Incidence and Factors Correlating With Incisional Hernia Following Open Bowel Resection in Patients With Inflammatory Bowel Disease: A Review of 1000 Patients.

OBJECTIVE: The aim of this study was to identify the incidence and factors associated with the development of incisional hernia (IH) in patients with inflammatory bowel disease (IBD) undergoing open bowel resections. BACKGROUND: Predisposing factors for IH have not been well studied in patients with IBD undergoing open bowel resection. The role of duration of the disease, nutritional factors, anti-inflammatory treatment, previous operative procedures, wound infection, and other complicating factors remains unclear. METHODS: One thousand patients with ulcerative colitis and Crohn's disease were followed for a mean of 8 years after open bowel resection. The incidence of IH was recorded as well as correlating factors with the development of IH. RESULTS: The overall incidence of IH in this series was 20% (21% for ulcerative colitis and 20% for Crohn's disease). Statistically significant risk factors for development of IH were wound infection (HR 3.66, P <0.001), hypoalbuminemia (HR 2.02, P = 0.002), history of previous bowel resection (HR 1.60, P = 0.003), creation of ileostomy at the time of procedure (HR 1.53, P = 0.01), history of smoking (HR 1.52, P = 0.013), body mass index at surgery (1.036, P = 0.009), age at surgery (HR 1.021, P <0.001), and age at the onset of disease (HR 1.018, P <0.001). CONCLUSIONS: Patients with IBD have a high incidence of incisional hernia after open bowel resection. Wound infection had the strongest correlation with the development of IH. The other factors were age at onset of IBD, age at surgery, body mass index, serum albumin, presence of ileostomy, previous surgical procedures, and history of smoking. Duration of disease, preoperative steroids, immunosuppressive therapy, and blood transfusion were not found to correlate with IH.

Can laparoscopic surgery prevent incisional hernia in patients with Crohn's disease: a comparison study of 750 patients undergoing open and laparoscopic bowel resection.

BACKGROUND: Incisional hernia (IH) is a frequent occurrence following open surgery for Crohn's disease (CD). This study compares the IH rates of patients with CD undergoing open versus laparoscopic bowel resection. METHODS: Seven hundred and fifty patients with CD operated by the authors at the Mount Sinai Medical Center, New York, USA, were reviewed from a prospectively maintained surgical database. Five hundred patients with Crohn's disease undergoing open surgery were compared to 250 patients undergoing laparoscopic bowel resection. RESULTS: The mean duration of follow-up in the study population was 6.8 years. Patients undergoing open surgery had a significantly higher age at onset of disease, age at surgery, longer duration of disease, lower serum albumin, history of multiple previous resections, were more likely to be on steroids, needed more blood transfusions, and had an increased necessity for an ileostomy during resection. Nevertheless, the incidence of IH at 36 months was nearly identical in both groups (10.8 vs. 8.4% for open vs laparoscopic). 16% of the patients in the laparoscopic group (range: 7-20%) required conversion to open surgery. Patients undergoing laparoscopic resection that required conversion to open surgery had the highest IH rate at 18%. There was a significant correlation between IH and the length of the midline vertical extraction incision. Patients undergoing laparoscopic resection with intracorporeal anastomosis and small transverse or trocar site extraction incisions had no IH. CONCLUSIONS: A marked decrease or complete elimination of IH in patients with CD undergoing bowel resection may be possible using advanced laparoscopic techniques that require intra-abdominal anastomosis and use of the smallest transverse extraction incisions.

Laparoscopic subtotal colectomy for medically refractory ulcerative colitis: the time has come.

