Ileocolic Intussusception: Iterative Quality Improvement to Address a Recurring Problem.

INTRODUCTION: Recent quality improvement (QI) initiatives indicate that pediatric patients with uncomplicated ileocolic intussusception can be safely discharged from the emergency department (ED) after fluoroscopic reduction. These programs improve patient experience and reduce cost. We sought to build on these efforts by developing a QI initiative at our own institution that included patients transferred from a satellite campus and focused on iterative improvement of our treatment pathway based on continual reassessment of our processes and data. MATERIALS AND METHODS: We formed a multidisciplinary team, established a collaborative open-access clinical pathway, and implemented educational plans for each participating division. Data were tracked prospectively, and process adjustments were made as clinically indicated. In this report, we compare patients treated before and after the QI initiative. RESULTS: There were 155 patients treated before the QI initiative (January 1, 2018-June 30, 2022) and 87 after the initiative began (July 1, 2022-October 31, 2023). There were significant improvements in the rate of ED discharge (4/155 (2.6%) versus 51/87 (59%), P < 0.001) and mean time to discharge (40.7 versus 23.1 h, P = 0.002), while the average cost of a visit fell by 30% (P = 0.012). The mean time to discharge from the ED increased (6.9 versus 11.0 h, P < 0.001), and the rate of readmission was unchanged. For patients transferred from the satellite campus, time to fluoroscopic reduction significantly improved during the initiative (9.4 versus 6.5 h, P = 0.048). CONCLUSIONS: We implemented a QI program for patients with fluoroscopically reduced ileocolic intussusception that was serially adjusted based on continual reassessment of data. The protocol was associated with a decreased admission rate, total cost, and time to hospital discharge.

Clinical outcomes and perioperative morbidity and mortality following segmental resections of the colon for Crohn's colitis.

INTRODUCTION: Crohn's disease (CD) is a chronic inflammatory bowel disease of a multifactorial pathogenesis. Recently numerous genetic variants linked to an aggressive phenotype were identified, leading to a progress in therapeutic options, resulting in a decreased necessity for surgery. Nevertheless, surgery is often inevitable. The aim of the study was to evaluate possible risk factors for postoperative complications and disease recurrence specifically after colonic resections for CD. PATIENTS AND METHODS: A total of 241 patients who underwent colonic and ileocaecal resections for CD at our instiution between 2008 and 2018 were included. All data was extracted from clinical charts. RESULTS: Major complications occurred in 23.8% of all patients. Patients after colonic resections showed a significantly higher rate of major postoperative complications compared to patients after ICR (p = < 0.0001). The most common complications after colonic resections were postoperative bleeding (22.2%), the need for revision surgery (27.4%) and ICU (17.2%) or hospital readmission (15%). As risk factors for the latter, we identified time interval between admission and surgery (p = 0.015) and the duration of the surgery (p = 0.001). Isolated distal resections had a higher risk for revision surgery and a secondary stoma (p = 0.019). Within the total study population, previous bowel resections (p = 0.037) were identified as independent risk factors for major perioperative complications. CONCLUSION: The results indicate that both a complex surgical site and a complex surgical procedure lead to a higher perioperative morbidity in colonic resections for Crohn's colitis.

Influence of the bile acid/microbiota axis in ileal surgery: a systematic review.

AIM: The gastrointestinal bile acid (BA)/microbiota axis has emerged as a potential mediator of health and disease, particularly in relation to pathologies such as inflammatory bowel disease (IBD) and colorectal cancer. Whilst it presents an exciting new avenue for therapies, it has not yet been characterized in surgical resection of the ileum, where BA reabsorption occurs. The identification of BA/microbiota signatures may provide future therapies with perioperative personalized medicine. In this work we conduct a systematic review with the aim of investigating the microbiome and BA changes that are associated with resection of the ileum. METHOD: The databases included were MEDLINE, EMBASE, Web of Science and Cochrane libraries. The outcomes of interest were faecal microbiome and BA signatures after ileal resection. RESULTS: Of the initial 3106 articles, three studies met the inclusion/exclusion criteria for data extraction. A total of 257 patients (46% surgery, 54% nonsurgery controls) were included in the three studies. Two studies included patients with short bowel syndrome and the other included patients with IBD. Large-scale microbiota changes were reported. In general, alpha diversity had decreased amongst patients with ileal surgery. Phylum-level changes included decreased Bacteroidetes and increased Proteobacteria and Fusobacteria in patients with an intestinal resection. Surgery was associated with increased total faecal BAs, cholic acid and chenodeoxycholic acid. There were decreases in deoxycholic acid and glycine and taurine conjugated bile salts. Integrated BA and microbiota data identified correlations with several bacterial families and BA. CONCLUSION: The BA/microbiota axis is still a novel area with minimal observational data in surgery. Further mechanistic research is necessary to further explore this and identify its role in improving perioperative outcomes.

