Ileoanal pouch revision and excision surgery in a newly established pouch center: requirements and costs for service provision.

Complications of ileoanal pouch surgery affecting function and quality of life may require surgical correction or pouch excision. The management of patients with pouch dysfunction requires a multidisciplinary approach and demand for service provision include multiple healthcare professionals and resources. The aim of this study is to present the service requirements, and surgical outcomes for redo pouch surgery and pouch excision, with cost analysis of the required resources. All patients undergoing surgery for revision or excision of the ileoanal pouch from June 2021 to May 2023 were prospectively included. Patient undergoing only diagnostic procedures, or perineal procedures were excluded. Outcomes within 30 days of surgery were collected, including readmissions and re-operations. Cost analysis of all investigations, outpatient appointments and procedures prior to pouch revision or pouch excision was conducted. Twenty patients were included during the 24 months study period: 13 underwent abdominal revisional pouch surgery, 7 had ileoanal pouch excision. 15 patients (75%) were tertiary referrals from other hospitals in the UK. The median interval between index IPAA surgery and revision was 113 months. Three multidisciplinary clinical appointments, two imaging modalities, and at least one invasive day-surgery procedure were required for each patient prior to surgery. Expertise and infrastructure are needed for indication and peri-operative management of patients with pouch dysfunction requiring pouch revision or pouch excision. We estimated a starting cost of £22.605 ($29.589) for provision of pouch revision or excision surgery for investigations and treatments from referral to the pouch unit to surgery. This likely represents an underestimate as only accounts for procedures performed since referral with pouch dysfunction.

Patient-reported Outcome Measures in Ileoanal Pouch Surgery: a Systematic Review.

OBJECTIVE: To summarise frequency, type, and heterogeneity of patient-reported outcomes measures [PROMs] in papers reporting on outcomes after ileal pouch anal anastomosis [IPAA]. BACKGROUND: Prevalence of ulcerative colitis [UC] has risen in Western countries, and one in three patients requires surgery. IPAA is a frequently performed procedure for UC, and a lack of standardisation is manifest in reporting outcomes for inflammatory bowel disease [IBD] despite the clear need for inclusion of PROMs as primary outcomes in IBD trials. METHODS: Scopus, Pubmed, and Web of Science databases were searched from January 2010 to January 2023 for studies investigating outcomes in IPAA surgery. The primary outcome was the proportion of studies reporting outcomes for IPAA surgery for UC, which included PROMs. RESULTS: The search identified a total of 8028 studies which, after de-duplication and exclusion, were reduced to 79 articles assessing outcomes after IPAA surgery. In all 44 [55.7%] reported PROMs, with 23 including validated questionnaires and 21 papers using authors' questions, 22 different PROMs were identified, with bowel function as the most investigated item. The majority of studies [67/79, 85%] were retrospective, only 14/79 [18%] were prospective papers and only two were [2.5%] randomised, controlled trials. CONCLUSIONS: Only half of the papers reviewed used PROMs. The main reported item is bowel function and urogenital, social, and psychological functions are the most neglected. There is lack of standardisation for use of PROMs in IPAA. Complexity of UC and of outcomes after IPAA demands a change in clinical practice and follow-up, given how crucial PROMs are, compared with their non-routine use.

Assessment of the ileoanal pouch for the colorectal surgeon.

INTRODUCTION: Many pouch complications following ileoanal pouch surgery have an inflammatory or mechanical nature, and specialist colorectal surgeons are required to assess the anatomy of the ileoanal pouch in multiple settings. In this study, we report our stepwise clinical and endoscopic assessment of the patient with an ileoanal pouch. METHODS: The most common configuration of the ileoanal pouch is a J-pouch, and the stapled anastomosis is more frequently performed than a handsewn post-mucosectomy. A structured clinical and endoscopic assessment of the ileoanal pouch must provide information on 7 critical areas: anus and perineum, rectal cuff, pouch anal anastomosis, pouch body, blind end of the pouch, pouch inlet and pre-pouch ileum. RESULTS: We have developed a structured pro forma for step-wise assessment of the ileoanal pouch, according to 7 essential areas to be evaluated, biopsied and reported. The structured assessment of the ileoanal pouch in 102 patients allowed reporting of abnormal findings in 63 (61.7%). Strictures were diagnosed in 27 patients (26.4%), 3 pouch inlet strictures, 21 pouch anal anastomosis strictures, and 3 pre-pouch ileum strictures. Chronic, recurrent pouchitis was diagnosed in 9 patients, whilst 1 patient had Crohn's disease of the pouch. CONCLUSIONS: Detailed clinical history, assessment of symptoms and multidisciplinary input are all essential for the care of patients with an ileoanal pouch. We present a comprehensive reporting pro forma for initial clinical assessment of the patient with an ileoanal pouch, with the aim to guide further investigations and inform multidisciplinary decision-making.

Ten steps for ileoanal pouch anastomosis.

AIM: Appropriate patient selection, surgical technique, and follow-up pathways can provide optimal functional outcomes and good quality of life in many patients undergoing ileoanal pouch surgery. The aim of this study was to demonstrate the standardised approach to ileoanal pouch formation that we have developed in our pouch surgery centre. METHODS: We developed a structured approach to laparoscopic proctectomy with ileoanal pouch anastomosis formation, divided into 10 different steps. All patients referred to our centre from January 2020 to December 2022 for ulcerative colitis were included in the study. RESULTS: A total of 38 consecutive patients underwent ileal pouch-anal anastomosis (IPAA) surgery. All procedures were completed laparoscopically with one conversion to open (2.6%). A total of 13 patients had postoperative complications within 30 days of surgery (34.2%), with six (15.8%) being Clavien Dindo class 3 or higher. Median follow-up length was 18 months (range 2-30). Median number of bowel movements in 24 h at 12 months post-surgery was 4 (range 1-11). CONCLUSIONS: Our modular 10 steps approach could provide a standardised framework to surgeons in the learning curve. IPAA is a complex surgical procedure with significant postoperative morbidity. Our stepwise approach resulted in a high rate of minimally invasive surgery and could facilitate introduction of the technique.

