Restorative Surgery Is More Common in Ulcerative Colitis Patients With a High Income: A Population-Based Study.

BACKGROUND: To avoid a permanent stoma, restorative surgery is performed after the colectomy. Previous studies have shown that less than half of patients with ulcerative colitis undergo restorative surgery. OBJECTIVE: The primary aim was to explore the association between socioeconomic status and restorative surgery after colectomy. DESIGN: This was a nationwide register-based cohort study. SETTINGS: The study was conducted in Sweden. PATIENTS: All Swedish patients with ulcerative colitis who underwent colectomy between 1990 and 2017 at the age of 15 to 69 years were included. MAIN OUTCOME MEASURES: The main outcome was restorative surgery, and the secondary outcome was failure of the reconstruction (defined as the need for a new ileostomy after the reconstruction or nonreversal of a defunctioning stoma within 2 years of the reconstruction). To calculate HRs for restorative surgery after colectomy, as well as failure after restorative surgery, multivariable Cox regression models were performed (adjusted for sex, year of colectomy, colorectal cancer diagnosis, education, civil status, country of birth, income (quartiles 1 to 4, where Q4 represents highest income), hospital volume, and stratified by age). RESULTS: In all, 5969 patients with ulcerative colitis underwent colectomy, and of those, 2794 (46.8%) underwent restorative surgery. Restorative surgery was more common in patients with a high income at the time of colectomy (quartile 1, reference; quartile 2, 1.09 (0.98-1.21); quartile 3, 1.20 (1.07-1.34); quartile 4, 1.27 (1.13-1.43)) and less common in those born in a Nordic country than in immigrants born in a non-Nordic country (0.86 (0.74-0.99)), whereas no association was seen with educational level and civil status. There was no association between socioeconomic status and the risk of failure after restorative surgery. LIMITATIONS: The study was restricted to register data. CONCLUSIONS: Restorative surgery in ulcerative colitis appears to be more common in patients with a high income and patients born in a non-Nordic country, indicating inequality in the provided care. See Video Abstract at http://links.lww.com/DCR/B433. LA CIRUGA RESTAURADORA ES MS COMN EN PACIENTES CON COLITIS ULCEROSA CON INGRESOS ALTOS UN ESTUDIO POBLACIONAL: ANTECEDENTES:Para evitar un estoma permanente, se realiza una cirugía reparadora después de la colectomía. Estudios anteriores han demostrado que menos de la mitad de los pacientes con colitis ulcerosa se someten a cirugía reconstituyente.OBJETIVO:El objetivo principal fue explorar la asociación entre el nivel socioeconómico y la cirugía reconstituyente después de la colectomía.DISEÑO:Estudio de cohorte basado en registros a nivel nacional.MARCO:Suecia.PACIENTES:Todos los pacientes Suecos con colitis ulcerosa que se sometieron a colectomía desde el 1990 a 2017 a la edad de 15 a 69 años.MEDIDAS DE RESULTADOS PRINCIPALES:El resultado principal fue la cirugía restaurativa y el resultado secundario fue el fracaso de la reconstrucción (definida como la necesidad de una nueva ileostomía después de la reconstrucción o la no-reversión de un estoma disfuncional dentro de los dos años posteriores a la reconstrucción). Para calcular los cocientes de riesgo para la cirugía restauradora después de la colectomía, así como el fracaso después de la cirugía restauradora, se realizaron modelos de regresión de Cox multivariables (ajustados por sexo, año de colectomía, diagnóstico de cáncer colorrectal, educación, estado civil, país de nacimiento e ingresos (cuartiles 1- 4; donde Q4 representa los mayores ingresos), volumen de hospitales y estratificado por edad).RESULTADOS:En total 5969 pacientes con colitis ulcerosa se sometieron a colectomía, y de ellos 2794 (46,8%) se sometieron a cirugía restauradora. La cirugía restauradora fue más común en pacientes con altos ingresos en el momento de la colectomía (referencia del cuartil 1, cuartil 2: 1,09 (0,98-1,21), cuartil 3: 1,20 (1,07-1,34), cuartil 4: 1,27 (1,13-1,43)), y menos común en los nacidos en un país nórdico que en los inmigrantes nacidos en un país no-nórdico (0,86 (0,74-0,99)), mientras que no se observó asociación con el nivel educativo y el estado civil. No hubo asociación entre el nivel socioeconómico y el riesgo de fracaso después de la cirugía reparadora.LIMITACIONES:Restricción para registrar datos.CONCLUSIONES:La cirugía reparadora en colitis ulcerosa parece ser más común en pacientes con ingresos altos y en pacientes nacidos en un país no-nórdico, lo que indica desigualdad en la atención brindada. Consulte Video Resumen en http://links.lww.com/DCR/B433.

