Acute Severe Ulcerative Colitis Is Associated With an Increased Risk of Acute Pouchitis

BACKGROUND

Pouchitis occurs in up to 80% of patients after total proctocolectomy (TPC) with ileal pouch-anal anastomosis (IPAA) and has been associated with microbial and host-related immunological factors. We hypothesized that a more robust immune response at the time of colectomy, manifested by acute severe ulcerative colitis (ASUC), may be associated with subsequent acute pouchitis.

METHODS

This was a retrospective cohort analysis of all patients with UC or indeterminate colitis complicated by medically refractory disease or dysplasia who underwent TPC with IPAA at Mount Sinai Hospital between 2008 and 2017 and at least 1 subsequent pouchoscopy. Acute pouchitis was defined according to the Pouchitis Disease Activity Index. Cox regression was used to assess unadjusted relationships between hypothesized risk factors and acute pouchitis.

RESULTS

A total of 416 patients met inclusion criteria. Of the 165 (39.7%) patients who underwent urgent colectomy, 77 (46.7%) were admitted with ASUC. Acute pouchitis occurred in 228 (54.8%) patients a median of 1.3 (interquartile range, 0.6-3.1) years after the final surgical stage. On multivariable analysis, ASUC (hazard ratio [HR], 1.50; 95% confidence interval [CI], 1.04-2.17) and a greater number of biologics precolectomy (HR, 1.57; 95% CI, 1.06-2.31) were associated with an increased probability of acute pouchitis, while older age at colectomy (HR, 0.98; 95% CI, 0.97-0.99) was associated with a decreased probability. Time to pouchitis was significantly less in patients admitted with ASUC compared with those not (P = .002).

CONCLUSION

A severe UC disease phenotype at the time of colectomy was associated with an increased probability of acute pouchitis.

Iron Deficiency Is Common after Restorative Proctocolectomy with Ileal Pouch-Anal Anastomosis in Patients with Ulcerative Colitis

Background

Micronutrient deficiencies may occur after restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) in patients with ulcerative colitis (UC), largely due to malabsorption and/or pouch inflammation.

Objectives

The objective of this study was to report the frequency of iron deficiency in patients with UC who underwent RPC with IPAA and identify associated risk factors.

Methods

We conducted a retrospective chart review of patients with UC or IBD-unclassified who underwent RPC with IPAA at Mount Sinai Hospital between 2008 and 2017. Patients younger than 18 years of age at the time of colectomy were excluded. Descriptive statistics were used to analyze baseline characteristics. Medians with interquartile range (IQR) were reported for continuous variables, and proportions were reported for categorical variables. Iron deficiency was defined by ferritin <30 ng/mL. Logistic regression was used to analyze unadjusted relationships between hypothesized risk factors and the outcome of iron deficiency.

Results

A total of 143 patients had iron studies a median of 3.0 (IQR 1.7-5.6) years after final surgical stage, of whom 73 (51.0%) were men. The median age was 33.5 (IQR 22.7-44.3) years. Iron deficiency was diagnosed in 80 (55.9%) patients with a median hemoglobin of 12.4 g/dL (IQR 10.9-13.3), ferritin of 14 ng/mL (IQR 9.0-23.3), and iron value of 44 μg/dL (IQR 26.0-68.8). Of these, 29 (36.3%) had a pouchoscopy performed within 3 months of iron deficiency diagnosis. Pouchitis and cuffitis were separately noted in 4 (13.8%) and 13 (44.8%) patients, respectively, and concomitant pouchitis-cuffitis was noted in 9 (31.0%) patients. Age, sex, anastomosis type, pouch duration, and history of pouchitis and/or cuffitis were not associated with iron deficiency.

Conclusion

Iron deficiency is common after RPC with IPAA in patients with UC. Cuffitis is seen in the majority of patients with iron deficiency; however, iron deficiency may occur even in the absence of inflammation.

Pouch Body Anastomotic Ulcerations Are Not Associated With an Increased Risk of Pouchitis

Patients with isolated pouch body anastomotic ulcers may present with clinically significant symptoms such as increased stool frequency and hematochezia. Isolated pouch body anastomotic ulcers do not increase the risk of future pouchitis.

Predictors of pouch failure: A tertiary care inflammatory bowel disease centre experience

AIM

Rates of pouch failure after total proctocolectomy with ileal pouch-anal anastomosis (IPAA) range from 5% to 18%. There is little consistency across studies regarding the factors associated with failure, and most include patients who underwent IPAA in the pre-biologic era. Our aim was to analyse a cohort of patients who underwent IPAA in the biologic era at a large-volume inflammatory bowel disease institution to better determine preoperative, perioperative and postoperative factors associated with pouch failure.

METHODS

A retrospective cohort analysis was performed with data from an institutional review board approved prospective database with ulcerative colitis or unclassified inflammatory bowel disease patients who underwent total proctocolectomy with IPAA at Mount Sinai Hospital between 2008 and 2017. Preoperative, perioperative and postoperative data were collected and univariate and multivariate analyses were performed to identify factors associated with increased risk of pouch failure.

