Segmental Colectomy in Ulcerative Colitis.

BACKGROUND: Segmental colectomy in ulcerative colitis is performed in select patients who may be at increased risk for postoperative morbidity. OBJECTIVE: To identify ulcerative colitis patients who underwent segmental colectomy and assess their postoperative and long-term outcomes. DESIGN: Retrospective case series. SETTING: A tertiary-care inflammatory bowel disease center. PATIENTS: Ulcerative colitis patients who underwent surgery between 1995 and 2022. INTERVENTION: Segmental colectomy. MAIN OUTCOME MEASURES: Postoperative complications, early and late colitis, metachronous cancer development, completion proctocolectomy-free survival rates and stoma at follow-up. RESULTS: Fifty-five patients were included [20 (36.4%) female; 67.8 (57.4-77.1) years of age at surgery; body mass index 27.7 (24.2-31.1) kg/m2; median follow-up 37.3 months]. ASA score was III in 32 (58.2%) patients, 48 (87.3%) had at least one comorbidity, 48 (87.3%) had Mayo endoscopic subscore of 0-1. Patients underwent right hemicolectomy (28, 50.9%), sigmoidectomy (17, 30.9%), left hemicolectomy (6, 10.9%), low anterior resection (2, 3.6%), or a non-anatomic resection (2, 3.6%) for; endoscopically unresectable polyps (21, 38.2%), colorectal cancer (15, 27.3%), symptomatic diverticular disease (13, 23.6%), and stricture (6, 10.9%). Postoperative complications occurred in 16 (29.1%) patients [7 (12.7%) Clavien-Dindo Class III-V]. Early and late postoperative colitis rates were 9.1% and 14.5%, respectively. Metachronous cancer developed in 1 patient. 4 (7.3%) patients underwent subsequent completion proctocolectomy with ileostomy. Six (10.9%) patients had stoma at the follow-up. Two and 5-year completion proctocolectomy-free survival rates were 91% and 88%, respectively. LIMITATIONS: Retrospective study, small sample size. CONCLUSIONS: Segmental colectomy in ulcerative colitis is associated with low postoperative complication rates, symptomatic early colitis and late colitis rates, metachronous cancer development and the need for subsequent completion proctocolectomy. Therefore, it can be safe to consider select patients, such as the elderly with quiescent colitis and other indications for colectomy. See Video Abstract.

Colosplenic fistula diagnosis and management: a case series and review of literature.

BACKGROUND: A colosplenic fistula (CsF) is an extremely rare complication. Its diagnosis and management remain poorly understood, owing to its infrequent incidence. Our objective was to systematically review the etiology, clinical features, diagnosis, management, and prognosis to help clinicians gain a better understanding of this unusual complication and provide aid if it is to be encountered. METHODS: A systematic review of studies reporting CsF diagnosis in Ovid MEDLINE, Ovid EMBASE, Scopus, Web of Science, and Wiley Cochrane Library from 1946 to June 2022. Additionally, a retrospective review of four cases at our institution were included. Cases were evaluated for patient characteristics (age, sex, and comorbidities), CsF characteristics including causes, symptoms at presentation, diagnosis approach, management approach, pathology findings, intraoperative complications, postoperative complications, 30-day mortality, and prognosis were collected. RESULTS: Thirty patients with CsFs were analyzed, including four cases at our institution and 26 single-case reports. Most of the patients were male (70%), with a median age of 56 years. The most common etiologies were colonic lymphoma (30%) and colorectal carcinoma (17%). Computed tomography (CT) was commonly used for diagnosis (90%). Approximately 87% of patients underwent a surgical intervention, most commonly segmental resection (81%) of the affected colon and splenectomy (77%). Nineteen patients were initially managed surgically, and 12 patients were initially managed nonoperatively. However, 11 of the nonoperative patients ultimately required surgery due to unresolved symptoms. The rate of postoperative complications was (17%). Symptoms resolved with surgical intervention in 25 (83%) patients. Only one patient (3%) had had postoperative mortality. CONCLUSIONS: Our review of 30 cases worldwide is the largest in literature. CsFs are predominantly complications of neoplastic processes. CsF may be successfully and safely treated with splenectomy and resection of the affected colon, with a low rate of postoperative complications.

Transanal ileal pouch-anal anastomosis for inflammatory bowel disease: a systematic review and meta-analysis of short-term outcomes.