Stapler size independently predicts postoperative complications following stapled ileocolic anastomosis: A retrospective cohort study.

AIM: Staplers used in ileocolic anastomosis construction differ in length and height. We assessed the impact of stapler type in creating ileocolic anastomoses on postoperative outcomes. METHODS: This retrospective cohort study of an Institutional Review Board approved database included patients who underwent laparoscopic right colectomy for cancer between January 2011 and August 2021. All patients had construction of extracorporeal antiperistaltic stapled ileocolic anastomosis using a linear cutting stapler. Main outcome measures were short-term (<30 day) morbidity and mortality. RESULTS: In all, 270 patients (136 men; median age 70.2 years) were included. A 75 mm stapler was used in 49 (18.1%) patients, 80 mm in 97 (35.9%) and 100 mm in 124 (45.9%). Blue cartridge (stapler height 3.5 mm) was used in 175 (64.5%) and green cartridge (4.8 mm) in 18 (7%) patients; this information was unavailable in 77 (28.5%) cases. Apical enterotomy closure was performed by linear stapler in 54% and linear cutting stapler in 46%. Apical staple line reinforcement or imbrication suturing was used in 26.3%. The overall postoperative complication rate was 28.9%. The anastomotic leak rate was 2.6%. Independent predictors of complications after laparoscopic right colectomy were older age (OR 1.03, 95%CI 1-1.06; P = 0.01), extended colectomy (OR 2.76, 95%CI 1.07-7.08; P = 0.035) and emergency surgery (OR 4.5, 95%CI 1.3-14.9; P = 0.014). A 100-mm linear cutting stapler was an independent protective factor against postoperative complications (OR 0.3, 95%CI 0.18-0.85; P = 0.019). Stapler height and closure technique of apical enterotomy did not affect postoperative complications. CONCLUSION: Independent predictors of complications after laparoscopic right colectomy were older age, extended colectomy and emergency surgery. Using a 100 mm stapler was an independent protective factor against postoperative complications.

Laparoscopic right hemicolectomy: a SICE (Società Italiana di Chirurgia Endoscopica e Nuove tecnologie) network prospective study on the approach to right colon lymphadenectomy in Italy: is there a standard?-CoDIG 2 (ColonDx Italian Group).

BACKGROUND: Colon cancer is a disease with a worldwide spread. Surgery is the best option for the treatment of advanced colon cancer, but some aspects are still debated, such as the extent of lymphadenectomy. In Japanese guidelines, the gold standard was D3 dissection to remove the central lymph nodes (203, 213, and 223), but in 2009, Hoenberger et al. introduced the concept of complete mesocolic excision, in which surgical dissection follows the embryological planes to remove the mesentery entirely to prevent leakage of cancer cells and collect more lymph nodes. Our study describes how lymphadenectomy is currently performed in major Italian centers with an unclear indication on the type of lymphadenectomy that should be performed during right hemicolectomy (RH). METHODS: CoDIG 2 is an observational multicenter national study that involves 76 Italian general surgery wards highly specialized in colorectal surgery. Each center was asked not to modify their usual surgical and clinical practices. The aim of the study was to assess the preference of Italian surgeons on the type of lymphadenectomy to perform during RH and the rise of any new trends or modifications in habits compared to the findings of the CoDIG 1 study conducted 4 years ago. RESULTS: A total of 788 patients were enrolled. The most commonly used surgical technique was laparoscopic (82.1%) with intracorporeal (73.4%), side-to-side (98.7%), or isoperistaltic (96.0%) anastomosis. The lymph nodes at the origin of the vessels were harvested in an inferior number of cases (203, 213, and 223: 42.4%, 31.1%, and 20.3%, respectively). A comparison between CoDIG 1 and CoDIG 2 showed a stable trend in surgical techniques and complications, with an increase in the robotic approach (7.7% vs. 12.3%). CONCLUSIONS: This analysis shows how lymphadenectomy is performed in Italy to achieve oncological outcomes in RH, although the technique to achieve a higher lymph node count has not yet been standardized. Trial registration (ClinicalTrials.gov) ID: NCT05943951.

