rates of emergent intestinal resection for inflammatory bowel disease, prompt diagnosis and management remain of utmost importance to ensure appropriate patient care with reduced morbidity and mortality. Emergent indications for surgery include toxic colitis, acute obstruction, perforation, acute abscess, or massive hemorrhage. Given this broad spectrum of emergent presentations, a multidisciplinary team including surgeons, gastroenterologists, radiologists, nutritional support services, and enterostomal therapists are required for optimal patient care and decision making. Management of each emergency should be individualized based on patient age, disease type and duration, and patient goals of care.

The ACS National Surgical Quality Improvement Program-Inflammatory Bowel Disease Collaborative: Design, Implementation, and Validation of a Disease-specific Module.

BACKGROUND: Surgery for inflammatory bowel disease (IBD) involves a complex interplay between disease, surgery, and medications, exposing patients to increased risk of postoperative complications. Surgical best practices have been largely based on single-institution results and meta-analyses, with multicenter clinical data lacking. The American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) has revolutionized the way in which large-volume surgical outcomes data have been collected. Our aim was to employ the ACS-NSQIP to collect disease-specific variables relevant to surgical outcomes in IBD. STUDY DESIGN: A collaborative of 13 high-volume IBD surgery centers was convened to collect 5 IBD-specific variables in NSQIP. Variables included biologic and immunomodulator medications usage, ileostomy utilization, ileal pouch anastomotic technique, and colonic dysplasia/neoplasia. A sample of the Surgical Clinical Reviewer collected data was validated by a colorectal surgeon at each institution, and kappa's agreement statistics generated. RESULTS: Over 1 year, data were collected on a total of 956 cases. Overall, 41.4% of patients had taken a biologic agent in the 60 days before surgery. The 2 most commonly performed procedures were laparoscopic ileocolic resections (159 cases) and subtotal colectomies (151 cases). Overall, 56.8% of cases employed an ileostomy, and 134 ileal pouches were constructed, of which 92.4% used stapled technique. A sample of 214 (22.4%) consecutive cases was validated from 8 institutions. All 5 novel variables were shown to be reliably collected, with excellent agreement for 4 variables (kappa ≥ 0.70) and very good agreement for the presence of colonic dysplasia (kappa = 0.68). CONCLUSION: We report the results of the initial year of implementation of the first disease-specific collaborative within NSQIP. The selected variables were demonstrated to be reliably collected, and this collaborative will facilitate high-quality, large case-volume research specific to the IBD patient population.

Endorectal Advancement Flaps for Perianal Fistulae in Crohn's Disease: Careful Patient Selection Leads to Optimal Outcomes.

BACKGROUND: Anorectal fistulae resultant from Crohn's disease (CD) is a clinical challenge. The advent of immune therapy (IT) has altered the way in which fistulae have responded to treatment. Endorectal advancement flap (ERAF) is a surgical procedure that is used to treat complex fistulae. We have employed ERAF as our second stage treatment of choice in this patient population. Our aim was to determine the success of ERAF in treating perianal fistulas in patients with CD in an era of IT. METHODS: Multicenter retrospective review from 2007 to 2017 of all patients with CD and a perianal fistulae who underwent ERAF. RESULTS: Forty-one flaps were performed in 39 patients with perianal CD with an average follow-up of 797 days. There were no significant differences in patient demographics; however, all patients who were diverted at the time of surgery had successful healing. Of patients, 73.2% were on IT at an average of 380 days prior to surgery. The duration of single-agent therapy was associated with better healing rates (p = 0.03). The overall failure rate was 19.5% (n = 8). Six patients underwent secondary techniques for fistulae closure; five were successful. In combination with the patients who did not initially fail, the overall healing rate was 92.6%. CONCLUSIONS: This study demonstrates several factors that may improve fistulae closure for CD patients. Patients who were diverted prior to surgery did not have a fistulae recurrence. Patients who were on IT longer prior to ERAF were more likely to achieve successful closure.

Case series: Incarcerated massive rectal prolapse successfully treated with Altemeier's procedure.

INTRODUCTION: Incarceration and necrosis of rectal prolapse is rare but when it occurs it requires urgent management. Perineal rectosigmoidectomy (Altemeier's procedure) may be a reasonable approach for the treatment of this condition. In some cases, a diverting stoma may be necessary. METHODS: We report two cases of incarcerated massive rectal prolapse, one of which also manifested tissue necrosis, that were successfully treated with perineal rectosigmoidectomy. In one case a diverting colostomy was required. Both patients recovered uneventfully. RESULTS: A literature review was performed to determine the optimal management of incarcerated and necrotic rectal prolapse, and to determine the indication for fecal diversion. CONCLUSION: Perineal rectosigmoidectomy (Altemeier's procedure) can be utilized in emergency circumstances and, in our experience, the procedure was both safe and effective. The need for fecal diversion depends on the condition of the patient and the experience and judgement of the surgeon.