AIM: Restorative proctocolectomy with transabdominal ileal pouch-anal anastomosis (abd-IPAA) has become the standard surgical treatment for medically refractory ulcerative colitis (UC). However, it requires a technically difficult distal anorectal dissection and anastomosis due to the bony confines of the deep pelvis. To address these challenges, the transanal IPAA approach (ta-IPAA) was developed. This novel approach may offer increased visibility and range of motion compared with abd-IPAA, although its postoperative benefits remain unclear. The aim of this work was to perform a systematic review and meta-analysis to compare and inform the frequency of postoperative outcomes between ta-IPAA and abd-IPAA for patients with UC. METHOD: Several databases were searched from inception until May 2022 for studies reporting postoperative outcomes of patients undergoing ta-IPAA. Reviewers, working independently and in duplicate, evaluated studies for inclusion and graded the risk of bias. Odds ratios (OR), mean differences (MD) and prevalence ratio (PR) and their corresponding 95% confidence intervals (CIs) were calculated using random-effects models. Sensitivity analysis was performed. RESULTS: Ten retrospective studies comprising 284 patients with ta-IPAA were included. Total mesorectal excision was performed in 61.8% of cases and close rectal dissection in 27.9%. There was no difference in the odds of Clavien-Dindo (CD) I-II complications, CD III-IV and anastomotic leak (OR 0.96, 95% CI 0.27-3.40; OR 1.18, 95% CI 0.65-2.16; OR 1.37, 95% CI 0.58-3.23; respectively) between ta-IPAA and abd-IPAA. The ta-IPAA pooled CD I-II complication rate was 18% (95% CI 5%-35%) and for CD III-IV 10% (95% CI 5%-17%), and the anastomotic leak rate was 6% (95% CI 2%-10%). There were no deaths reported. CONCLUSIONS: This meta-analysis compared the novel ta-IPAA procedure with abd-IPAA and found no difference in postoperative outcomes. While the need for randomized controlled trails and comparison of functional outcomes between both approaches remains, this evidence should assist colorectal surgeons to decide if ta-IPAA is a viable alternative.

State of the Art: Pouch Surgery in the 21st Century.

BACKGROUND: An ileoanal pouch with IPAA is the preferred method to restore intestinal continuity in patients who require a total proctocolectomy. Pouch surgery has evolved during the past decades thanks to increased experience and research, changes in the medical management of patients who require an ileal pouch, and technological innovations. OBJECTIVE: To review the main changes in pouch surgery over the past 2 decades, with a focus on staging, minimally invasive and transanal approaches, pouch design, and anastomotic configuration. RESULTS: The decision on the staging approach depends on the patient's conditions, their indication for surgery, and the risk of anastomotic leak. A minimally invasive approach should be performed whenever feasible, but open surgery still has a role in this technically demanding operation. Transanal IPAA may be performed in experienced centers and may reduce conversion to open surgery in the hostile pelvis. The J-pouch is the easiest, fastest, and most commonly performed design, but other designs may be used when a J-pouch is not feasible. A stapled anastomosis without mucosectomy can be safely performed in the majority of cases, with a low incidence of rectal cuff neoplasia and better functional outcomes than handsewn. Finally, Crohn's disease is not an absolute contraindication to an ileoanal pouch, but pouch failure may be higher compared to other indications. CONCLUSIONS: Many technical nuances contribute to the success of an ileoanal pouch. The current standard of care is a laparoscopic J-pouch with double-stapled anastomosis, but this should not be seen as a dogma, and the optimal approach and design should be tailored to each patient. See video from symposium.

The value of national accreditation program for rectal cancer: A survey of accredited programs and programs seeking accreditation.

BACKGROUND: Significant variation in rectal cancer care has been demonstrated in the United States. The National Accreditation Program for Rectal Cancer was established in 2017 to improve the quality of rectal cancer care through standardization and emphasis on a multidisciplinary approach. The aim of this study was to understand the perceived value and barriers to achieving the National Accreditation Program for Rectal Cancer accreditation. METHODS: An electronic survey was developed, piloted, and distributed to rectal cancer programs that had already achieved or were interested in pursuing the National Accreditation Program for Rectal Cancer accreditation. The survey contained 40 questions with a combination of Likert scale, multiple choice, and open-ended questions to provide comments. This was a mixed methods study; descriptive statistics were used to analyze the quantitative data, and thematic analysis was used to analyze the qualitative data. RESULTS: A total of 85 rectal cancer programs were sent the survey (22 accredited, 63 interested). Responses were received from 14 accredited programs and 41 interested programs. Most respondents were program directors (31%) and program coordinators (40%). The highest-ranked responses regarding the value of the National Accreditation Program for Rectal Cancer accreditation included "improved quality and culture of rectal cancer care," "enhanced program organization and coordination," and "challenges our program to provide optimal, high-quality care." The most frequently cited barriers to the National Accreditation Program for Rectal Cancer accreditation were cost and lack of personnel. CONCLUSION: Our survey found significant perceived value in the National Accreditation Program for Rectal Cancer accreditation. Adhering to standards and a multidisciplinary approach to rectal cancer care are critical components of a high-quality care rectal cancer program.

Tofacitinib Is Associated With Increased Risk of Postoperative Venous Thromboembolism in Patients With Ulcerative Colitis.