Is diverting loop ileostomy necessary for completion proctectomy with ileal pouch-anal anastomosis? A multicenter randomized trial of the GETAID Chirurgie group (IDEAL trial): rationale and design (NCT03872271).

BACKGROUND: There is no quality evidence of the benefit of defunctioning ileostomy (DI) in ileal pouch-anal anastomoses (IPAAs) performed for inflammatory bowel disease (IBD), but most surgical teams currently resort to DI. In the case of a staged procedure with subtotal colectomy first, completion proctectomy with IPAA is performed for healthy patients, namely, after nutritional support, inflammation reduction and immunosuppressive agent weaning. Therefore, the aim of this trial is to assess the need for systematic DI after completion proctectomy and IPAA for IBD. METHODS/DESIGN: This is a multicenter randomized open trial comparing completion proctectomy and IPAA without (experimental) or with (control) DI in patients presenting with ulcerative colitis or indeterminate colitis. Crohn's disease patients will not be included. The design is a superiority trial. The main objective is to compare the 6-month global postoperative morbidity, encompassing both surgical and medical complications, between the two groups. The morbidity of DI closure will be included, as appropriate. The sample size calculation is based on the hypothesis that the overall 6-month morbidity rate is 30% in the case of no stoma creation (i.e., experimental group) vs. 55% otherwise (control group). With the alpha risk and power are fixed to 0.05 and 0.80, respectively, and considering a dropout rate of 10%, the objective is set to 194 patients. The secondary objectives are to compare both strategies in terms of morbi-mortality at 6 months and functional results as well as quality of life at 12 months, namely, the 6-month major morbidity and unplanned reoperation rates, 6-month anastomotic leakage rate, 6-month mortality, length of hospital stay, 6-month unplanned readmission rate, quality of life assessed 3 and 12 months from continuity restoration (i.e., either IPAA or stoma closure), functional results assessed 3 and 12 months from continuity restoration, 12-month pouch results, 12-month cost-utility analysis, and 12-month global morbidity. DISCUSSION: The IDEAL trial is a nationwide multicenter study that will help choose the optimal strategy between DI and no ileostomy in completion proctectomy with IPAA for IBD. TRIAL REGISTRATION: ClinicalTrial.gov: NCT03872271, date of registration March 13th, 2019.

Economic Evaluations of Treatments for Inflammatory Bowel Diseases: A Literature Review.

Objective: The objective of this literature review was to evaluate the existing evidence regarding the cost-effectiveness of treatment options in IBD. Methods: A systematic review of the literature was conducted to identify economic evaluations of IBD therapy. The literature search was performed using electronic databases MEDLINE and EMBASE. Searches were limited to full economic evaluations published in English or French between 2004 and 2016. Results: A total of 5,403 potentially relevant studies were identified. After screening titles and abstracts, 48 studies were included, according to the eligibility criteria. A total of 56% and 42% of the studies were assessing treatments of UC or CD, respectively. Treatment options under evaluation included biological agents, mesalamine, immunosuppressants, and surgery. The majority of studies evaluated the cost-effectiveness of biological treatments. Biological therapies were dominant in 23% of the analyses and were cost-effective according to a $CAD50,000/QALY and $CAD100,000/QALY threshold in 41% and 62% of the analyses, respectively. Conclusion: This literature review provided a comprehensive overview of the economic evaluations for the different treatment options for IBD over the past 12 years and represents a helpful reference for future economic evaluations.

