Risk and location of cancer in patients with preoperative colitis-associated dysplasia undergoing proctocolectomy.

OBJECTIVE: To evaluate the influence of preoperative dysplasia grade, appearance, and site on risk and location of cancer in patients with colitis. BACKGROUND: The ability to predict the presence and location of cancer in colitis patients with dysplasia is essential to facilitate recommendations regarding the necessity and type of surgery. METHODS: Ulcerative and indeterminate colitis patients who underwent proctocolectomy for dysplasia were retrospectively selected. Patient characteristics and findings at colonoscopic surveillance were associated with findings on the surgical specimen by regression analysis. RESULTS: From 1984 to 2007, 348 proctocolectomy specimens with preoperative dysplasia showed cancer in 51 (15%) and dysplasia in 172 (49%) cases. Patients with preoperative high-grade dysplasia (HGD) had cancer in 29% compared with 3% in low-grade dysplasia (LGD) (P < 0.001). Patients with preoperative dysplasia-associated lesion/mass (DALM) had cancer in 25% compared with 8% in flat dysplasia (P < 0.001). In LGD with DALM, the risk of cancer was not significantly higher than in flat LGD (7% vs 2%, P = 0.3), but risk of cancer or HGD was higher with a threefold increase (29% vs 9%, P = 0.015). On multivariate analysis, HGD, DALM, and disease duration were independent risk factors for postoperative cancer. In patients with isolated colonic dysplasia above the sigmoid level, postoperative rectal involvement was limited. CONCLUSIONS: Risk of cancer for patients with HGD or DALM is substantial. Despite low risk of cancer in patients with flat LGD, threshold for surgery should be low given the high prevalence of postoperative pathologic findings. Only in selected cases, colonoscopic surveillance after discussion of associated risks may be acceptable, provided high patient compliance can be assured. Surgery should be considered in all other cases, because it is the only modality that can eliminate the risk of cancer. The location of preoperative dysplasia may allow for the clarification of the need for proctectomy especially in the poor risk surgical patient.

Less than 12 nodes in the surgical specimen after total mesorectal excision following neoadjuvant chemoradiation: it means more than you think!

BACKGROUND: A minimum of 12 examined lymph nodes (LN) is recommended to ensure adequate staging and oncologic resection of patients undergoing proctectomy for rectal adenocarcinoma. However, a decreased number of LN is not unusual in patients receiving neoadjuvant chemoradiation. PURPOSE: We hypothesized that a decreased number of LN in the proctectomy specimen of these patients may be an indicator of tumor response and be associated with improved prognosis. METHODS: A single-center colorectal cancer database was queried for c-stage II-III rectal cancer patients undergoing neoadjuvant chemoradiation followed by proctectomy between 1997 and 2007. Patients were categorized into two groups according to the number of LN retrieved from the proctectomy specimen: <12 LN versus ≥12 LN. Groups were compared with respect to demographics, tumor and treatment characteristics, and the following oncologic outcomes: overall-survival (OS), cancer-specific-mortality (CSM), cancer-free-survival (CFS), distant (DR), and local recurrences (LR). RESULTS: The query returned 237 patients. There were 173 (73 %) males, and the median age was 57 years [interquartile range (IQR) 49-66 years]. The median number of LN retrieved was 15 (IQR 10-23) and 70 (30 %) patients had less than 12 nodes examined. The <12 nodes group was older [60 (IQR 51-71 years) vs. 55 (IQR 48-65 years), p = 0.009] and had more pathologic complete responders (36 vs. 19 %, p = 0.01). No <12 nodes patient experienced a LR, whereas the 5-year LR rate was 11 % in the ≥12 nodes group (p = 0.004). Other oncologic outcomes were not significantly different. CONCLUSIONS: Retrieval of less than 12 nodes in the proctectomy specimen of rectal cancer patients treated with neoadjuvant chemoradiation does not affect OS, CSM, CFS, or DR and may be a marker of higher tumor response and, consequently, decreased LR rate.

Impact of smoking on disease phenotype and postoperative outcomes for Crohn's disease patients undergoing surgery.

