Restorative proctectomy with ileal pouch-anal anastomosis in obese patients

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.

The effect of percentage of ideal body weight on outcomes in ileo-anal pull through for ulcerative colitis

PURPOSE

Ileo-anal pull through (IAPT) is a commonly performed operation for the surgical management of ulcerative colitis. The effect of body weight on outcomes for patients undergoing this operation has not been extensively studied.

METHODS

This was a prospective cohort study at a single tertiary care inflammatory bowel disease (IBD) center. A total of 457 patients who were operated on at the Mount Sinai Medical Center between 1983 and 2015 were included. Demographic characteristics, the patients' body weight at the time of IAPT, and postoperative outcome data were collected.

RESULTS

For each patient, body weight was calculated as a percentage of the ideal body weight (IBW) for that patient's height. The mean percentage of ideal body weight was 93.9% with a standard deviation of 20%. The range for the population was 53.1 to 175%. Four hundred forty (96%) of the patients had a weight within two standard deviations of the mean, indicating a normal distribution. Seventy-nine patients developed a Clavien-Dindo class III complication necessitating a procedural treatment. The most common of these was a stricture at the anastomotic site (n = 54). Our study identified an association between a percentage of ideal body weight in the lowest quartile of our population and development of an anastomotic stricture. This association was statistically significant on multivariate analysis.

CONCLUSION

Low body weight at the time of ileo-anal pull through for treatment of UC may be a risk factor for development of anastomotic stricture requiring dilation.

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.

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 ).

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.

A comprehensive review and update on ulcerative colitis. Dis Mon 2019;65:100851. [PMID: 30837080 DOI: 10.1016/j.disamonth.2019.02.004]

Ulcerative colitis (UC) is a chronic idiopathic inflammatory bowel disorder of the colon that causes continuous mucosal inflammation extending from the rectum to the more proximal colon, with variable extents. UC is characterized by a relapsing and remitting course. UC was first described by Samuel Wilks in 1859 and it is more common than Crohn's disease worldwide. The overall incidence and prevalence of UC is reported to be 1.2-20.3 and 7.6-245 cases per 100,000 persons/year respectively. UC has a bimodal age distribution with an incidence peak in the 2nd or 3rd decades and followed by second peak between 50 and 80 years of age. The key risk factors for UC include genetics, environmental factors, autoimmunity and gut microbiota. The classic presentation of UC include bloody diarrhea with or without mucus, rectal urgency, tenesmus, and variable degrees of abdominal pain that is often relieved by defecation. UC is diagnosed based on the combination of clinical presentation, endoscopic findings, histology, and the absence of alternative diagnoses. In addition to confirming the diagnosis of UC, it is also important to define the extent and severity of inflammation, which aids in the selection of appropriate treatment and for predicting the patient's prognosis. Ileocolonoscopy with biopsy is the only way to make a definitive diagnosis of UC. A pathognomonic finding of UC is the presence of continuous colonic inflammation characterized by erythema, loss of normal vascular pattern, granularity, erosions, friability, bleeding, and ulcerations, with distinct demarcation between inflamed and non-inflamed bowel. Histopathology is the definitive tool in diagnosing UC, assessing the disease severity and identifying intraepithelial neoplasia (dysplasia) or cancer. The classical histological changes in UC include decreased crypt density, crypt architectural distortion, irregular mucosal surface and heavy diffuse transmucosal inflammation, in the absence of genuine granulomas. Abdominal computed tomographic (CT) scanning is the preferred initial radiographic imaging study in UC patients with acute abdominal symptoms. The hallmark CT finding of UC is mural thickening with a mean wall thickness of 8 mm, as opposed to a 2-3 mm mean wall thickness of the normal colon. The Mayo scoring system is a commonly used index to assess disease severity and monitor patients during therapy. The goals of treatment in UC are three fold-improve quality of life, achieve steroid free remission and minimize the risk of cancer. The choice of treatment depends on disease extent, severity and the course of the disease. For proctitis, topical 5-aminosalicylic acid (5-ASA) drugs are used as the first line agents. UC patients with more extensive or severe disease should be treated with a combination of oral and topical 5-ASA drugs +/- corticosteroids to induce remission. Patients with severe UC need to be hospitalized for treatment. The options in these patients include intravenous steroids and if refractory, calcineurin inhibitors (cyclosporine, tacrolimus) or tumor necrosis factor-α antibodies (infliximab) are utilized. Once remission is induced, patients are then continued on appropriate medications to maintain remission. Indications for emergency surgery include refractory toxic megacolon, colonic perforation, or severe colorectal bleeding.