Considering Value in Rectal Cancer Surgery: An Analysis of Costs and Outcomes Based on the Open, Laparoscopic, and Robotic Approach for Proctectomy.

OBJECTIVE: The aim of the study was to compare value (outcomes/costs) of proctectomy in patients with rectal cancer by 3 approaches: open, laparoscopic, and robotic. BACKGROUND: The role of minimally invasive proctectomy in rectal cancer is controversial. In the era of value-based medicine, costs must be considered along with outcomes. METHODS: Primary rectal cancer patients undergoing curative intent proctectomy at our institution between 2010 and 2014 were included. Patients were grouped by approach [open surgery, laparoscopic surgery, and robotic surgery (RS)] on an intent-to-treat basis. Groups were compared by direct costs of hospitalization for the primary resection, 30-day readmissions, and ileostomy closure and for short-term outcomes. RESULTS: A total of 488 patients were evaluated; 327 were men (67%), median age was 59 (27-93) years, and restorative procedures were performed in 333 (68.2%). Groups were similar in demographics, tumor characteristics, and treatment details. Significant outcome differences between groups were found in operative and anesthesia times (longer in the RS group), and in estimated blood loss, intraoperative transfusion, length of stay, and postoperative complications (all higher in the open surgery group). No significant differences were found in short-term oncologic outcomes. Direct cost of the hospitalization for primary resection and total direct cost (including readmission/ileostomy closure hospitalizations) were significantly greater in the RS group. CONCLUSIONS: The laparoscopic and open approaches to proctectomy in patients with rectal cancer provide similar value. If robotic proctectomy is to be widely applied in the future, the costs of the procedure must be reduced.

Disability in Restorative Proctocolectomy Recipients Measured using the Inflammatory Bowel Disease Disability Index.

BACKGROUND AND AIMS: The inflammatory bowel disease [IBD] disability index [IBD-DI], which measures IBD-associated disability, has been validated on IBD patients but not those who have had restorative proctocolectomy with ileal pouch-anal anastomosis [RP with IPAA]. This study aimed to utilize the IBD-DI in RP with IPAA recipients and compare ulcerative colitis [UC]-indicated RP with IPAA patients to medically treated UC patients. METHODS: This study was population based. Demographic, indication, complication and direct cost data were collected via medical records while disability, quality of life [QoL] and indirect costs were measured using questionnaires and structured interviews. De-identified raw data about medically treated UC patients were provided by a previous study for comparison. RESULTS: In total there were 136 RP with IPAA patients [mean 11.5 years of follow up]. Eighty-four completed the IBD-DI and 80 completed the IBD questionnaire [IBDQ]. The IBDQ and IBD-DI were highly correlated [r = 0.84, p < 0.01]. Worse QoL and disability were found in those who had their position affected at work [both p < 0.01] and those who had more than 100 days off work in the last year [p < 0.01 for QoL and p = 0.012 for disability]. Lower QoL and disability scores were associated with higher indirect and total costs [p < 0.01]. UC patients treated with RP with IPAA had less disability than medically treated UC patients [p = 0.04]. CONCLUSIONS: Disability in RP with IPAA recipients can be measured using the IBD-DI. Perioperative complications and high costs of care are associated with higher levels of disability. Disability of RP with IPAA recipients was lower than that of medically managed UC patients.

Comparison of Costs and Quality of Life in Ulcerative Colitis Patients with an Ileal Pouch-Anal Anastomosis, Ileostomy and Anti-TNFα Therapy.