AIM: Whether smoking affects disease distribution, phenotype, and perioperative outcomes for Crohn's disease (CD) patients undergoing surgery is not well characterized. The aim of this study is to evaluate the impact of smoking on disease phenotype and postoperative outcomes for CD patients undergoing surgery METHODS: Prospectively collected data of CD patients undergoing colorectal resection were evaluated. CD patients who were current smokers (CS) were compared to nonsmokers (NS) and ex-smokers (ES) for disease phenotype, anatomic site involved, procedures performed, postoperative outcomes, and quality of life using the Cleveland Global Quality of Life instrument (CGQL). RESULTS: Of 691 patients with a diagnosis of CD requiring surgery 314 were classified as CS, 330 as NS, and 47 as ES. CS and ES in comparison to NS were significantly older at diagnosis of Crohn's disease (mean, 29.3 vs. 29.2 vs. 26.3 years) (P = 0.001) and older at the time of primary surgery (mean, 42.9 vs. 48.4 vs. 39 years) (P = 0.001) with a greater frequency of diabetes. In all groups requiring surgery, there was a significant change in disease phenotype from the time of diagnosis to surgical intervention. The predominant phenotype at diagnosis was inflammatory which changed to stricturing and penetrating as the dominant phenotypes at time of surgery. All groups had a significant improvement in CGQL scores post-surgery with the greatest benefit observed in NS. Postoperative complications and 30-day readmission rates were similar between all groups. CONCLUSIONS: The findings of this study show that in patients with CD, disease phenotype changes over time. This occurs independent of smoking. Smoking does not appear to predispose to complications for CD patients undergoing surgery. CS and ES have a persistently reduced quality of life in comparison to NS post-surgery.

Impact of resident participation in surgical operations on postoperative outcomes: National Surgical Quality Improvement Program.

OBJECTIVE: To evaluate whether resident participation in operations influences postoperative outcomes. BACKGROUND: : Identification of potential differences in outcome associated with resident participation in operations may facilitate planning from educational and health resource perspectives. METHODS: From the National Surgical Quality Improvement Program database (2005-2007), postoperative outcomes were compared for patients with and without resident participation (RES vs no-RES). Groups were matched in a 2:1 ratio, based on age, sex, specialty, surgical procedure, morbidity probability, and important comorbidities and risk factors. RESULTS: RES (40,474; 66.7%) and no-RES (20,237; 33.3%) groups were comparable for matched characteristics. Mortality was similar (0.18% vs 0.20%, P = 0.55). Thirty-day complications classified as "mild" (4.4% vs 3.5%, P < 0.001) and "surgical" (7% vs 6.2%, P < 0.001) were higher in RES group. Individual complications were largely similar, except superficial surgical site infection (3.0% vs 2.2%, P < 0.001). Operative time was longer in the RES group [mean (SD) 122 (80) vs 97 (67) minutes, P < 0.001]. Overall complications were lower for postgraduate year 1-2 residents than for other years. These differences persisted on multivariate analysis adjusting for confounders. CONCLUSIONS: Resident involvement in surgical procedures is safe. The small overall increase in mild surgical complications is mostly caused by superficial wound infections. Reasons for this are likely multifactorial but may be related to prolonged operative time.

Dysplasia associated with Crohn's colitis: segmental colectomy or more extended resection?

BACKGROUND AND OBJECTIVE: There is limited data on the appropriate management of dysplasia in Crohn's colitis. An evidence-based surgical strategy is provided. METHODS: Patients with a pathologic diagnosis of dysplasia in Crohn's colitis from 1987 to 2009 were identified. Patients were classified by dysplasia grade (low grade or LGD, high grade or HGD). Clinical, endoscopic, operative, and pathologic data were retrieved. Factors associated with a final cancer diagnosis were analyzed. Survival data on patients undergoing limited versus radical resection for cancer and HGD was compared. RESULTS: From 1987 to 2009, 50 patients underwent a colectomy for Crohn's colitis-associated dysplasia. The predictive value of HGD for a final HGD or cancer diagnosis was 73%. The predictive value of LGD on biopsy for HGD in the colectomy was 36%. Sixteen patients (44%) who underwent a total proctocolectomy (TPC) or subtotal colectomy (STC) had multifocal dysplasia. Four of 10 (40%) cancer patients had evidence of dysplasia remote from cancer site on pathologic examination. During follow-up, there were 3 cancer-related deaths. One patient died of metachronous cancer after STC. CONCLUSIONS: The findings confirm the risk of cancer in patients with CD dysplasia. Because of the multifocal nature of dysplasia in Crohn's colitis, TPC is recommended in good-risk patients. In specific circumstances, such as poor-risk patients especially in the setting of LGD, close endoscopic surveillance or alternatively segmental or STC with close postoperative endoscopic surveillance, depending upon the individual circumstance, may be discussed.

Pelvic sepsis after IPAA adversely affects function of the pouch and quality of life.

