Controversies in IPAA for Ulcerative Colitis: A Systematic Review of Different Anastomotic Techniques.

BACKGROUND: Available techniques for IPAA in ulcerative colitis include handsewn, double-stapled, and single-stapled anastomoses. There are controversies, indications, and different outcomes regarding these techniques. OBJECTIVE: To describe technical details, indications, and outcomes of 3 specific types of anastomoses in restorative proctocolectomy. DATA SOURCE: Systematic literature review for articles in the PubMed database according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. STUDY SELECTION: Studies describing outcomes of the 3 different types of anastomoses, during pouch surgery, in patients undergoing restorative proctocolectomy for ulcerative colitis. INTERVENTION: IPAA technique. MAIN OUTCOME MEASURES: Postoperative outcomes (anastomotic leaks, overall complication rates, and pouch function). RESULTS: Twenty-one studies were initially included: 6 studies exclusively on single-stapled IPAA, 2 exclusively on double-stapled IPAA, 6 studies comparing single-stapled to double-stapled techniques, 6 comparing double-stapled to handsewn IPAA, and 1 comprising single-stapled to handsewn IPAA. Thirty-seven studies were added according to authors' discretion as complementary evidence. Between 1990 and 2015, most studies were related to double-stapled IPAA, either only analyzing the results of this technique or comparing it with the handsewn technique. Studies published after 2015 were mostly related to transanal approaches to proctectomy for IPAA, in which a single-stapled anastomosis was introduced instead of the double-stapled anastomosis, with some studies comparing both techniques. LIMITATIONS: A low number of studies with handsewn IPAA technique and a large number of studies added at authors' discretion were the limitations of this strudy. CONCLUSIONS: Handsewn IPAA should be considered if a mucosectomy is performed for dysplasia or cancer in the low rectum or, possibly, for re-do surgery. Double-stapled IPAA has been more widely adopted for its simplicity and for the advantage of preserving the anal transition zone, having lower complications, and having adequate pouch function. The single-stapled IPAA offers a more natural design, is feasible, and is associated with reasonable outcomes compared to double-stapled anastomosis. See video from symposium.

Intracorporeal anastomosis could be associated with a higher lymph node yield in right colon cancer surgery: Results of the ICA-LATAM study, a retrospective, multicentre, comparative analysis in Latin America.

AIM: The aim of this work was to compare lymph node (LN) yield in patients operated on for right colon cancer (RCC) using a laparoscopic approach between those receiving an intracorporeal (ICA) or extracorporeal anastomosis (ECA). METHOD: This is a retrospective multicentre study involving patients operated on for RCC in nine tertiary referral centres in Latin America during a 2-year period. The main comparative outcome between groups was the number of LNs harvested between groups. RESULTS: The study included 416 patients, 261 (62.7%) in the ECA group and 155 (37.3%) in the ICA group. Patients in the ECA group were elderly (66 vs. 61 years, p < 0.001). Patients receiving an ICA achieved a significantly higher LN yield than those receiving an ECA (24 vs. 18, p < 0.001). This group also had a lower percentage of patients achieving a substandard LN yield (<12 LNs) (10% vs. 24.8%, p = 0.001) and more patients achieving a high number of harvested LNs (>32 LNs) (15.5% vs. 8.3%, p = 0.039). In the multivariate analysis, ICA was independently related to the primary outcome (LN yield) (OR 3.28, p = 0.027, 95% CI 1.14-9.38). CONCLUSION: In this retrospective study, patients operated on for RCC who received an ICA achieved a higher LN yield. Further studies are needed to reconfirm these findings, and also to find an explanation for these results.

A narrative on diversity, equity, and inclusion in surgery: insights from the European Society of Coloproctology and identification of points for action.