Practice of proctology among general surgery residents and young specialists in Italy: a snapshot survey.

Anal diseases are very common and, in most of the cases, require surgery of minor or medium complexity, and, therefore, are among the most accessible diseases for surgeons in training. Aim of this study is to investigate the status of the training in proctology in Italy. A 31-items questionnaire was administered to residents and young specialists (≤ 2 years) in general surgery, using mailing lists, and the social media accounts of the Italian Society of Colorectal Surgery. Answers from 338 respondents (53.8% males) were included in the final analysis. Overall, 252 respondents (74.5%) were residents and 86 (25.5%) young specialists. Two hundred and fifty-five (75.4%) respondents practiced proctology for the first time early on during their postgraduate training, but only 19.5% did it continuously for ≥ 24 months. Almost all respondents (334; 98.8%) had the chance to participate in proctological procedures, 205 (60.5%) as first surgeon. This percentage decreases according to the complexity of the surgery. In fact, only 11 (3.3%) and 24 (7.1%) of the respondents were allowed to be the first surgeon in more complex proctological diseases such as surgery for rectal prolapse and fecal incontinence. The present survey suggests that, in Italy, most surgeons in training deal with anal diseases. However, only few of them could achieve sufficient professional skills in the management of proctological diseases to be able to practice autonomously as young specialists.

Stapled disc excision for the repair of intraoperative rectal injury during robotic surgery for deep infiltrating endometriosis.

INTRODUCTION: Intraoperative rectal perforation is an uncommon complication of pelvic surgery, which can be life-threatening and often leads to high morbidity and stoma formation rate. PURPOSE: No consensus has been reached regarding a standard of care for intraoperative iatrogenic pelvic injury. This article presents a technique for a stapled repair to completely resect a full-thickness low rectal perforation during robotic surgery for advanced endometriosis and avoid a high-risk colorectal anastomosis and the possible need for stoma formation. CONCLUSION: Stapled discoid excision is a novel and safe technique for the repair of intraoperative rectal injuries, showing multiple benefits compared to the standard colorectal resection with or without anastomosis.

Falciform Ligament Flap as Crural Buttress in Laparoscopic Hiatal Hernia Repair.

Background: Crural repair is an essential technical component in laparoscopic hiatal hernia surgery, but there is no consensus regarding the optimal method to prevent postoperative hernia recurrence. Mesh augmentation, especially with permanent materials, is associated with dysphagia and complications. The rotational falciform ligament flap (FLF) has been reported to be effective in reinforcing standard suture closure of the hiatus. Materials and Methods: Patients with primary or secondary hiatal hernia in whom FLF was used to buttress the hiatus repair were included. The FLF was dissected from the anterior abdominal wall, detached from the umbilical area, and transposed below the left lateral liver segment to buttress the cruroplasty. Indocyanine green fluorescence was used to assess vascularization of the flap before and after mobilization. Results: Eighteen consecutive patients underwent laparoscopic FLF cruroplasty reinforcement between October 2019 and January 2021. Indications were primary hiatal hernia (n = 9), recurrent hiatal hernia (n = 4), postsleeve gastrectomy hernia (n = 1), prophylactic hiatal repair during esophagectomy and gastric conduit reconstruction (n = 2), and postesophagectomy hernia (n = 2). All flaps were well vascularized and covered the entire hiatal area. There was no morbidity. At a median follow-up of 8 months (range 3-15), the symptomatic and quality of life scores significantly improved compared with baseline (P < .001), and no anatomic hernia recurrences were detected. Conclusions: FLF is safe for crural buttress and is a viable alternative to mesh in laparoscopic hiatal hernia surgery.

Retroperitoneoscopic Drainage of Psoas Abscess: A Systematic Review.

BACKGROUND: Psoas abscess is a relatively rare clinical condition that can occur worldwide, is difficult to diagnose, and has a severe clinical course. Conventional treatment ranges from antibiotic therapy alone to computed tomography (CT)-guided and/or open surgical drainage. Retroperitoneoscopic drainage represents a minimally invasive and potentially definitive therapeutic option. MATERIALS AND METHODS: A systematic review of the literature on minimally invasive extraperitoneal access for drainage of psoas abscess was conducted through PUBMED, EMBASE, and COCHRANE databases, according to the PRISMA statement guidelines. We considered only studies in English and with a full text. The quality of all selected articles was assessed for the risk of methodological bias. Additional literature sources were used to put into context the indications and limits of retroperitoneoscopic drainage. RESULTS: Seven papers published between 2004 and 2020, including a total of 56 patients, met the eligibility criteria and were included in the qualitative analysis. Causative agents of psoas abscess included Mycobacterium tuberculosis, Klebsiella pneumoniae, Enterobacter aerogenes, Staphylococcus aureus, and Streptococcus spp. Tuberculous abscess was more common than pyogenic abscess (92.8% vs. 7.2%). Main clinical findings were back pain (76.8%) and fever (53.6%). All patients were preoperatively evaluated by CT or magnetic resonance imaging. Only 4 patients (7.1%) had previously undergone CT-guided percutaneous drainage. Retroperitoneoscopic drainage was combined with antibiotic therapy in all cases. No Clavien-Dindo grade >3 complications occurred, and there was no 30-day postoperative mortality. The recurrence rate was 1.8% at a mean follow-up of 21 months. CONCLUSION: Retroperitoneoscopic surgical drainage is a safe and effective approach for the treatment of psoas abscess.