Complications and functional results after ileoanal pouch formation in obese patients

State of the Art: Pouch Surgery in the 21st Century

BACKGROUND

An ileoanal pouch with IPAA is the preferred method to restore intestinal continuity in patients who require a total proctocolectomy. Pouch surgery has evolved during the past decades thanks to increased experience and research, changes in the medical management of patients who require an ileal pouch, and technological innovations.

OBJECTIVE

To review the main changes in pouch surgery over the past 2 decades, with a focus on staging, minimally invasive and transanal approaches, pouch design, and anastomotic configuration.

RESULTS

The decision on the staging approach depends on the patient's conditions, their indication for surgery, and the risk of anastomotic leak. A minimally invasive approach should be performed whenever feasible, but open surgery still has a role in this technically demanding operation. Transanal IPAA may be performed in experienced centers and may reduce conversion to open surgery in the hostile pelvis. The J-pouch is the easiest, fastest, and most commonly performed design, but other designs may be used when a J-pouch is not feasible. A stapled anastomosis without mucosectomy can be safely performed in the majority of cases, with a low incidence of rectal cuff neoplasia and better functional outcomes than handsewn. Finally, Crohn's disease is not an absolute contraindication to an ileoanal pouch, but pouch failure may be higher compared to other indications.

CONCLUSIONS

Many technical nuances contribute to the success of an ileoanal pouch. The current standard of care is a laparoscopic J-pouch with double-stapled anastomosis, but this should not be seen as a dogma, and the optimal approach and design should be tailored to each patient. See video from symposium.

Creation of an institutional preoperative checklist to support clinical risk assessment in patients with ulcerative colitis (UC) considering ileoanal pouch surgery

Background

Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the most established restorative operative approach for patients with ulcerative colitis. It has associated morbidity and the potential for major repercussions on quality of life. As such, patient selection is crucial to its success. The main aim of this paper is to present an institutional preoperative checklist to support clinical risk assessment and patient selection in those considering IPAA.

Methods

A literature review was performed to identify the risk factors associated with surgical complications, decreased functional outcomes/quality of life, and pouch failure after IPAA. Based on this, a preliminary checklist was devised and modified through an iterative process. This was then evaluated by a consensus group comprising the pouch multidisciplinary team (MDT) core members.

Results

The final preoperative checklist includes assessment for risk factors such as gender, advanced age, obesity, comorbidities, sphincteric impairment, Crohn's disease and pelvic radiation therapy. In addition, essential steps in the decision-making process, such as pouch nurse counselling and discussion regarding surgical alternatives, are also included. The last step of the checklist is discussion at a dedicated pouch-MDT.

Discussion

A preoperative checklist may support clinicians with the selection of patients that are suitable for pouch surgery. It also serves as a useful tool to inform the discussion of cases at the MDT meeting.

Ethnic Disparities in Ileal Pouch Anal Anastomosis Outcomes: An ACS-NSQIP Study

INTRODUCTION

Ileal pouch-anal anastomosis (IPAA) has become the gold standard operation performed for patients with ulcerative colitis (UC) who require colectomy for medically refractory disease or colitis-associated neoplasia. This study aims to evaluate whether differences in surgical outcomes following IPAA creation is associated with minority ethnicity using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical outcomes database.

METHODS

The ACS-NSQIP proctectomy-targeted data files (2016-2019) were reviewed to identify patients who underwent an IPAA creation (Current Procedural Terminology codes: 44157, 44158, 44211, and 45113). Demographic, comorbidity, perioperative characteristics, and postoperative outcomes, particularly total-morbidity, surgical site infection, and anastomotic leak, were compared for White, African-American, Hispanic, and Asian patients. Separate multivariable logistic regressions were calculated for each outcome of interest. Certain postoperative outcomes required collation to be analyzed due to low numbers, such as combining all surgical site infections (SSIs), anastomotic leak, and septic complications as "infection complications". For each regression, a P value of <0.05 was considered to be significant.

RESULTS

A total of 1462 patients were identified who underwent an IPAA creation. There were 1290 (88.2%) Caucasian, 66 (4.5%) African-American, 49 (3.4%) Hispanic, and 57 (3.9%) Asian patients. Minority race or ethnicity was not associated with higher odds of total morbidity, readmission, reoperation, the development of any SSI, anastomotic leak, or other septic complications as compared to White patients. African-American ethnicity was associated with higher odds of developing postoperative bleeding complications (odds ratio [OR] 2.45, 95% confidence interval [CI] 1.15-5.21; P = 0.020) and postoperative renal dysfunction (OR 4.32, CI 1.43-13.07; P = 0.010) as compared to White patients. Elevated body mass index (BMI) was associated with higher odds of developing an SSI (OR 1.03, CI 1.00-1.06; P = 0.045), or an "infection" complication (OR 1.04, CI 1.01-1.07; P = 0.012), but was protective against bleeding complications (OR 0.94, CI 0.9-0.98; P = 0.004). Smoking was associated with higher odds of developing an SSI, anastomotic leak, or septic complications in the combined "infection" regression analysis (OR 2.02, CI 1.25-3.26; P = 0.004). In the analysis of total-morbidity, both hypertension (OR 1.64, CI 1.11-2.42; P = 0.013) and an ASA Class score >3 (OR 1.36, CI 1.03-1.79; P = 0.029) were associated with increased odds of complications.

CONCLUSIONS

This analysis of the ACS-NSQIP national database data suggests that ethnicity is not associated with disparities in surgical outcomes following IPAA surgery. African-American ethnicity was however associated with higher odds of developing postoperative bleeding complications and renal dysfunction as compared to White patients. Elevated BMI and smoking history are associated with an increased risk of SSI, anastomotic leak and septic complications.

Elective and Emergent Surgery in the Ulcerative Colitis Patient

Ulcerative colitis (UC) requires surgical management in 20 to 30% of patients. Indications for surgery include medically refractory disease, dysplasia, cancer, and other complications of UC. Appropriate patient selection for timing and staging of surgery is paramount for optimal outcomes. Restorative proctocolectomy is the preferred standard of care and can afford many patients with excellent quality of life. There have been significant shifts in the treatment of UC-associated dysplasia, with less patients requiring surgery and more entering surveillance programs. There is ongoing controversy surrounding the management of UC-associated colorectal cancer and the techniques that should be used. This article reviews the most recent literature on the indications for elective and emergent surgical intervention for UC and the considerations behind the surgical options.

Bariatric Surgery in Patients With Inflammatory Bowel Disease: A Case-Control Study from the GETAID

BACKGROUND

The prevalence of obesity and the number of bariatric surgeries in both the general population and in patients with inflammatory bowel disease (IBD) have increased significantly in recent years. Due to small sample sizes and the lack of adequate controls, no definite conclusions can be drawn from the available studies on the safety and efficacy of bariatric surgery (BS) in patients with IBD. Our aim was to assess safety, weight loss, and deficiencies in patients with IBD and obesity who underwent BS and compare findings to a control group.

METHODS

Patients with IBD and a history of BS were retrospectively recruited to centers belonging to the Groupe d'Etude Thérapeutique des Affections Inflammatoires du Tube Digestif (GETAID). Patients were matched 1:2 for age, sex, body mass index (BMI), hospital of surgery, and type of BS with non-IBD patients who underwent BS. Complications, rehospitalizations, weight, and deficiencies after BS were collected in cases and controls.