The focus of the 2022 European Society of Coloproctology (ESCP) annual campaign was diversity, equity, and inclusion (DEI) in surgery. The ESCP "Operation Equal Access" campaign sought to interview key-opinion leaders and trainees, to raise awareness on inequalities, inform the community of the status of the topic, and to identify future areas for improvement. The ESCP Social Media Working Group interviewed experts who have made significant contributions to DEI in colorectal surgery and were acknowledged opinion leaders in the field. The interviews focused on their career, professional life, experiences, and opportunities during their training, and their views on DEI in colorectal surgery. DEI principles, education, and values need further promotion to reduce and address bias within the profession and overall improve the experience of minority community including health professionals and patients. International Societies are working to facilitate training opportunities and overcome DEI, and networking have contributed to that. Collaborations between societies will be pivotal to contribute to offering research and leadership opportunities equally. Access to advanced workshops including cadaveric training and simulation can be consistently promoted and provided globally via societies through telemonitoring. Involving patients in research should be encouraged, as it brings the perspective of a living experience.

Short and long-term outcomes of surgery for inflammatory (uncomplicated) ileocecal Crohn's disease: Multicentric retrospective analysis of 211 patients.

BACKGROUND: Surgical management for patients with inflammatory ileocecal Crohn's disease (CD) could be a reasonable alternative to second-line medical treatment. AIM: To assess short and long-term outcomes of patients operated on for inflammatory, ileocecal Crohn's disease. METHODS: A retrospective analysis of patients intervened at four referral hospitals during 2012-2021 was performed. RESULTS: 211 patients were included. 43% of patients underwent surgery more than 5 years after diagnosis, and 49% had been exposed to at least one biologic agent preoperatively. 89% were operated by laparoscopy, with 1.6% conversion rate. The median length of the resected bowel was 25 cm (7-92) and three patients (1.43%) received a stoma. Median follow-up was 36 (17-70) months. The endoscopic recurrence-free survival proportion at 24, 48, 72, 96, and 120 months was 56%, 52%, 45%, 38%, and 33%, respectively. The clinical recurrence-free survival proportion at 24, 48, 72, 96, and 120 months was 83%, 79%, 76%, 74%, and 74%, respectively. In multivariate analysis, previous biological treatment (HR=2.01; p = 0.001) was associated with a higher risk of overall recurrence. CONCLUSION: Surgery in patients with primary inflammatory ileocecal CD is associated with good postoperative outcomes, low postoperative morbidity with reasonable recurrence rates.

Risk factors for major complications after surgical treatment of primary ileocecal Crohn's disease. A multicenter Latin American experience / Factores de riesgo para complicaciones mayores posteriores al tratamiento quirúrgico de la enfermedad de Crohn con afectación ileocecal. Trabajo retrospectivo, multicéntrico en América Latina

Introduction: Complications after ileocecal resection for Crohn's disease (CD) are frequent. The aim of this study was to analyze risk factors for postoperative complications after these procedures. Materials and methods: We conducted a retrospective analysis of patients treated surgically for Crohn's disease limited to the ileocecal region during an 8-year period at 10 medical centers specialized in inflammatory bowel disease (IBD) in Latin America. Patients were allocated into 2 groups: those who presented major postoperative complications (Clavien-Dindo>II), the “postoperative complication” (POC) group; and those who did not, the “no postoperative complication” (NPOC) group. Preoperative characteristics and intraoperative variables were analyzed to identify possible factors for POC. Results: In total, 337 patients were included, with 51 (15.13%) in the POC cohort. Smoking was more prevalent among the POC patients (31.37 vs 17.83; p=0.026), who presented more preoperative anemia (33.33 vs 17.48%; p=0.009), required more urgent care (37.25 vs 22.38; p=0.023), and had lower albumin levels. Complicated disease was associated with higher postoperative morbidity. POC patients had a longer operative time (188.77 vs 143.86min; p=0.005), more intraoperative complications (17.65 vs 4.55%; p<0.001), and lower rates of primary anastomosis. In the multivariate analysis, both smoking and intraoperative complications were independently associated with the occurrence of major postoperative complications. (AU)