Prospective Validation of the Iowa Rectal Surgery Risk Calculator

BACKGROUND

The Iowa Rectal Surgery Risk Calculator estimates risk for proctectomy procedures. The Iowa Calculator performed well on NSQIP 2010-2011 training and 2005-2009 validation datasets, but was not prospectively validated and did not include low anterior resections. This study sought to demonstrate validity on new independent data, to update the calculator to include low anterior resection, and to compare performance to other risk assessment tools.

METHODS

Non-emergent ACS-NSQIP proctectomy and low anterior resection data from 2010 to 2015 (n = 65,683) were included. The Iowa Calculator generated risk estimates for 30-day morbidity using 2012-2015 data. An Updated Calculator used 2010-2011 training data to include low anterior resection, with validation on 2012-2015 data. NSQIP data provided NSQIP Morbidity Model predictions and a custom web-script collected ACS-NSQIP Online Surgical Risk Calculator predictions for all patients.

RESULTS

Proctectomy morbidity (not including low anterior resection) decreased from 40.4% in 2010-2011 to 37.0% in 2012-2015. Low anterior resection had lower morbidity (22.4% in 2012-15). The Iowa Calculator demonstrated good discrimination and calibration using 2012-2015 data (C-statistic 0.676, deviance + 9.2%). After including low anterior resection, the Updated Iowa Calculator performed well during training (c-statistic 0.696, deviance 0%) and validation (C-statistic 0.706, deviance + 7.9%). The Updated Iowa Calculator had significantly better discrimination and calibration than morbidity predictions from the ACS Online Calculator (C-statistic 0.693, P < 0.001, deviance - 28.1%) and NSQIP General/Vascular Surgery Model (C-statistic 0.703, P < 0.05, deviance - 40.8%).

CONCLUSION

When applied to new independent data, the Iowa Calculator supplies accurate risk estimates. The Updated Iowa Calculator includes low anterior resection, and both are prospectively validated. Risk estimation by the Iowa Calculators was superior to ACS-provided risk tools.

Impact of sex on 30-day complications and long-term functional outcomes following ileal pouch-anal anastomosis for chronic ulcerative colitis

PURPOSE

To determine the impact of patient sex on operative characteristics, short-term complications, and long-term functional outcomes following ileal pouch-anal anastomosis (IPAA) for chronic ulcerative colitis (CUC).

METHODS

A retrospective review was performed on all patients undergoing two- or three-stage IPAA for CUC at our institution between January 2002 and August 2013. Patient demographics, operative characteristics, 30-day postoperative complications, and long-term functional outcomes from annual survey data were analyzed comparing men and women patients.

RESULTS

During the study period, 911 IPAAs (542 men, 369 women) were performed. Men were older and were more often obese (both p < 0.01). Use of a three-stage approach and laparoscopic approach were similar between men and women, but operation length, intraoperative blood loss, and hospital length of stay were all higher in men (all p < 0.05). At 30 days, women had increased rates of superficial surgical site infections and urinary tract infections (both p < 0.05), while men had increased rates of urinary retention (p = 0.03). Five hundred forty-six patients (60%; 307 men, 239 women) responded to the annual post IPAA survey with a median follow-up of 5.1 and 5.0 years in men and women, respectively. Women reported increased frequency of daytime stools in the early follow-up period, but this difference resolved with time. Other functional outcomes were similar.

CONCLUSION

Patient sex impacts intraoperative complexity, postoperative length of stay, 30-day postoperative outcomes, and initial long-term function. These findings underscore the need to adjust preoperative counseling regarding IPAA outcomes based on sex.

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 associated with exacerbation of newly diagnosed mild ulcerative colitis based on a nationwide registry in Japan

BACKGROUND

The exacerbation of disease in patients with ulcerative colitis (UC) can greatly affect quality of life and can impose economic burdens. In Japan, a large nationwide registry for the medical reimbursement of UC patients has existed since 1975. We aimed to examine factors associated with UC exacerbation among patients newly diagnosed with mild UC using electronic data from the registry.

METHODS

We retrospectively reviewed the clinical data of patients (n = 8120) newly diagnosed with mild UC between 2003 and 2011, and examined the association of patient background, medications, clinical symptoms and laboratory data, and pathological findings with exacerbation of UC, using the Cox proportional hazards model.

RESULTS

The incidence of UC exacerbation was 94.6 per 1000 person-years (mean follow-up of 2.1 years). We found that male sex, age <17 years, an extensive lesion (left-sided colitis or pancolitis), overweight or obesity, hematochezia (mild or moderate-to-severe), mushy stools, frequency of bowel movements, and crypt architectural distortion were positively associated with UC exacerbation. On the other hand, age >40 years, high hemoglobin concentration, and high serum albumin levels were inversely associated with UC exacerbation among patients with mild UC in Japan.