BACKGROUND: In 2019, the Food and Drug Administration issued a black box warning for increased risk of venous thromboembolism in patients with rheumatoid arthritis exposed to tofacitinib. There are limited data regarding postoperative venous thromboembolism risk in patients with ulcerative colitis exposed to tofacitinib. OBJECTIVE: To assess whether preoperative exposure to tofacitinib is associated with increased odds of postoperative venous thromboembolism. DESIGN: Retrospective review. SETTINGS: Tertiary academic medical center. PATIENTS: Consecutive patients exposed to tofacitinib within 4 weeks before total abdominal colectomy or total proctocolectomy, with or without ileostomy, from 2014 to 2021, matched 1:2 for tofacitinib exposure or no exposure. INTERVENTION: Tofacitinib exposure versus no exposure. MAIN OUTCOME MEASURES: Ninety-day postoperative venous thromboembolism rate. RESULTS: Forty-two patients with tofacitinib exposure and 84 case-matched patients without tofacitinib exposure underwent surgery for medically refractory ulcerative colitis. Nine (22.0%) tofacitinib-exposed patients and 7 (8.5%) unexposed patients were diagnosed with venous thromboembolism within 90 days of surgery. In univariate logistic regression, patients exposed to tofacitinib had 3.01 times increased odds of developing venous thromboembolism within 90 days after surgery compared to unexposed patients ( p = 0.04; 95% CI, 1.03-8.79). Other venous thromboembolism risk factors were not significantly associated with venous thromboembolisms. Venous thromboembolisms in both groups were most commonly portomesenteric vein thromboses (66.7% in the tofacitinib-exposed group and 42.9% in the unexposed group) and were diagnosed at a mean of 23.2 days (range, 3-90 days) postoperatively in the tofacitinib-exposed group and 7.9 days (1-19 days) in the unexposed group. There were no statistically significant differences in location or timing between the 2 groups. LIMITATIONS: Retrospective nature of the study and associated biases. Reliance on clinically diagnosed venous thromboembolisms may underreport the true incidence rate. CONCLUSIONS: Tofacitinib exposure before surgery for medically refractory ulcerative colitis is associated with 3 times increased odds of venous thromboembolism compared with patients without tofacitinib exposure. See Video Abstract . TOFACITINIB SE ASOCIA CON UN MAYOR RIESGO DE TROMBOEMBOLISMO VENOSO POSTOPERATORIO EN PACIENTES CON COLITIS ULCEROSA: ANTECEDENTES:En 2019, la FDA emitió una advertencia de recuadro negro sobre un mayor riesgo de tromboembolismo venoso en pacientes con artritis reumatoide expuestos a tofacitinib. Hay datos limitados sobre el riesgo de tromboembolismo venoso postoperatorio en pacientes con colitis ulcerosa expuestos a tofacitinib.OBJETIVO:Evaluar si la exposición preoperatoria a tofacitinib se asocia con mayores probabilidades de tromboembolismo venoso postoperatorio.DISEÑO:Revisión retrospectiva.LUGARES:Centro médico académico terciario.PACIENTES:Pacientes consecutivos expuestos a tofacitinib dentro de las 4 semanas previas a la colectomía abdominal total o proctocolectomía total, con o sin ileostomía, entre 2014 y 2021, emparejados 1:2 para exposición a tofacitinib o ninguna exposición.INTERVENCIÓN(S):Exposición a tofacitinib versus ninguna exposición.PRINCIPALES MEDIDAS DE RESULTADO:Tasa de tromboembolismo venoso posoperatorio a los 90 días.RESULTADOS:Cuarenta y dos pacientes con exposición a tofacitinib y 84 pacientes de casos similares sin exposición a tofacitinib se sometieron a cirugía por colitis ulcerosa médicamente refractaria. Nueve (22,0%) pacientes expuestos a tofacitinib y 7 (8,5%) pacientes no expuestos fueron diagnosticados con tromboembolismo venoso dentro de los 90 días posteriores a la cirugía. En la regresión logística univariada, los pacientes expuestos a tofacitinib tuvieron 3,01 veces más probabilidades de desarrollar un tromboembolismo venoso dentro de los 90 días posteriores a la cirugía en comparación con los no expuestos ( p = 0,04, IC del 95 %: 1,03-8,79). Otros factores de riesgo de tromboembolismo venoso no se asociaron significativamente con el tromboembolismo venoso. Los tromboembolismos venosos en ambos grupos fueron más comúnmente trombosis de la vena portomesentérica (66,7% en los expuestos a tofacitinib y 42,9% en los no expuestos) y se diagnosticaron en una media de 23,2 días (rango, 3-90 días) después de la operación en los expuestos a tofacitinib y 7,9 días. (1-19 días) en los grupos no expuestos, respectivamente. No hubo diferencias estadísticamente significativas en la ubicación o el momento entre los dos grupos.LIMITACIONES:Carácter retrospectivo del estudio y sesgos asociados. La dependencia de tromboembolismos venosos diagnosticados clínicamente puede subestimar la tasa de incidencia real.CONCLUSIONES:La exposición a tofacitinib antes de la cirugía para la colitis ulcerosa médicamente refractaria se asocia con probabilidades 3 veces mayores de tromboembolismo venoso en comparación con los pacientes sin exposición a tofacitinib. (Traducción-Dr. Mauricio Santamaria ).

Assessing prognostic factors of long-term survival after surgery for colorectal gastrointestinal stromal tumours.

