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

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

A Prospective Multicenter Comparison of Trauma and Injury Severity Score, American Society of Anesthesiologists Physical Status, and National Surgical Quality Improvement Program Calculator's Ability to Predict Operative Trauma Outcomes.

BACKGROUND: Trauma outcome prediction models have traditionally relied upon patient injury and physiologic data (eg, Trauma and Injury Severity Score [TRISS]) without accounting for comorbidities. We sought to prospectively evaluate the role of the American Society of Anesthesiologists physical status (ASA-PS) score and the National Surgical Quality Improvement Program Surgical Risk-Calculator (NSQIP-SRC), which are measurements of comorbidities, in the prediction of trauma outcomes, hypothesizing that they will improve the predictive ability for mortality, hospital length of stay (LOS), and complications compared to TRISS alone in trauma patients undergoing surgery within 24 hours. METHODS: A prospective, observational multicenter study (9/2018-2/2020) of trauma patients ≥18 years undergoing operation within 24 hours of admission was performed. Multiple logistic regression was used to create models predicting mortality utilizing the variables within TRISS, ASA-PS, and NSQIP-SRC, respectively. Linear regression was used to create models predicting LOS and negative binomial regression to create models predicting complications. RESULTS: From 4 level I trauma centers, 1213 patients were included. The Brier Score for each model predicting mortality was found to improve accuracy in the following order: 0.0370 for ASA-PS, 0.0355 for NSQIP-SRC, 0.0301 for TRISS, 0.0291 for TRISS+ASA-PS, and 0.0234 for TRISS+NSQIP-SRC. However, when comparing TRISS alone to TRISS+ASA-PS (P = .082) and TRISS+NSQIP-SRC (P = .394), there was no significant improvement in mortality prediction. NSQIP-SRC more accurately predicted both LOS and complications compared to TRISS and ASA-PS. CONCLUSIONS: TRISS predicts mortality better than ASA-PS and NSQIP-SRC in trauma patients undergoing surgery within 24 hours. The TRISS mortality predictive ability is not improved when combined with ASA-PS or NSQIP-SRC. However, NSQIP-SRC was the most accurate predictor of LOS and complications.

Helicopter Transport Has Decreased Over Time and Transport From Scene or Hospital Matters.

OBJECTIVE: Several reports have found helicopter emergency medical services (HEMS) to be associated with a lower risk of mortality compared with ground emergency medical services (GEMS); however, most studies did not control for transport time or stratify interfacility versus scene. We hypothesize that the HEMS transport rate has decreased nationally and that the risk of mortality for HEMS is similar to GEMS when adjusting for transport time and stratifying by scene or interfacility. METHODS: The Trauma Quality Improvement Program (2010-2016) was queried for adult patients transported by HEMS or GEMS. Multivariable logistic regression was used. RESULTS: The HEMS transport rate decreased by 38.2% from 2010 to 2016 (P < .001). After controlling for known predictors of mortality and transport time, HEMS was associated with a decreased risk of mortality compared with GEMS for adult trauma patient transports (odds ratio = 0.74; 95% confidence interval [CI], 0.71-0.77; P < .001). Compared with GEMS, HEMS transports from the scene were associated with a decreased risk of mortality (OR = 0.63; 95% CI, 0.60-0.66; P < .001), whereas HEMS interfacility transfer was associated with an increased risk of mortality (OR = 1.22; 95% CI, 1.14-1.31; P < .001). CONCLUSION: The rate of HEMS transports in trauma has decreased by nearly 40% over the past 7 years. Our results suggest that HEMS use for scene transports is beneficial for the survival of trauma patients.

What is the Optimal Strategy for Pouch Salvage at the Time of Redo Ileal-Pouch Anal Anastomosis? Pouch Repair with Re-Anastomosis vs Pouch Excision with Neo-Pouch.