BACKGROUND: Pelvic sepsis after IPAA predisposes to pouch failure. There are limited data on long-term pouch function for patients with pelvic sepsis. OBJECTIVE: The aim of this study was to investigate functional outcomes and quality of life for patients undergoing IPAA who develop pelvic sepsis and preserve their pouch long-term. DESIGN: This study is based on retrospective analysis of prospectively accrued data. SETTINGS: This study was conducted at a single-center institution. PATIENTS: All patients undergoing IPAA from 1983 to 2007 were included. MAIN OUTCOME MEASURES: The primary outcomes measured were functional outcomes (urgency, incontinence, bowel movements) and quality-of-life (restrictions, energy, happiness) parameters. RESULTS: Two hundred (6.2%) of 3234 patients developed pelvic septic complications within 3 months of IPAA. In the comparison of complications at the time of IPAA for the 2 groups, patients with pelvic sepsis had higher rates of postoperative hemorrhage (13.5% vs 3.7%, p < 0.001), anastomotic leak (35% vs 3.7%, p < 0.001), wound infection (14% vs 7.4%, p < 0.001), and fistula formation (37% vs 7.1%, p < 0.001). The overall median follow-up was 7 years. Pelvic sepsis was associated with greater pouch failure (19.5% vs 4%, p < 0.001). For patients with follow-up (pelvic sepsis = 144, nonpelvic sepsis = 2677) with a retained pouch, for whom we compared functional outcomes and quality of life, incontinence was worse (never/rare: 69.5% vs 77.8%, p = 0.03). Urgency scores were lower in pelvic sepsis but not statistically significant. The overall Cleveland Global Quality of Life score (and components) in the sepsis group were significantly worse than in the nonsepsis group (0.74 vs 0.79, p < 0.001). Patients who developed sepsis were also less likely to recommend IPAA to others than patients who did not develop pelvic sepsis. LIMITATIONS: This study was limited by the retrospective analysis and the use of questionnaires. CONCLUSIONS: Pelvic sepsis after IPAA leads to worse functional outcomes and quality of life even when it does not lead to pouch failure. This finding argues for careful attention to preoperative and intraoperative planning and strategies aimed at reducing this complication after IPAA.

Permanent ostomy after ileoanal pouch failure: pouch in situ or pouch excision?

BACKGROUND: The risks and benefits of pouch excision and end ileostomy creation when compared to the alternative option of a permanent diversion with the pouch left in situ when restoration of intestinal continuity is not pursued for patients who develop pouch failure after IPAA have not been well characterized. OBJECTIVE: This study aimed to compare the early and long-term outcomes after permanent diversion with the pouch left in situ vs pouch excision with end ileostomy creation for pouch failure. DESIGN: This study is a retrospective review of prospectively gathered data. SETTINGS: This investigation was conducted at a tertiary center. PATIENTS: Patients with pouch failure who underwent a permanent ileostomy with the pouch left in situ and those who underwent pouch excision were included in the study. MAIN OUTCOME MEASURES: The primary outcomes measured were the perioperative outcomes and quality of life using the pouch and Short Form 12 questionnaires. RESULTS: One hundred thirty-six patients with pouch failure underwent either pouch left in situ (n = 31) or pouch excision (n = 105). Age (p = 0.72), sex (p = 0.72), ASA score (p = 0.22), BMI (p = 0.83), disease duration (p = 0.74), time to surgery for pouch failure (p = 0.053), diagnosis at pouch failure (p = 0.18), and follow-up (p = 0.76) were similar. The predominant reason for pouch failure was septic complications in 15 (48.4%) patients in the pouch left in situ group and 39 (37.1%) patients in the pouch excision group (p = 0.3). Thirty-day complications, including prolonged ileus (p = 0.59), pelvic abscess (p = 1.0), wound infection (p = 1.0), and bowel obstruction (p = 1.0), were similar. At the most recent follow-up (median, 9.9 y), quality of life (p = 0.005) and health (p = 0.008), current energy level (p = 0.026), Cleveland Global Quality of Life score (p = 0.005), and Short Form 12 mental (p = 0.004) and physical (p = 0.014) component scales were significantly higher after pouch excision than after pouch left in situ. Urinary and sexual function was similar between the groups. Anal pain (n = 4) and seepage with pad use (n = 8) were the predominant concerns of the pouch left in situ group on long-term follow-up. None of the 18 patients with pouch in situ, for whom information relating to long-term pouch surveillance was available, developed dysplasia or cancer. LIMITATIONS: This study was limited by its retrospective nature. CONCLUSIONS: Although technically more challenging, pouch excision, rather than pouch left in situ, is the preferable option for patients who develop pouch failure and are not candidates for restoration of intestinal continuity. Because pouch left in situ was not associated with neoplasia, this option is a reasonable intermediate or long-term alternative when pouch excision is not feasible or advisable.

The role of primary surgical procedure in maintaining intestinal continuity for patients with Crohn's colitis.