RESULTS

Out of 664 patients included in the study, pouch failure occurred in 41 (6.2%) patients, a median of 23.3 months after final surgical stage. Of these, 17 (41.4%) underwent pouch excision and 24 (58.5%) had diverting ileostomies. The most common indications for pouch failure were Crohn's disease like pouch inflammation (CDLPI) (n = 17, 41.5%), chronic pouchitis (n = 6, 14.6%), chronic cuffitis (n = 5, 12.2%) and anastomotic stricture (n = 4, 9.8%). On multivariate analysis, pre-colectomy biologic use (hazard ratio [HR] 2.25, 95% CI 1.09-4.67), CDLPI (HR 3.18, 95% CI 1.49-6.76) and pouch revision (HR 2.59, 95% CI 1.26-5.32) were significantly associated with pouch failure.

CONCLUSIONS

Pouch failure was significantly associated with CDLPI, preoperative biologic use and pouch revision; however, reassuringly it was not associated with postoperative complications.

Emergent Subtotal Colectomies Have Higher Leak Rates in Subsequent J-Pouch Stages

PURPOSE

The most common surgery for ulcerative colitis (UC) is the staged restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). On occasion, an emergent first-stage subtotal colectomy must be performed. The purpose of this study was to compare rates of postoperative complications in three-stage IPAA patients who underwent emergent vs non-emergent first-stage subtotal colectomies in the subsequent staged procedures.

METHODS

This was a retrospective chart review conducted at a single tertiary care inflammatory bowel disease (IBD) center. All UC or IBD-Unspecified patients who underwent a three-stage IPAA between 2008 and 2017 were identified. Emergent surgery was defined as that performed on an inpatient who had perforation, toxic megacolon, uncontrolled hemorrhage, or septic shock. The primary outcomes were the presence of anastomotic leak, obstruction, bleeding, and the need for reoperation for each within a 6-month postoperative period of the second (RPC with IPAA and DLI) and third surgical stages (ileostomy reversal).

RESULTS

A total of 342 patients underwent a three-stage IPAA, of which 30 (9.4%) had emergent first-stage operations. Patients who underwent an emergent STC were more likely to have a post-operative anastomotic leak and need an additional procedure following the subsequent second and third-staged operations on both univariate and multivariate analysis (p < 0.05). No difference was found for obstruction, wound infection, intra-abdominal abscess, or bleeding (p > 0.05).

CONCLUSION

Three-stage IPAA patients with emergent first-stage subtotal colectomies were more likely to have a post-operative anastomotic leak and need an additional procedure for a leak following the subsequent second- and third-stage operations.

Association of hospital volume with postoperative outcomes in Crohn's disease

AIM

Most patients diagnosed with Crohn's disease (CD) require surgery during their lifetime. While the literature has shown that certain cancer patients have superior postoperative outcomes at high-volume hospitals, there remains a paucity of data on the hospital volume-outcome relationship in CD. Given the complexities in both medical and surgical management, this study aims to determine whether patients with CD have superior postoperative outcomes at high-volume hospitals.

METHOD

A retrospective analysis of patients undergoing abdominal surgery for CD in New York hospitals between 2012 and 2018 was performed using data from the Statewide Planning and Research Cooperation System. Outcomes included postoperative mortality, 30-day readmission and postoperative complications. Using a penalized B-spline plot, high-volume centres were defined as those performing more than 160 abdominal surgeries for CD each year.

RESULTS

A total of 13,221 surgeries were performed across 176 hospital centres in New York State. Of these, 73.9% of procedures occurred at low-volume centres. High-volume hospitals had lower in-hospital mortality (0.5% vs. 1.5%; p < 0.001) and 30-day readmission rates (8.3% vs. 10.4%; p < 0.001) than low-volume centres. Major postoperative complications and reoperation rates did not differ by hospital volume. On multivariate analysis, patients at high-volume hospitals had lower odds of in-hospital mortality (OR 0.54, 95% CI 0.38-0.75) and 30-day readmission (OR 0.79, 95%CI 0.64-0.98). Hospital volume remained an independent predictor of 30-day readmission for emergent admissions (OR 0.72, 95% CI 0.61-0.85) and in-hospital mortality for nonemergent admissions (OR 0.39, 95% CI 0.19-0.82).

CONCLUSION

Patients undergoing abdominal surgery for CD have lower odds of postoperative mortality and 30-day readmission when the operation occurs at a high-volume hospital. These findings suggest that surgical patients with CD may benefit from care at specialized centres.

Management of Anastomotic Leaks in Ileal Pouch Anal Anastomosis for Ulcerative Colitis

Anastomotic leaks remain a dreaded complication after ileal pouch anal anastomosis (IPAA). Their impacts can be devastating, ranging from an acute leak leading to postoperative sepsis to chronic leaks and sinus tracts resulting in long-term pouch dysfunction and subsequent pouch failure. The management of acute leaks is intricate. Initial management is important to resolve acute sepsis, but the type of acute intervention impacts long-term pouch function. Aggressive management in the postoperative period, including the use of IV fluids, broad-spectrum antibiotics, and operative interventions may be necessary to preserve pouch structure and function. Early identification and knowledge of the most common areas of leak, such as at the IPAA anastomosis, are important for guiding management. Long-term complications, such as pouch sinuses, pouch-vaginal fistulas, and diminished IPAA function complicate the overall survival and functionality of the pouch. Knowledge and awareness of the identification and management of leaks is crucial for optimizing IPAA success.