Incidence and Factors Correlating With Incisional Hernia Following Open Bowel Resection in Patients With Inflammatory Bowel Disease: A Review of 1000 Patients.

OBJECTIVE: The aim of this study was to identify the incidence and factors associated with the development of incisional hernia (IH) in patients with inflammatory bowel disease (IBD) undergoing open bowel resections. BACKGROUND: Predisposing factors for IH have not been well studied in patients with IBD undergoing open bowel resection. The role of duration of the disease, nutritional factors, anti-inflammatory treatment, previous operative procedures, wound infection, and other complicating factors remains unclear. METHODS: One thousand patients with ulcerative colitis and Crohn's disease were followed for a mean of 8 years after open bowel resection. The incidence of IH was recorded as well as correlating factors with the development of IH. RESULTS: The overall incidence of IH in this series was 20% (21% for ulcerative colitis and 20% for Crohn's disease). Statistically significant risk factors for development of IH were wound infection (HR 3.66, P <0.001), hypoalbuminemia (HR 2.02, P = 0.002), history of previous bowel resection (HR 1.60, P = 0.003), creation of ileostomy at the time of procedure (HR 1.53, P = 0.01), history of smoking (HR 1.52, P = 0.013), body mass index at surgery (1.036, P = 0.009), age at surgery (HR 1.021, P <0.001), and age at the onset of disease (HR 1.018, P <0.001). CONCLUSIONS: Patients with IBD have a high incidence of incisional hernia after open bowel resection. Wound infection had the strongest correlation with the development of IH. The other factors were age at onset of IBD, age at surgery, body mass index, serum albumin, presence of ileostomy, previous surgical procedures, and history of smoking. Duration of disease, preoperative steroids, immunosuppressive therapy, and blood transfusion were not found to correlate with IH.

Outcome of incisional hernia repair in patients with Inflammatory Bowel Disease.

BACKGROUND: Incisional Hernia (IH) repair in patients with Inflammatory Bowel Disease (IBD) has not been well studied. METHODS: Outcomes of 170 patients with IBD who underwent IH repair were included in the study. RESULTS: The incidence of recurrence after IH repair in IBD is 27%. Patients with Crohn's disease (CD) had larger defects at the time of repair, higher proportion of bowel resection and a longer postoperative stay when compared to Ulcerative colitis (UC). The only significant predictor of recurrence after IH repair was the number of previous bowel resections prior to hernia repair (HR 1.59, p < 0.01). Three cases (10%) of late onset enterocutaneous fistulas were identified in patients who underwent IH repair with synthetic mesh inlay. CONCLUSION: Surgical repair results in a recurrence of IH in 27% of patients with IBD. The number of previous bowel resections is the only factor that correlates with development of recurrent IH in IBD.

Can laparoscopic surgery prevent incisional hernia in patients with Crohn's disease: a comparison study of 750 patients undergoing open and laparoscopic bowel resection.

BACKGROUND: Incisional hernia (IH) is a frequent occurrence following open surgery for Crohn's disease (CD). This study compares the IH rates of patients with CD undergoing open versus laparoscopic bowel resection. METHODS: Seven hundred and fifty patients with CD operated by the authors at the Mount Sinai Medical Center, New York, USA, were reviewed from a prospectively maintained surgical database. Five hundred patients with Crohn's disease undergoing open surgery were compared to 250 patients undergoing laparoscopic bowel resection. RESULTS: The mean duration of follow-up in the study population was 6.8 years. Patients undergoing open surgery had a significantly higher age at onset of disease, age at surgery, longer duration of disease, lower serum albumin, history of multiple previous resections, were more likely to be on steroids, needed more blood transfusions, and had an increased necessity for an ileostomy during resection. Nevertheless, the incidence of IH at 36 months was nearly identical in both groups (10.8 vs. 8.4% for open vs laparoscopic). 16% of the patients in the laparoscopic group (range: 7-20%) required conversion to open surgery. Patients undergoing laparoscopic resection that required conversion to open surgery had the highest IH rate at 18%. There was a significant correlation between IH and the length of the midline vertical extraction incision. Patients undergoing laparoscopic resection with intracorporeal anastomosis and small transverse or trocar site extraction incisions had no IH. CONCLUSIONS: A marked decrease or complete elimination of IH in patients with CD undergoing bowel resection may be possible using advanced laparoscopic techniques that require intra-abdominal anastomosis and use of the smallest transverse extraction incisions.

Outcomes and cost of diverted versus undiverted restorative proctocolectomy.