AIM: Due to their rarity, the management of colorectal gastrointestinal stromal tumours (CR GISTs) is still under debate. The aim of this study was to assess prognostic factors. METHOD: We performed a retrospective review of patients who underwent surgery with curative intent for CR GIST at our centre from 2002 to 2019. Factors associated with overall (OS) and recurrence-free survival (RFS) were analysed. RESULTS: Fifty-six patients were included [median age 63 years, 29 (52%) female, 30 (54%) Miettinen high-risk, 40 (71%) with rectal GIST]. Nineteen (34%) patients received perioperative (neoadjuvant and/or adjuvant) imatinib. All cases of colonic GIST had an R0 resection, compared with 28 (70%) of rectal GISTs. After a median follow-up of 97 months (interquartile range 48-155 months), 14 (25%) deaths and 14 (25%) recurrences occurred. In the high-risk cohort, factors associated with improved RFS were R0 resection (OR 0.19, 95% CI 0.1-0.5, p = 0.002) and perioperative imatinib (OR 0.33, 95% CI 0.42-0.97, p = 0.04). Patients who had received perioperative imatinib had longer RFS (60% vs. 11% at 5 years, p = 0.006) but not OS. In rectal GISTs, 5-year OS was 85% for R0 and 70% for R1 resections (p = 0.164) and 5-year RFS was 85% for R0 and 12% for R1 resection (p < 0.001). When stratifying patients by perioperative imatinib, there were no differences in OS or RFS in the R0 or R1 groups. CONCLUSION: Perioperative imatinib and R0 resection were associated with improved RFS in high-risk patients with CR GIST. In patients with rectal GIST, R1 resection was associated with worse RFS irrespective of perioperative imatinib treatment.

Does the age of ulcerative colitis diagnosis impact outcomes of restorative proctocolectomy?

BACKGROUND: Ulcerative colitis (UC) can be diagnosed at a variety of different ages. We evaluated if age of ulcerative colitis (UC) diagnosis impacts outcomes of restorative proctocolectomy (RP) with ileal pouch-anal anastomosis (IPAA). METHODS: A prospectively maintained pouch database (1983-2020) was queried to identify patients undergoing an RP for UC. The cohort was stratified based on bimodal disease presentation into 2 groups: the early adulthood group (19-30 years old) and the mid/late adulthood group (40-70 years old). Patients' demographics, postoperative complications, functional (stool number, seepage), and quality of life (QoL) rates were compared between the groups. RESULTS: A total of 628 patients with an age range of 19-30 years old (18.1 ± 2.2 at the time of diagnosis, 24.2 ± 10.5 at the time of IPAA) and 706 patients with an age range of 40-70 years old (45 ± 3.0 at time of diagnosis, 52.3 ± 9.4 at time of IPAA) were identified. Older patients had longer disease duration, higher BMI, lower biologic use, and greater one-/two-staged IPAA, with 20% hand sewn anastomosis and 16.5% of S pouch configuration compared to younger ones. No difference was observed in anastomotic separation, pelvic sepsis, fistulas, or pouch failure in follow-up. Postoperatively, older patients more frequently developed bowel obstructions, strictures, and pouchitis, in addition to higher rates of seepage (p < 0.05). QoL was comparable between groups. CONCLUSION: While IPAA retention rates are comparable between different age cohorts, older age at diagnosis and IPAA construction is associated with higher rates of pouchitis, bowel obstruction, anastomotic strictures, and worse functional outcome. Quality of life is similar in those who retain their ileal pouch on the long-term.

Ileal Pouch-anal Anastomosis in Primary Sclerosing Cholangitis-inflammatory Bowel Disease (PSC-IBD): Long-term Pouch and Liver Transplant Outcomes.

OBJECTIVE: To compare the effect of liver transplantation (LT) on ileal pouch-anal anastomosis (IPAA) outcomes in patients with primary sclerosing cholangitis and inflammatory bowel disease (PSC-IBD). BACKGROUND: Patients with PSC-IBD may require both IPAA for colitis and LT for PSC. METHODS: Patients with PSC-IBD from out institutional pouch registry (1985-2022) were divided according to LT status and timing of LT (before and after IPAA) and their outcomes analyzed. RESULTS: A total of 160 patients were included: 112 (70%) nontransplanted at last follow-up; 48 (30%) transplanted, of which 23 (14%) before IPAA and 25 (16%) after. Nontransplanted patients at IPAA had more laparoscopic procedures [37 (46%) vs 8 (18%), P =0.002] and less blood loss (median 250 vs 400 mL, P =0.006). Morbidity and mortality at 90 days were similar. Chronic pouchitis was higher in transplanted compared with nontransplanted patients [32 (67%) vs 51 (45.5%), P =0.03], but nontransplanted patients had a higher rate of chronic antibiotic refractory pouchitis. Overall survival was similar, but nontransplanted patients had more PSC-related deaths (12.5% vs 2%, P =0.002). Pouch survival at 10 years was 90% for nontransplanted patients and 100% for transplanted patients (log-rank P =0.052). Timing of LT had no impact on chronic pouchitis, pouch failure, or overall survival. PSC recurrence was 6% at 10 years. For transplanted patients, graft survival was similar regardless of IPAA timing. CONCLUSIONS: In patients with PSC-IBD and IPAA, LT is linked to an increased pouchitis rate but does not affect overall and pouch survival. Timing of LT does not influence short-term and long-term pouch outcomes.