Vitamin D Deficiency is Common in Patients with Ulcerative Colitis After Total Proctocolectomy with Ileal Pouch Anal Anastomosis

In a retrospective study of 412 patients with ulcerative colitis who underwent total proctocolectomy with ileal pouch anal anastomosis and had subsequent pouchoscopy, low 25-hydroxyvitamin D was common and was not significantly associated with age, sex, ethnicity, or precolectomy medication use.

Early Pouchitis Is Associated With Crohn's Disease-like Pouch Inflammation in Patients With Ulcerative Colitis

BACKGROUND

Despite the initial diagnosis of ulcerative colitis (UC), approximately 10% to 20% of patients develop Crohn's disease-like pouch inflammation (CDLPI) after restorative proctocolectomy (RPC) with ileal pouch anal anastomosis (IPAA). The aim of this study was to evaluate whether early pouchitis, defined as pouchitis within the first year after IPAA, is a predictor of CDLPI.

METHODS

This was a retrospective cohort analysis of patients with UC or IBD unclassified (IBDU) who underwent RPC with IPAA at Mount Sinai Hospital between January 2008 and December 2017. The primary outcome was development of CDLPI. Predictors of CDLPI were analyzed via univariable and multivariable Cox regression models.

RESULTS

The analytic cohort comprised 412 patients who underwent at least 1 pouchoscopy procedure between 2009 and 2018. Crohn's disease-like pouch inflammation developed in 57 (13.8%) patients a median interval of 2.1 (interquartile range, 1.1-4.3) years after surgery. On univariable analysis, older age at colectomy (hazard ratio [HR], 0.97; 95% CI, 0.95-0.99) was associated with a reduced risk of CDLPI; although early pouchitis (HR, 2.43; 95% CI, 1.32-4.45) and a greater number of pouchitis episodes (HR, 1.38; 95% CI, 1.17-1.63) were associated with an increased risk. On multivariable analysis, early pouchitis (HR, 2.35; 95% CI, 1.27-4.34) was significantly associated with CDLPI. Time to CDLPI was significantly less in patients who developed early pouchitis compared with those who did not (P = .003).

CONCLUSION

Early pouchitis is significantly associated with subsequent CDLPI development and may be the first indication of enhanced mucosal immune activation in the pouch.

The association between pre-colectomy thiopurine use and risk of neoplasia after ileal pouch anal anastomosis in patients with ulcerative colitis or indeterminate colitis: a propensity score analysis

BACKGROUND

The risk of neoplasia of the pouch or residual rectum in patients with ulcerative colitis (UC) who undergo total proctocolectomy (TPC) with ileal pouch anal anastomosis (IPAA) is incompletely investigated. Thiopurine use is associated with a reduced risk of colorectal neoplasia in patients with UC. We tested the hypothesis that thiopurine use prior to TPC may be associated with a reduced risk of primary neoplasia after IPAA.

METHODS

We conducted a retrospective cohort analysis of patients from a tertiary referral center from January 2008 to December 2017. Eligible patients with UC or IC underwent TPC with IPAA and had at least two pouchoscopies with biopsies ≥ 6 months after surgery. Propensity score analysis was conducted to match thiopurine exposed vs unexposed groups based on clinical covariates. Multivariable Cox regression analysis estimated the risk of neoplasia.

RESULTS

A total of 284 patients with UC or IC (57.4% male, median age 35.6 years) were analyzed. Ninety-seven patients (34.2%) were confirmed to have thiopurine exposure ≥ 12 weeks immediately prior to TPC ("exposed") and 187 (65.8%) were confirmed to have no thiopurine exposure for at least 365 days prior to TPC ("non-exposed"). Compared to non-exposed patients, patients with thiopurine exposure less often had dysplasia (7.2% vs 23.0%, p = 0.001) and had lower grades of dysplasia before colectomy. After IPAA, patients with neoplasia were older (44.0 vs 34.8 years, p = 0.03), more likely to have had dysplasia as colectomy indication (44.4% vs 15.4%, p = 0.007), and more likely to require pouch excision (55.6% vs 10.2%, p < 0.0001), compared to patients without neoplasia. On propensity-matched cohort analysis, no factors were significantly associated with risk of primary neoplasia.

CONCLUSION

Thiopurine exposure for at least the 12 weeks prior to TPC in patients with UC or IC does not appear to be independently associated with risk of primary neoplasia following IPAA.

Outcomes of Primary Ileocolic Resection for Pediatric Crohn Disease in the Biologic Era

OBJECTIVES

Current clinical algorithms position surgery as the last option in pediatric Crohn disease (CD). Studies suggest improved outcomes with earlier surgery, but pediatric postoperative outcomes data in the biologic era are limited. We aimed to describe the preoperative management and postoperative outcomes in a pediatric CD cohort who underwent ileocolic resection (ICR) at a tertiary care inflammatory bowel disease center over the last decade.