RESULTS

We included 88 procedures in 85 patients (64 Crohn's disease, 20 ulcerative colitis, 1 unclassified IBD) with a mean BMI of 41.6 ± 5.9 kg/m2. Bariatric surgery included Roux-en-Y gastric bypass (n = 3), sleeve gastrectomy (n = 73), and gastric banding (n = 12). Eight (9%) complications were reported, including 4 (5%) requiring surgery. At a mean follow-up of 34 months, mean weight was 88.6 ± 22.4 kg. No difference was observed between cases and controls for postoperative complications (P = .31), proportion of weight loss (P = .27), or postoperative deficiencies (P = .99).

CONCLUSIONS

Bariatric surgery is a safe and effective procedure in patients with IBD and obesity; outcomes in this patient group were similar to those observed in a control population.

Short- and Long-term Outcomes of Ileal Pouch Anal Anastomosis Construction in Obese Patients With Ulcerative Colitis

BACKGROUND

Obese patients are traditionally considered difficult pouch candidates because of the potential for intraoperative technical difficulty and increased postoperative complications.

OBJECTIVE

The purpose of this study was to compare the outcomes of obese versus nonobese patients with ulcerative colitis undergoing an IPAA.

DESIGN

This is a retrospectively, propensity score-matched, prospectively collected cohort study.

SETTING

This study was conducted at an IBD quaternary referral center.

PATIENTS

Patients with ulcerative colitis undergoing IPAA (1990-2018) were included. Obesity was defined as a BMI ≥30 kg/m 2 .

MAIN OUTCOME MEASURES

The primary measures included 30-day complications, long-term anastomotic leak, and pouch failure rate (excision, permanent diversion, revision).

RESULTS

Of 3300 patients, 631 (19.1%) were obese (median BMI = 32.4 kg/m 2 ). On univariate analysis, obese patients were more likely to be >50 years old (32.5% versus 22.7%, p < 0.001), ASA class 3 (41.7% versus 27.7%, p < 0.001), have diabetes (8.1% versus 3.3%, p < 0.001), and have had surgery in the biologic era (72.4% versus 66.2%, p = 0.003); they were less likely to have received preoperative steroids (31.2% versus 37.4%, p = 0.004). After a median follow-up of 7 years, 66.7% had completed at least 1 quality-of-life survey. Pouch survival in the matched sample was 99.2% (99.8% nonobese versus 95.4% obese, p = 0.002). After matching and controlling for confounding variables, worse clinical outcomes associated with obesity included global quality of life (relative risk, -0.71; p = 0.002) and long-term pouch failure (HR, 4.24; p = 0.007). Obesity was also independently associated with an additional 27 minutes of operating time ( p < 0.001). There was no association of obesity with the likelihood of developing a postoperative complication, length of stay, or pouch leak.

CONCLUSION

Restorative ileoanal pouch surgery in obese patients with ulcerative colitis is associated with a relatively decreased quality of life and increased risk of long-term pouch failure compared with nonobese patients. Obese patients may benefit from focused counseling about these risks before undergoing restorative pouch surgery. See Video Abstract at http://links.lww.com/DCR/B873 .

RESULTADOS A CORTO Y LARGO PLAZO EN LA REALIZACIN DEL RESERVORIO ILEAL EN PACIENTES OBESOS CON COLITIS ULCEROSA

ANTECEDENTES:Habitualmente se considera a los obesos como pacientes difíciles para la realización de un reservorio ileal, debido a su alta probabilidad de presentar dificultades técnicas intraoperatoria y aumento de las complicaciones posoperatorias.OBJETIVO:El propósito de este estudio fue comparar los resultados de pacientes con colitis ulcerosa obesos versus no obesos sometidos a un reservorio ileal y anastomosis anal (IPAA).DISEÑO:Este es un estudio de cohorte recopilado prospectivamente, retrospectivo, emparejado por puntajes de propensión.AJUSTE:Este estudio se llevó a cabo en un centro de referencia de cuarto nivel para enfermedades inflamatorias del intestino.PACIENTES:Se incluyeron pacientes con colitis ulcerosa sometidos a un reservorio ileal y anastomosis anal (1990-2018). Obesidad definida como un IMC ≥ 30 kg/m2.PRINCIPALES RESULTADO MEDIDOS:Los principales resultados medidos incluyeron complicaciones a los 30 días, fuga anastomótica a largo plazo y tasa de falla del reservorio ileal (escisión, derivación permanente, revisión).RESULTADOS:De 3.300 pacientes, 631 (19,1%) eran obesos (mediana de IMC = 32,4 kg/m2). En el análisis univariado, los pacientes obesos tenían más probabilidades de ser > 50 años (32,5% frente a 22,7%, p < 0,001), clase ASA 3 (41,7% frente a 27,7%, p < 0,001), tener diabetes (8,1% frente a 3,3%, p < 0,001), haberse sometido a cirugía en la era biológica (72,4% frente a 66,2%, p = 0,003), y tenían menos probabilidades de haber recibido esteroides preoperatorios (31,2% frente a 37,4%, p = 0,004). Después de una mediana de seguimiento de 7 años, el 66,7% había completado al menos una encuesta de calidad de vida. La supervivencia de la bolsa en la muestra emparejada fue del 99,2% (99,8% no obesos versus 95,4% obesos, p = 0,002). Después de emparejar y controlar las variables de confusión, los peores resultados clínicos asociados con la obesidad incluyeron la calidad de vida global (RR = -0,71, p = 0,002) y el fracaso de la bolsa a largo plazo (HR = 4,24, p = 0,007). La obesidad también se asoció de forma independiente con 27 minutos adicionales de tiempo quirúrgico ( p < 0,001). No hubo asociación de la obesidad con la probabilidad de desarrollar una complicación posoperatoria, la duración de la estadía o la fuga de la bolsa.CONCLUSIÓNES:La cirugía restauradora del reservorio ileoanal en pacientes obesos con colitis ulcerosa se asocia a una disminución relativa de la calidad de vida y un mayor riesgo de falla del reservorio a largo plazo en comparación con los pacientes no obesos. Los pacientes obesos pueden beneficiarse de un asesoramiento centrado en estos riesgos antes de someterse a una cirugía restauradoracon reservorio ileal y anastomosis anal. Consulte Video Resumen en http://links.lww.com/DCR/B873 . (Traducción-Dr. Rodrigo Azolas ).

Diagnosis of Anastomotic Leak

Anastomotic leaks after colorectal surgery is associated with increased morbidity and mortality. Understanding the impact of anastomotic leaks and their risk factors can help the surgeon avoid any modifiable pitfalls. The diagnosis of an anastomotic leak can be elusive but can be discerned by the patient's global clinical assessment, adjunctive laboratory data and radiological assessment. The use of inflammatory markers such as C-Reactive Protein and Procalcitonin have recently gained traction as harbingers for a leak. A CT scan and/or a water soluble contrast study can further elucidate the location and severity of a leak. Further intervention is then individualized on the spectrum of simple observation with resolution or surgical intervention.

A systematic review and meta-analysis of the outcome of ileal pouch anal anastomosis in patients with obesity

BACKGROUND

Ileal-pouch anal anastomosis is used for treatment of different conditions, including mucosal ulcerative colitis and familial adenomatous polyposis. The present systematic review aimed to assess the literature for studies that compared the outcome of ileal-pouch anal anastomosis in patients with obesity versus patients with ideal weight.