Impact of a 6-12-h delay between ileocolic intussusception diagnostic US and fluoroscopic reduction on patients' outcomes.

BACKGROUND: Image-guided reduction of intussusception is considered a radiologic urgency requiring 24-h radiologist and technologist availability. OBJECTIVE: To assess whether a delay of 6-12 h between US diagnosis and fluoroscopic reduction of ileocolic intussusception affects the success frequency of fluoroscopic reduction. MATERIALS AND METHODS: Retrospective review of 0-5-year-olds undergoing fluoroscopic reduction for ileocolic intussusception from 2013 to 2023. Exclusions were small bowel intussusception, self-reduced intussusception, first fluoroscopic reduction attempt>12 h after US, prior bowel surgery, inpatient status, and patient transferred for recurrent intussusception. Data collected included demographics, symptoms, air/contrast enema selection, radiation dose, reduction failure, 48-h recurrence, surgery, length of stay, and complications. Comparisons between<6-h and 6-12-h delays after ultrasound diagnosis were made using chi-square, Fisher's exact test, and Mann-Whitney U tests (P< 0.05 considered significant). RESULTS: Of 438 included patients, 387 (88.4%) were reduced in <6 h (median age 1.4 years) and 51 (11.7%) were reduced between 6 and 12 h (median age 2.05 years), with median reduction times of 1:42 and 7:07 h, respectively. There were no significant differences between the groups for reduction success (<6 h 87.3% vs. 6-12 h 94.1%; P-value = 0.16), need for surgery (<6 h 11.1% vs. 6-12 h 3.9%; P-value=0.112), recurrence of intussusception within 48 h after reduction (<6 h 9.3% vs. 6-12 h 15.7%; P-value=0.154), or length of hospitalization (<6 h 21:07 h vs. 6-12 h 20:03 h; P-value=0.662). CONCLUSION: A delay of 6-12 h between diagnosis and fluoroscopic reduction of ileocolic intussusception is not associated with reduced fluoroscopic reduction success, need for surgical intervention after attempted reduction, recurrence of intussusception following successful reduction, or hospitalization duration after reduction.

Optimising surgical anastomosis in ileocolic resection for Crohn's disease with respect to recurrence and functionality: two international parallel randomized controlled trials comparing handsewn (END-to-end or Kono-S) to stapled anastomosis (HAND2END and the End2End STUDIES).