BACKGROUND AND AIMS: More data are warranted on the economic impact of different treatment strategies in ulcerative colitis (UC) patients. We compared the costs and quality of life of UC patients with a pouch reconstruction, an ileostomy or anti-tumour necrosis factor α (TNFα) therapy. METHODS: UC patients filled out 3-monthly questionnaires for 2 years. Differences in 3-monthly healthcare costs, productivity costs and patient costs were tested using mixed model analysis. Quality of life was assessed employing the ) and the inflammatory bowel disease questionnaire (IBDQ). RESULTS: Out of 915 UC patients, 81 (9%) had a pouch and 48 (5%) an ileostomy, and 34 (4%) were on anti-TNFα therapy. Anti-TNFα-treated patients reported high UC related-healthcare costs per 3 months (€5350). Medication use accounted for 92% of healthcare costs. UC-attributable healthcare costs were 3-fold higher in ileostomy patients compared with pouch patients (€1581 versus €407; p < 0.01). Main cost drivers in ileostomy patients were healthcare costs and ileostomy supplies (2 and 23% of healthcare costs, respectively). In pouch patients, the main cost driver was hospitalization, accounting for 50% of healthcare costs. Productivity loss did not differ between pouch and ileostomy patients (€483 versus €377; p < 0.23), but was significantly higher in anti-TNFα-treated patients (€1085). No difference was found in IBDQ scores, but pouch patients were found to have higher quality-adjusted life years than ileostomy patients and anti-TNFα-treated patients (0.90 [interquartile range 0.78-1.00] versus 0.84 [0.78-1.00] and 0.84 [0.69-1.00], respectively; p < 0.01). CONCLUSION: Patients receiving anti-TNFα therapy reported the highest healthcare cost, in which medication use was the major cost driver. Ileostomy patients were three times more expensive than pouch patients due to frequent hospitalization and ileostomy supplies.

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.

The potential benefits and disadvantages of laparoscopic surgery for ulcerative colitis: A review of current evidence.

Up to 35% of patients with ulcerative colitis will require surgery during the course of their disease. Nowadays, a total colectomy with ileal pouch-anal anastomosis is the preferred procedure, which can be performed open or via laparoscopic approach. Since the early '90s, minimally invasive techniques have gained popularity, but the extend of restorative procedures in these patients has restricted the use of laparoscopic approaches mainly to elective procedures in specialised centres. This review discusses the benefits and disadvantages of laparoscopic surgery when compared to open surgery. It presents the current evidence on short-term and long-term post-operative results, functional outcome, fecundity, and costs, for both elective and emergency indications. In addition, the value of new techniques (including single port surgery) and alternative laparoscopic approaches (e.g. ileo-rectal anastomosis, Kock-pouch and appendectomy) will be discussed.

A systematic review of economic evaluations of enhanced recovery pathways for colorectal surgery.

OBJECTIVE: To perform a systematic review of economic evaluations of enhanced recovery pathways (ERP) for colorectal surgery. BACKGROUND: Although there is extensive literature investigating the clinical effectiveness of ERP, little is known regarding its cost-effectiveness. METHODS: A systematic literature search identified all relevant articles published between 1997 and 2012 that performed an economic evaluation of ERP for colorectal surgery. Studies were included only if their ERP included all 5 of the key components (patient information, preservation of GI function, minimization of organ dysfunction, active pain control, and promotion of patient autonomy). Quality assessment was performed using the Consensus on Health Economic Criteria instrument (scored 0-19; high quality ≥ 12). Incremental cost-effectiveness ratios were calculated if sufficient data were provided, using difference in length of stay and overall complication rates as effectiveness measures. RESULTS: Of a total of 263 unique records identified (253 from databases and 10 from other sources), 10 studies met our inclusion criteria and were included for full qualitative synthesis. Overall quality was poor (mean quality 7.8). Eight reported lower costs for ERP. The majority (8 of 10) of studies were performed from an institutional perspective and therefore did not include costs related to changes in productivity and other indirect costs (eg, caregiver burden). Five studies provided enough information to calculate ICERs, of which ERP was dominant (less costly and more effective) in all cases for reduction in length of stay and was dominant or potentially cost-effective in 4 and questionable (no difference in costs nor effectiveness) in 1 for reduction in overall complications. CONCLUSIONS: The quality of the current evidence is limited but tends to support the cost-effectiveness of ERP. There is need for well-designed trials to determine the cost-effectiveness of ERP from both the institutional and societal perspectives.