METHODS

A systematic literature search of electronic databases including PubMed, Scopus, Web of Science, and Cochrane library was performed and reported in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The main outcome measures were pouch failure, pouch complications, overall complications, operation time, blood loss, and hospital stay.

RESULTS

This systematic review included 6 retrospective studies (3,460 patients). Out of the total number of patients, 19.8% had obesity or overweight. Patients with obesity were significantly less likely to have laparoscopic ileal-pouch anal anastomosis compared with patients with ideal body mass index (odds ratio = 0.436; P = .017). The weighted mean operation time and blood loss were significantly longer in the obesity group than the ideal weight group (weighted mean difference = 22.84; P = .006) and (weighted mean difference = 85.8; P < .001). The obesity group was associated with significantly higher odds of total complications (odds ratio = 2.27; P < .001), leak (odds ratio = 1.81; P = .036), and incisional hernia (odds ratio = 4.56; P < .001). The 2 groups had comparable rates of pouch failure, pouchitis, stricture, pelvic sepsis, wound infection, bowel obstruction, ileus, and venous thromboembolism. Male sex, longer operation time, and including inflammatory bowel disease patients only were significantly associated with higher complications in the obesity group.

CONCLUSION

Patients with obesity who undergo ileal-pouch anal anastomosis are more likely to have laparotomy rather than a laparoscopic procedure, have longer operation time, greater blood loss, higher overall complications, leak and incisional hernia, and longer hospital stay.

Minimally invasive ileal pouch-anal anastomosis for patients with obesity: a propensity score-matched analysis

BACKGROUND

Obesity is a risk factor for failure of pouch surgery completion. However, little is known about the impact of obesity on short-term outcomes after minimally invasive (MIS) ileal pouch-anal anastomosis (IPAA). This study aimed to assess short-term postoperative outcomes in patients undergoing MIS total proctocolectomy (TPC) with IPAA in patients with and without obesity.

MATERIALS AND METHODS

All adult patients (≥ 18 years old) who underwent MIS IPAA as reported in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant User Files 2007 to 2018 were included. Patients were divided according to their body mass index (BMI) into two groups (BMI ≥ 30 kg/m² vs. BMI < 30 kg/m²). Baseline demographics, preoperative risk factors including comorbidities, American Society of Anesthesiologists Class, smoking, different preoperative laboratory parameters, and operation time were compared between the two groups. Propensity score matching (1:1) based on logistic regression with a caliber distance of 0.2 of the standard deviation of the logit of the propensity score was used to overcome biases due to different distributions of the covariates. Thirty-day postoperative complications including overall surgical and medical complications, surgical site infection (SSI), organ space infection, systemic sepsis, 30-day mortality, and length of stay were compared between both groups.

RESULTS

Initially, a total of 2158 patients (402 (18.6%) obese and 1756 (81.4%) nonobese patients) were identified. After 1:1 matching, 402 patients remained in each group. Patients with obesity had a higher risk of postoperative organ/space infection (12.9%; vs. 6.5%; p-value 0.002) compared to nonobese patients. There was no difference between the groups regarding the risk of postoperative sepsis, septic shock, need for blood transfusion, wound disruption, superficial SSI, deep SSI, respiratory, renal, major adverse cardiovascular events (myocardial infarction, stroke, cardiac arrest requiring cardiopulmonary resuscitation), venous thromboembolism, 30-day mortality, and length of stay.

CONCLUSION

MIS IPAA can be safely performed in patients with obesity. However, patients with obesity have a 2-fold risk of organ space infection compared to patients without obesity. Loss of weight before MIS IPAA is recommended not only to allow for pouch creation but also to decrease organ space infections.

Impact of Bariatric Surgery on the Long-term Disease Course of Inflammatory Bowel Disease

BACKGROUND

An association between inflammatory bowel disease (IBD) and obesity has been observed. Little is known about the effect of weight loss on IBD course. Our aim was to determine the impact of bariatric surgery on long-term clinical course of obese patients with IBD, either Crohn's disease (CD) or ulcerative colitis (UC).

METHODS

Patients with IBD who underwent bariatric surgery subsequent to IBD diagnosis were identified from 2 tertiary IBD centers. Complications after bariatric surgery were recorded. Patients were matched 1:1 for age, sex, IBD subtype, phenotype, and location to patients with IBD who did not undergo bariatric surgery. Controls started follow-up at a time point in their disease similar to the disease duration in the matched case at the time of bariatric surgery. Inflammatory bowel disease medication usage and disease-related complications (need for corticosteroids, hospitalizations, and surgeries) among cases and controls were compared.

RESULTS

Forty-seven patients met inclusion criteria. Appropriate matches were found for 25 cases. Median follow-up among cases (after bariatric surgery) and controls was 7.69 and 7.89 years, respectively. Median decrease in body mass index after bariatric surgery was 12.2. Rescue corticosteroid usage and IBD-related surgeries were numerically less common in cases than controls (24% vs 52%; odds ratio [OR], 0.36; 95% confidence interval [CI], 0.08-1.23; 12% vs 28%; OR, 0.2; 95% CI, 0.004-1.79). Two cases and 1 control were able to discontinue biologics during follow-up.

CONCLUSIONS

Inflammatory bowel disease patients with weight loss after bariatric surgery had fewer IBD-related complications compared with matched controls. This observation requires validation in a prospective study design.

Bowel Function After J-Pouch May Be More Complex Than Previously Appreciated: A Comprehensive Analysis to Highlight Existing Knowledge Gaps

BACKGROUND

Functional outcomes following J-pouch for ulcerative colitis have been studied, but lack standardization in which symptoms are reported. Furthermore, the selection of symptoms studied has not been patient centered.

OBJECTIVE

This study aimed to utilize a validated bowel function survey to determine which symptoms are present after J-pouch creation, and whether patients display a functional profile similar to low anterior resection syndrome.

DESIGN

This study is a retrospective analysis of a prospectively maintained single-center database.

SETTINGS

This study was conducted at the colorectal surgery center of a tertiary care academic hospital PATIENTS:: Included were 159 patients with J-pouch, ≥6 months after ileostomy reversal.

MAIN OUTCOME MEASURES

The primary outcomes were individual answers to the Memorial Sloan Kettering Cancer Center Bowel Function Instrument. The original Bowel Function Instrument validation cohort was used as an historical comparison (n = 127).

RESULTS

The mean total Bowel Function Instrument score for the J-pouch cohort was 59.9 ± 9.7 compared with a reported average score of 63.7 ± 11.6 for patients with low anterior resection in the validation cohort (p < 0.001), indicating worse bowel function in patients with J-pouch. When evaluating the Bowel Function Instrument subscales, patients with J-pouch reported frequency subscale scores of 18.2 ± 3.8, diet scores of 12.2 ± 3.8, and urgency scores of 15.9 ± 3.7, compared with 21.7 ± 4.5 (p < 0.001), 14.1 ± 3.7 (p < 0.001), and 15.0 ± 3.9 (p = 0.04) for patients undergoing rectal resection. Furthermore, 90.4% of patients with J-pouch state that they are sometimes, rarely, or never able to wait 15 minutes to get to the toilet. In addition, 56.4% of patients report having another bowel movement within 15 minutes of the last bowel movement, sometimes, always, or most of the time, and 50.6% of patients say that they sometimes, rarely, or never feel like their bowels have been totally emptied after a bowel movement.

LIMITATIONS

This study is limited because it took place at a single center and the Bowel Function Instrument was only validated for patients undergoing rectal resection.