METHODS

Single-center, retrospective study of pediatric (<18 years) CD patients who underwent ICR between 2008 and 2019 with primary outcome of rate of endoscopic recurrence (Rutgeerts' >i2) at 2 years post-ICR. Key secondary outcomes included endoscopic remission (Rutgeerts' i0), frequency of 30-day postoperative complications, anthropometric changes, and histologic recurrence. Uni- and multivariable analyses examined associations of clinical/laboratory characteristics with endoscopic recurrence. Factors predictive of 30-day complications were also analyzed.

RESULTS

Seventy-eight children underwent ICR a median of 17.8 months (interquartile range [IQR] 2.6-53.9) from diagnosis. Median age at diagnosis and surgery was 13.8 (11.1-16.7) and 16.8 years (15.1-17.8), respectively. In the 41 patients with >1 post-operative endoscopy, the rate of endoscopic recurrence was 46% at 2 years (median time to recurrence: 10 [7-20] months). Histologic recurrence was present in 44% in endoscopic remission (κ = 0.11, P = 0.53). Endoscopic recurrence was associated with younger age at diagnosis and longer disease duration. 30-day complications occurred at a rate of 18%; only 1% experienced severe complications. All anthropometric measures significantly improved after surgery.

CONCLUSIONS

Given the inherent risk of postoperative recurrence associated with age and disease duration, children would benefit from postoperative surveillance and effective prophylaxis.

Slow and Steady Wins the Race: A Solid Case for a 3-Stage Approach in Ulcerative Colitis

BACKGROUND

Approximately 10% to 20% of patients with ulcerative colitis require surgery during their disease course, of which the most common is the staged restorative proctocolectomy with IPAA.

OBJECTIVE

The aim was to compare the rates of anastomotic leaks among all staged restorative proctocolectomy with IPAA procedures.

DESIGN

This was a retrospective cohort study.

SETTINGS

This study was conducted at a single tertiary care IBD center.

PATIENTS

All patients with ulcerative colitis or IBD-unspecified who underwent a primary total proctocolectomy with IPAA for medically refractory disease or dysplasia between 2008 and 2017 were identified.

MAIN OUTCOME MEASURES

The primary outcome was anastomotic leak within a 6-month postoperative period. Univariate and multivariate logistic regression were used to compare patients with and without anastomotic leaks.

RESULTS

The sample was composed of 584 nonemergent patients, of whom 50 (8.6%) underwent 1-stage, 162 (27.7%) underwent 2-stage, 58 (9.9%) underwent modified 2-stage, and 314 (53.7%) underwent a 3-stage total proctocolectomy with IPAA. The primary indication was medically refractory disease in 488 patients and dysplasia/cancer in 101 patients. Anastomotic leak occurred in 10 patients (3.2%) after 3-stage, 14 patients (8.6%) after 2-stage, 6 patients (10.3%) after modified 2-stage, and 10 patients (20.0%) after a 1-stage procedure. A 3-stage procedure had fewer leaks and additional procedures for leaks compared with 1- and modified 2-stage procedures (p < 0.03). The 3-stage procedure had fewer combined anastomotic leaks and pelvic abscesses than all of the other staged procedures (p < 0.05).

LIMITATIONS

This study was limited by its retrospective design and evolving electronic medical charts system.

CONCLUSIONS

The 3-stage total proctocolectomy with IPAA is the optimal staged method in ulcerative colitis to reduce leaks and related complications. See Video Abstract at http://links.lww.com/DCR/B693.