Turnbull-Cutait Pull-Through Procedure Is an Alternative to Permanent Ostomy in Patients With Complex Pelvic Fistulas.

BACKGROUND: A permanent stoma is frequently recommended in the setting of complex or recurrent rectovaginal fistulas because of the high failure rate of reconstructive procedures. The Turnbull-Cutait pull-through procedure is a salvage operation for motivated patients desiring to avoid permanent fecal diversion. OBJECTIVE: To analyze the cure rates of complex rectovaginal fistulas after the Turnbull-Cutait pull-through procedure based on cause. DESIGN: After the institutional review approval board, a retrospective review of women who underwent the procedure (1993-2018) for a rectovaginal fistula was conducted. Patients' demographics, cause, and postoperative outcomes were analyzed. SETTING: Colorectal surgery department at a tertiary center in the United States. PATIENTS: Adult women with a rectovaginal fistula who underwent a colonic pull-through procedure were included. MAIN OUTCOME MEASURES: Recurrence after the colonic pull-through procedure. RESULTS: There were 81 patients who underwent colonic pull-through; of those, 26 patients had a rectovaginal fistula, had a median age of 51 (43-57) years, and had a mean BMI of 28 ± 3.2 kg/m 2 . A total of 4 patients (15%) had a recurrence and 85% of the patients healed. Ninety-three percent of the patients healed after the prior anastomotic leak. Patients with a Crohn's disease-related fistula had a 75% cure rate. The Kaplan-Meier analysis showed a cumulative incidence of recurrence of 8% (95% CI, 0%-8%) within 6 months after surgery and 12% at 12 months. LIMITATIONS: Retrospective design. CONCLUSIONS: The Turnbull-Cutait pull-through procedure may be the last option to preserve intestinal continuity and successfully treat rectovaginal fistulas in 85% of cases. EL PROCEDIMIENTO PULLTHROUGH DE TURNBULLCUTAIT ES UNA ALTERNATIVA A LA OSTOMA PERMANENTE EN PACIENTES CON FSTULAS PLVICAS COMPLEJAS: ANTECEDENTES:Con frecuencia se recomienda un estoma permanente en el contexto de una fístula rectovaginal compleja o recurrente debido a la alta tasa de fracaso de los procedimientos reconstructivos. El procedimiento de extracción de Turnbull-Cutait es una operación de rescate para pacientes motivados que desean evitar la desviación fecal permanente.OBJETIVO:Analizar las tasas de curación de la fístula rectovaginal compleja después del procedimiento de extracción de Turnbull-Cutait según la etiología.DISEÑO:Después de la junta de aprobación de revisión institucional, se realizó una revisión retrospectiva de mujeres que se sometieron a un procedimiento (1993-2018) por fístula rectovaginal. Se analizaron los datos demográficos, la etiología y los resultados posoperatorios de los pacientes.AJUSTE:Departamento de cirugía colorrectal en un centro terciario en los Estados Unidos.PACIENTES:Mujeres adultas con fístula rectovaginal que se sometieron a extracción del colon.RESULTADO PRINCIPAL:recurrencia después de la extracción del colon.RESULTADOS:Hubo 81 pacientes que tenían extracción colónica, de esas 26 fístulas rectovaginales con una mediana de edad de 51 (43 - 57) años, y un índice de masa corporal promedio de 28 ± 3,2 kg/m2. Un total de 4 (15%) pacientes tuvieron una recurrencia y el 85% de los pacientes se curaron. El noventa y tres por ciento de los pacientes se curaron después de la fuga anastomótica previa. Los pacientes con fístula relacionada con EC tuvieron una tasa de curación del 75%. El análisis de Kaplan Meier mostró una incidencia acumulada de recurrencia del 8% [95% intervalo de confianza 0%-18%] dentro de los 6 meses posteriores a la cirugía y del 12% a los 12 meses.LIMITACIONES:Diseño retrospectivo.CONCLUSIONES:El procedimiento de extracción de Turnbull-Cutait puede ser la última opción que se puede ofrecer para preservar la continuidad intestinal y tratar la fístula rectovaginal con éxito en el 85% de los casos. (Traducción-Yesenia.Rojas-Khalil).

Clinical approach to patients with an ileal pouch.

Restorative proctocolectomy with ileal pouch-anal anastomosis is the procedure of choice to maintain intestinal continuity when a total proctocolectomy is a required. It is a technically challenging operation that may be burdened by several nuanced complications both in the immediate postoperative period and in the long term. Most patients with a pouch and any kind of complication will undergo radiological studies, thus multidisciplinary collaboration between surgeons, gastroenterologists, and radiologists is paramount to their timely and accurate diagnosis. When treating pouch patients, radiologists should be familiar with regular pouch anatomy and its appearance in imaging studies, as well as with the most common complications that can occur in this population. In this review, we examine the clinical decision-making process at each step before and after pouch creation, as well as the most common complications associated with pouch surgery, their diagnosis, and their management.

Salvage surgery is an effective alternative for J-pouch afferent limb stricture treatment.