PURPOSE: To evaluate laparoscopic versus open subtotal colectomy (STC) in patients with ulcerative colitis (UC) requiring urgent or emergent operative intervention. METHODS: A retrospective review was performed of 90 patients with medically refractory UC who underwent STC with end ileostomy at The Mount Sinai Medical Center from 2002 to 2007. Patients with toxic megacolon were excluded. Univariate analysis was conducted by unpaired Student t-test and chi-square test. Results are presented as mean +/- 95% confidence interval. RESULTS: Ninety patients underwent STC, 29 by laparoscopic and 61 by open approach. In patients undergoing laparoscopic versus open STC, intraoperative blood loss was decreased (130.4 +/- 38.4 vs. 201.4 +/- 43.2 ml, p < 0.05) and operative time prolonged (216.4 +/- 20.2 vs. 169.9 +/- 14.4 min, p < 0.01). In the absence of postoperative complication, hospital length of stay (4.5 +/- 0.7 vs. 6 +/- 1.3 days, p < 0.001) was shorter in laparoscopic versus open group. No mortalities occurred. Overall morbidity, 30-day readmission, and reoperation were equivalent regardless of operative approach. Wound complications were absent in the laparoscopic group compared with 21.4% in the open group (p < 0.01). Follow-up at a mean of 36 months demonstrated no difference in restoration of gastrointestinal continuity. CONCLUSION: Laparoscopic STC confers the benefits of improved cosmesis, reduced intraoperative blood loss, negligible wound complications, and shorter hospital stay. Laparoscopy is a feasible and safe alternative to open STC in patients with UC refractory to medical therapy requiring urgent or emergent operation.

Outcome of incisional hernia repair in patients with Inflammatory Bowel Disease.

BACKGROUND: Incisional Hernia (IH) repair in patients with Inflammatory Bowel Disease (IBD) has not been well studied. METHODS: Outcomes of 170 patients with IBD who underwent IH repair were included in the study. RESULTS: The incidence of recurrence after IH repair in IBD is 27%. Patients with Crohn's disease (CD) had larger defects at the time of repair, higher proportion of bowel resection and a longer postoperative stay when compared to Ulcerative colitis (UC). The only significant predictor of recurrence after IH repair was the number of previous bowel resections prior to hernia repair (HR 1.59, p < 0.01). Three cases (10%) of late onset enterocutaneous fistulas were identified in patients who underwent IH repair with synthetic mesh inlay. CONCLUSION: Surgical repair results in a recurrence of IH in 27% of patients with IBD. The number of previous bowel resections is the only factor that correlates with development of recurrent IH in IBD.

Oversewing staple lines to prevent anastomotic complications in primary ileocolic resections for Crohn's disease.

BACKGROUND: Oversewing staple lines may be a novel way to reduce anastomotic complications after primary ileocolic resections for Crohn's disease (CD). STUDY DESIGN: This is a single-institution, non-concurrent cohort study of CD patients undergoing primary ileocolic resections (ICR) with stapled anastomoses from 2007 to 2013. Demographic and clinical characteristics were collected. Propensity scores were calculated for oversewing versus not. Postoperative outcomes within 30 days of surgery were collected. Anastomotic leak, intra-abdominal abscess, small bowel obstruction, and anastomotic bleed were considered major anastomotic complications (MACs). Multivariate analysis controlling for inverse probability weights was used to identify predictors of MACs. RESULTS: A total of 269 patients were included, of which 120 had undergone oversewing (OS). After controlling for propensity scores, not oversewing (NOS) and OS groups were similar in all preoperative characteristics with the exception of more laparoscopic resections and intracorporeal anastomoses in the NOS group. On univariate analysis, OS was protective against MACs (odds ratio (OR) 0.29, p < 0.01). In a multivariable model using inverse propensity weights and controlling for laparoscopic and intracorporeal approaches, oversewing remained a significant predictor of reduced MACs (OR 0.37, p < 0.001), while intracorporeal anastomoses increased their likelihood (OR 3.7, p < 0.001). CONCLUSIONS: After controlling for clinical and surgical factors, oversewing staple lines in primary ICRs for CD is correlated with reduced MACs.

Ileal j pouch complications and surgical solutions: a review.