CONCLUSION

Using data from the Japanese nationwide registry, we identified several factors, including body mass index and pathological findings, associated with disease exacerbation among patients with newly diagnosed mild UC. Our findings may lead to earlier recognition of exacerbation in patients with mild UC, thus enabling optimal care.

Electrothermal bipolar vessel ligation improves operative time during laparoscopic total proctocolectomy: a large single-center experience

BACKGROUND

Laparoscopic total proctocolectomy (TPC) with or without ileoanal pouch is a major operation for which the traditional benefits of laparoscopy were not immediately apparent, in part due to the longer operating times. The use of energy devices has been shown to improve operative outcomes for patients who undergo laparoscopic segmental colectomies, but there are limited data for laparoscopic TPC (LTPC).

METHODS

All patients who underwent LTPC between January 2002 and July 2011 were identified from a prospectively maintained institutional-review-board-approved database. Univariate and multiple linear regression analyses were performed to assess the impact of electrothermal bipolar vessel sealers (EBVS) for vessel ligation on operative time. Secondary outcomes included vessel ligation failures, estimated blood loss, and other intra- and postoperative outcomes.

RESULTS

One hundred and forty-five patients underwent LTPC, including 126 restorative ileoanal pouch and diverting ileostomy operations and 19 TPC and end ileostomy procedures. Fifteen percent of LTPCs were totally laparoscopic, 45 % were laparoscopic-assisted, 32 % were hand-assisted, and 8 % were laparoscopic-converted cases. Laparoscopic vessel ligation was performed using EBVS (76 %), endoscopic staplers (12 %), or hybrid techniques (12 %). Vessel ligation groups were similar in demographics, body mass index, surgical indication, immunosuppression, and prior surgery. EBVS were associated with shorter median operative times (247 vs. 290 vs. 300 min, p = 0.018) and fewer vessel ligation failures (1 vs. 11 vs. 12 %, p = 0.027) compared with endoscopic staplers and hybrid techniques, respectively. There were no differences in estimated blood loss and intra-operative complications among the three groups. Length of stay, 30-day morbidity, and 30-day re-operation rates were also similar. On multiple linear regression analysis, EBVS were a significant predictor of operative time (p = 0.019).

CONCLUSIONS

Routine use of electrothermal bipolar vessel ligation for LTPC is associated with shorter operative time and fewer vessel ligation failures without higher risk of complications than other vessel control methods.

Epidemiology, demographic characteristics and prognostic predictors of ulcerative colitis

Ulcerative colitis (UC) is a chronic disease characterized by diffuse inflammation of the mucosa of the colon and rectum. The hallmark clinical symptom of UC is bloody diarrhea. The clinical course is marked by exacerbations and remissions, which may occur spontaneously or in response to treatment changes or intercurrent illnesses. UC is most commonly diagnosed in late adolescence or early adulthood, but it can occur at any age. The incidence of UC has increased worldwide over recent decades, especially in developing nations. In contrast, during this period, therapeutic advances have improved the life expectancy of patients, and there has been a decrease in the mortality rate over time. It is important to emphasize that there is considerable variability in the phenotypic presentation of UC. Within this context, certain clinical and demographic characteristics are useful in identifying patients who tend to have more severe evolution of the disease and a poor prognosis. In this group of patients, better clinical surveillance and more intensive therapy may change the natural course of the disease. The aim of this article was to review the epidemiology and demographic characteristics of UC and the factors that may be associated with its clinical prognosis.

Development of an improved risk calculator for complications in proctectomy

BACKGROUND

Rectal surgery is associated with high complication rates, but tools to prospectively define surgical risk are lacking. Improved preoperative risk assessment could better inform patients and refine decision making by surgeons. Our objective was to develop a validated model for proctectomy risk prediction.

METHODS

We reviewed non-emergent ACS-NSQIP proctectomy data from 2005 to 2011 (n = 13,385). Logistic regression identified variables available prior to surgery showing independent association with 30-day morbidity in 2010-2011 (n = 5,570). The resulting risk model's discrimination and calibration were tested against the NSQIP-supplied morbidity model, and performance was validated against independent 2005-2009 data.

RESULTS

Overall morbidity for proctectomy in 2010-2011 was 40.2%; significantly higher than the 23.0 % rate predicted by the NSQIP-provided general and vascular surgery risk model. Frequent complications included bleeding (16.3%), superficial infection (9.2%), and sepsis (7.4%). Our novel model incorporating 17 preoperative variables provided better discrimination and calibration (p < 0.05) than the NSQIP model and was validated against the 2005-2009 data. A web-based calculator makes this new model available for prospective risk assessment.