CONCLUSIONS

Patients that undergo J-pouch surgery exhibit a constellation of bowel function symptoms that is more complex than fecal incontinence and frequency alone, despite the focus on these functional outcomes in the literature. See Video Abstract at http://links.lww.com/DCR/B73. LA FUNCIÓN INTESTINAL DESPUÉS DE LA BOLSA EN J PUEDE SER MÁS COMPLEJA DE LO QUE SE APRECIABA ANTERIORMENTE: UN ANÁLISIS EXHAUSTIVO PARA RESALTAR LAS BRECHAS DE CONOCIMIENTO EXISTENTES: Se han estudiado los resultados funcionales después de la bolsa en J para la colitis ulcerosa, pero carecen de estandarización en la que se informen los síntomas. Además, la selección de los síntomas estudiados no se ha centrado en el paciente.Utilizar una encuesta validada de la función intestinal para determinar qué síntomas están presentes después de la bolsa en J y si los pacientes muestran un perfil funcional similar al síndrome de resección anterior baja.Análisis retrospectivo de una base de datos de un solo centro mantenida prospectivamente.Centro de cirugía colorrectal de un hospital académico de atención terciaria.159 pacientes con bolsa en J, ≥6 meses después de la reversión de ileostomía.Instrumento para la función intestinal del "Memorial Sloan Kettering Cancer Center"; cohorte de validación original de instrumentos de función intestinal utilizada como comparación histórica (n = 127).La puntuación media total del instrumento de función intestinal para la cohorte de bolsa J fue 59.9 ± 9.7 en comparación con un puntaje promedio reportado de 63.7 ± 11.6 para pacientes con resección anterior baja en la cohorte de validación (p < 0.001), lo que indica peor función intestinal en pacientes con bolsa en J. Al evaluar las subescalas del instrumento de función intestinal, los pacientes con bolsa en J informaron puntuaciones de subescala de frecuencia de 18.2 ± 3.8, puntuaciones de dieta de 12.2 ± 3.8 y puntuaciones de urgencia de 15.9 ± 3.7, en comparación con 21.7 ± 4.5 (p < 0.001), 14.1 ± 3.7 (p < 0.001) y 15.0 ± 3.9 (p = 0.04) respectivamente para pacientes con resección rectal. Además, el 90.4% de los pacientes con bolsa en J afirman que a veces, rara vez o nunca pueden esperar 15 minutos para llegar al baño. Además, el 56.4% de los pacientes reportan haber tenido otra evacuación intestinal dentro de los 15 minutos posteriores a la última evacuación intestinal, a veces, siempre o la mayor parte del tiempo, y el 50.6% de los pacientes dicen que a veces, rara vez o nunca sienten que sus intestinos han sido vaciados totalmente después de una evacuación intestinal.Estudio en un solo centro, instrumento de función intestinal validado solo para pacientes con resección rectalLos pacientes que se someten a una bolsa en J exhiben una constelación de síntomas de la función intestinal que es más compleja que la incontinencia fecal y la frecuencia sola, a pesar del enfoque en estos resultados funcionales en la literatura.Consulte Video Resumen en http://links.lww.com/DCR/B73. (Traducción-Dr. Gonzalo Federico Hagerman).

Ileal-pouch anal anastomosis in pediatric NSQIP: Does a laparoscopic approach reduce complications and length of stay?

PURPOSE

The purpose of this study was to determine if a laparoscopic approach reduces complications and length of stay (LOS) after total proctocolectomy with ileal pouch-anal anastomosis (TPC-IPAA) in pediatric patients using a multicenter prospective database.

METHODS

The American College of Surgeons National Surgical Quality Improvement Project Pediatric database from 2012 to 2015 was used to identify patients with a diagnosis of chronic ulcerative colitis (CUC) or familial adenomatous polyposis (FAP) undergoing TPC-IPAA. Major complications, minor complications, and prolonged LOS were compared based on laparoscopic versus open approach.

RESULTS

195 (108 female) patients underwent TPC-IPAA at a median age of 14 years (IQR: 11-16) for CUC (N = 99) or FAP (N = 96). Two-thirds of cases were laparoscopic. A laparoscopic approach was not associated with major complications, but lower odds of minor complications were observed. A reduced LOS was seen in laparoscopic versus open surgery (median LOS 6 vs 8 days, p < 0.01). Open IPAA was independently associated with prolonged LOS (>9 days) in the FAP cohort (OR 4.0, 95% CI 1.1-14.0).

CONCLUSION

A laparoscopic approach was not associated with increased major complications but was associated with lower odds of minor complications and shorter LOS. The laparoscopic approach should continue to be preferred for pouch procedures in pediatric patients.

TYPE OF STUDY

Treatment; retrospective study.

LEVEL OF EVIDENCE

Level III.

Modified Pfannenstiel Open Approach as an Alternative to Laparoscopic Total Proctocolectomy and IPAA: Comparison of Short- and Long-term Outcomes and Quality of Life

BACKGROUND

A laparoscopic approach to total proctocolectomy with IPAA has been suggested to have better short-term outcomes and cosmesis, whereas open surgery by midline incision may result in shorter operative times. We hypothesized that a modified Pfannenstiel open approach would combine the advantages of both techniques.

OBJECTIVE

The purpose of this study was to compare outcomes of open total proctocolectomy with IPAA using a modified Pfannenstiel incision versus those following the laparoscopic approach.

DESIGN

This was a retrospective study comparing patients submitted to open IPAA using modified Pfannenstiel incision versus laparoscopy from 1998 to 2014.

SETTINGS

The study was conducted at a high-volume tertiary referral center.

PATIENTS

Among 1275 patients, 119 patients underwent the laparoscopic approach and 33 underwent the modified Pfannenstiel approach.

MAIN OUTCOME MEASURES

Short- and long-term outcomes were evaluated, and quality-of-life questionnaires were assessed.

RESULTS

Patients who underwent the modified Pfannenstiel approach were younger, more often women, and had lower BMI and ASA classification compared with those who underwent laparoscopy. Surgical time was lower in Pfannenstiel, and no difference was observed in length of hospital stay. No difference was observed in postoperative complications, pouch failure rate, or quality of life. Patients were then matched 1:1 by diagnosis, sex, age (±5 y) and BMI (±5 kg/m). The Pfannenstiel approach still had a shorter surgical time. No difference was observed in the length of hospital stay, complications, pouch failure, or quality of life. In long-term follow-up, pouchitis symptoms occurred more frequently in Pfannenstiel (mean follow-up = 7.3 y), and seepage was more frequently observed in the laparoscopy group (mean follow-up = 4.2 y). These differences were not observed in matched patients.

LIMITATIONS

The study was limited by its retrospective design and inherent selection bias.

CONCLUSIONS

The modified Pfannenstiel approach provides equivalent short- and long-term outcomes and similar quality of life compared with laparoscopy but with a significantly shorter operative time. The modified Pfannenstiel approach to total proctocolectomy with IPAA may be the most efficient method in selected patients. See Video Abstract at http://links.lww.com/DCR/A562.

Risk factors for organ space infection after ileal pouch anal anastomosis for chronic ulcerative colitis: An ACS NSQIP analysis

BACKGROUND

Organ space infection (OSI) after ileal pouch anal anastomosis (IPAA) is a devastating complication. The aim of this was study was to determine separately risk factors for OSI after total proctocolectomy (TPC) with IPAA and completion proctectomy (CP) with IPAA.