BACKGROUND: The most common intestinal operation in Crohn's disease (CD) is an ileocolic resection. Despite optimal surgical and medical management, recurrent disease after surgery is common. Different types of anastomoses with respect to configuration and construction can be made after resection for example, handsewn (end-to-end and Kono-S) and stapled (side-to-side). The various types of anastomoses might affect endoscopic recurrence and its assessment, the functional outcome, and costs. The objective of the present study is to compare the three types of anastomoses with respect to endoscopic recurrence at 6 months, gastrointestinal function, and health care consumption. METHODS: This is a randomized controlled multicentre superiority trial, allocating patients either to side-to-side stapled anastomosis as advised in current guidelines or a handsewn anastomoses (an end-to-end or Kono-S). It is hypothesized that handsewn anastomoses do better than stapled, and end-to-end perform better than the saccular Kono-S. Two international studies with a similar setup will be conducted mainly in the Netherlands (End2End) and Italy (HAND2END). Patients diagnosed with CD, aged over 16 years in the Netherlands and 18 years in Italy requiring (re)resection of the (neo)terminal ileum are eligible. The first part of the study compares the two handsewn anastomoses with the stapled anastomosis. To detect a clinically relevant difference of 25% in endoscopic recurrence, a total of 165 patients will be needed in the Netherlands and 189 patients in Italy. Primary outcome is postoperative endoscopic recurrence (defined as Rutgeerts score ≥ i2b) at 6 months. Secondary outcomes are postoperative morbidity, gastrointestinal function, quality of life (QoL) and costs. DISCUSSION: The research question addresses a knowledge gap within the general practice elucidating which type of anastomosis is superior in terms of endoscopic and clinical recurrence, functionality, QoL and health care consumption. The results of the proposed study might change current practice in contrast to what is advised by the guidelines. TRIAL REGISTRATION: NCT05246917 for HAND2END and NCT05578235 for End2End ( http://www. CLINICALTRIALS: gov/ ).

Assessing robotic-assisted surgery versus open approach in penetrating Crohn's disease: advantages and outcomes in ileocolic resection.

INTRODUCTION: Penetrating Crohn's disease (CD) often necessitates surgical intervention, with the open approach traditionally favored. Robotic-assisted surgery offers potential benefits but remains understudied in this complex patient population. Additionally, the lack of standardized surgical complexity scoring in CD hinders research and comparisons. METHODS: We retrospectively analyzed adult patients with penetrating CD who underwent either robotic-assisted ileocolic resection (RICR) or open ileocolic resection (OICR) at our institution from January 2007 to December 2021. We assessed endpoints, including length of stay, complications, readmissions, reoperations, and other perioperative outcomes. RESULTS: RICR demonstrated safety outcomes comparable to OICR. Importantly, RICR patients experienced significantly reduced estimated blood loss (p < 0.0001), shorter hospital stays (median 4.5 days versus 6.9 days; p = 0.01), lower surgical site infection rates (0% versus 15.4%; p = 0.01), and decreased 30-day readmission rates (0% versus 15.4%; p = 0.01). Linear regression analysis revealed the need for additional strictureplasties (coefficient: 84.8; p = 0.008), colonic resections (coefficient: 41.7; p = 0.008), and estimated blood loss (coefficient: 0.07; p = 0.002) independently correlated with longer operative times). CONCLUSION: Robotic-assisted surgery appears to be a safe and potentially beneficial alternative for the surgical management of penetrating CD, offering advantages in perioperative outcomes reducing length of stay, blood loss, surgical site infection rates, and readmission rates. Further validation with larger cohorts is warranted.

Postoperative intussusception in children operated for primary intussusception - A very rare entity.

Postoperative intussusception (POI) after abdominal and non-abdominal operations is a rare but recognized condition discussed several times in literature. There are scarce reports regarding POI in children operated primarily for intussusception. We discuss three such cases that were seen in our institution in the last two years. The patients showed symptoms of atypical ileus that failed to resolve two to eight days following primary surgery. Ultrasound reported intussusception and surgical intervention was sought. All patients had ileoileal intussusception. Manual reduction was successful in two cases. One had intestinal necrosis and underwent resection and anastomosis. Recovery was satisfactory without recurrence. POI should be suspected in patients who show signs of intestinal obstruction in early postoperative period. A second POI should be kept in mind after surgical reduction of the first intussusception. Ultrasound should be performed to aid diagnosis followed by urgent surgical intervention.

Preoperative screening and prehabilitation strategies prior to ileocolic resection in patients with Crohn's disease are not incorporated in routine care.