LENTO Y CONSTANTE GANA LA CARRERA UN CASO SLIDO PARA UN ENFOQUE DE TRES ETAPAS EN LA COLITIS ULCEROSA

ANTECEDENTES:Aproximadamente el 10-20% de los pacientes con colitis ulcerosa requieren cirugía durante el curso de su enfermedad, de los cuales la más común es la proctocolectomía restauradora escalonada con anastomosis con bolsa ileo-anal.OBJETIVO:El objetivo fue comparar las tasas de fugas anastomóticas entre todos los procedimientos de proctocolectomía restauradora por etapas con procedimiento de anastomosis con bolsa ileo-anal.DISEÑO:Este fue un estudio de cohorte retrospectivo.ENTORNO CLÍNICO:Este estudio se llevó a cabo en un único centro de atención terciaria de tercer nivel para enfermedades inflamatorias del intestino.PACIENTES:Se identificaron todos los pacientes con colitis ulcerosa o enfermedad inflamatoria intestinal inespecífica que se sometieron a una proctocolectomía total primaria mas anastomosis con bolsa ileo-anal por enfermedad médicamente refractaria o displasia entre 2008 y 2017.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la fuga anastomótica dentro de un período posoperatorio de seis meses. Se utilizó regresión logística univariante y multivariante para comparar pacientes con y sin fugas anastomóticas.RESULTADOS:La muestra estuvo compuesta por 584 pacientes no emergentes, de los cuales 50 (8,6%) se sometieron a una etapa, 162 (27,7%) se sometieron a dos etapas, 58 (9,9%) se sometieron a modificación en dos etapas y 314 (53,7%) se sometieron a una proctocolectomía total en tres tiempos mas anastomosis con bolsa ileo-anal. La indicación principal fue enfermedad médicamente refractaria en 488 pacientes y displasia / cáncer en 101 pacientes. Se produjo una fuga anastomótica en 10 (3,2%) pacientes después de tres etapas, 14 (8,6%) pacientes después de dos etapas, 6 (10,3%) pacientes después de dos etapas modificadas y 10 (20,0%) pacientes después de una etapa procedimiento. Un procedimiento de tres etapas tuvo menos fugas y procedimientos adicionales para las fugas en comparación con los procedimientos de una y dos etapas modificadas (p <0.03). El procedimiento de tres etapas tuvo menos fugas anastomóticas y abscesos pélvicos combinados que todos los demás procedimientos por etapas (p <0,05).LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo y su sistema de registros médicos electrónicos en evolución.CONCLUSIONES:La proctocolectomía total en tres etapas mas anastomosis con bolsa ileo-anal es el método óptimo por etapas en la colitis ulcerosa para reducir las fugas y las complicaciones relacionadas. Consulte Video Resumen en http://links.lww.com/DCR/B693.

The role of laparoscopic surgery in repeat ileocolic resection for Crohn's disease

AIM

Laparoscopic surgery is the preferred approach for primary uncomplicated ileocolic resection (ICR); however, its role for repeat resections is unclear. This study assessed the outcomes of primary and repeated ICRs for Crohn's disease to examine rates of laparoscopy and patient morbidity.

METHODS

A retrospective review of a prospectively maintained database was conducted at a tertiary centre between 2013 and 2019. All patients undergoing ICRs for Crohn's disease were included. The cohort was divided into three groups based on number of resections-primary (1R), secondary (2R) and tertiary or more (>2R) groups. The primary outcome was 30-day postoperative morbidity.

RESULTS

Over a 6-year period, 474 patients underwent ICR for Crohn's disease, including 369 primary (1R, 77.8%) and 105 repeat (≥2R, 22.2%) resections. A laparoscopic approach was less common in the ≥2R versus 1R groups (79.0% vs. 93.8%, P < 0.001), but rates of conversion to an open procedure were comparable. Morbidity was higher amongst repeat resections although this was not significant (20.0% vs. 14.1%, P = 0.18). Amongst cases approached laparoscopically (n = 429), rates of conversion and postoperative morbidity did not differ by stage of resection, although operative time was longer for repeat operations. Even in the group undergoing laparoscopy for tertiary or greater resections (>2R, n = 29), the rates of conversion (10%) and morbidity (14%) were relatively low.

CONCLUSION

In this contemporary series of primary and reoperative ICR for ileal CD, a laparoscopic approach is feasible and safe for the majority of repeat ICRs when performed at a high volume centre.

Recycling of Precolectomy Anti-Tumor Necrosis Factor Agents in Chronic Pouch Inflammation Is Associated With Treatment Failure

Despite improvements in medical management, 10%-15% of patients with ulcerative colitis (UC) require total proctocolectomy (TPC) with ileal pouch anal anastomosis (IPAA) for refractory disease.¹ Acute pouchitis is the most common post-IPAA inflammatory condition, with cumulative incidence of 45% at 5 years.² Up to 20%-30% of patients develop chronic pouch inflammation (CPI), categorized as antibiotic responsive, antibiotic refractory, or Crohn's disease-like (CDL).³.

Clostridioides Difficile Infection Is a Rare Cause of Infectious Pouchitis

Introduction

The true incidence of Clostridioides difficile infection (CDI) in patients with an ileal pouch is unknown, and there is little published on its associated risk factors.

Objective

We aimed to evaluate the rate and risk factors of CDI in pouch patients.

Methods

This was a retrospective review conducted at a single tertiary care inflammatory bowel disease (IBD) center. All ulcerative colitis or IBD-unspecified (IBD-U) patients who underwent total proctocolectomy with ileal pouch anal anastomosis for medically refractory disease or dysplasia between 2008 and 2017 were identified. Symptomatic patients tested for CDI were included. Demographic, disease, and surgical characteristics were collected. Nonparametric methods were used to compare continuous outcomes, and χ² and Fisher's exact tests were used to compare patients with and without CDI as appropriate.

Results

A total of 154 pouch patients had postoperative C. difficilestool testing for symptoms of fever, urgency, increased stool frequency, hematochezia, incontinence, and abdominal and/or pelvic pain. CDI was diagnosed in 11 (7.1%) patients a median of 139 days (IQR 34-1,170) after the final surgical stage. Ten patients (90.9%) received oral vancomycin for 10 days and 1 patient (9.1%) received oral metronidazole for 2 weeks. Ten patients (90.9%) reported improvement in symptoms at completion of therapy. Nine patients (81.8%) were retested for CDI for recurrent symptoms and found to be negative. No patient had CDI recurrence. There was no significant difference in demographic and surgical characteristics, previous antibiotic or proton pump inhibitor use, or previous hospital admission among the patients with and without CDI.