METHODS

4049 patients with a diagnosis of chronic ulcerative colitis undergoing TPC with IPAA or CP with IPAA between 2005 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Primary outcome was an OSI within 30 days of surgery. Multivariable analyses were conducted for the development of OSI after each operation.

RESULTS

For TPC with IPAA, urgent surgery (OR: 2.0, p < 0.01) and obesity (OR: 1.6, p < 0.01) were independent risk factors for OSI. Operation length of 275 + minutes (versus <170 min; OR: 2.2, p = 0.02) was predictive of OSI after CP with IPAA.

CONCLUSION

Risk factors for OSI differed between the operations. This highlights the importance of the consideration of the physiologic status of the patient when deciding to perform TPC with IPAA or subtotal colectomy with ileostomy initially.

Obesity and inflammatory bowel disease: diagnostic and therapeutic implications

PURPOSE OF REVIEW

The review summarizes our current understanding of how obesity impacts diagnostic studies and therapies used in inflammatory bowel disease (IBD) as well as the safety and efficacy of medical and surgical weight loss therapies in the obese IBD patient.

RECENT FINDINGS

Many of the diagnostic tools we rely on in the identification and monitoring of IBD can be altered by obesity. Obesity is associated with increased acute phase proteins and fecal calprotectin. It can be more difficult to obtain and interpret cross sectional imaging of obese patients. Recent studies have also shown that common therapies used to treat IBD may be less effective in the obese population and may impact comorbid disease. Our understanding of how best to measure obesity is evolving. In addition to BMI, studies now include measures of visceral adiposity and subcutaneous to visceral adiposity ratios. An emerging area of interest is the safety and efficacy of obesity treatment including bariatric surgery in patients with IBD. A remaining question is how weight loss may alter the course of IBD.

SUMMARY

The proportion of obese IBD patients is on the rise. Caring for this population requires a better understanding of how obesity impacts diagnostic testing and therapeutic strategies. The approach to weight loss in this population is complex and future studies are needed to determine the safety of medical or surgical weight loss and its impact on the course of disease.

Obese Patients Undergoing Ileal Pouch-Anal Anastomosis: Short-and Long-term Surgical Outcomes

BACKGROUND

Ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment for patients with chronic ulcerative colitis. Little is known about the impact of obesity on operative characteristics, short-term postoperative complications and long-term functional outcomes after IPAA.

METHODS

A retrospective review of all patients undergoing IPAA for chronic ulcerative colitis at a single tertiary referral center between January 2002 and August 2013 was performed. Thirty-day postoperative complications and long-term functional outcomes were analyzed according to body mass index.

RESULTS

Nine hundred nine IPAAs (154 obese [body mass index ≥ 30] and 755 not obese [body mass index < 30]) were performed during the study period. For 2-stage IPAA, obese patients were less likely to undergo laparoscopic IPAA (P < 0.0001), had greater estimated blood loss (P = 0.005), and longer operative times (P = 0.02). For 3-stage IPAA, obese patients were less likely to undergo a laparoscopic procedure (P = 0.03), had greater estimated blood loss (P < 0.0001), and longer operative times (P = 0.0002). Postoperatively, obese patients had a longer length of stay after a 2-stage procedure (P = 0.009), an increased rate of superficial surgical site infections (P = 0.003), and an increased rate of urinary tract infections (P = 0.03). Of the 61% (n = 546) of patients with IPAA with long-term (median 5.0 years) follow-up, there were no significant differences in functional outcomes including incontinence, frequency of bowel movements, pad usage, and pouchitis between the groups.

CONCLUSIONS

Obesity impacts intraoperative complexity and 30-day postoperative outcomes. Long-term functional outcomes are not affected. These findings underscore the need to counsel patients on preoperative weight loss before undergoing elective IPAA.

Factors affecting pouch-related outcomes after restorative proctocolectomy

Purposes

Restorative proctocolectomy (RPC) with ileal pouch anal anastomosis (IPAA) is the procedure of choice for patients with familial adenomatous polyposis (FAP) and ulcerative colitis (UC) despite morbidities that can lead to pouch failure. We aimed to identify factors associated with pouch-related morbidities.

Methods

A retrospective analysis of patients who underwent RPC with IPAA was performed. To investigate the factors associated with pouch-related morbidities, patients' preoperative demographic and clinical factors, and intraoperative factors were included in the analysis.

Results

A total of 49 patients with UC, FAP, and colorectal cancer were included. Twenty patients (40.8%) experienced leakage-related, functional, and/or pouchitis-related morbidities. Patients with American Society of Anesthesiologists (ASA) grade 2 or 3 had a higher risk of functional morbidity than those with grade 1. Intraoperative blood loss exceeding 300.0 mL was associated with an increased risk of pouchitis-related morbidity.

Conclusions

Our study demonstrated associations of higher ASA grade and increased intraoperative blood loss with poor functional outcomes and pouchitis, respectively.

Obesity in IBD: epidemiology, pathogenesis, disease course and treatment outcomes

Incidence of IBD is rising in parallel with overweight and obesity. Contrary to conventional belief, about 15-40% of patients with IBD are obese, which might contribute to the development of IBD. Findings from cross-sectional and retrospective cohort studies are conflicting on the effect of obesity on natural history and course of IBD. Most studies are limited by small sample size, low event rates, non-validated assessment of disease activity and lack robust longitudinal follow-up and have incomplete adjustment for confounding factors. The effect of obesity on the efficacy of IBD-related therapy remains to be studied, though data from other autoimmune diseases suggests that obesity results in suboptimal response to therapy, potentially by promoting rapid clearance of biologic agents leading to low trough concentrations. These data provide a rationale for using weight loss interventions as adjunctive therapy in patients with IBD who are obese. Obesity also makes colorectal surgery technically challenging and might increase the risk of perioperative complications. In this Review, we highlight the existing literature on the epidemiology of obesity in IBD, discuss its plausible role in disease pathogenesis and effect on disease course and treatment response, and identify high-priority areas of future research.

Effect of BMI on outcomes in proctectomy

BACKGROUND

The unique surgical challenges of proctectomy may be amplified in obese patients. We examined surgical outcomes of a large, diverse sample of obese patients undergoing proctectomy.

OBJECTIVE

The purpose of this work was to determine whether increased BMI is associated with increased complications in proctectomy.

DESIGN

This was a retrospective review.

SETTINGS

The study uses the American College of Surgeons National Surgical Quality Improvement Program database (2010 and 2011).

PATIENTS

Patients included were those undergoing nonemergent proctectomy, excluding rectal prolapse cases. Patients were grouped by BMI using the World Health Organization classifications of underweight (BMI <18.5); normal (18.5-24.9); overweight (25.0-29.9); and class I (30.0-34.9), class II (35.0-39.9), and class III (≥40.0) obesity.

MAIN OUTCOME MEASURES

We analyzed the effect of preoperative and intraoperative factors on 30-day outcomes. Continuous variables were compared with Wilcoxon rank-sum tests and proportions with the Fisher exact or χ tests. Logistic regression controlled for the effects of multiple risk factors.

RESULTS

Among 5570 patients, class I, II, and III obesity were significantly associated with higher rates of overall complications (44.0%, 50.8%, and 46.6% vs 38.1% for normal-weight patients; p < 0.05). Superficial wound infection was significantly higher in classes I, II, and III (11.6%, 17.8%, and 13.0% vs 8.0% for normal-weight patients; p < 0.05). Operative times for patients in all obesity classes were significantly longer than for normal-weight patients. On multivariate analysis, an obese BMI independently predicted complications; ORs (95% CIs) were 1.36 (1.14-1.62) for class I obesity, 1.99 (1.54-2.54) for class II, and 1.42 (1.02-1.96) for class III.