PURPOSE: Recently, recommendations on perioperative care have been published to optimize postoperative outcomes in preoperative patients with inflammatory bowel disease. This study evaluated the current use of preoperative screening and prehabilitation strategies (PS) prior to elective ileocolic resection (ICR) in patients with Crohn's disease (CD). METHODS: Patients with CD who underwent an elective ICR were identified from a Dutch prospective cohort study. Primary endpoint was to evaluate to what extent IBD-relevant PS were applied in patients with CD prior to ICR according to the current recommendations. RESULTS: In total, 109 CD patients were included. Screening of nutritional status was performed in 56% of the patients and revealed malnutrition in 46% of these patients. Of the malnourished patients, 46% was referred to a dietitian. Active smoking and alcohol consumption were reported in 20% and 28%; none of these patients were referred for a cessation program. A preoperative anemia was diagnosed in 61%, and ferritin levels were assessed in 26% of these patients. Iron therapy was started in 25% of the patients with an iron deficiency anemia. Exposure to corticosteroids at time of ICR was reported in 29% and weaned off in 3%. Consultation of a dietitian, psychologist, and physiotherapist was reported in 36%, 7%, and 3%. Physical fitness was assessed in none of the patients. CONCLUSION: PS are not routinely applied and not individually tailored in the preoperative setting prior to elective ICR in patients with CD. Prior to implementation, future research on the costs and effectiveness of PS on postoperative outcomes and quality of life is necessary.

Risk factors and predictors of 30-day complications and conversion to open surgery after repeat ileocolic resection of Crohn's disease.

BACKGROUND: Repeat ileocolic resection of Crohn's disease (CD) is a challenging procedure that can be followed by a high rate of complications. The present study aimed to identify the factors associated with complications and conversion to open surgery in patients undergoing repeat ileocolic resection for CD. METHODS: This was a retrospective review of an IRB-approved prospective database of CD patients who underwent elective repeat ileocolic resection between 2011 and 2021. Univariate and multivariate analyses were performed to determine the predictive factors of postoperative complications and conversion to open surgery. RESULTS: The present study included 65 patients (47.7% male) with a mean age of 52.5 years. 43.1% of patients developed short-term complications, most of which were of Clavien-Dindo class I-II. Longer operative time was found to be an independent predictor of complications (OR 1.016, p = 0.014). The preoperative use of biological therapy was an independent protective factor from complications (OR 0.243, p = 0.016). The only significant risk factor of a longer operation time was higher BMI (OR 3.11, p = 0.044). Overall, 28.1% of laparoscopic procedures were converted to laparotomy. According to bivariate analysis, previous ileocolic open resection (OR 190, p < 0.0001), longer operation time (OR 1.01; p = 0.036), and takedown of incidental fistula of incidental fistula (OR 3.78, p = 0.04) were associated with higher odds of conversion to open surgery. CONCLUSION: Longer operation time was significantly associated with and predictive of complications after repeat ileocolic resection of CD. Preoperative biological therapy was predictive of a lower rate of complications. Previous ileocolic resection by laparotomy, longer operation time, and takedown of fistula were associated with a higher likelihood of conversion to open surgery.

Ultrasound-guided hydrostatic reduction of intussusception: comparison of success rates between subspecialized pediatric radiologists and non-pediatric radiologists or radiology residents.

Ileocolic intussusception is the most common cause of intestinal obstruction in children under two years of age. Treatment in most cases is radiologically guided reduction. In Slovenia, ultrasound (US)-guided hydrostatic reduction is currently the standard of care. The purpose of this study was to compare the success rate of US-guided hydrostatic reduction when performed by subspecialty-trained pediatric radiologists, non-pediatric radiologists, or radiology residents. We retrospectively analyzed medical records of patients with ileocolic intussusception who underwent US-guided hydrostatic intussusception reduction at University Medical Centre Ljubljana between January 2012 and December 2022 (n = 101). During regular daily working hours, the reduction was performed by pediatric radiologists. After hours (evenings and overnight), pediatric radiologists, non-pediatric radiologists, or radiology residents performed the reduction procedure. Patients were divided into three groups based on the operator performing the procedure. Data was analyzed using the chi-square test. Pediatric radiologists had thirty-seven (75.5%) successful first attempts, non-pediatric radiologists had nineteen (76.0%), and radiology residents had twenty (74.1%). There was no statistically significant difference in the success rate of ileocolic intussusception reduction depending on the operator who performed the procedure (p = 0.98). No perforation was observed in either group during the reduction attempts.  Conclusion: Our results demonstrate that US-guided hydrostatic reduction is a reliable and safe procedure that achieves good results even in the hands of less experienced, however appropriately trained, radiologists. The results should encourage more medical centers to consider the implementation of US-guided hydrostatic reduction of ileocolic intussusception. What is Known: • US-guided hydrostatic reduction is a well-established method of treatment for ileocolic intussusception in children. • The results regarding the influence of operator's experience with the procedure on its success rate are scarce and contradictory. What is New: • US-guided hydrostatic intussusception reduction is a reliable and safe technique that achieves similar success rates when performed by experienced subspecialized pediatric radiologists or less experienced but trained operators such as non-pediatric radiologists and radiology residents. • The implementation of US-guided hydrostatic reduction in general hospitals without subspecialized pediatric radiologists could improve patient care by increasing access to radiologically guided reduction and simultaneously decreasing the time to reduction attempts.