OBJECTIVE: This study evaluates surgical procedures for Crohn's colitis. The risk of recurrence and how it interacts with future avoidance of permanent stoma and quality of life (QoL) is studied. BACKGROUND: Segmental and subtotal colectomy are widely used surgical options in isolated Crohn's colitis. It is not clear which procedure offers the best outcomes. METHODS: Patients undergoing index resection for isolated colonic Crohn's disease (CD) from 1995 to 2009, were identified from a prospectively maintained CD database. Patients were categorized into subtotal colectomy or segmental groups. Demographics, disease characteristics, operative details, morbidity, stoma formation, recurrence requiring surgery and QoL data were extracted. Recurrence and stoma free survival was calculated for each group and independent risk factors for recurrence and stoma formation identified. RESULTS: One hundred and eight patients (49 segmental, 59 subtotal) underwent primary colectomy with anastomosis. Segmental colectomy patients had significantly reduced recurrence free survival (P = 0.032) but not stoma free survival P = 0.62 on univariate analysis. On multivariate analysis, the presence of perianal sepsis (P = 0.032) and >1 medical comorbidity (P = 0.01), but not segmental colectomy, were associated with reduced SFS. There was no difference in Cleveland Global Quality of Life (P = 0.88), or Short Form Inflammatory Bowel Disease Questionnaire scores between groups (P = 0.92). CONCLUSIONS: Using a strictly defined cohort of patients, we were unable to identify segmental resection as an independent risk factor for recurrence or stoma formation and no reduction in QoL scores to suggest an adverse effect of recurrence was observed. Segmental colectomy affords good function, and our data supports the practice of a conservative approach with anastomosis in anatomically linked CD.

A characterization of factors determining postoperative ileus after laparoscopic colectomy enables the generation of a novel predictive score.

BACKGROUND/OBJECTIVE: Postoperative ileus (POI) after colorectal surgery is associated with prolonged hospital stay and increased costs. The aim of this study is to investigate pre-, intra-, and postoperative risk factors associated with the development of POI in patients undergoing laparoscopic partial colectomy. METHODS: Patients operated between 2004 and 2008 were retrospectively identified from a prospectively maintained database, and clinical, metabolic, and pharmacologic data were obtained. Postoperative ileus was defined as the absence of bowel function for 5 or more days or the need for reinsertion of a nasogastric tube after starting oral diet in the absence of mechanical obstruction. Associations between likelihood of POI and study variables were assessed univariably by using χ tests, Fisher exact tests, and logistic regression models. A scoring system for prediction of POI was constructed by using a multivariable logistic regression model based on forward stepwise selection of preoperative factors. RESULTS: A total of 413 patients (mean age, 58 years; 53.5% women) were included, and 42 (10.2%) of them developed POI. Preoperative albumin, postoperative deep-vein thrombosis, and electrolyte levels were associated with POI. Age, previous abdominal surgery, and chronic preoperative use of narcotics were independently correlated with POI on multivariate analysis, which allowed the creation of a predictive score. Patients with a score of 2 or higher had an 18.3% risk of POI (P < 0.001). CONCLUSION: Postoperative ileus after laparoscopic partial colectomy is associated with specific preoperative and postoperative factors. The likelihood of POI can be predicted by using a preoperative scoring system. Addressing the postoperative factors may be expected to reduce the incidence of this common complication in high-risk patients.

Backwash ileitis does not affect pouch outcome in patients with ulcerative colitis with restorative proctocolectomy.

BACKGROUND & AIMS: There has been controversy over the significance of active inflammation of the terminal ileum (also known as backwash ileitis) in patients with ulcerative colitis (UC) and idiopathic inflammatory bowel disease of indeterminate type for diagnosis and pouch construction. We investigated the impact of backwash ileitis on pouch outcome after restorative proctocolectomy with ileoanal pouch anastomosis. METHODS: Data from patients with backwash ileitis (n = 132) were compared with those from 132 matched controls without ileal inflammation for age, sex, and type of proctocolectomies with ileal pouch construction (1- or 2-stage). We evaluated terminal ileal sections from original colectomies of 2213 patients with either UC or idiopathic inflammatory bowel disease of indeterminate type, collected during a 21-year period, for extent and severity of chronic and active ileitis. Clinical pouch outcomes were assessed through a longitudinally maintained clinical outcome database that systematically catalogued all short-term and long-term pouch complications, including pouchitis, sepsis, impaired long-term pouch survival, and conversion to Crohn's disease. RESULTS: Regardless of severity or extent, backwash ileitis was not correlated with any clinical outcome examined, short-term or long-term. CONCLUSIONS: Ileal inflammation is not a contraindication for restorative proctocolectomy with ileal pouch construction in patients with UC or idiopathic inflammatory bowel disease of indeterminate type. Ileal inflammation with pancolitis is not a useful criterion for classifying otherwise typical UC as colitis of indeterminate type, because pouch outcomes are not affected.