BACKGROUND: Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice for patients requiring surgery for inflammatory bowel disease. A stricture located at the inlet of the afferent limb can lead to small bowel obstruction in a limited number of patients with a pelvic pouch. This paper aims to examine our experience with afferent limb stricture surgical correction when other endoscopic treatment methods have failed to control obstructive symptoms. METHODS: All consecutive eligible patients with ileal pouch-anal anastomosis and afferent limb stricture were identified from our institutional review board-approved database from 1990 to 2021. Patients surgically treated with excision and reimplantation/strictureplasty of afferent limb stricture were included in this study. RESULTS: Twenty patients met our inclusion criteria. Fifteen (75%) were female, and the overall mean age was 41 ± 10.3 years at afferent limb stricture surgery. The interval from ileal pouch-anal anastomosis formation to surgery for afferent limb stricture was 13.5 ± 6.7 years. Nine (45%) underwent strictureplasty, and 11 (55%) had resection and reimplantation of the afferent limb into the pouch. Before afferent limb stricture surgery, 3 (15%) required a diverting ileostomy for their obstructive symptoms. An additional 12 (60%) had a stoma constructed during afferent limb stricture surgery, and 5 had a strictureplasty and no stoma. Postoperatively, 1 patient (5%) had a leak at the afferent limb stricture repair site. All patients had their ileostomy closed 3.2 (2.99-3.6) months after surgery. Long-term after afferent limb stricture surgery, recurrent small bowel obstruction symptoms recurred in 7 (35%) patients 3.9 (2.6-5.8) years later. CONCLUSION: Afferent limb stricture can be treated effectively with salvage surgery. The surgical intervention appears durable and provides an acceptable outcome for their obstructive symptoms.

Long-term Outcomes of Perianal Fistulas in Pediatric Crohn's Disease.

BACKGROUND: Approximately 30% of Crohn's disease-related perianal fistulas heal in the adult population with conventional medical and surgical interventions. This healing rate remains unknown in pediatric patients. OBJECTIVE: This study aimed to determine the healing rate of pediatric perianal Crohn's fistulas and identify factors associated with healing. DESIGN: Retrospective case series. SETTING: A quaternary referral center. PATIENTS: Patients aged <18 years with a Crohn's perianal fistula, seen between January 1, 1991, and August 1, 2021, were included in the study. INTERVENTIONS: Multivariable logistic regression to identify factors independently associated with perianal fistula healing. MAIN OUTCOME MEASURES: Healing of Crohn's perianal fistula at the date of last clinical encounter, defined as the clinical note reporting a healed fistula or normal perianal examination. RESULTS: A total of 91 patients aged <18 years with a Crohn's disease-related perianal fistula were identified (59% female, 76% white). The mean (SD) age at Crohn's diagnosis was 12 (±4) years. The mean follow-up after Crohn's diagnosis was 10 (±7) years. Overall, 89% of patients had a perianal fistula, 2% had an anovaginal fistula, and 10% had an ileal pouch-associated fistula. Patients underwent a median (interquartile range) of 2 (1-5) operations. A seton was placed in 60% of patients, 47% underwent abscess drainage, and 44% underwent fistulotomy or fistulectomy. Fistula healing occurred in 71% of patients over a median of 1.3 (0.4-2.5) years. Seven patients (7%) underwent proctectomy, and 3 (3%) underwent ileal pouch excision. After multivariable adjustment, younger age at diagnosis of perianal fistula was associated with an increased likelihood of healing (OR 0.56 for each increased year; 95% CI, 0.34-0.92). LIMITATIONS: Retrospective, single institution. CONCLUSIONS: Over two-thirds of fistulas heal in pediatric Crohn's disease patients with conventional surgical and medical intervention. Younger age at fistula development is associated with an increased likelihood of healing. See Video Abstract at http://links.lww.com/DCR/C185 . RESULTADOS A LARGO PLAZO DE LAS FSTULAS PERIANALES EN LA ENFERMEDAD DE CROHN EN PACIENTES PEDITRICOS: ANTECEDENTES:Aproximadamente el 30% de las fístulas perianales relacionadas con la enfermedad de Crohn se curan en la población adulta con intervenciones médicas y quirúrgicas convencionales. Esta tasa de curación sigue siendo desconocida en pacientes pediátricos.OBJETIVO:Determinar la tasa de curación de las fístulas de Crohn perianales en población pediátrica e identificar los factores asociados con la curación.DISEÑO:Serie de casos retrospectiva.ESCENARIO:Un centro de referencia cuaternario.PACIENTES:Pacientes menores de 18 años con fístula(s) perianal(es) por enfermedad de Crohn, atendidos entre el 1 de enero de 1991 y el 1 de agosto de 2021.INTERVENCIONES:Regresión logística multivariable para identificar factores asociados de forma independiente con la cicatrización de la fístula perianal.PRINCIPALES MEDIDAS DE RESULTADO:Curación de la fístula perianal de Crohn en la fecha del último encuentro clínico, definida como la nota clínica que informa una fístula curada o un examen perianal normal.RESULTADOS:Se identificó un total de 91 pacientes <18 años de edad con una fístula perianal relacionada con la enfermedad de Crohn (59% mujeres, 76% blancos). La edad media (DE) al diagnóstico de Crohn fue de 12 (±4) años. El seguimiento medio tras el diagnóstico de Crohn fue de 10 (±7) años. En general, el 89 % de los pacientes tenía fístula perianal, el 2 % tenía fístula anovaginal y el 10 % de los pacientes tenía fístula asociada a reservorio ileal. Los pacientes fueron sometidos a una mediana (RIC) de 2 (1-5) operaciones. En el 60% de los pacientes se colocó sedal, en el 47% se drenó el absceso y en el 44% se realizó fistulotomía o fistulectomía. La curación de la fístula se produjo en el 71% de los pacientes durante una mediana de 1,3 (0,4-2,5) años. Siete pacientes (7%) se sometieron a proctectomía y 3 (3%) se sometieron a escisión del reservorio ileal. Después del ajuste multivariable, la edad más joven en el momento del diagnóstico de la fístula perianal se asoció con una mayor probabilidad de curación (OR 0,56 por cada año de aumento, IC del 95%, 0,34-0,92).LIMITACIONES:Retrospectivo, institución única.CONCLUSIONES:Más de dos tercios de las fístulas se curan en pacientes pediátricos con enfermedad de Crohn con intervención médica y quirúrgica convencional. Una edad más joven en el momento del desarrollo de la fístula se asocia con una mayor probabilidad de curación. Consulte Video Resumen en http://links.lww.com/DCR/C185 . (Traducción--Dr. Felipe Bellolio ).