Introducción: Las complicaciones posteriores a resección ileocecal por enfermedad de Crohn (EC) son frecuentes. El objetivo de este estudio fue analizar los factores de riesgo para presentar complicaciones postoperatorias después de estos procedimientos. Materiales y métodos: Se realizó un análisis retrospectivo de los pacientes operados por EC limitada a la región ileocecal durante un período de 8 años en 10 centros especializados en enfermedad inflamatoria intestinal (EII) de América Latina. Los pacientes fueron divididos en 2 grupos, los que presentaron complicaciones postoperatorias mayores (Clavien-Dindo>II) (denominado grupo de complicaciones postoperatorias [POC]) y los que no (grupo sin complicaciones postoperatorias [NPOC]). Se analizaron las características preoperatorias y las variables intraoperatorias para identificar posibles factores relacionados con las POC. Resultados: Se incluyeron 337 pacientes, 51 (15,13%) en el grupo con POC. El grupo POC presentó mayor índice de tabaquismo (31,37 vs. 17,83; p=0,026), quienes presentaron más anemia preoperatoria (33,33 vs. 17,48%; p=0,009), urgencias (37,25 vs. 22,38; p=0,023) y menores niveles de albúmina. Los procedimientos por enfermedad complicada se asociaron con una mayor morbilidad postoperatoria. Los pacientes con POC tuvieron un tiempo operatorio más largo (188,77 vs. 143,86min; p=0,005), más complicaciones intraoperatorias (17,65 vs. 4,55%; p<0,001) y menores tasas de anastomosis primaria. En el análisis multivariado, tanto tabaquismo como complicaciones intraoperatorias se asociaron de forma independiente con la aparición de complicaciones mayores postoperatorias. (AU)

Crossing barriers: the burden of inflammatory bowel disease across Western Europe.

An estimated 2.5-3 million individuals (0.4%) in Europe are affected by inflammatory bowel disease (IBD). Whilst incidence rates for IBD are stabilising across Europe, the prevalence is rising and subsequently resulting in a significant cost to the healthcare system of an estimated 4.6-5.6 billion euros per year. Hospitalisation and surgical resection rates are generally on a downward trend, which is contrary to the rising cost of novel medication. This signifies a large part of healthcare cost and burden. Despite publicly funded healthcare systems in most European countries, there is still wide variation in how patients receive and/or pay for biologic medication. This review will provide an overview and discuss the different healthcare systems within Western Europe and the barriers that affect overall management of a changing IBD landscape, including differences to hospitalisation and surgical rates, access to medication and clinical trial participation and recruitment. This review will also discuss the importance of standardising IBD management to attain high-quality care for all patients with IBD.

Prospective evaluation of bowel function and quality of life after colon cancer surgery - is it time for routine screening for late sequelae?

AIM: Bowel dysfunction after colon cancer (CC) surgery is widely neglected in current follow up programmes. This study explored changes in bowel function and quality of life (QoL) from three (3 m) to twelve months (12 m) after surgery in CC patients undergoing right- or left-sided colon resection (RightSCR/LeftSCR) and investigated differences between the two groups 12 m after surgery. METHOD: CC patients undergoing surgical resection in 2018-2020 at five surgical departments were included in this population-based prospective cohort study. Included patients completed electronic surveys consisting of a collection of validated scores 3 m and 12 m after surgery. RESULTS: A total of 708 CC patients (423 RightSCR, 285 LeftSCR) were included. In RightSCR, no improvement was observed from 3 m to 12 m in most scores/items, on the contrary, symptom worsening in flatus- and faecal incontinence and urgency was observed (p < 0.05). Also, the proportion of patients rating their bowel function as very good/good decreased (p < 0.05) in this group. In LeftSCR improvement was found in flatus and faecal incontinence, urgency and night-time defaecation (p < 0.02), while no improvement was observed in the remaining scores/items. At 12 m, higher proportions of RightSCR than LeftSCR reported loose stools, incontinence and urgency (all p < 0.001), whereas LeftSCR more often reported hard stools and flatus incontinence (p < 0.05). Among all CC patients 18.3% reported bowel-related impairment of QoL at 12 m with no differences between the two groups. CONCLUSION: From 3 m to 12 m no significant change was observed in the majority of bowel function and QoL scores/items, however, some symptoms worsened in RightSCR, while a few improved in LeftSCR. Bowel dysfunction and impaired QoL were still common in both groups at 12 m, although the symptom pattern differed between the groups. These findings call for a systematic screening for bowel dysfunction to ensure early treatment of symptoms.