Incisional hernia rates between intracorporeal and extracorporeal anastomosis in minimally invasive ileocolic resection for Crohn's disease.

PURPOSE: One-third of patients with Crohn's disease (CD) require multiple surgeries during their lifetime. So, reducing the incisional hernia rate is crucial. We aimed to define incisional hernia rates after minimally invasive ileocolic resection for CD, comparing intracorporeal anastomosis with Pfannenstiel incision (ICA-P) versus extracorporeal anastomosis with midline vertical incision (ECA-M). METHODS: This retrospective cohort compares ICA-P versus ECA-M from a prospectively maintained database of consecutive minimally invasive ileocolic resections for CD performed between 2014 and 2021 in a referral center. RESULTS: Of the 249 patients included: 59 were in the ICA-P group, 190 in the ECA-M group. Both groups were similar according to baseline and preoperative characteristics. Overall, 22 (8.8%) patients developed an imaging-proven incisional hernia: seven at the port-site and 15 at the extraction-site. All 15 extraction-site incisional hernias were midline vertical incisions [7.9%; p = 0.025], and 8 patients (53%) required surgical repair. Time-to-event analysis showed a 20% rate of extraction-site incisional hernia in the ECA-M group after 48 months (p = 0.037). The length of stay was lower in the intracorporeal anastomosis with Pfannenstiel incision group [ICA-P: 3.3 ± 2.5 vs. ECA-M: 4.1 ± 2.4 days; p = 0.02] with similar 30-day postoperative complication [11(18.6) vs. 59(31.1); p = 0.064] and readmission rates [7(11.9) vs. 18(9.5); p = 0.59]. CONCLUSION: Patients in the ICA-P group did not encounter any incisional hernias while having shorter hospital length of stay and similar 30-day postoperative complications or readmission compared to ECA-M. Therefore, more consideration should be given to performing intracorporeal anastomosis with Pfannenstiel incision during Ileocolic resection in patients with CD to reduce hernia risk.

Biological therapy prior to repeat ileocolic resection in Crohn's disease can reduce the postoperative complication rate.

BACKGROUND: The aim of this study was to assess the effect of preoperative biologic therapy on the surgical outcome of Crohn's disease (CD) patients undergoing repeat ileocolic resection. METHODS: This was a retrospective analysis of all CD patients who underwent repeat ileocolic resection at Cleveland Clinic Florida between January 2011 and April 2021. Patients were divided into two groups: treatment biologic therapy prior to surgery and controls. RESULTS: Sixty-five patients (31males, median age 54 [range 23-82] years) were included in the study. Twenty nine (44.6%) were treated with biologic therapy prior to repeat ileocolic resection. No demographic differences were found between the biologic therapy and control groups. In addition, no differences were found in mean time from index ileocolic resection (p = 0.9), indication for surgery (p = 0.11), and preoperative albumin (p = 0.69). The majority of patients (57; 87.7%) were operated on laparoscopically, and mean overall operation time was 225 (SD 49.27) min. Overall, the postoperative complication rate was 43.1% (28 patients) and median length of stay was 5 (range 2-21) days. Postoperative complications were more common in the control group, compared to the biologic therapy group (55.6 vs 27.5%; p = 0.04). Conversion rate (35.7 vs 20.7%; p = 0.24), operation time (223 vs 219 min; p = 0.75), length of stay (5.2 vs 5.9 days; p = 0.4), and readmission (16.6 vs 11.1%; p = 0.72) were similar between the two groups. Multivariate analysis of risk factors for postoperative complications showed that biologic treatment was correlated with a lower risk (HR -0.28, CI 95% -0.5596 to -0.01898, p = 0.03). CONCLUSIONS: Patients treated with biologic therapy for CD who underwent repeat ileocolic resection had fewer postoperative complications.