Preoperative colorectal neoplasia increases risk for pouch neoplasia in patients with restorative proctocolectomy.

BACKGROUND & AIMS: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has substantially reduced the risk for ulcerative colitis (UC)-associated dysplasia or cancer (neoplasia). We characterized features, risk factors, and outcomes of pouch neoplasia in patients with inflammatory bowel disease in a historical cohort study. METHODS: A total of 3203 patients with a preoperative diagnosis of inflammatory bowel disease underwent restorative proctocolectomy with IPAA from 1984 to 2009 at the Cleveland Clinic. Demographic, clinical, and endoscopic data were reviewed and samples were examined by histological analyses. Univariable and Cox regression analyses were performed. RESULTS: Cumulative incidences for pouch neoplasia at 5, 10, 15, 20, and 25 years were 0.9%, 1.3%, 1.9%, 4.2%, and 5.1%, respectively. Thirty-eight patients (1.19%) had pouch neoplasia, including 11 (0.36%) with adenocarcinoma of the pouch and/or the anal-transitional zone (ATZ), 1 (0.03%) with pouch lymphoma, 3 with squamous cell cancer of the ATZ, and 23 with dysplasia (0.72%). In the Cox model, the risk factor associated with pouch neoplasia was a preoperative diagnosis of UC-associated cancer or dysplasia, with adjusted hazard ratios of 13.43 (95% confidence interval: 3.96-45.53; P < .001) and 3.62 (95% confidence interval: 1.59-8.23; P = .002), respectively. Mucosectomy did not protect against pouch neoplasia. CONCLUSIONS: Risk for neoplasia in patients with UC and IPAA is small and not eliminated by colectomy or mucosectomy. A preoperative diagnosis of dysplasia or cancer of colon or rectum is a risk factor for pouch dysplasia or adenocarcinoma.

Individual surgeon, pathologist, and other factors affecting lymph node harvest in stage II colon carcinoma. is a minimum of 12 examined lymph nodes sufficient?

BACKGROUND: Insufficient lymph node harvest in presumed stage II colon carcinomas can result in understaging and worsened cancer outcomes. The purpose of this study was to evaluate factors affecting the number of lymph node examined, their corresponding impact on cancer outcomes, and the optimal number of examined nodes with reference to the standard of 12. MATERIALS AND METHODS: We evaluated all patients undergoing surgery alone for stage II colon cancer included in our colorectal cancer database since 1976. RESULTS: A total of 901 patients were included. Mean follow-up exceeded 8 years. The individual pathologist had no statistically significant association with the number of lymph nodes examined. Harvest of at least 12 nodes was related to surgery after 1991 (85% vs 69%, P < 0.001), right vs left colon carcinomas (85% vs 72%, P < 0.001), individual surgeon (P = 0.018), and length of specimen at different cutoffs of at least 30, 25, and 20 cm (P < 0.001). Increasing age was associated with fewer examined lymph nodes (Spearman correlation = -0.22, P < 0.001). Fewer than 12 nodes and T4N0 staging independently affected overall survival (P = 0.003 and P = 0.022, respectively), disease-free survival (P = 0.010 and P = 0.09, respectively), disease-specific mortality (P = 0.009 and P < 0.001, respectively), and overall recurrence (P = 0.13 and P = 0.023, respectively). A minimal number of more than 12 examined nodes had no significant effect on cancer outcomes. CONCLUSIONS: A number of factors influenced lymph node harvest in stage II colon cancer. However, lymph node assessment of at least 12 nodes was the only modifiable factor optimizing cancer outcomes.

Pathologic complete response after neoadjuvant treatment for rectal cancer decreases distant recurrence and could eradicate local recurrence.

BACKGROUND: The aim of this study was to evaluate the clinical implications of pathologic complete response (pCR) (i.e., T0N0M0) after neoadjuvant chemoradiation and radical surgery in patients with locally advanced rectal cancer. MATERIALS AND METHODS: A single-center, prospectively maintained colorectal cancer database was queried for patients with primary cII and cIII rectal cancer staged by CT and ERUS/MRI undergoing long-course neoadjuvant chemoradiation followed by proctectomy with curative intent between 1997 and 2007. Patients were stratified into pCR and no-pCR groups and compared with respect to demographics, tumor and treatment characteristics, and oncologic outcomes. Outcomes evaluated were 5-year overall survival, disease-free survival, disease-specific mortality, local recurrence, and distant recurrence. RESULTS: The query returned 238 patients (73% male), with a median age of 57 years and median follow-up of 54 months. Of these, 58 patients achieved pCR. Patients with pCR vs no-pCR were statistically comparable with respect to demographics, chemoradiation regimens, tumor distance from anal verge, clinical stage, surgical procedures performed, and follow-up time. No patient with pCR had local recurrence. Overall survival and distant recurrence were also significantly improved for patients achieving pCR. CONCLUSIONS: Achievement of pCR after neoadjuvant chemoradiation is associated with greatly improved cancer outcomes in locally advanced rectal cancer. Future studies should evaluate the relationship between increases in pCR rates and improvements in cancer outcomes in this population.