Divertículo de Meckel en el hiato de Winslow como causa extraordinaria de oclusión intestinal / Meckel's diverticulum in the foramen of Winslow as a rare cause of small bowel obstruction

RESUMEN El divertículo de Meckel es la malformación congénita más frecuente del tracto gastrointestinal. Puede permanecer completamente oculto sin dar síntomas o puede ser causa de abdomen agudo quirúrgico en donde se debe descartar patología inflamatoria, infecciosa y/o mecánica. Se presenta un caso excepcional de una obstrucción intestinal producido por una hernia interna generada por un divertículo de Meckel en el hiato de Winslow.

ABSTRACT Meckel's diverticulum is the most common congenital defect of the gastrointestinal tract. It may remain asymptomatic or may cause acute abdomen requiring surgery due to inflammation, infection or mechanical obstruction. We report case of small bowel obstruction produced by an internal hernia generated by a Meckel's diverticulum in the foramen of Winslow.

Increasing opportunities for international surgeons.

Social media has completely transformed communication among surgeons. Although we have learned a lot, we still have many challenges to resolve with these tools. Nevertheless, social media has opened many novel opportunities for the surgical community worldwide. Many of these opportunities would never be realized without social media tools, especially in low and middle-income countries. We will discuss the main tools and their applications for increasing opportunities for international surgeons.

Risk factors for major complications after surgical treatment of primary ileocecal Crohn's disease. A multicentric Latin American experience.

INTRODUCTION: Complications after ileocecal resection for Crohn's disease (CD) are frequent. The aim of this study was to analyze risk factors for postoperative complications after these procedures. MATERIALS AND METHODS: We conducted a retrospective analysis of patients treated surgically for Crohn's disease limited to the ileocecal region during an 8-year period at 10 medical centers specialized in inflammatory bowel disease (IBD) in Latin America. Patients were allocated into 2 groups: those who presented major postoperative complications (Clavien-Dindo > II), the "postoperative complication" (POC) group; and those who did not, the "no postoperative complication" (NPOC) group. Preoperative characteristics and intraoperative variables were analyzed to identify possible factors for POC. RESULTS: In total, 337 patients were included, with 51 (15.13%) in the POC cohort. Smoking was more prevalent among the POC patients (31.37 vs. 17.83; P = .026), who presented more preoperative anemia (33.33 vs. 17.48%; P = .009), required more urgent care (37.25 vs. 22.38; P = .023), and had lower albumin levels. Complicated disease was associated with higher postoperative morbidity. POC patients had a longer operative time (188.77 vs. 143.86 min; P = .005), more intraoperative complications (17.65 vs. 4.55%; P < .001), and lower rates of primary anastomosis. In the multivariate analysis, both smoking and intraoperative complications were independently associated with the occurrence of major postoperative complications. CONCLUSION: This study shows that risk factors for complications after primary ileocecal resections for Crohn's disease in Latin America are similar to those reported elsewhere. Future efforts in the region should be aimed at improving these outcomes by controlling some of the identified factors.

Prolapso hemorroidal circunferencial mixto. Tratamiento combinado con sutura mecánica y fotocoagulación con láser / Mixed circumferential hemorrhoidal prolapse. Combined treatment with mechanical stapler and laser coagulation

RESUMEN El manejo del prolapso hemorroidal circunferencial representa un desafío para los cirujanos. Actualmente existen alternativas a los procedimientos convencionales; sin embargo, ninguna de éstas consideran el tratamiento de la enfermedad externa. Aun en los casos en que se utiliza un procedimiento como la hemorroidectomía con sutura mecánica o la ligadura de los paquetes guiados por Doppler, técnicas que se han asociado a un posoperatorio menos doloroso, estas no contemplan el tratamiento del componente externo. El objetivo de esta publicación fue presentar la técnica detallada para el tratamiento de pacientes con prolapso hemorroidal mixto, combinando los procedimientos de hemorroidopexia con grapas, seguida de una fotocoagulación con láser de las hemorroides externas. Los resultados han sido previamente documentados en un total de 25 pacientes. Se describieron complicaciones en un 4% de los casos, concluyendo que se trata de una alternativa para considerar ante pacientes con prolapso hemorroidal circunferencial con componente externo.