Cost-effectiveness of biological agents used in ulcerative colitis.

Ulcerative colitis (UC) produces bloody diarrhoea, severe abdominal pain, and need for clinic visits, hospitalizations, and surgeries. UC results in reduced health-related quality of life for patients and large direct medical and indirect costs for health systems and employers. Patients with the most severe disease require the most medical services, and these patients have larger costs than patients with mild or moderate disease. Despite biological therapies being quite expensive, they are indicated for patients unresponsive to initial standard therapies. Future hospitalizations may be reduced by starting a biological treatment. Cost-effectiveness results vary between countries, health systems, and model designs. Since restorative proctocolectomy can be curative, this surgery dominates biological therapy by being both less costly and more effective when measuring health system costs and patient quality-adjusted life years for 20 years. However the dose, duration, and effectiveness of biological treatments significantly impact estimates of their cost-effectiveness.

Trends in the surgical treatment of ulcerative colitis over time: increased mortality and centralization of care.

BACKGROUND: New medical therapies available to ulcerative colitis (UC) patients have influenced operative mortality for patients requiring colectomy. We sought to examine trends in treatment and outcome for UC patients treated surgically. METHODS: A review of 36,447 UC patients from the Nationwide Inpatient Sample was performed, comparing the pre-monoclonal antibody era (1990-1996) to the present-day era (2000-2006). Patients treated with total colectomy with ileostomy or proctocolectomy with ileal pouch were reviewed for outcome measures and practice setting (rural, urban non-teaching, urban teaching). Our main outcome measures were in-hospital mortality, length of stay, and total charges. RESULTS: Total colectomy (n = 30,362) was performed five times more often than proctocolectomy (n = 6,085). When comparing the two study periods, mortality after total colectomy increased 3.8% to 4.6% (p = 0.0003). This difference was primarily due to increasing mortality in later years; when 1995-1996 was compared to 2005-2006, mortality increased from 3.6% to 5.6% (p < 0.0001). There were no deaths in the proctocolectomy group (p < 0.0001). The distribution by practice setting shifted over the two study periods, decreasing in rural (7.0% to 4.8%) and urban non-teaching (43.7% to 28.4%) centers, and increasing in urban teaching centers (49.3% to 66.8%). The total inflation-adjusted charges per patient increased significantly ($34,638 vs. $43,621; p < 0.0001). CONCLUSIONS: The mortality rate after total colectomy is increasing, and the difference is accentuated in the years since widespread use of monoclonal antibody therapy. The care of these patients is being shifted to urban teaching centers and is becoming more expensive.

Long-term direct costs before and after proctocolectomy for ulcerative colitis: a population-based study in Olmsted County, Minnesota.