CONCLUSIONS

We conclude that the NSQIP-supplied risk model underestimates proctectomy morbidity and that this new, validated risk model and risk prediction tool ( http://myweb.uiowa.edu/sksherman ) may allow clinicians to counsel patients with accurate risk estimates using data available in the preoperative setting.

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.

High prevalence of overweight and obesity in adults with Crohn's disease: associations with disease and lifestyle factors

BACKGROUND AND AIMS

Obesity and overweight are major public health issues. Although traditionally associated with weight loss, there is now evidence that increasing Body Mass Index (BMI) and overweight are emerging features of Crohn's disease (CD) and may be associated with more severe disease course. The aim of the study was to determine the prevalence of overweight and obesity in patients with CD compared with matched healthy controls and to identify disease-specific and generic factors associated with current BMI in this group.

METHODS

This was a prospective case-control study (n=200), comprising 100 CD outpatients and 100 age-, sex- and socioeconomically-matched healthy controls. BMI, Crohn's disease activity index (CDAI), clinical and lifestyle factors and circulating inflammatory markers were assessed.

RESULTS

Overall, 40% of patients with CD were overweight/obese (BMI ≥ 25 kg/m(2)) compared with 52% of controls (P = 0.206). On regression analysis, higher current BMI was significantly associated with disease specific factors, namely lower disease activity (CDAI) and lower white cell count, suggesting stable disease, as well as older age and lower physical activity. BMI was not significantly associated with the need for surgery or the need for corticosteroids. We identified a novel association between higher BMI and higher CRP, a marker linked both with obesity in the general population and with CD.

CONCLUSIONS

Overweight was common in out-patients with CD and appeared to reflect current wellness, older age and sedentary lifestyles. The potential long-term implications of high BMI for CRP and inflammatory load merit further study.

Does morbid obesity change outcomes after laparoscopic surgery for inflammatory bowel disease? Review of 626 consecutive cases

BACKGROUND

Little is known about the impact of obesity on morbidity in patients with inflammatory bowel disease (IBD) who are undergoing laparoscopic resections. The aim of this study was to evaluate outcomes in a consecutive series of normal weight (NW), overweight (OW), and obese (OB) patients undergoing elective laparoscopic colorectal surgery for IBD.

STUDY DESIGN

This study is a retrospective analysis of a prospectively collected, Institutional Review Board-approved IBD database.

RESULTS

Laparoscopic colorectal resection was performed in 626 patients (335 NW, 206 OW, and 85 OB) between August 2002 and December 2011. Operative time and blood loss were significantly higher in the OW and OB groups compared with the NW group (p = 0.001 and p < 0.001). No differences were observed in terms of intraoperative blood transfusions (p = 0.738) or complications (p = 0.196). The OW and OB groups had a significantly higher conversion rate (p = 0.049 and p = 0.037) and a longer incision compared with the NW group (p = 0.002 and p < 0.001). Obesity was an independent predictor of conversion to open surgery. No significant differences between groups were observed in terms of overall 30-day postoperative morbidity (p = 0.294) and mortality (p = 0.796). Long-term complications occurred in 6.3% NW, 7.3% OW, and 4.7% OB patients (p = 0.676). Incisional hernias were more common in the OB group compared with the NW group (p = 0.020). On multivariate analysis, obesity was not an independent risk factor for either early or late postoperative complications.

CONCLUSIONS

Obesity increases the complexity of laparoscopic resections in IBD with higher blood loss, operative time, and conversion rates, without worsening outcomes.

Telescopic straight ileo-anal anastomosis in dogs

PURPOSE

To study outcomes and functional results of a telescopic straight ileo-anal anastomosis.

METHODS

Thirty-six mongrel dogs were submitted to total proctocolectomy and telescopic straight ileo-anal anastomosis (ileal mucosa-submucosa pulled-through the rectal cuff). They were divided in 3 groups, sacrificed after one, two or eight weeks after the initial procedure. Gross and microscopic (degree of cooptation and signs of ischemia) aspects of the anastomosis, as well, the aspect of defecation were analyzed.

RESULTS

On microscopy all anastomosis analysed showed a continuous epithelial line and were considered good. After two-months no signs of ischemia were identified. Defecation aspect has considerably changed during the study, so no dogs presented solid defecation within the first two weeks, whereas 80% of dogs presented solid stools after two months.

CONCLUSION

Telescopic ileo-anal anastomosis is a safe alternative and may provide good functional results after some small period of time.