ABSTRACT Management of circumferential hemorrhoidal prolapse represents a challenge for surgeons. There are currently many alternatives to conventional procedures.; however, none of these techniques consider treatment of external disease. Even procedures associated with less postoperative pain as stapled hemorrhoidectomy or Doppler-guided hemorrhoidal artery ligation do not involve treatment of the external component. The aim of this publication is to present the technique detailed to treat patients with mixed hemorrhoidal prolapse, combining stapled hemorrhoidopexy with laser coagulation of external hemorrhoids. The results have been previously documented in a total of 25 patients, with 4% of complications. We conclude that the procedure is an option to consider in patients with circumferential hemorrhoidal prolapse with external component.

Short-Term Results of Operative Treatment of Primary Ileocecal Crohn's Disease: Retrospective, Comparative Analysis between Early (Luminal) and Complicated Disease.

Early surgical treatment for patients with ileocecal Crohn's disease (CD) could be an alternative to biological therapy. The aim of this study is to compare operative outcomes following ileocecal resection for patients with luminal and complicated CD. Patients operated for primary ileocecal CD during 8 years in one tertiary-referral hospital were allocated into 2 groups: those operated for early (luminal) disease (ECD), and for complications of CD (CCD). A retrospective comparative analysis was performed. A total of 273 patients were included in the analysis, 85 (31%) of which were in the ECD group. No difference was found regarding time from diagnosis to surgery. Surgical procedures were longer in the CCD group, with lower rates of laparoscopic approach (93 vs. 99%, p = 0.035) and higher conversion rates (20 vs. 2%, p < 0.001). ECD had non-significant differences in terms of major postoperative complications (9.4 vs. 14.9%, p = 0.215), shorter hospital stays, and lower rates of anastomotic leakage (3.5 vs. 6.8%, p = 0.285). Conversely, the CCD group had higher reoperation and re-hospitalization rates. Adequate timing for the indication of surgery in primary ileocecal CD, including an early discussion considering both medical and surgical treatment as options, could positively influence operative outcomes.

Rodeando al enemigo: colectomía derecha laparoscópica por enfermedad de Crohn estenosante y fistulizante / Surrounding the enemy: laparoscopic right colectomy for stenosing and fistulizing Crohn's disease