Conclusions

CDI is a rare cause of infectious pouchitis and treatment with oral vancomycin improves symptoms.

Inflammatory Pouch Conditions Are Common After Ileal Pouch Anal Anastomosis in Ulcerative Colitis Patients

BACKGROUND

Total proctocolectomy (TPC) with ileal pouch anal anastomosis (IPAA) is the gold standard surgery for ulcerative colitis (UC) patients with medically refractory disease. The aim of this study was to report the rates and risk factors of inflammatory pouch conditions.

METHODS

This was a retrospective review of UC or IBD unspecified (IBDU) patients who underwent TPC with IPAA for refractory disease or dysplasia between 2008 and 2017. Pouchoscopy data were used to calculate rates of inflammatory pouch conditions. Factors associated with outcomes in univariable analysis were investigated in multivariable analysis.

RESULTS

Of the 621 patients more than 18 years of age who underwent TPC with IPAA between January 2008 and December 2017, pouchoscopy data were available for 386 patients during a median follow-up period of 4 years. Acute pouchitis occurred in 205 patients (53%), 60 of whom (30%) progressed to chronic pouchitis. Cuffitis and Crohn's disease-like condition (CDLC) of the pouch occurred in 119 (30%) patients and 46 (12%) patients, respectively. In multivariable analysis, female sex was associated with a decreased risk of acute pouchitis, and pre-operative steroid use and medically refractory disease were associated with an increased risk; IBDU was associated with chronic pouchitis; rectal cuff length ≥2 cm and medically refractory disease were associated with cuffitis; age 45-54 at colectomy was associated with CDLC. Rates of pouch failure were similar in chronic pouchitis and CDLC patients treated with biologics and those who were not.

CONCLUSIONS

Inflammatory pouch conditions are common. Biologic use for chronic pouchitis and CDLC does not impact the rate of pouch failure.

Analysis of Outcomes by Extraction Site following Subtotal Colectomy in Ulcerative Colitis: A Retrospective Cohort Study

BACKGROUND

Ulcerative colitis frequently requires surgery as a definitive management strategy. The colonic specimen can be extracted from various sites including a midline incision, the stoma site, or a Pfannenstiel incision. It is unclear if one extraction site offers improved outcomes and fewer complications.

METHODS

A retrospective review of charts obtained of colorectal surgery patients was conducted for all patients with ulcerative colitis who underwent a subtotal colectomy between 2008 and 2016 at a single tertiary care institution. Demographic data and outcomes data including parastomal and incisional hernias, advanced wound/ostomy certified nurse referrals, surgical site infections, reoperations, and readmissions were collected. Univariate and multivariate analyses were completed to detect any significant differences in outcomes between groups based on extraction site (midline incision, stoma site, or Pfannenstiel incision).

RESULTS

Univariate analysis did not show any statistical differences between groups in regard to outcomes. Stoma site extraction did not statistically differ from midline extraction in regard to hernias, advanced ostomy referrals, infections, or reoperations, but midline incision extraction did have a lower risk of readmission (OR = 0.56, p = 0.0066). Pfannenstiel extraction had lower risk of incisional hernias (OR = 0.25, p = 0.0002), advanced ostomy referrals (OR = 0.45, p = 0.0164) and readmission (OR = 0.26, p < 0.0001) as compared to stoma site extraction.

CONCLUSIONS

While stoma site extraction can be successfully performed for most patients requiring subtotal colectomy for ulcerative colitis, Pfannenstiel extraction leads to the fewest number of complications and provides the most consistent results.

Portomesenteric Venous Thrombosis in Patients Undergoing Surgery for Medically Refractory Ulcerative Colitis

BACKGROUND

Portomesenteric venous thrombosis (PMVT) is an under-recognized complication of colorectal surgery. The aim of this study was to describe the rate and risk factors for PMVT in patients undergoing surgery for medically refractory ulcerative colitis (UC).

METHODS

A retrospective review of medically refractory UC patients who underwent surgery between January 2010 and December 2016 at a single tertiary care center was conducted. PMVT was defined as thrombus within the portal, splenic, superior, or inferior mesenteric vein on postoperative abdominal computed tomography scans. Factors associated with PMVT on univariable analysis were tested in multivariable analysis. Clinical relevance of risk factors was examined with receiver operating characteristic curves and Kaplan-Meier curves.

RESULTS

A total of 434 patients were identified. Postoperative venous thromboembolism (VTE) prophylaxis was administered to 428 (98.5%) inpatients for a mean duration of 7.7 ± 0.17 days. PMVT developed in 36 (8.3%) patients a mean interval of 55.3 ± 10.8 days after index surgery. The majority of PMVT occurred after subtotal colectomy, and the most common initial symptom was abdominal pain. Preoperative C-reactive protein (CRP) was associated with PMVT (odds ratio, 1.01; 95% confidence interval, 1.00-1.02; P = 0.01), and the optimal predictive CRP threshold was 45 mg/L. The rate of PMVT development was greater for patients with CRP >45 mg/L (P = 0.01).