Perioperative factors during ileal pouch-anal anastomosis predict pouchitis.

PURPOSE: Pouchitis is the most common complication of IPAA. Identifying factors predictive of pouchitis may improve outcomes by modifying contributing factors and enhancing patient selection. The most objective means for confirming pouchitis is by histology because the clinical and endoscopic diagnoses rely on more subjective assessments. The importance of histological pouchitis in the absence of clinical or endoscopic findings is unknown. METHODS: Prospectively collected data on patients with IPAA and pouch surveillance were evaluated. Patients who developed pouchitis, defined as symptoms of pouchitis confirmed by endoscopic biopsy (group B) were compared with those without any episode of clinical, endoscopic, or histological pouchitis (group A) for pre- and intraoperative factors and outcomes. Asymptomatic patients with histological pouchitis on surveillance biopsies (group C) were further compared with group A. Patients with Crohn's disease were excluded. RESULT: Of the 673 patients with pouch biopsies, 422 (62.7%) were in group A, 161 (23.9%) in group B, and 90 (13.4%) in group C. Mean follow-up was 9.8 (±5.1), 12.4 (±5.4), and 13. (±4.7) years. Of the 43 preoperative factors evaluated, those associated with group B included leukocytosis (P < .001), rheumatologic extraintestinal disease (P < .001), disease proximal to splenic flexure (P = .001), pulmonary comorbidity (P = .004), prior steroid use (P = .006), and age at operation and diagnosis (P = .018 and .021). Of the 10 intraoperative factors evaluated, pouchitis was associated with S-pouch reconstruction (P < .001), transfusion (P < .001), and 2-stage instead of 3-stage operation (P = .05), all surrogates for operative complexity. On multivariate analysis, pulmonary comorbidity (OR 3.38, 95% CI 1.62-7.07), disease proximal to splenic flexure (OR 2.37, 95% CI 1.18-4.77), extraintestinal disease manifestations (OR 1.6, 95% CI 1.01-2.54), and S-pouch reconstruction (OR 1.59, 95% CI 0.99 - 2.54) were associated with pouchitis. Patients in group B had worse outcomes, including more strictures (P = .015), bowel obstructions (P = .019), fistulas (P = .18), and lower quality of life (P < .001). Group C patients had the same outcomes as those in group A and the finding was not predicted by the above-mentioned parameters. CONCLUSION: Patients with symptomatic, biopsy-confirmed pouchitis have worse long-term outcomes than those without pouchitis. This complication is associated with specific pre- and intraoperative factors. Histological pouchitis incidentally found on surveillance biopsy in asymptomatic patients is of no clinical relevance and does not influence outcome. Identification of these preoperative factors associated with the subsequent development of pouchitis will strengthen patient counseling and may facilitate risk stratification.

Factors associated with ileoanal pouch failure in patients developing early or late pouch-related fistula.

BACKGROUND: The natural history of a pouch-related fistula in terms of timing of its development and its impact on pouch survival is poorly defined. OBJECTIVE: This study aimed to evaluate factors associated with the time of onset of ileoanal pouch-related fistulas and predictors of pouch failure after the development of fistulas. DESIGN: This study is an evaluation of prospectively collected data from a cohort of patients with pouch-related fistulas. SETTING: Patients were identified from a prospective ileoanal pouch database, with data recorded from 1983 to 2009. PARTICIPANTS: Patients who participated had developed a fistula after ileoanal pouch surgery. Patients were classified according to the time of onset, origin, and target of pouch fistulas into "early" and late" groups. MAIN OUTCOME MEASURE: Ileoanal pouch failure was the main outcome measure. RESULTS: Three hundred six patients (158 early-onset, 148 late-onset) with 373 pouch-related fistulas were identified. The early-onset group had a higher mean body mass index (P = .013) and more patients in this group developed a postoperative leak (P < .001), whereas diagnosis revision to Crohn's disease was more frequent in the late-onset group (P = .018). Overall, pouch failure occurred in 89 (29%) patients. Major abdominal procedures were more common in the early-onset group (18 vs 6%). There was no difference in pouch failure between the early- and late-onset groups (P = .24). On multivariate analysis, a current Crohn's diagnosis (P < .001), major fistula (P = .022), history of colectomy before ileoanal pouch (P = .005), handsewn anastomosis (P = .008), anastomotic leak (P = .012), and body mass index over 30 (P = .018) were independent risk factors for failure. No individual risk factor for failure was separately associated with either early or late fistula groups. CONCLUSIONS: The timing and etiology of pouch fistula appear to be interrelated. There is a temporal association between procedure-related sepsis and early and delayed diagnosis of Crohn's disease and late fistula development. Cause of the fistula and associated factors rather than timing after IPAA is associated with long term pouch retention.