Gracilis Muscle Interposition for the Treatment of Rectovaginal Fistula: A Systematic Review and Pooled Analysis.

BACKGROUND: A rectovaginal fistula is a debilitating condition that often severely impacts quality of life. Despite many treatment options available, the best surgical treatment is far from being established, and many patients will undergo several procedures before fistula closure is achieved. Gracilis muscle interposition, which is the transposition of the gracilis muscle into the rectovaginal septum, is an option for complex and persistent fistulas, but literature on the subject is scarce, mainly consisting of small case series. OBJECTIVE: This study aimed to assess the success rate of gracilis muscle interposition for the surgical treatment of rectovaginal fistula. DATA SOURCES: MEDLINE, Embase, Cochrane Library, and Web of Science. STUDY SELECTION: Studies comprising at least 5 patients who underwent gracilis muscle interposition for rectovaginal fistula were included. No date or language restrictions was applied. INTERVENTION: Gracilis muscle interposition. MAIN OUTCOME MEASURES: The primary outcome is the fistula closure rate (%). Other domains analyzed are stoma closure rate, postoperative complications, quality of life, fecal continence, and sexual function. RESULTS: Twenty studies were included for a total of 384 patients. The pooled fistula closure rate for gracilis muscle interposition was 64% (95% CI, 53%-74%; range, 33%-100%). Risk factors for failure were smoking, underlying Crohn's disease, and more than 2 previous repairs, whereas stoma formation was associated with improved outcomes. Postoperative complications ranged from 0% to 37%, mostly related to surgical site occurrences at the harvest site and perineal area. No deaths occurred. Gracilis muscle interposition improved quality of life and fecal continence, but impairment of sexual function was common. LIMITATIONS: Most of the included studies were small case series. CONCLUSIONS: Gracilis muscle interposition is a safe and moderately effective treatment that could be taken into consideration as second- or third-line therapy for recurrent rectovaginal fistula. REGISTRATION NO: CRD42022319621.

Redo Continent Ileostomy in Patients With IBD: Valuable Lessons Learned Over 25 Years.