BACKGROUND: The long-term risk of pouch failure after restorative proctocolectomy with ileal-pouch anal anastomosis (IPAA) range from 5 and 15%. Salvage surgery for failing IPAA's may be achieved by disconnecting the IPAA and either repairing and re-using the existing pouch (REP) or constructing a neo-pouch (NEO). We aimed to evaluate whether there are differences in long-term functional pouch survival and functional outcomes between the REP group and the NEO group. We hypothesized patients undergoing REP have higher long-term pouch survival rates compared to patients who require NEO pouch construction. METHODS: Our prospectively maintained Pouch Registry was queried for patients who underwent a pouch salvage surgery with either pouch REP or NEO from 1988 - 2020. Patients who underwent pouch repair without disconnection from the anus were excluded. The primary endpoint was long-term pouch survival after redo pouch surgery. Secondary outcomes were patient reported quality of life and pouch function. RESULTS: Of 653 patients undergoing redo IPAA, 462 met inclusion criteria of transabdominal redo surgery with pouch reconnection: 243 (52.6%) had REP and 219 (47.4%) had NEO. Median age was 39 years and 59% were female. Median time between index and redo IPAA was 34 months for REP vs 54 months for NEO (p=0.002). The 5-year pouch survival after redo IPAA was similar between REP (79.5%) and NEO (76.8%) groups (p=0.4). Fewer patients in the REP group reported nighttime pad use (51.4% vs 68.2%, p=0.04). CONCLUSION: Pouch survival and functional outcomes after salvage surgery for failing ileoanal pouch was similar regardless of pouch salvage procedure. When performing redo pouch surgery, surgeons should not hesitate to construct a new pouch if indicated.

Delayed gastric emptying is associated with increased risk of mortality in patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma.

Delayed gastric emptying (DGE) is common in patients undergoing pancreaticoduodenectomy (PD). The effect of DGE on mortality is less clear. We sought to identify predictors of mortality in patients undergoing PD for pancreatic adenocarcinoma hypothesizing DGE to independently increase risk of 30-day mortality. The ACS-NSQIP targeted pancreatectomy database (2014-2017) was queried for patients with pancreatic adenocarcinoma undergoing PD. A multivariable logistic regression analysis was performed. Separate sensitivity analyses were performed adjusting for postoperative pancreatic fistula (POPF) grades A-C. Out of 8011 patients undergoing PD, 1246 had DGE (15.6%). About 8.5% of patients with DGE had no oral intake by postoperative day-14. The DGE group had a longer median operative duration (373 vs. 362 min, p = 0.019), and a longer hospital length of stay (16.5 vs. 8 days, p < 0.001). After adjusting for age, gender, comorbidities, preoperative chemotherapy, preoperative radiation, open versus laparoscopic approach, vascular resection, deep surgical space infection (DSSI), postoperative percutaneous drain placement, and development of a POPF, DGE was associated with an increased risk for 30-day mortality (OR 3.25, 2.16-4.88, p < 0.001). On sub-analysis, grades A and B POPF were not associated with risk of mortality while grade C POPF was associated with increased risk of mortality (OR 5.64, 2.24-14.17, p < 0.001). The rate of DGE in patients undergoing PD in this large database was over 15%. DGE is associated with greater than three times the increased associated risk of mortality, even when controlling for POPF, DSSI, and other known predictors of mortality.

CIGARETTE SMOKING IS ASSOCIATED WITH DECREASED MORTALITY IN CRITICALLY ILL TRAUMA PATIENTS.

ABSTRACT: Background: Smoking may offer pathophysiologic adaptations that increase survivability in certain patients with cardiovascular disease. We sought to identify if smoking increases survivability in trauma patients, hypothesizing that critically ill trauma patients who smoke have a decreased risk of mortality compared with non-smokers. Methods: The Trauma Quality Improvement Program (2010-2016) database was queried for trauma patients with intensive care unit admissions. A multivariable logistic regression model was performed. Results: From the 630,278 critically ill trauma patients identified, 116,068 (18.4%) were current cigarette smokers. Critically ill trauma smokers, compared with non-smokers, had a higher rate of pneumonia (7.8% vs. 6.9%, P< 0.001) and lower mortality rate (4.0% vs. 8.0%, P< 0.001). After controlling for covariates, smokers had a decreased associated risk of mortality compared with non-smokers (OR = 0.55, CI = 0.51-0.60, P< 0.001), and no difference in the risk of major complications (OR = 0.98, CI = 0.931.03, P = 0.44). The same analysis was performed using age as a continuous variable with associated decreased risk of mortality (OR 0.57 (CI 0.53-0.62), P< 0.001). Conclusion: Critically ill trauma smokers had a decreased associated mortality risk compared with non-smokers possibly due to biologic adaptations such as increased oxygen delivery developed from smoking. Future basic science and translational studies are needed to pursue potential novel therapeutic benefits without the deleterious long-term side effects of smoking.