Ileal pouch-anal anastomosis is currently accepted as the standard method to restore continence after total proctocolectomy for medically refractory ulcerative colitis and familial adenomatous polyposis. Ileal pouches offer improved quality of life and high patient satisfaction; however, there are many pouch-related complications due to the original disease process and change in anatomy. This is a review article of the common and some rare surgical complications after J pouches, which can be subdivided into the septic and nonseptic categories. Septic-related complications include anastomotic leak, abscess, and fistulas, whereas common nonseptic-related complications include small bowel obstruction, strictures, Crohn's disease, pouchitis, and cuffitis. Rare nonseptic complications to be discussed are prolapse, volvulus, and neoplasia.

Small bowel adenocarcinoma in Crohn's disease.

BACKGROUND: An association between small bowel adenocarcinoma and Crohn's disease (CD) is well-established. We present our recent experience with this entity in order to further elucidate its clinicopathological features and update our series from 1991. METHODS: A retrospective review was undertaken of all surgical patients with small bowel adenocarcinoma and CD seen at our institution between 1993 and 2009. Follow-up was assessed until time of death or by interview with survivors. Survival was calculated based on TNM (tumor extent, lymph node status, metastases staging) staging and comparing between our current and previous series. RESULTS: Twenty-nine patients (ten females and 19 males) were identified and followed for a median of 2 years. The median age at onset of CD symptoms was 25, and the median age at cancer diagnosis was 55.4, for a mean interval of 25.3 years. Twenty-two cancers were ileal and five were jejunal. There were no cancers in excluded intestinal loops. Significant differences in 2-year survival were determined for: node-negative (79.3%, 95%CI 58.3-100%) versus node-positive cancers (49% %, 95%CI 20.0-78.0%), and for localized (92.3%, 95%CI 77.8-100%) versus metastatic disease (33.3%, 95%CI 6.6-60%). Overall 36-month survival was 69.3% (95%CI 51.5-87.1%) compared to 40% among those without excluded loops in our series from 1991. Sixteen patients had long periods of quiescent disease before diagnosis (7-45 years), and 16 required surgery for bowel obstruction that was refractory to medical management. Adequate information was not retrievable for three patients. CONCLUSIONS: A comparison to our previous series reveals similar clinical characteristics and a high rate of node-positive cancer at diagnosis. Our findings also confirm two important clinical indicators of malignancy: recrudescent symptoms after long periods of relative quiescence and small bowel obstruction that is refractory to medical therapy.

Adenocarcinoma following ileal pouch-anal anastomosis for ulcerative colitis: review of 26 cases.

The occurrence of adenocarcinoma following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) is an infrequent and but potentially lethal complication. We have seen 1 such case among 520 IPAAs performed in our group practice between 1978 and February 2008. We have added this case to a review of 25 previously reported cases of adenocarcinoma of the pouch or outflow tract following IPAA for UC. Our conclusions are 1) that post-IPAA cancer can occur following either mucosectomy or stapled anastomosis; 2) that this malignancy can occur after IPAA performed for UC either with or without neoplasia; and 3) that this complication is seen whether or not the initial cancer or dysplasia had involved the rectum.

Colorectal carcinoma in indeterminate colitis.

BACKGROUND: For all the interest in the natural history of colorectal cancer (CRC) in ulcerative colitis (UC) and Crohn's disease (CD), surprisingly few data have been published regarding CRC in indeterminate colitis (IC). We present our experience with 15 cases of IC-associated CRC in order to assess their clinicopathological features and to determine their survival rates. METHODS: We retrospectively reviewed the medical records of patients with IC admitted to the Mount Sinai Hospital between 1994 and 2007 and who developed CRC. All patients were operated on and follow-up was complete for all patients to the closing date of study or to the time of death. RESULTS: A total of 19 adenocarcinomas were present in this series. There were 3 patients with multiple cancers; all cancers occurred in segments of colitis. The mean age at onset of IC was 28 years and the average time progression from the IC diagnosis to CRC was 19 years. Dysplasia was detected in 10 of the cases; 3 patients had mucinous tumors. Five patients had stage I tumors; 5 stage II; 4 stage III; 1 stage IV. There were 4 deaths due to CRC. The overall 5-year survival was 42%. CONCLUSIONS: CRC in IC shares most of the clinical and pathologic features as well as survival outcomes with CRC that occurs in the most prevalent forms of inflammatory bowel disease (IBD), UC and CD. Surveillance regimens currently used in the other forms of IBD seem applicable to IC patients as well.