Use of the Kono-S anastomosis in pediatric Crohn's disease: a single-institution experience.

OBJECTIVES: About 24% of children with Crohn's Disease (CD) require surgery. In 2003, Kono et al. described a novel anastomosis reported to decrease the rate of anastomotic CD recurrence. Subsequent studies have reproduced these outcomes, but none has demonstrated its effect in pediatric patients. This study evaluates short-term outcomes of pediatric patients following ileocolic resection and Kono-S anastomosis. METHODS: A retrospective review of patients < 18 years old who underwent ileocolic resection followed by Kono-S anastomosis compared with those who underwent a stapled anastomosis. RESULTS: Nine Kono-S patients were matched with nine patients preceding them who received traditional side-to-side and end-to-side anastomoses. All patients underwent minimally invasive surgery. Demographics, pre-operative medication usage, and symptom profiles were not significantly different. Traditional anastomosis (TA) patients had longer lengths of stay (4.6 vs 2.9 days; p = 0.03) but had no statistically significant differences in blood loss, procedure length, and pathologic findings. One Kono-S patient had a superficial surgical site infection, and one TA patient had an anastomotic leak requiring reoperation within 30 days. More TA patients experienced post-operative symptoms at both 30-day and 6-month follow-up (66.7% vs 33.3%; p = 0.16 and 77.8% vs 25%; p = 0.03). CONCLUSION: The Kono-S anastomosis appears to be safe in pediatric CD when compared to traditional stapled anastomoses.

Ileocolic Anastomoses.

Ileocolic anastomoses are commonly performed by surgeons in both open and minimally invasive settings and can be created by using many different techniques and configurations. Here the authors review both current literature and the author's preference for creation of ileocolic anastomoses in the setting of malignancy, inflammatory bowel disease, and colonic inertia. The authors also review evidence surrounding adjuncts to creation of anastomoses such as use of indocyanine green and closing mesenteric defects. While many techniques of anastomotic creation have adapted with new evidence and technologies, several key principles still provide the foundation for current practice.

Laparoscopic Intracorporeal Anastomosis.

Given the progression of laparoscopic surgery, questions continue to arise as to the ideal technique for a laparoscopic colectomy. The most debated of these questions is whether it is best to complete an intracorporeal (ICA) or extracorporeal (ECA) intestinal anastomosis. Here, we review the literature to date and report the equivalent safety and efficacy of ICA and ECA for laparoscopic right colectomy. However, these studies also indicate that when completed, ICA may prove beneficial with respect to earlier return of bowel function, less postoperative pain, shorter incision length, and reduced risk of wound infections. For this, we present the tips and tricks for completing all forms of laparoscopic ICAs during laparoscopic colectomy.

Delayed Repeat Contrast Enema for Treatment of Pediatric Intussusception.

INTRODUCTION: Ileocolic intussusception is a common cause of pediatric bowel obstruction. Contrast enema is successful in treating the majority of patients, and if initially unsuccessful, approximately one-third may be reduced with repeat enemas. We sought to study protocol implementation for delayed repeat enema in pediatric patients not reduced completely by an initial contrast enema. Our aims were to assess repeat enema success rates and outcome differences in preprotocol and postprotocol patients with respect to (1) intussusception recurrence, (2) surgical intervention and complication rates, and (3) length of stay. MATERIALS AND METHODS: We performed a retrospective review of treatment and clinical outcomes prior to and following protocol implementation for repeat enema for intussusception at two tertiary pediatric referral hospitals. The preprotocol period was defined from 2/2013 to 2/2016, and the postprotocol period was from 8/2016 to 11/2019. RESULTS: There were 112 patients in the preprotocol group, with 74 (66%) having successful reduction following the first enema. Of the 38 patients without successful reduction, 16 (42%) patients underwent repeat enema, and five were successful (31%). The postprotocol group included 122 patients, with 84 (69%) having successful first reduction. Of the 38 patients that failed, 25 patients (66%) underwent repeat enema, of which 13 (52%) were successful. Compared to preprotocol patients, postprotocol patients had significantly more enemas repeated and a trend toward fewer surgical interventions. CONCLUSIONS: Protocol implementation of repeat delayed enemas was significantly associated with an increased rate of repeat enemas at our institutions and reduced need for operative intervention during the index stay.