LIMITATIONS

This study was a retrospective design with limited follow-up.

CONCLUSIONS

Class I, II, and III obese patients were at significantly increased risk for morbidity compared with normal BMI patients. Class II obese patients had the highest rate of complications, a finding that deserves further investigation.

Obesity increases risk for pouch-related complications following restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA)

PURPOSE

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment for patients with ulcerative colitis and familial adenomatous polyposis. As obesity is becoming more epidemic in surgical patients, the aim of this study was to investigate if obesity increases complication rates following IPAA.

METHODS

This study was conducted as a retrospective review of patients undergoing IPAA between January 1990 and April 2011. Patients were categorized by body mass index (BMI): BMI < 30 (non-obese) and BMI ≥ 30 (obese). Preoperative patient demographics, operative variables, and postoperative complications were recorded through chart review. The primary outcome studied was cumulative complication rate.

RESULTS

A total of 103 non-obese and 75 obese patients were identified who underwent IPAA. Obese patients had an increased rate of overall complications (80 % vs. 64%, p = 0.03), primarily accounted for by increased pouch-related complications (61% vs. 26%, p < 0.01). In particular, obese patients had more anastomotic/pouch strictures (27% vs. 6%, p < 0.01), inflammatory pouch complications (17 % vs. 4%, p < 0.01) and pouch fistulas (12% vs. 3%, p = 0.03). In a regression model, obesity remained a significant risk factor (odds ratio [OR] = 2.86, p = 0.01) for pouch-related complications.

CONCLUSIONS

Obesity is associated with an increased risk of overall and pouch-related complications following IPAA. Obese patients should be counseled preoperatively about these risks accordingly.

Excessive weight gain is associated with an increased risk for pouch failure in patients with restorative proctocolectomy

BACKGROUND

The aim was to evaluate the impact of weight gain on pouch outcomes after ileostomy closure.

METHODS

Consecutive inflammatory bowel disease patients with ileal pouches followed up at our subspecialty Pouch Center from 2002 to 2011 were studied. The association of excessive weight gain (defined as a 15% increase the index weight) with pouch outcomes were evaluated using univariate and multivariate analyses.

RESULTS

A total of 846 patients met inclusion criteria, with 470 (55.6%) being men. The mean age at the diagnosis of inflammatory bowel disease and at pouch surgery was 27.2 ± 11.9 years and 37.8 ± 12.8 years, respectively. Patients with weight gain more likely had mechanical or surgical complications of the pouch (18.4% versus 12.3%, P = 0.049), Crohn's disease of the pouch (30.6% versus 18.5%, P = 0.001), Pouch Center visits (2.0 [1.0-4.0] versus 2.0 [1.0-3.0], P = 0.008), and postoperative pouch-related hospitalization (21.1% versus 10.6%, P < 0.001). After a median follow-up of 9.0 (interquartile range = 4.0-14.0) years, 68 patients (8.0%) developed pouch failure. In the multivariate analysis, excessive weight gain was an independent risk factor for pouch failure with a hazard ratio of 1.69 (95% confidence interval = 1.01-2.84, P = 0.048) after adjusting for preoperative or postoperative use of anti-tumor necrosis factor biologics, postoperative use of immunosuppressants, Crohn's disease of the pouch, mechanical or surgical complications of the pouch, and postoperative pouch-associated hospitalization.

CONCLUSIONS

Excessive weight gain after closure of the ileostomy is associated with worse pouch outcomes in patients with inflammatory bowel disease. Appropriate weight control may help improve pouch retention.

Impact of obesity on operation performed, complications, and long-term outcomes in terms of restoration of intestinal continuity for patients with mid and low rectal cancer

BACKGROUND

The impact of obesity per se on the surgical strategy, ie, sphincter sacrifice (abdominoperineal resection) vs sphincter-preserving resection, outcomes, and long-term maintenance of intestinal continuity has been poorly studied in patients with mid and low rectal cancer.

OBJECTIVE

The aim of this study is to compare the outcomes and long-term maintenance of intestinal continuity for obese and nonobese patients treated surgically for mid and low rectal cancers.

DESIGN

This is a retrospective cohort study from a prospectively collected database.

SETTING

The investigation took place in a high-volume specialized colorectal surgery department.

PATIENTS

All patients who underwent curative surgery for mid or low rectal adenocarcinoma at a single institution from 1976 to 2011 were identified.

MAIN OUTCOME MEASURES

Obese (BMI ≥ 30 kg/m) and nonobese patients were matched 1:2 for age, sex, ASA class, location, and stage of tumor. Demographics, use of neoadjuvant chemoradiotherapy, operative and perioperative outcomes, pathology, long-term outcomes including oncologic outcomes, and whether restoration of intestinal continuity was obtained were compared.

RESULTS

One hundred fifty-seven obese patients and 314 nonobese patients were included in the study. The groups were similar for matched characteristics. The use of neoadjuvant chemoradiotherapy (p = 0.048) and anastomotic leak (p = 0.0003) rates were higher in obese patients. A similar proportion of nonobese and obese patients underwent sphincter-preserving resection (p > 0.99), and postoperative hospital stay (p = 0.23), 30-day postoperative reoperation (p = 0.83), mortality (p > 0.99), and readmissions (p = 0. 13) were similar. The obese and nonobese groups had similar overall (p = 0.61) and disease-free survival (p = 0.74) at a mean follow-up of 5 years for both groups.

LIMITATIONS

This study was limited by its retrospective and nonrandomized nature.

CONCLUSION

At a high-volume specialized colorectal unit, proctectomy can be performed in obese patients with similar long-term oncologic outcomes and ability to restore intestinal continuity in comparison with nonobese patients. Proctectomy in obese patients, however, is associated with an increased risk of anastomotic leak in comparison with nonobese patients.

Complications following colon rectal surgery in the obese patient

It is well recognized that obesity contributes to multiple co-morbidities, and it would seem intuitive that obese patients experience an increase in post-operative complications after colorectal surgery. Overall, the data examining postoperative morbidity and mortality in the obese colorectal patient is inconsistent. Studies have shown a trend for obese patients have a higher post-operative risk of pulmonary embolism, atelectasis, cardiac complications, and thromboembolic disease. However, even with multiple large trials concluding this, there are also many studies showing no difference. The literature has shown that using laparoscopic techniques is safe and feasible, but there is a higher rate of conversion to open, and longer operative times. In addition, obese patients might have a higher leak rate for distal anastomosis as compared with normal weight patients. These patients also have a higher post-operative rate of stomal complications and fascial dehiscense. In reviewing the literature, at best, the complication rate in obese patients is the same as non-obese patients after colorectal surgery, but there are significant trends that suggest a negative effect of obesity after colorectal surgery.

Familial adenomatous polyposis: challenges and pitfalls of surgical treatment

Surgical management of familial adenomatous polyposis (FAP) is complex and requires both sound judgment and technical skills. Because colorectal cancer risk approaches 100%, prophylactic colorectal surgery remains a cornerstone of management. Both patient factors and disease characteristics influence surgical decision-making regarding the timing of prophylactic surgery, the extent of resection, and types of reconstruction. Making appropriate choices can be challenging and there is continued debate regarding optimal strategies. This chapter reviews the controversies in colorectal surgery for FAP.