CONCLUSIONS

PMVT can present as abdominal pain and occur multiple weeks after discharge. Further studies are needed to identify the appropriate postoperative outpatient thrombosis prophylaxis regimen for at-risk patients.

Endoscopic activity in asymptomatic patients with an ileal pouch is associated with an increased risk of pouchitis

BACKGROUND

The significance of endoscopic activity in asymptomatic ulcerative colitis (UC) patients with an ileal pouch is unknown.

AIM

To investigate the association of endoscopic pouch activity in asymptomatic patients with the subsequent development of pouchitis.

METHODS

We analyzed a retrospective cohort of patients with UC or IBD-unspecified who underwent a total proctocolectomy with ileal pouch anal anastomosis (IPAA). Asymptomatic patients with a Pouchitis Disease Activity Index (PDAI) symptom sub-score of zero who underwent an index surveillance pouchoscopy were included. Endoscopic pouch body activity was graded as 0: normal, 1: mucosal inflammation, or 2: mucosal breaks (ulcers and/or erosions). The primary outcome was primary acute idiopathic pouchitis defined as PDAI score ≥ 7 with symptoms lasting less than four weeks and responsive to standard antibiotics, not otherwise meeting criteria for secondary pouchitis. The secondary outcome was chronic idiopathic pouchitis defined as PDAI score ≥ 7 with symptoms lasting greater than four weeks despite standard antibiotics. Predictors of pouchitis were analyzed using Kaplan-Meier and Cox regression methods with hazard ratios (HR) and 95% confidence intervals (CI) reported.

RESULTS

143 asymptomatic pouch patients were included. Index endoscopic pouch body activity was 0 in 86 (60.1%) patients, 1 in 26 (18.2%) and 2 in 31 (21.7%). The median length of follow-up after index surveillance pouchoscopy was 3.03 [IQR 1.24-4.60] years. Primary acute idiopathic pouchitis occurred in 44 (31%) patients and chronic idiopathic pouchitis in 12 (8.4%). Grade 2 endoscopic pouch activity was associated with the development of acute pouchitis (HR 2.39, 95% CI 1.23-4.67), although not chronic pouchitis (HR 1.76, 95% CI 0.53-5.87). Histologic inflammation in endoscopically normal pouch mucosa was not associated with acute or chronic pouchitis.

CONCLUSIONS

Mucosal breaks are present in nearly a quarter of asymptomatic patients with IPAA and are associated with an increased risk of acute pouchitis.

Endorectal Advancement Flaps for Perianal Fistulae in Crohn's Disease: Careful Patient Selection Leads to Optimal Outcomes

BACKGROUND

Anorectal fistulae resultant from Crohn's disease (CD) is a clinical challenge. The advent of immune therapy (IT) has altered the way in which fistulae have responded to treatment. Endorectal advancement flap (ERAF) is a surgical procedure that is used to treat complex fistulae. We have employed ERAF as our second stage treatment of choice in this patient population. Our aim was to determine the success of ERAF in treating perianal fistulas in patients with CD in an era of IT.

METHODS

Multicenter retrospective review from 2007 to 2017 of all patients with CD and a perianal fistulae who underwent ERAF.

RESULTS

Forty-one flaps were performed in 39 patients with perianal CD with an average follow-up of 797 days. There were no significant differences in patient demographics; however, all patients who were diverted at the time of surgery had successful healing. Of patients, 73.2% were on IT at an average of 380 days prior to surgery. The duration of single-agent therapy was associated with better healing rates (p = 0.03). The overall failure rate was 19.5% (n = 8). Six patients underwent secondary techniques for fistulae closure; five were successful. In combination with the patients who did not initially fail, the overall healing rate was 92.6%.

CONCLUSIONS

This study demonstrates several factors that may improve fistulae closure for CD patients. Patients who were diverted prior to surgery did not have a fistulae recurrence. Patients who were on IT longer prior to ERAF were more likely to achieve successful closure.

Rectus sheath catheters-a novel approach to perioperative analgesia for colorectal surgery in an enhanced recovery after surgery (ERAS) protocol: a case series

INTRODUCTION

Opioids have played a critical role in the management of perioperative pain following abdominal surgery. Increasing attention is being paid to the deleterious side effects and limitations of this practice. This case report offers a novel alternative to opioid-based analgesia in the form of rectus sheath catheters (RSCs) which we employed as part of an enhanced recovery after surgery (ERAS) protocol.

METHODS

Three patients underwent laparoscopic- assisted colorectal surgery and were treated intra- and postoperatively with local anesthesia administered via bilateral rectus sheath catheters as well as by multimodal adjuncts. Evaluations of the patients' pain scores, opioid usage, and abdominal sensitivity to sharp stimuli were conducted daily.

RESULTS

The patients demonstrated a substantially lessened opioid requirement over their hospital stay with two of them requiring no opioid analgesic medications postoperatively.

DISCUSSION

We suggest that the incorporation of these catheters into an ERAS protocol can play an important role in further reducing perioperative opioid usage for procedures in which pain control can be especially challenging.