PURPOSE: This study was designed to test the hypothesis that patients undergoing definitive surgery for chronic ulcerative colitis have reduced direct medical costs after, as compared with before, total proctocolectomy. METHODS: A population-based cohort of patients who underwent proctocolectomy for ulcerative colitis from 1988 to 2007 was identified using the Rochester Epidemiology Project. Total direct healthcare costs were estimated from an administrative database. The primary outcome was the observed cost difference between the two-year period before surgery and the two-year period after a surgery/recovery period (surgery + 180 days). Statistical significance was assessed using paired t-tests and bootstrapping methods. Demographic data were presented as median (interquartile range) or frequency (proportion). Mean costs are reported in 2007 constant dollars. RESULTS: Sixty patients were Olmsted County, Minnesota, residents at the time of surgery and for the entire period of observation. Overall 40 patients (66%) were men, median age was 42 (range, 31-52) years, and duration of median colitis was four (range, 1-11) years. Operations included ileal pouch-anal anastomosis (n = 45, mean cost of surgery/recovery period = $50,530) and total proctocolectomy with Brooke ileostomy (n = 15, mean cost of surgery/recovery period = $39,309). In the pouch subgroup, direct medical costs on average were reduced by $9,296 (P < 0.001, bootstrapped 95% confidence interval: $324-$15,628) during the two years after recovery. In the Brooke ileostomy subgroup, direct medical costs on average were reduced by $12,529 (P < 0.001, bootstrapped 95% confidence interval: $6,467-$18,688) in the two years after recovery. CONCLUSION: Surgery for chronic ulcerative colitis resulted in reduced direct costs in the two years after surgical recovery. These observations suggest that surgical intervention for ulcerative colitis is associated with long-term economic benefit.

[Laparoscopic surgery for inflammatory bowel disease; an update]. / Laparoscopische chirurgie voor inflammatoire darmziekten: een update.

OBJECTIVE: To carry out a review of the literature for the short- and long-term effects of various laparoscopic operations in the inflammatory bowel diseases ulcerative colitis and Crohn's disease and to compare these operations with open surgical procedures. DESIGN: Review of the literature. METHOD: PubMed (Medline), Embase and Cochrane databases were searched for randomised clinical trials and meta-analyses on this topic, published between January 1991 and August 2008. If no level A1, A2 or A2B studies were found, we searched for the best available evidence. RESULTS: For Crohn's disease, there was level A2 evidence that, in comparison with open surgery, in experienced hands laparoscopic ileocaecal resection enhanced recovery and led to a shorter hospital stay and lower costs. Following laparoscopic surgery, subjective body image and cosmetic appearance scores were higher, when compared in the long term. In patients with ulcerative colitis, the expected benefits of laparoscopic proctocolectomy have not yet been demonstrated in a randomised study. Although there was a trend towards a reduced hospital stay (1.6 days) when laparoscopy proctocolectomy was performed, the operating time was 1.5 h longer than in conventional surgery. Body image and cosmetic appearance scores were also higher here when compared in the long term. CONCLUSION: Laparoscopic ileocaecal resection is preferable in Crohn's disease, provided that it is performed in a centre with sufficient expertise in laparoscopic surgery. In patients with ulcerative colitis, laparoscopic proctocolectomy with construction of an ileoanal pouch is indicated in young active patients who are concerned for their appearance. Given its complexity, this operation should be performed only in specialist centres.

Laparoscopic restorative proctocolectomy with ileal S-pouch.

PURPOSE: Restorative proctocolectomy has revolutionized the surgical management of ulcerative colitis and familial polyposis syndromes. Though now evolved to include laparoscopy, this approach has not included alternative pouch designs such as ileal S-pouch reconstruction. This comparative analysis evaluated the combination of laparoscopic-assisted total proctocolectomy with an ileal S-pouch design. METHODS: One hundred fifty-six (65 laparoscopic-assisted) total proctocolectomy and ileal S-pouch-anal anastomosis procedures performed between 2003 to 2007 were identified from a prospective surgical database. Operative time, length of incision, length of hospital stay, complications, and return of bowel function were examined. A cost analysis including preoperative through postoperative hospital stay and operating room and postanesthesia care unit costs was performed. RESULTS: The laparoscopic-assisted total proctocolectomy and ileal S-pouch-anal anastomosis procedures were performed for ulcerative colitis in 60 cases and familial adenomatous polyposis in the remaining 5 patients. Four conversions to open technique occurred (6 percent). Comparing laparoscopic and open procedures, the laparoscopic approach took longer to perform than the open technique (mean 451 minutes vs. 347 minutes open; P < 0.001). The mean hospital stay was 6.3 days in the laparoscopic group vs. 8.2 days in the open group (P < 0.001). A detailed cost analysis revealed similar overall costs between the laparoscopic ($18,700) and open approaches ($18,500). CONCLUSION: Use of a laparoscopic total proctocolectomy with ileal S-pouch-anal anastomosis reconstruction minimizes incision size and shortens hospital stay. At a teaching academic institution, the laparoscopic approach requires longer operative times yet a negligible cost disadvantage.