Management of leak from the tip of the "J" in ileal pouch-anal anastomosis.

BACKGROUND: Diagnosis and management of leak from the tip of the J-pouch after IPAA has not been systematically studied. OBJECTIVE: The aim of this study is to report our experience in the diagnosis and management of these leaks following primary IPAA. DESIGN: This study is a retrospective review of prospectively gathered data. SETTINGS: Data were obtained from a prospectively maintained single-institution pelvic pouch database. PATIENTS: Included in this study were patients with a leak from the tip of the J-pouch after primary IPAA. MAIN OUTCOME MEASURES: The main measures of outcomes after salvage surgery were pouch failure, pouch function, and quality of life. RESULTS: There were 27 (14 male) patients. Median age was 37 years (range, 20-73). Underlying disease in these patients was ulcerative colitis in 22 patients. Predominant symptoms were abdominal pain (n = 15) and fever (n = 5). Twenty patients had either a pelvic abscess detected by CT or MRI or a leak demonstrated at gastrografin enema or pouchoscopy. In 6 patients, the diagnosis was only made at salvage surgery. In 1 patient, the leak-associated abscess was detected during emergent laparotomy for acute peritonitis before salvage surgery. Of 27 patients, 1 had successful CT-guided drainage without the need for further surgery. Another patient had pouch resection with end ileostomy. Salvage surgery was performed in 25 patients by means of pouch repair (n = 23) and new pouch creation (n = 2); 8 patients had a repeat anastomosis. Median time from primary IPAA to salvage surgery was 0.9 years (0.13-9.8). Twenty-four patients with salvage surgery have a functioning pouch after a mean follow-up of 3.2 ± 1.9 years. LIMITATIONS: : The study was limited by its retrospective nature. CONCLUSIONS: Leak from the tip of the J-pouch is indolent and diagnosis can be difficult. Satisfactory outcomes in terms of pouch retention may be expected after appropriate surgical management.

Prone or lithotomy positioning during an abdominoperineal resection for rectal cancer results in comparable oncologic outcomes.

BACKGROUND: There is debate whether performing the perineal part of the abdominoperineal resection in a prone position in comparison with a lithotomy position optimizes circumferential resection margins and, subsequently, cancer outcomes. OBJECTIVE: The aim of this study was to compare outcomes of patients undergoing abdominoperineal in a prone vs a lithotomy position. DESIGN: A single-center, prospectively maintained colorectal cancer database was queried for patients with stages I to III rectal cancer undergoing abdominoperineal resection in a prone vs a lithotomy position from 1997 to 2007. Patients were compared with respect to demographics, tumor and treatment characteristics, perioperative morbidity, and oncologic outcomes. Oncologic outcomes were adjusted for age, ASA class, tumor stage, and use of adjuvant treatments. χ², Fisher exact probability test, Wilcoxon rank-sum test, Kaplan-Meier estimates, log-rank sum test, and Cox regression models were used for the analysis. P < .05 was considered significant. RESULTS: The query returned 168 patients (81 prone and 87 lithotomy), with a median age of 63 (interquartile range, 52-74) years and a median follow-up of 42 (interquartile range, 23-69) months. Prone and lithotomy patients were not statistically different regarding demographics, tumor stage, rates of R0 resection, number of harvested nodes, perioperative morbidity, follow-up time, and oncologic outcomes. CONCLUSIONS: Surgical positioning during the perineal part of the abdominoperineal resection does not affect perioperative morbidity or oncologic outcomes and should be left to the surgeon's discretion.

Transmural inflammation is not pathognomonic for Crohn's disease of the pouch.

