Effects of minimizing access trauma in laparoscopic colectomy in patients with IBD

Impact of Coronavirus Disease 2019 (COVID-19) Pandemic on Surgical Site Infection in Patients with Inflammatory Bowel Disease-A Monocentric, Retrospective Cohort Study

(1) Background: Surgical site infections (SSIs) are a relevant problem with a 25% incidence rate after elective laparotomy due to inflammatory bowel disease (IBD). The aim of this study was to evaluate whether stricter hygienic measures during the COVID-19 pandemic influenced the rate of SSI. (2) Methods: This is a monocentric, retrospective cohort study comparing the rate of SSI in patients with bowel resection due to IBD during COVID-19 (1 March 2020-15 December 2021) to a cohort pre-COVID-19 (1 February 2015-25 May 2018). (3) Results: The rate of SSI in IBD patients with bowel resection was 25.8% during the COVID-19 pandemic compared to 31.8% pre-COVID-19 (OR 0.94; 95% CI 0.40-2.20; p = 0.881). There were seventeen (17.5%) superficial and four (4.1%) deep incisional and organ/space SSIs, respectively, during the COVID-19 pandemic (p = 0.216). There were more postoperative intra-abdominal abscesses during COVID-19 (7.2% vs. 0.9%; p = 0.021). The strictness of hygienic measures (mild, medium, strict) had no influence on the rate of SSI (p = 0.553). (4) Conclusions: Hygienic regulations in hospitals during COVID-19 did not significantly reduce the rate of SSI in patients with bowel resection due to IBD. A ban on surgery, whereby only emergency surgery was allowed, was likely to delay surgery and exacerbate the disease, which probably contributed to more SSIs and postoperative complications.

Minimally invasive surgery for glycogen storage disease combined with inflammatory bowel disease: A case report

BACKGROUND

Inflammatory bowel disease (IBD) is rare in patients with glycogen storage disease (GSD). In GSD patients, a decrease in the number of neutrophils leads to prolonged intestinal infection, leading to the formation of chronic inflammation and eventually the development of IBD. Minimally invasive surgery for patients with IBD has been proven to reduce inflammatory responses and postoperative risks and ultimately promote rapid recovery. Herein we discuss minimally invasive surgery and the perioperative management in a patient with GSD and IBD.

CASE SUMMARY

A 23-year-old male had GSD Ib associated with IBD-like disease for 10 years. Despite standard treatments, such as mesalazine, prednisone and adalimumab, the patient eventually developed colonic stenosis with incomplete ileus. After adequate assessment, the patient was treated with minimally invasive surgery and discharged in stable condition.

CONCLUSION

Minimally invasive surgery for patients with IBD and GSD is safe, feasible and effective.

Trends and Outcomes for Minimally Invasive Surgery for Inflammatory Bowel Disease

BACKGROUND

The relapsing and remitting nature of inflammatory bowel disease (IBD) predisposes patients to the development of fibrotic strictures, which must often be managed surgically. Laparoscopy provides the potential for enhanced perioperative care. Previous studies comparing morbidity and trends of open versus laparoscopic resection have been constrained by length of study and sample size.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database, patients with primary diagnosis of IBD undergoing surgical resection from 2005 to 2015 were identified. Morbidity and mortality rates were then compared between open and laparoscopic resections using multiple logistic regression analyses.

RESULTS

A total of 10,699 resections were performed on IBD patients; 4816 (45.0%) of which were performed laparoscopically. The use of laparoscopy increased annually from 20.9% in 2005 to 55.4% in 2015. Comparing laparoscopic versus open, all 30-d outcomes tended to favor laparoscopy with the exception of operating room time, which was equal between the two groups. The difference in 30-d outcomes was statistically significant in laparoscopy versus open technique for pneumonia (1.0% versus 2.0%), ventilator use >48 h (0.6% versus 1.9%), acute renal failure (0.1% versus 0.4%), renal insufficiency (0.2% versus 0.6%), superficial surgical site infection (4.6% versus 7.7%), deep incisional surgical site infection (1.1% versus 1.8%), organ space infection (5.4% versus 7.3%), urinary tract infection (1.3% versus 2.2%), death (0.2% versus 0.7%), and length of hospital stay (6.4 versus 9.4 d).