BACKGROUND: Some observational studies suggest that diversion during restorative proctocolectomy mitigates the risk of anastomotic complications. However, diversion has its own costs and complications. The aim of this study was to compare the cost and outcomes of diverted to undiverted restorative proctocolectomy. METHODS: This study took advantage of a natural experiment within one surgical department to understand the clinical and financial implications of diversion during restorative proctocolectomy. For the last 10 years, two surgeons routinely diverted all patients undergoing restorative proctocolectomy, and two other surgeons routinely did not. The medical records of 288 consecutive restorative proctocolectomy patients were reviewed. Minimum follow-up time was 1 year, with an average of 4.7 years. Complications rates and costs of care were collected. RESULTS: There were no significant differences between rates of anastomotic leak, fistula, or hernias in diverted versus undiverted patients. The odds of having stricture (odds ratio (OR) = 17.08, P < 0.001) and small bowel obstruction (OR = 5.05, P = 0.02) were both significantly higher in diverted patients. The average cost per patient was $43,000 more in the routinely diverted patients. CONCLUSION: Undiverted restorative proctocolectomy may be the highest value procedure with the most favorable outcomes at the lowest cost.

Colorectal surgery in cirrhotic patients.

Patients with cirrhosis have a greater risk of morbidity and mortality following colorectal surgery. Therefore, preoperative medical optimization and risk assessment using criteria such as the MELD score are vital in preventing complications. Some risk factors include age, urgency of surgery, and ASA score. Postoperative morbidity and mortality are related to portal hypertension, ascites, infection, and anastomotic and stomal complications. This review highlights the assessment of risk and perioperative management of cirrhotic patients undergoing colorectal surgery.

Prospective analysis of clinician accuracy in the diagnosis of benign anal pathology: comparison across specialties and years of experience.

PURPOSE: The majority of patients referred to a colorectal surgeon with anal complaints are told they have "hemorrhoids"; however, many of these patients have other anal pathology causing their symptoms. Therefore, we prospectively evaluated the diagnostic accuracy of physicians for common anal pathology, stratified by specialty and experience. METHODS: Seven common benign anal pathologic conditions were selected (prolapsed internal hemorrhoid, thrombosed external hemorrhoid, abscess, fissure, fistula, condyloma acuminata, and full-thickness rectal prolapse). Prospectively accrued subjects included attending physicians, fellows, residents, and medical students. Subjects were shown images and asked to provide a written diagnosis. We prospectively evaluated the overall diagnostic accuracy and stratified accuracy across specialties and years of clinical experience. Medical students were the control group. RESULTS: There were 198 physicians and 216 medical students. Overall diagnostic accuracy for physicians was 53.5% and for controls was 21.9% (P < .001). Surgeons had the highest overall accuracy at 70.4%, whereas all of the other groups had an accuracy of <50%. Physicians correctly identified condylomata and rectal prolapse most frequently and hemorrhoidal conditions least frequently. All 7 conditions were correctly identified by 4.1% of subjects and all of the conditions were incorrectly diagnosed by 20.2%. There was no correlation between years of experience and diagnostic accuracy (P = NS). CONCLUSION: Diagnostic accuracy for common benign anal pathologic conditions was suboptimal across all clinical specialties. Although many specialties had a diagnostic accuracy that was significantly better than the control group, there was no association between years of experience and accuracy. Improved programs for physician education for these common conditions should be developed.

Current surgical management of ulcerative colitis.

Inflammatory bowel disease is divided into 2 major disease entities: Crohn's disease and ulcerative colitis. Ulcerative colitis is characterized by contiguous inflammation of the colorectal mucosa, always beginning in and involving the rectum and progressing for variable distances proximally within the colon. In ulcerative colitis, medical therapy, which is not curative, is directed at controlling symptoms and reducing the underlying inflammatory process. However, emergent or elective removal of the colon and rectum does cure the disease and also eliminates the possibility of developing a malignancy. Here we present the current surgical treatment of ulcerative colitis and issues in the management of ulcerative colitis. We discuss indications for surgical treatment, elective and emergent operative management, early and late complications of surgery, and functional results.

Severity of inflammation as a predictor of colectomy in patients with chronic ulcerative colitis.

PURPOSE: We evaluated a large cohort of patients with longstanding ulcerative colitis in a colonoscopic surveillance program to determine predictors of colectomy. METHODS: We queried a retrospective database of patients who had symptoms of ulcerative colitis for seven years or more. Histologic inflammation in biopsies was graded on a validated four-point scale: absent, mild, moderate, severe. We performed a multivariate analysis of the inflammation scores and other variables to determine predictive factors for colectomy. Patients who underwent colectomy for neoplasia were censored at the time of surgery; those who did not undergo colectomy were censored at the time of last contact. RESULTS: A total of 561 patients were evaluated, with a median follow-up of 21.4 years since disease onset. A total of 97 patients (17.3 percent) underwent surgery; 25 (4.5 percent) for reasons other than dysplasia. These 25 constitute events for this analysis. For univariate analysis, mean inflammation (P < 0.001) and steroid use (P = 0.01) were predictors of colectomy. For multivariable proportional hazards analysis, mean inflammation (P < 0.001) and steroid use (P = 0.03) were predictors of colectomy, whereas salicylate use (P = 0.007) was protective. CONCLUSIONS: Higher median inflammation scores and corticosteroid use were predictors of colectomy in this patient population. The overall rate of colectomy during a long period of follow-up was low (<1 percent per year).