BACKGROUND: Transmural inflammation shown by imaging and histology has been considered a hallmark of Crohn's disease (CD). However, the diagnostic and prognostic value of this feature in CD of the pouch has not been evaluated. This study aimed to evaluate the clinical utility of transmural inflammation in patients with ileal pouch-anal anastomosis (IPAA) using in vivo optical coherence tomography (OCT) and histopathology. METHODS: All the patients were recruited from the subspecialty Pouchitis Clinic. The study consisted of two parts: (1) a prospective study with in vivo through-the-scope OCT for the evaluation of transmural disease in patients with normal or diseased pouches and (2) a retrospective pathology re-review for transmural inflammation in excised pouch specimens of CD and chronic pouchitis. RESULTS: This prospective OCT study enrolled 53 patients: 11 (20.8%) with normal pouches or irritable pouch syndrome, 10 (18.9%) with acute pouchitis, 11 (20.8%) with chronic antibiotic-refractory pouchitis (CARP), and 21 (39.6%) with CD of the pouch. Transmural inflammation, characterized by the loss of layered structure on OCT, was detected in 16 patients (30.2%): 4 with chronic pouchitis and 12 with CD of the pouch. None of the patients with normal pouches, irritable pouch syndrome, or acute pouchitis had transmural disease shown on OCT. Of the 26 patients with pouch failure who had pouch excision, the surgical specimens showed transmural disease in 30% of the CARP patients (3/10) and 12.5% (2/16) of those with CD of the pouch. CONCLUSIONS: Transmural disease in the setting of IPAA is not pathognomonic of CD. Transmural inflammation shown by imaging or histopathology was seen in both CD and CARP. Transmural inflammation of the pouch appeared to be associated with poor pouch outcome.

Risk of colorectal adenoma and carcinoma after colectomy for colorectal cancer in patients meeting Amsterdam criteria.

OBJECTIVE: To report the risk of metachronous colorectal neoplasia after colectomy for cancer in Hereditary Nonpolyposis Colorectal Cancer (HNPCC) syndrome. SUMMARY BACKGROUND DATA: Patients meeting Amsterdam criteria for diagnosis of HNPCC have a lifetime colorectal cancer risk approaching 80%, and a metachronous cancer rate of approximately 25%. Therefore, when colon cancer is diagnosed, total rather than segmental colectomy is advocated. However, information about adenoma and carcinoma risk after index surgery is still underreported. METHODS: A hereditary colorectal cancer database was reviewed for patients meeting Amsterdam criteria who underwent colectomy for cancer. Patient demographics, surgical management, and results of follow-up were recorded. Metachronous colorectal adenoma and carcinoma development were the primary end points. RESULTS: A total of 296 patients (253 with segmental colectomy and 43 with total colectomy/ileorectal anastomosis) were analyzed. Of the 253 segmental colectomy patients, 221 (88%) had postoperative endoscopic surveillance with median follow-up of 104 months. In 74 patients (33%), 256 adenomas were detected, including 140 high-risk adenomas in 48 patients (22%). Fifty-five patients (25%) developed a second colorectal cancer at a median of 69 months after index surgery. Stages of the metachronous cancers were I-16, II-18, III-12, and IV-2. By comparison, 4 of 38 patients (11%) who underwent total colectomy developed subsequent high-risk adenomas and 3 (8%) developed metachronous cancer. CONCLUSIONS: Amsterdam patients undergoing partial colectomy have a high rate of metachronous high-risk adenomas and carcinomas. Total colectomy for the index cancer is the procedure of choice. For either surgical option, yearly endoscopic surveillance is essential to remove premalignant adenomas.

Factors associated with septic complications after restorative proctocolectomy.

OBJECTIVE: Few studies have evaluated factors that may be associated with the development of septic complications after restorative proctocolectomy. Therefore, the aim of this study is to evaluate preoperative and operative factors that might be associated with septic complications after restorative proctocolectomy. METHODS: Patients developing abdominal and pelvic septic complications after restorative proctocolectomy were identified from a prospective database. Patients with subclinical leaks and ileostomy closure leak were not included in the septic complication group. A multivariable logistic regression model for sepsis was constructed using a forward stepwise selection with entry criterion of P < 0.05. RESULTS: From 1983 to 2007, 3233 patients (56% male) were included in the database. Eight-four percent (2597) of patients underwent proximal diversion. Two hundred patients (6.2%) developed septic complications within 3 months of restorative proctocolectomy or within 3 months of ileostomy closure. On multivariate analysis, body mass index > 30 (P = 0.02, OR = 1.77), final pathologic diagnosis of ulcerative/indeterminate colitis (P = 0.02, OR = 2) or Crohn's disease (P = 0.02, OR = 3.6), intraoperative (P = 0.02, OR = 1.6), and postoperative transfusions (P = 0.01, OR = 1.9) were all independently associated with septic complications. We also demonstrated an independent association among individual surgeons (P = 0.04) with decreased septic complications. CONCLUSIONS: Body mass index greater than 30, final pathologic diagnosis of ulcerative/indeterminate colitis or Crohn's disease, intraoperative and postoperative transfusions, and surgeon were all independent factors associated with septic complications after restorative proctocolectomy.