Anastomosis technique and leakage rates in minimally invasive surgery for right-sided colon cancer. A retrospective national cohort study.

PURPOSE: The aim of this study was to describe the different techniques currently used in Denmark to construct right-sided ileocolic anastomoses in minimally invasive surgery, and investigate, compare and analyse the anastomotic configurations and their anastomotic leakage (AL) rates. METHODS: This was a retrospective register-based, study design using prospectively collected data from the Danish Colorectal Cancer Group (DCCG) database. All patients aged 18 years or older with a malignant colorectal tumour in Denmark in the period of 1 February 2015 until 31 December 2019, and who had an elective, curative, minimally invasive right hemicolectomy (MIRH) with ileocolic anastomosis, were included. RESULTS: Three thousand three hundred ninety-eight patients were included. The most commonly used anastomotic approach was the extracorporeal (EC) hand-sewn anastomosis (HA) with end-to-end configuration (59%) and the second most used was the EC stapled anastomosis (SA) side-to-side configuration (20%). The latter had a higher AL rate compared with the hand-sewn technique (3.8% vs. 1.3%), and had significantly higher odds ratio (OR) (OR: 2.85, 95% CI: 1.56-4.92, p < 0.0001) for AL in the adjusted regression model. The least used technique was the end-to-side HA which also had a significantly higher OR (OR: 3.05, 95% CI: 1.30-7.15, p = 0.010) compared with the end-to-end HA. Smoking was an independent factor associated with higher OR for AL. CONCLUSION: The ileocolic end-to-end HA was the most commonly used technique and had the lowest AL rate in MIRH for colon cancer. The EC SA technique and tobacco smoking were independent risk factors for leakage of the ileocolic anastomosis.

Ileocolic anastomosis after right hemicolectomy: stapled end-to-side, stapled side-to-side, or handsewn?

PURPOSE: Anastomotic leak (AL) following ileocolic anastomosis is a cause of significant morbidity and mortality. Stapled end-to-side (ESA), stapled side-to-side (SSA), and handsewn anastomoses (HSA) are commonly performed techniques. There is however conflicting data on the superiority of one technique over the other. The aim of this study was to compare the outcomes of ESA against SSA and HSA. METHODS: This retrospective cohort study was conducted at a tertiary colorectal unit. All patients who underwent an ileocolic anastomosis from October 2008 to May 2020 were included. Exclusion criteria were missing data on anastomotic technique or clinicopathological variables. Primary outcomes were AL and anastomotic bleeding (AB). Secondary outcomes were length of stay (LoS) and return of gut function. RESULTS: A total of 1390 patients met the inclusion criteria. A total of 976 (70%) ESA, 308 (22%) SSA, and 108 (8%) HSA were performed. AL occurred in 17/1390 (1.2%) patients, and 54/1390 (3.9%) had AB. On adjusted analysis, ESA experienced a lower AL when compared with SSA (OR 4.93, p = 0.005), with a trend towards a lower AL when compared to HSA (OR 2.6, p = 0.27). There was no difference in AB between all techniques: ESA vs. SSA (OR 1.07 p = 0.84), and ESA vs. HSA (OR 0.24 p = 0.76). Both stapled techniques were associated with a shorter return to gut function compared to HSA; 3.3 vs. 4.2 days (p < 0.001). There was no difference in LoS. CONCLUSION: ESA has the lowest leak rate when compared to other anastomotic techniques without any increased risk of anastomotic bleeding.