Recurrence patterns after first resection for stricturing or penetrating Crohn's disease.

BACKGROUND: Crohn's disease (CD) usually recurs after resection, but the factors associated with this risk remain obscure. We set out to determine the role of stricturing (Montreal Classification B2) versus penetrating (Classification B3) disease behavior in predicting early (<3 years) versus late (>or=3 years) postoperative recurrence. METHODS: We identified a cohort of 34 patients seen at The Mount Sinai Hospital who had undergone a first ileocolic resection prior to December 31, 2004, who had been clinically thought to have had stricturing (B2) disease, and for whom we could verify 1) the operative and surgical pathology findings; and 2) the time of onset of symptoms attributable to recurrent CD by endoscopy, radiology, or surgery. Cases were reclassified as either "stricturing" (B2) or "penetrating" (B3) on the basis of operative and surgical pathology reports. Recurrences were classified as either "early" (<3 years) or "late" (>or=3 years) depending on the first appearance of postoperative symptoms that were verified endoscopically and histologically, radiologically, or surgically as being attributable to anastomotic recurrence of the CD. RESULTS: Among these 34 patients clinically thought to have had B2 disease, 12 had B2 disease confirmed upon review of surgical and pathology reports and none of them had recurrence within 3 years. Among the 22 patients reclassified as B3 disease, 12 (55%) had early recurrence. This difference was significant at the 0.002 level by the Fisher Exact Test. CONCLUSIONS: There is a strong proclivity for early postoperative recurrence of penetrating CD compared to stricturing disease, which may not be evident by behavioral classification on clinical grounds alone. Patients with confirmed uncomplicated stricturing obstruction at their first resection seem unlikely to experience a clinical recurrence within the next 3 years.

Relationship of the number of Crohn's strictures and strictureplasties to postoperative recurrence.

BACKGROUND: Strictureplasty is well established as a safe and effective surgical therapy for Crohn's disease (CD). Yet, postoperative recurrence after strictureplasty remains a problem for CD patients, and associated risk factors are still uncertain. The goal of this study was to examine the relationship between recurrence and the number of strictures (NSX) and strictureplasties (NSXP). STUDY DESIGN: The authors' prospectively created database was used to retrospectively identify patients who had undergone strictureplasty between 1984 and 2004. Recurrence was defined as reoperation, and rates were compared based on the NSX and NSXP using Kaplan-Meier curves. Cox regression analyses were used to evaluate the relationship between both NSX and NSXP and recurrence after adjusting for potential confounders. RESULTS: There were 339 strictureplasties performed in 88 patients at initial operation. The 5-year reoperation rates were 14% for patients with 8 strictures (p=0.01). Five-year reoperation rates were 14% for patients with 4 strictureplasties (p < 0.01). In multivariate regression of NSX and NSXP as continuous variables, both were independently associated with recurrence (p

Surgical management and outcomes of patients with duodenal Crohn's disease.