Surgery insight: minimally invasive surgery for IBD.

The most frequently described laparoscopic operations for the management of patients with IBD are restorative proctocolectomy for ulcerative colitis and ileocolic resection for Crohn's disease. For patients with Crohn's disease, there is level 1b evidence that, in experienced hands, laparoscopic ileocolic resection enhances recovery and leads to a shorter hospital stay compared with conventional ileocolic resection. The demonstrated advantages of laparoscopic ileocolic resection with regard to cost and cosmesis, and the acceptable long-term results achieved (which are at least comparable to those achieved by conventional ileocolic resection) favor the use of laparoscopic ileocolic resection over conventional ileocolic resection in patients with ileocolic Crohn's disease. For patients with ulcerative colitis, the expected advantages of laparoscopic restorative proctocolectomy over conventional restorative proctocolectomy have yet to be clearly shown. Although there is a trend towards a reduced hospital stay (of only 1.6 days) when laparoscopic restorative proctocolectomy is performed, operating times are disproportionably prolonged. The most important argument for offering patients with IBD the chance to undergo a laparoscopic procedure, rather than conventional open surgery, is (particularly for women) the long-term superior cosmesis and body image it confers.

Hand-assisted laparoscopic versus open restorative proctocolectomy with ileal pouch anal anastomosis: a randomized trial.

OBJECTIVE: The aim of the study was to evaluate postoperative recovery after hand-assisted laparoscopic or open restorative proctocolectomy with ileal pouch anal anastomosis for ulcerative colitis and familial adenomatous polyposis in a randomized controlled trial. METHODS: Sixty patients were randomized for hand-assisted laparoscopic (n = 30) or open surgery (n = 30). Primary outcome parameter was postoperative recovery in the 3 months after surgery, measured by quality of life questionnaires (SF-36 and GIQLI). Secondary parameters were postoperative morphine requirement and surgical parameters, viz. operating time, morbidity, hospital stay, and costs. RESULTS: There was no difference between the 2 procedures in quality of life assessment in the 3 months after surgery. There was a significant decline in quality of life on all scales of the SF-36 (P < 0.001) and total GIQLI score (P < 0.001) in the first 2 weeks in both groups (no significant difference between the groups). Quality of life returned to baseline levels after 4 weeks. Operating times were longer in the laparoscopic group compared with the open group (210 and 133 minutes, respectively; P < 0.001). No significant differences were found in morphine requirement. Neither morbidity nor postoperative hospital stay differed between the laparoscopic and open group (20% versus 17%, in 10 versus 11 days, respectively). Median overall costs were 16.728 for the hand-assisted laparoscopic procedure and 13.406 for the open procedure (P = 0.095). CONCLUSIONS: Recovery measured using quality of life questionnaires is comparable for hand-assisted laparoscopic or open restorative proctocolectomy with ileal pouch anal anastomosis. The laparoscopic approach is as safe, but more costly than the open procedure.

Hospital costs and risk factors associated with complications of the ileal pouch anal anastomosis.