Is fecal diversion necessary during ileal pouch creation after initial subtotal colectomy in pediatric ulcerative colitis?

BACKGROUND

Pediatric patients with medically refractory ulcerative colitis (UC) often undergo an initial subtotal colectomy end ileostomy (STC-I). The role of fecal diversion in the subsequent completion proctectomy/ileal-pouch anal anastomosis (CP-IPAA) remains controversial.

METHODS

A multi-institutional retrospective review was performed of pediatric UC patients who underwent an STC-I followed by CP-IPAA from 2008 to 2016. 37 patients were included [diverted (n = 20), undiverted (n = 17)].

RESULTS

Children who underwent undiverted CP-IPAA had a longer length of stay (days) compared to the diverted group (9, 6.5-13 vs. 6, 5-6, p = 0.002). The 30-day complication rate was significantly higher in the undiverted group (p = 0.003) although the difference in anastomotic leak, readmission rate, unplanned computer tomography use, and reoperation was not statistically significant. Three patients with undiverted CP-IPAA required additional surgery in the perioperative period for fecal diversion. The mean long-term follow-up was 25.68 ± 21.56 months. There were no significant differences in functional pouch outcomes.

CONCLUSIONS

Patients who underwent an undiverted CP-IPAA after initial STC-I had significantly more complications in the immediate postoperative period compared to diverted patients, although this did not translate into long-term differences in functional outcomes. Questions remain regarding careful patient selection and counseling for undiverted pouches in the pediatric UC population.

Persistent noncompliance with the work-hour regulation

OBJECTIVE

To investigate the reason for noncompliance with the work-hour regulation by surgical residents.

DESIGN

Nationwide anonymous survey (November 1, 2007, to March 1, 2008).

SETTING

Academic center.

PARTICIPANTS

Surgical residents throughout the United States.

MAIN OUTCOME MEASURES

Incidence of noncompliance remains high and reasons for noncompliance are multifactorial.

RESULTS

The first 141 questionnaires returned were included in this analysis. Responders consisted of postgraduate year (PGY)-1 (32.6%), PGY-2 (19.1%), PGY-3 (17.7%), PGY-4 (13.5%), and PGY-5 (17.0%) surgical residents. Many residents were categorical (79.4%), male (61.7%), and married (53.2%). Ninety-eight percent of residents were aware of the work-hour regulation, with 72.1% of residents in favor of it. However, noncompliance with the work-hour regulation was 64.6%, with 21.1% of residents working more than 90 h/wk (average, 86.6 h/wk). The most problematic regulations to follow were "at least 10 hours of rest between duty hours" (36.9%), "24-hour limit of continuous care plus 6 additional hours for continuity of care and educational objectives" (26.1%), and "80-hour work limit over 4 weeks" (22.7%). Education and continuity in patient care were the main reasons associated with noncompliance. Noncompliance was highest in trauma (25.2%) and vascular surgery (16.3%) residents. In addition, 65.2% of the attending physicians do not agree with implementing work-hour regulation standards in the surgical faculty.

CONCLUSIONS

The survey demonstrates that noncompliance with the work-hour regulation is prevalent. The reasons for noncompliance are multifactorial. These findings will help restructure training programs in the efforts to increase compliance with the work-hour regulation.

Failure of medical treatment in an adult cystic fibrosis patient with meconium ileus equivalent

Meconium ileus equivalent is one of the lesser-known manifestations of cystic fibrosis. It manifests as distant small bowel obstruction caused by meconium-like stool plugs and occurs mostly in adult patients. With the improved overall survival of patients with cystic fibrosis, general surgeons may encounter this condition more often in the future. We treated a 19-year-old woman with cystic fibrosis who presented with complete distal small bowel obstruction. Medical therapy with Gastrografin and N-acetylcysteine failed to resolve the obstruction. At surgery, a meconium-like plug in the distal ileum was manually pushed into the colon with subsequent relief of symptoms. Meconium ileus equivalent should be considered and treated in cystic fibrosis patients presenting with small bowel obstruction.

[Surgery for quality of life improvement in Crohn's disease: long-term follow-up]

Crohn's disease is an inflammatory disorder that affects various parts of the gastrointestinal tract. The management of Crohn's disease involves various anti-inflammatory and antibiotic agents while the role of surgery is limited to the treatment of disease associated complications. During recent years surgical therapy was also advocated for the improvement of the quality of life in patients with incapacitating Crohn's disease. In a previous study we demonstrated both the safety and efficacy of bowel-preserving surgery in a group of patients with Crohn's disease with no absolute indication for surgery, but with severe impediment of their quality of life due to severe disease activity and its therapy. The present study was undertaken to evaluate the long-term outcome of this group of patients. Fifteen Crohn's disease patients operated on for the improvement of the quality of life were followed for a median of 106 (range 82-132) months. During this time only 27% of the patients required reoperation for the treatment of recurrent Crohn's disease. The median surgery-free interval was 92.6 months and the 10-year surgery-free survival was 72%. Based on our results in this small group of patients, we suggest that there is a long-term benefit of surgical therapy for patients with Crohn's disease operated on in an attempt to improve their quality of life.