BACKGROUND: Patients with IBD with continent ileostomies may require revision surgeries. There remains a paucity of data regarding outcomes after redo continent ileostomy. OBJECTIVE: This study aimed to evaluate patient outcomes after redo continent ileostomy. DESIGN: Retrospective cohort study. SETTINGS: This study was conducted at a high-volume, specialized colorectal surgery department. PATIENTS: We identified patients who underwent redo continent ileostomy (defined as neo-pouch construction or major operations changing the pouch configuration) for IBD between 1994 and 2020. MAIN OUTCOME MEASURES: The main outcomes measured were patient demographics, short- and long-term outcomes, and quality of life. RESULTS: A total of 168 patients met inclusion criteria; 102 (61%) were female, the mean age was 51 years (±13.1), and the mean BMI was 24.4 (±3.9). The median time between primary and redo continent ileostomy was 16.8 years. One hundred twenty-two patients (73%) who underwent redo surgery had ulcerative colitis, 36 (21%) had Crohn's disease, and 10 (6%) had indeterminate colitis. Slipped nipple valve and valve stricture were the most common indications for redo continent ileostomy (86%). After a median follow-up of 4 years, 48 patients (29%) required a subsequent reoperation and 27 (16%) had pouch failure requiring pouch excision. The pouch survival rate was 89% at 3 years, 84% at 5 years, and 79% at 10 years. On univariate analysis, a shorter interval between the primary and redo continent ileostomy was associated with long-term pouch failure ( p = 0.003). Cox regression multivariate analysis confirmed that a shorter interval between surgeries was independently associated with pouch failure ( p = 0.014). The mean Cleveland Clinic Global Quality of Life score was 0.61 (± 0.23) among the 70 patients who responded to the questionnaire. LIMITATIONS: The main limitations were that this was a retrospective, single-center study and that it had a low response rate for the Global Quality of Life questionnaire. CONCLUSIONS: Redo continent ileostomy surgery is associated with a long-term pouch retention rate of 79% and satisfactory quality of life. Therefore, redo surgery should be offered to patients who are motivated to keep their continent ileostomy. See Video Abstract at http://links.lww.com/DCR/C87 . REHACER LA ILEOSTOMA CONTINENTE EN PACIENTES CON ENFERMEDAD INFLAMATORIA INTESTINAL VALIOSAS LECCIONES APRENDIDAS DURANTE AOS: ANTECEDENTES:Los pacientes con enfermedad inflamatoria intestinal con ileostomías continentes pueden requerir cirugías de revisión. Sigue habiendo escasez de datos con respecto a los resultados después de volver a realizar la ileostomía continente.OBJETIVO:Evaluar los resultados después de rehacer la ileostomía continente.DISEÑO:Estudio de cohorte retrospectivo.ESCENARIO:Departamento especializado en cirugía colorrectal de alto volumen.PACIENTES:Identificamos pacientes que se sometieron a una nueva ileostomía continente (definida como construcción de una nueva bolsa u operaciones mayores que cambian la configuración de la bolsa) por enfermedad inflamatoria intestinal entre 1994 y 2020.PRINCIPALES MEDIDAS DE RESULTADO:Datos demográficos de los pacientes, resultados a corto y largo plazo y calidad de vida.RESULTADOS:Un total de 168 pacientes cumplieron con los criterios de inclusión; 102 (61%) eran mujeres, la edad media fue de 51 años (±13,1) y el IMC medio fue de 24,4 (±3,9). La mediana de tiempo entre la ileostomía primaria y la nueva ileostomía continente fue de 16,8 años. Ciento veintidós pacientes (73%) que se sometieron a una nueva cirugía tenían colitis ulcerosa, 36 (21%) tenían enfermedad de Crohn y 10 (6%) tenían colitis indeterminada. El deslizamiento de la válvula del pezón y la estenosis de la válvula fueron las indicaciones más comunes para rehacer la ileostomía continente (86%). Después de una mediana de seguimiento de 4 años, 48 (29%) pacientes requirieron una reintervención posterior y 27 (16%) tuvieron falla de la bolsa que requirió la escisión de la bolsa. La tasa de supervivencia de la bolsa fue del 89 % a los 3 años, del 84% a los 5 años y del 79% a los 10 años. En el análisis univariable, un intervalo de tiempo más corto entre la ileostomía continente primaria y la nueva se asoció con falla de la bolsa a largo plazo (p = 0,003). El análisis multivariable de regresión de Cox confirmó que el intervalo más corto entre cirugías se asoció de forma independiente con el fracaso de la bolsa (p = 0,014). La puntuación media de la Calidad de Vida Global fue de 0,61 (± 0,23) entre los 70 pacientes que respondieron al cuestionario.LIMITACIONES:Estudio retrospectivo de un solo centro. Baja tasa de respuesta al cuestionario de Calidad de Vida.CONCLUSIÓN:La cirugía de ileostomía continente se asocia con una tasa de retención de la bolsa a largo plazo del 79% y una calidad de vida satisfactoria. Por lo tanto, se debe ofrecer una nueva cirugía a los pacientes que están motivados para mantener su ileostomía continente. Consulte Video Resumen en http://links.lww.com/DCR/C87 . (Traducción-Dr. Felipe Bellolio ).

Techniques of perineal hernia repair: A systematic review and meta-analysis.

BACKGROUND: Perineal hernias are rare, underreported and poorly studied complications of extensive pelvic surgeries. Their management is challenging, with currently no treatment algorithm available. METHOD: MEDLINE, EMBASE, Cochrane Library, and Web of Science databases were searched. Studies comprising at least 3 patients who underwent surgical perineal hernia repair were included. The primary outcome was perineal hernia recurrence. The secondary outcomes were overall complications and surgical site occurrences. RESULTS: Twenty-nine studies were included, comprising 325 patients undergoing 347 repairs. Overall complications were 33% (95% confidence interval 24%-43%) in the entire cohort, 31% (19%-44%) after perineal repair, 39% (14%-67%) after abdominal repair, and 36% (19%-53%) after mesh repair (20% with biological, 46% with synthetic mesh). The surgical site occurrence rate was 18% (8%-29%). The overall recurrence rate was 22% (15%-29%). Recurrence after perineal repair was 19% (10%-29%): 20% with mesh (25% with biological, 19% with synthetic), 24% with primary repair, and 39% with flap repair. Recurrence after an abdominal repair was 18% (11%-26%): 16% with laparoscopic, 12% with open, 16% with mesh (24% with biological, 16% with synthetic), 30% with primary, and 25% with flap repair. No significant differences could be found in the meta-analysis regarding overall complications and recurrence. CONCLUSION: Synthetic mesh repair seems to be associated with a lower recurrence rate than other techniques, especially after an abdominal approach. The perineal and abdominal approaches appear to be safe, with similar recurrence rates. The combined approach seems promising, but more evidence is needed.