BACKGROUND: The purpose of this study was to estimate the costs associated with the most common complications of the ileal pouch anal anastomosis (IPAA) and identify factors that predispose to them. METHODS: Hospital costs of 135 patients undergoing the IPAA were combined with information abstracted from charts. Logistic and linear regression modeling were used to estimate the marginal costs for the most common IPAA complications and determine factors predisposing to their occurrence. RESULTS: The average overall cost for the IPAA was $20,865. Just more than half (53%) of patients experienced complications, the 3 most common being small-bowel obstruction (24.4%), pelvic/abdominal sepsis (6.7%), and dehydration (5.9%). The average cost to treat an episode of small-bowel obstruction was $6709. Treatment of pelvic/abdominal sepsis averaged $9268 per occurrence, whereas dehydration averaged $4860. Steroid use > 3 months before colectomy significantly increased the risk for any complication (P =.02). No factors were found to be good predictors of bowel obstruction. However, age > 42 years and low patient hematocrit were significant predictors of dehydration as a complication (P <.05). Trending toward significance were urgent operation and weight loss greater than 5%. CONCLUSIONS: The most common complications of the IPAA are small-bowel obstruction, pelvic/abdominal sepsis, and dehydration. Complications were responsible for approximately 44% of the overall cost of an IPAA. Factors that increase risk of IPAA complications are steroid use, low hematocrit, age > 42 years, nonelective procedures, and preoperative weight loss.

Laparoscopy for inflammatory bowel disease: pros and cons.

The role of laparoscopic surgery in the treatment of colorectal malignancies is still under investigation, although it can offer significant benefits to many patients with inflammatory bowel disease (IBD). The aim of this study was to assess the pros and cons of the laparoscopic management of IBD. Data were obtained from a review of the literature published since 1992, when the first report of laparoscopic surgery for IBD appeared in print. From 1992 to 1997 several series of laparoscopic colorectal surgery for the management of IBD have been reported. A close evaluation of these studies revealed that laparoscopy in patients with terminal ileal Crohn's disease or anal Crohn's disease in need of fecal diversion offers significant advantages compared to laparotomy, including decreased pain, length of hospitalization, and disability. An additional bonus is improved cosmesis and a reduction in symptomatic postoperative adhesions. These many benefits can be achieved without any increase in morbidity or expense. Conversely, the use of this technology for restorative proctocolectomy in patients with mucosal ulcerative colitis is associated with a longer operative time and an increased incidence of both intra- and postoperative complications compared to laparotomy. Laparoscopic colorectal surgery can thus be advantageous for treatment of terminal ileal Crohn's disease but cannot be routinely justified for the treatment of mucosal ulcerative colitis.

Implementation of a clinical pathway decreases length of stay and hospital charges for patients undergoing total colectomy and ileal pouch/anal anastomosis.

BACKGROUND: Clinical pathways are increasingly being used by hospitals to improve efficiency in the care of certain patient populations; however, little prospective data are available to support their use. This study examined whether using a clinical pathway for patients undergoing ileal pouch/anal anastomosis, a complex procedure in which we had extensive practical experience, affected hospital charges or length of stay (LOS). METHODS: A clinical pathway was developed to serve patients undergoing elective total colectomy and ileal pouch/anal anastomosis. All operations were performed by two attending physicians (J.E.F., M.S.N.). Before implementation, 10 pilot patients were prospectively monitored to ensure that hospital charges were accurately generated. In addition, charge audits were performed by an outside agency to verify the accuracy of the hospital bills. The pathway was then implemented, and 14 patients were prospectively analyzed. RESULTS: In all patients the principal diagnosis was ulcerative colitis, with the exception of three patients with familial polyposis. Mean external audit charges were within 2% of the hospital bills; therefore the hospital bills were used in all calculations. The mean LOS decreased from 10.3 days to 7.5 days (p = 0.046) for patients on the pathway versus pilot patients. Mean hospital charges also decreased significantly, from $21,650 to $17,958 per patient (p = 0.005). CONCLUSIONS: Implementation of a clinical pathway, even for an operation in which the surgeon has much experience, is an effective method for reducing LOS and charges for patients. This is likely the result of interdisciplinary cooperation, elimination of unnecessary interventions, and streamlined involvement of ancillary services. These results support the development of clinical pathways for procedures that involve routine preoperative and postoperative care. In addition, the benefits of clinical pathways should increase proportionally with increasing case volume for a particular procedure.