Update of complications and functional outcome of the ileo-pouch anal anastomosis: overview of evidence and meta-analysis of 96 observational studies

OBJECTIVE

The objective of this study is to provide a comprehensive update of the outcome of the ileo-pouch anal anastomosis (IPAA).

DATA SOURCES

An extensive search in PubMed, EMBASE, and The Cochrane Library was conducted.

STUDY SELECTION AND DATA EXTRACTION

All studies published after 2000 reporting on complications or functional outcome after a primary open IPAA procedure for UC or FAP were selected. Study characteristics, functional outcome, and complications were extracted.

DATA SYNTHESIS

A review with similar methodology conducted 10 years earlier was used to evaluate developments in outcome over time. Pooled estimates were compared using a random-effects logistic meta-analyzing technique. Analyses focusing on the effect of time of study conductance, centralization, and variation in surgical techniques were performed.

RESULTS

Fifty-three studies including 14,966 patients were included. Pooled rates of pouch failure and pelvic sepsis were 4.3% (95% CI, 3.5-6.3) and 7.5% (95% CI 6.1-9.1), respectively. Compared to studies published before 2000, a reduction of 2.5% was observed in the pouch failure rate (p = 0.0038). Analysis on the effect of the time of study conductance confirmed a decline in pouch failure. Functional outcome remained stable over time, with a 24-h defecation frequency of 5.9 (95% CI, 5.0-6.9). Technical surgery aspects did not have an important effect on outcome.

CONCLUSION

This review provides up to date outcome estimates of the IPAA procedure that can be useful as reference values for practice and research. It is also shows a reduction in pouch failure over time.

Changing shape of disease: nonalcoholic fatty liver disease in Crohn's disease-a case series and review of the literature

BACKGROUND

With improvements in therapy for inflammatory bowel disease (IBD) and changes in the prevalence of obesity, the phenotype of Crohn's disease (CD) is changing. These changes may herald an increase in the incidence of nonalcoholic fatty liver disease (NAFLD) in this population.

METHODS

Over a 10-month period we identified seven patients with CD who required liver biopsy for elevated liver function tests (LFTs), with an ultimate diagnosis of NAFLD. We performed a retrospective chart review and literature search to identify relevant data on NAFLD and CD. Specifically, we abstracted prior and current IBD-related medication exposures, disease severity, and the presence of typical comorbidities associated with NAFLD.

RESULTS

We describe seven patients with CD and biopsy-proven NAFLD. The majority of these patients were overweight or obese, had quiescent CD, and were more likely to be receiving a tumor necrosis factor-alpha inhibitor. Review of the literature produced a total of 29 articles describing NAFLD in IBD patients, primarily restricted to historical autopsy and surgical series. Limited contemporary studies highlight the rising prevalence of NAFLD in treated IBD populations.

CONCLUSIONS

NAFLD is increasing in incidence and prevalence among the general population. With improvements in therapy, NAFLD is likely increasing among the CD population as well. When evaluating an IBD patient with abnormal LFTs, clinicians need to consider NAFLD. NAFLD may impact IBD management in the future if therapeutic modalities are limited due to elevated LFTs. Further, patients should be monitored for excessive weight gain and counseled regarding healthy dietary and exercise habits.

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.

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.

A laparoscopic approach does reduce short-term complications in patients undergoing ileal pouch-anal anastomosis

BACKGROUND

Studies to date examining the impact of laparoscopy in the IPAA have failed to demonstrate a significant, consistent benefit in terms of a reduction in short-term morbidity or length of stay.

OBJECTIVE

The aim of this study was to establish the impact of the operative approach (laparoscopic or open) on outcomes after IPAA formation.

DESIGN, SETTING, AND PATIENTS

With use of the American College of Surgeons National Surgical Quality Improvement Program participant use file (2005-2008), the records of patients who underwent open or laparoscopic IPAA with diverting ileostomy were examined.

MAIN OUTCOME MEASURES

Risk-adjusted 30-day outcomes and length of stay were assessed by use of regression modeling, adjusting for patient characteristics, comorbidities, and operative approach.

RESULTS

Six hundred seventy-six cases were included, of which 339 (50.1%) were laparoscopic procedures. After adjustment, a laparoscopic approach was associated with a lower rate of major (OR = 0.67, 95% CI: 0.45-0.99, P = .04) and minor (OR = 0.44, 95% CI: 0.27-0.70, P = .01) complications. Laparoscopy was not associated with a significant reduction in length of postoperative stay compared with open pouch formation (laparoscopic vs open approach, -0.05 ± 0.30 d (P = .87)).

LIMITATIONS

The sampling strategy used by the National Surgical Quality Improvement Program means that only a proportion of all relevant cases would have been analyzed and no data are available about the potential impact of surgeon experience on outcome.

CONCLUSIONS

A laparoscopic approach to ileal pouch formation was associated with a significant reduction in both major and minor complications compared with the traditional open approach. Given the high financial costs associated with complications arising from this procedure, this study provides support for the adoption of the laparoscopic approach in the formation of an IPAA.

Outcomes after laparoscopic intestinal resection in obese versus non-obese patients

BACKGROUND

The degree of benefit derived from laparoscopic bowel resection in obese compared with non-obese patients is poorly understood.

METHODS

A total of 436 obese patients (body mass index (BMI) at least 30 kg/m(2), mean 34·9 kg/m(2)) who underwent laparoscopic bowel resection during 1992-2008 were identified from a prospective database. An equal number of non-obese patients (mean BMI 24·8 kg/m(2)) was case-matched by age, sex, year of surgery, American Society of Anesthesiologists score, diagnosis and type of operation. Patients with previous major abdominal surgery were excluded. Postoperative morbidity and recovery were compared between obese and non-obese patients.

RESULTS

Mean duration of operation (171·5 versus 157·3 min; P = 0·017), estimated blood loss (EBL; 224·9 versus 164·6 ml; P = 0·001) and conversion rate (13·3 versus 7·1 per cent; P = 0·003) were increased significantly in obese patients. Overall postoperative morbidity was also greater (32·1 versus 25·7 per cent; P = 0·041), particularly wound infection rate (10·6 versus 4·8 per cent; P = 0·002). Among laparoscopically completed operations, obese patients had higher rates of overall morbidity (31·5 versus 24·2 per cent; P = 0·026) and wound infection (10·2 versus 4·4 per cent; P = 0·002). Conversion was associated with increased EBL, intraoperative complications, overall morbidity and length of stay in both groups. The effect of conversion in worsening outcomes was comparable in obese and non-obese patients, except for a greater increase in incision length (11·0 versus 8·0 cm; P = 0·001) and EBL (304·8 versus 89·8 ml; P = 0·001) in obese patients.

CONCLUSION

Laparoscopic bowel resection results in greater morbidity in obese than in non-obese individuals. This difference remains comparable whether the procedure is completed laparoscopically or converted.

Restorative proctectomy with ileal pouch-anal anastomosis in obese patients

PURPOSE

The aim of this study was to assess outcomes of ileal pouch-anal anastomosis in obese patients compared with a matched cohort of nonobese patients.

METHODS

A review of all obese patients who underwent ileal pouch-anal anastomosis from 1998 to 2008 was performed. Obesity was defined as body mass index >or=30 kg/m. A matched control group of patients with body mass index within 18.5 to 25 kg/m was created. Primary end points included operative time, length of hospital stay, operative blood loss, and early (<or=6 wk) and long-term (>6 wk) postoperative complications.