Introducción: La enfermedad de Crohn presenta una incidencia en aumento en los últimos años en los países industrializados. La afectación ileocecal es la forma de presentación más frecuente en esta patología. En una primera instancia los pacientes pueden recibir tratamiento médico, pero un porcentaje significativo de estos puede evolucionar hacia complicaciones de la enfermedad, como estenosis o fístulas. Cuando estas se presentan, deben ser tratadas quirúrgicamente, representando un desafío para el equipo quirúrgico, ya que se trata de pacientes en mal estado general y con un gran compromiso inflamatorio a nivel abdominal que dificulta la correcta identificación de los planos anatómicos. Descripción: Se presenta el caso de un paciente de 84 años que ingresa por guardia en nuestra institución por presentar diagnóstico de enfermedad de Crohn de 10 años de evolución, mal estado general y deterioro nutricional severo. En el examen físico se palpa tumor a nivel de flanco derecho y fosa ilíaca derecha. Entero-TC: Íleon terminal con fístula hacia colon derecho y transverso asociado a cavidad intermedia con colección de 3 cm (Fig.1 y 2). Laboratorio: glóbulos blancos: 12.000/mm3, albúmina: 1,3 gr/dl. Se decide internar al paciente e instaurar tratamiento antibiótico, medidas de sostén y nutrición parenteral total. A las 3 semanas presenta una mejoría en los parámetros nutricionales (albúmina de 2,1 gr/dl) y en el estado general, por lo cual se programa tratamiento quirúrgico de la patología. Se realiza una laparoscopía exploradora donde se evidencia gran tumor inflamatorio que involucra íleon terminal, colon derecho y transverso (fig. 3). Se logra la movilización completa de las estructuras mencionadas, las cuales se exteriorizan por una mini laparotomía mediana supraumbilical y se hace la resección en bloque del tumor inflamatorio, confeccionando una ileostomía terminal y abocando el colon transverso en tejido celular subcutáneo (fig. 4 y 5). La decisión de no realizar una anastomosis primaria se basó en el mal estado nutricional del paciente. Por otro lado, abocar el colon transverso en el tejido celular subcutáneo y no exteriorizar junto a la ileostomía es una técnica que facilita el manejo de la bolsa en el postoperatorio. Sin embargo, consideramos que la alternativa de exteriorizar el colon es válida. Lo que no se debe hacer en ningún caso es abandonar el cabo distal dentro de la cavidad abdominal, dado que, en caso de abrirse el cierre (lo cual es una posibilidad viendo el estado nutricional), conllevaría complicaciones sépticas que podrían requerir una reoperación.El paciente presenta una buena evolución postoperatoria y recibe el alta senatorial al séptimo día postoperatorio sin complicaciones. Conclusiones: El tratamiento quirúrgico de la enfermedad de Crohn representa un desafío para el cirujano. Si es realizado por vía laparoscópica y luego de optimizar al paciente desde el punto de vista clínico y nutricional, se pueden obtener buenos resultados postoperatorios. (AU)

Introduction: Crohn's disease has an increasing incidence in recent years in industrialized countries, and ileocecal involvement is the most frequent in this pathology. Firstly, patients can receive medical treatment, but many of them can present complications of the disease such as stenosis or fistulas. When these appear, they must be treated surgically, representing a challenge for the surgical team because these are patients in poor general condition and with a large abdominal inflammatory compromise that makes it difficult to correctly identify the anatomical planes. Description: We present the case of an 84-year-old patient who is admitted to our institution in Emergency Service for presenting a diagnosis of Crohn's disease of 10 years of evolution, poor general condition and severe nutritional deterioration. Physical examination revealed a palpable tumor at the level of the right flank and right iliac fossa. Entero-CT: Terminal ileum with fistula towards the right and transverse colon and intermediate cavity with a 3 cm collection. Laboratory: White blood cells: 12,000x10-9 / L, Albumin: 1.3 gr / dl. Decision is made to admit the patient, antibiotic treatment, support measures and total parenteral nutrition were instituted. At 3 weeks, the patient shows improvement in nutritional parameters and general condition, for which surgical treatment of the pathology is scheduled. An exploratory laparoscopy is performed where a large inflammatory tumor involving the terminal ileum, right and transverse colon is evidenced. Complete mobilization of the aforementioned structures is achieved, which are externalized by a supraumbilical median mini laparotomy, and enbloc resection of the inflammatory tumor is made, performing a terminal ileostomy and leaving the transverse colon in subcutaneous cellular tissue. We do not perform primary anastomosis given the compromised nutritional state of the patient. On the other hand, transverse colon is left in subcutaneous tissue because taking it out along with the ileostomy sometimes complicates the handling of the ileostomy. However, exteriorization is a possibility, but what a surgeon shouldn't do in no case is to abandon the distal end inside the abdominal cavity, because in case the closure fails (chances are real given the nutritional status) it would probably be a complication that would take a re operation. Patient presented good postoperative evolution, receiving a sanatorial discharge on the seventh postoperative day without complications. Conclusions: Surgical treatment of Crohn's disease represents a challenge for the surgeon. Performed laparoscopically and after optimizing the patient from a clinical and nutritional point of view, good postoperative results can be obtained. (AU)