BACKGROUND: Duodenal Crohn's disease (DCD) has been reported to occur in 0.5% to 4% of patients with Crohn's disease. When patients fail to respond to conservative therapy or severe narrowing of the duodenum develops, operation is required. The recent literature is limited in description of surgical treatment of such patients. We reviewed our experience with surgical management and outcomes in patients with DCD, including outcomes of laparoscopic bypass procedures. STUDY DESIGN: A retrospective review was undertaken of all patients who underwent surgical intervention for DCD between 1995 and 2006. Data collected included demographics, clinical presentation, operative and hospital course, and postoperative followup. RESULTS: Thirty patients had surgical intervention for DCD during the selected period. Four patients had duodenoenteric fistulas, resulting from complications of their disease in the distal gastrointestinal tract. Operations done for intrinsic DCD were: open bypass (n = 11), laparoscopic bypass (n = 13), and stricturoplasty (n = 2). Only one vagotomy was done. Mean followup was 58 months (range 6 to 144 months). Patients resumed oral diet 3.0 days after laparoscopic bypass, with mean discharge of 6.9 days, as compared with 4.4 days and 12.2 days after open bypass, respectively. In the early postoperative period (0 to 30 days), six major complications (n=5, 19%): persistent obstruction, anastomotic leak, small bowel obstruction, anastomotic bleeding (two patients), and respiratory failure, developed in four patients in the open (36%) and one patient in the laparoscopic (8%) bypass group. There were two more complications during longterm followup, for an overall major morbidity rate of 27%. Two patients experienced recurrence requiring revision (one in the open group and one in the laparoscopic group). Gastroduodenal ulcers requiring operation did not develop in any of the patients. CONCLUSIONS: Surgery is a viable and safe option for patients with intractable duodenal Crohn's disease. The laparoscopic approach during a bypass procedure, as opposed to an open bypass, may result in faster recovery, less morbidity, and comparable recurrence rate. There is no role for vagotomy in bypass procedures.

Superior mesenteric vein thrombosis after colectomy for inflammatory bowel disease: a not uncommon cause of postoperative acute abdominal pain.

PURPOSE: Thromboembolism is a significant cause of morbidity and mortality in inflammatory bowel disease. Several prothrombotic conditions have been investigated in inflammatory bowel disease. The aim of this study was to evaluate the incidence of symptomatic postoperative superior mesenteric vein thrombosis in inflammatory bowel disease patients undergoing colonic resections and to identify and characterize their clinical presentation. METHODS: Between January 1999 and December 2001, 83 consecutive patients undergoing total colectomy for inflammatory bowel disease were studied retrospectively. Patients who developed new-onset postoperative acute abdominal pain were evaluated by CT scan of the abdomen. A complete coagulation profile, including thrombin time, platelet count, protein C, protein S, antithrombin III, homocysteine level, factor V Leiden mutation, plasminogen, and prothrombin G20210A mutation, was obtained in patients diagnosed with superior mesenteric vein thrombosis. RESULTS: Four patients (4.8 percent; 3 females; 3 patients with ulcerative colitis and 1 with Crohn's colitis) developed symptomatic postoperative superior mesenteric vein thrombosis. Two of these patients had extension of the clot into the portal vein. Their presenting symptom was abdominal pain, with a median interval of ten days from the index surgery. The hematologic workup was negative in three patients, with one heterozygous for prothrombin G20210A mutation. All patients were treated with systemic anticoagulation for at least six months. One ulcerative colitis patient was diagnosed after abdominal colectomy and underwent an uneventful ileal pouch-anal anastomosis after systemic anticoagulation. CONCLUSION: Postoperative superior mesenteric vein thrombosis is a more frequent occurrence than previously reported in patients with inflammatory bowel disease. Direct surgical trauma to the middle colic veins, with resulting thrombosis, is likely to be the precipitating factor in a borderline intrinsically hypercoagulable environment. All patients became asymptomatic after systemic anticoagulation and recovered uneventfully.

Bleeding diathesis in amyloidosis with renal insufficiency associated with Crohn's disease: response to desmopressin.

A 53-yr-old man with a 33-yr history of Crohn's ileocolitis, complicated by arthritis and cologastric fistulization, was diagnosed with GI amyloidosis at the time of proctocolectomy. He had marked proteinuria (4.2 g/24 h) and moderate renal insufficiency (BUN of 35 mg/dl and serum creatinine of 2.5 mg/dl). During the operation, he had severe bleeding that required 11 U of blood. Postoperatively, desmopressin was administered, which resulted in a prompt cessation of bleeding. This case demonstrates the efficacy of desmopressin in reversing the bleeding diathesis in surgical patients with amyloidosis complicated by renal insufficiency.