RESULTS

Sixty-five obese patients (mean body mass index, 34.3 +/- 0.51 kg/m) underwent proctectomy with ileal pouch-anal anastomosis or proctocolectomy with ileal pouch-anal anastomosis. Mean body mass index of the control group was 22.45 +/- 0.2 kg/m (P < .0001). The most common diagnosis was mucosal ulcerative colitis (84.6%), followed by familial adenomatous polyposis (13.9%) and Crohn's disease (1.5%). The obese population had a higher incidence of cardiorespiratory comorbidities (P = .044), and a trend for steroid and immunosuppressive therapy (P = .06) preoperatively. Obese patients required longer operative time (P = .001) and longer hospital stay (P = .009). Early postoperative complications were comparable (P > .05). Long-term outcomes were also similar, except for a higher incidence of incisional hernia in the obese group (P = .01).

CONCLUSIONS

The overall postoperative complication rate in obese patients undergoing ileal pouch-anal anastomosis was similar to a matched nonobese cohort of patients. However, longer operative time, longer length of stay, and a higher rate of incisional hernia were noted in the obese population. Obese patients should be appropriately consulted about these issues before undergoing ileal pouch-anal anastomosis.

Asymmetric endoscopic inflammation of the ileal pouch: a sign of ischemic pouchitis?

BACKGROUND

Pouchitis is associated with dysbiosis and dysregulated mucosal immunity, although secondary pouchitis with special etiologic factors, such as ischemia, can occur. The aim was to describe a disease phenotype of the ileal pouch with an endoscopic appearance suggestive of ischemia.

METHODS

We identified consecutive patients with endoscopic asymmetric inflammation of the pouch (inflammation of side of the pouch with a completely normal other limb of the pouch one limb and a sharp demarcation along the staple suture line). Patients with Crohn's disease (CD) of the pouch or antibiotic-responsive pouchitis, matched for duration of the pouch, served as controls. Histology slides of mucosal biopsies were re-reviewed independently by 2 blinded gastrointestinal pathologists. Demographic, clinical, endoscopic, histologic, and imaging characteristics were compared between the groups.

RESULTS

Ten patients with "ischemic" pouchitis, 15 with CD of the pouch, and 15 with antibiotic-responsive pouchitis were studied. Pyloric gland metaplasia was observed only in the groups with CD of the pouch (23.1%) or antibiotic-responsive pouchitis (13.3%). Of patients with "ischemic" pouchitis, 80% had extracellular hemosiderin or hematoidin deposits (versus 30.8% those with CD of the pouch and 13.3% of those with pouchitis, P = 0.003). The majority of patients (80%) with "ischemic" pouchitis did not respond to conventional antibiotic therapy. It appeared that subsequent abdominal surgeries after pouch construction and a history of postoperative portal vein thrombi were associated with "ischemic" pouchitis.

CONCLUSIONS

Endoscopic asymmetric inflammation of the pouch may represent an ischemia-associated pouchitis with characteristic clinical, radiographic, and histologic features. Its hemodynamic, cellular, and molecular basis of mechanism warrants further study.

Role of surgery in familial adenomatous polyposis and hereditary nonpolyposis colorectal cancer (Lynch syndrome)

Surgery remains the mainstay of treatment for patients who develop colorectal cancer (CRC) in the setting of a hereditary CRC syndrome. In patients with a hereditary CRC syndrome, surgery can be prophylactic, therapeutic with curative intent, and, in some cases, palliative. The type and extent of surgical resection in familial adenomatous polyposis (FAP) and in the Lynch syndrome is influenced by differences in the natural history of carcinogenesis between the two syndromes and by the effectiveness of and patient compliance with available surveillance strategies. In this article, the surgical options for the management of patients with FAP and Lynch syndrome are discussed.

Early readmission after ileoanal pouch surgery

PURPOSE

This study was designed to evaluate factors that might be predictive of readmission and early and long-term outcomes for patients readmitted after ileal pouch-anal anastomosis.

METHODS

Data for patients readmitted within 30 days after ileal pouch-anal anastomosis were identified from a prospectively maintained database and compared with the remaining patients. Early and delayed outcomes for readmitted patients, including long-term functional outcomes and quality of life, were evaluated. Potential predictors of readmission were assessed using a multivariate analysis of factors.

RESULTS

Of 3,410 patients who underwent ileal pouch-anal anastomosis from 1984 to 2008, 410 (12%) were readmitted. Reasons for readmission included ileus, obstruction or dyselectrolytemia (54.9%), surgical site infection (19.8%), anastomotic problems (9.8%), and thrombotic (3.4%), hemorrhagic (3.2%), infectious (2.9%), cardiac (1.2%), and miscellaneous (4.3%) complications. Thirty-two (7.8%) patients underwent reoperation; 74 (18%) required invasive nonoperative interventions. Median hospital stay for readmission was four (range, 1-52) days. Readmitted patients had worse long-term functional results (P = 0.015) and social (P = 0.024), work (P = 0.008), and sexual (P = 0.046) restriction as compared with patients who were not readmitted. The Cleveland Global Quality of Life (P = 0.018) and physical SF-36 (P = 0.008) scores were also significantly lower for readmitted patients. On multivariate analysis, comorbid conditions (P = 0.014, odds ratio = 1.36), laparoscopic technique (P = 0.008, odds ratio = 1.8), proctocolectomy (rather than initial subtotal colectomy) at ileal pouch-anal anastomosis (P < 0.001, odds ratio = 1.55), and postoperative blood transfusion (P = 0.02, odds ratio = 1.54) were independently associated with readmission.

CONCLUSION

Early readmission after ileal pouch-anal anastomosis is common. Associated comorbidity, laparoscopic approach, reconstruction of the ileal pouch-anal anastomosis at the index surgery, and postoperative blood transfusion are associated with readmission.

A brief report of the epidemiology of obesity in the inflammatory bowel disease population of Tayside, Scotland

AIM

Obesity in inflammatory bowel disease (IBD), particularly Crohn's disease (CD), has previously been considered unusual (3%). CD patients who are obese tend to have increased perianal complications and a higher level of disease activity on an annual basis. Obesity in Scotland has been documented to have increased over the last decade, and over half all men and women in Scotland are now considered to be overweight. This study aims to assess obesity prevalence in the IBD community in Tayside, Scotland.

METHODS

All IBD patients (n = 1,269) were considered for inclusion. Inclusion criteria required a weight measurement taken from the preceding 12 months and a height measurement within the last decade. 489 patients were included in the analysis.

RESULTS

18% of the Tayside IBD population were obese in comparison to approximately 23% of the Scottish population on a whole. A further 38% of patients were over-weight, the same percentage as the general population. In the overweight and obese ulcerative colitis patients there were higher levels of surgery, but the converse was true in the CD group, where the normal-weight group had the highest levels of surgery. There were significantly more obese men and women with CD than with ulcerative colitis (P = 0.05).

CONCLUSION

Obesity prevalence has increased in IBD patients. This is significant because of the known increased levels of postoperative complications, perianal disease and requirement for more aggressive medical therapy. Research needs to be done to look at the effects of obesity on the co-morbid associations of other diseases with IBD, in particular colorectal cancer, and to ascertain whether or not screening frequency should be altered depending on BMI.