CONCLUSIONS

These data not only display trends that indicate that the number of laparoscopic resections for IBD have increased over time but are associated with favorable complication rates, operating time, and length of hospital stay, suggesting that laparoscopy may be a safer option for treatment of fibrotic strictures associated with IBD.

Incidence Rates and Predictors of Colectomy for Ulcerative Colitis in the Era of Biologics: Results from a Provincial Database

BACKGROUND

We evaluated long-term incidence and identified risk factors of colectomy in pre-biologics and biologics eras for treatment of ulcerative colitis.

METHODS

After IRB approval, using data obtained from the Régie d'assurance maladie du Québec, we defined two cohorts: pre-biologics (1998-2004) and biologics (2005-2011) eras. Patients with inflammatory bowel disease or colectomy 1 year prior to first diagnosis of ulcerative colitis were excluded. Multivariate logistic regression model compared patient baseline characteristics. Kaplan-Meier curves displayed unadjusted time to event. Cox proportional hazards models were used to compare adjusted colectomy and mortality rates, respectively.

RESULTS

In pre-biologics and biologics eras, 335/2829 and 314/3313 patients, respectively, underwent colectomy. Median follow-up (first and third quartiles) was similar (p = 0.206). Incidence rates for colectomy were 36.08/1000 and 29.99/1000 patient years. Unadjusted rate of colectomy was higher in pre-biologics era (p = 0.004). Predictors of colectomy included anemia (1.66; 1.38-2.01), gastrointestinal hospitalizations (1.24; 1.04-1.47), congestive heart failure (2.08; 1.27-3.40), and male gender (1.47; 1.26-1.72). Mortality was 8.06 and 3.18% in pre-biologics and biologics eras. After adjusting for potential confounders, age (1.08; 1.05-1.12) and urgent colectomy (5.65; 2.19-14.54) remained associated with increased mortality hazard.

CONCLUSION

Incidence of colectomy decreased after introduction of biologics. Risk factors for colectomy were gastrointestinal hospitalizations, anemia, male gender, and congestive heart failure. Emergent surgery and age were predictors of mortality.

Subtotal colectomy for ulcerative colitis: lessons learned from a tertiary centre

AIM

Subtotal colectomy (STC) is a well-established treatment for complicated and refractory ulcerative colitis (UC). A laparoscopic approach offers potentially improved outcomes. The aim of the study was to report our experience with STC for UC in a single large centre.

METHOD

From January 2007 to May 2015, all consecutive patients undergoing STC for UC were retrospectively analysed from a prospectively managed database. Patients with known Crohn's disease or those undergoing one-stage procedures were excluded. Demographics, perioperative outcomes and second-stage procedures were analysed.

RESULTS

During the study period, 151 STCs were performed for UC [100 emergency (66%) and 51 elective (34%)]. Acute severe colitis refractory to therapy was the most common indication (62%). Overall, 117 laparoscopic (78%) and 34 open STCs were performed, with a conversion rate of 14.5%. Mortality and morbidity rates were 0.7% and 38%, respectively. Whilst operative time was shorter for open STC (by 75 min; P = 0.001), there were fewer complications (32% vs 62%; P = 0.002) and a shorter hospital stay (by 6.9 days; P = 0.0002) following laparoscopic STC. Fewer complications and shorter hospital stay were also observed after elective STC. Patients undergoing laparoscopic STC were more likely to undergo a restorative second-stage procedure than those having open STC (75% vs 50%; P = 0.03).

CONCLUSION

Laparoscopic STC for UC is feasible and safe, even in the emergency situation. A laparoscopic approach may offer advantages in terms of lower morbidity and reduced length of stay. Elective resection may offer similar advantages and is best performed whenever possible.

A National Database Analysis Comparing the Nationwide Inpatient Sample and American College of Surgeons National Surgical Quality Improvement Program in Laparoscopic vs Open Colectomies: Inherent Variance May Impact Outcomes

BACKGROUND

Clinical and administrative databases each have fundamental distinctions and inherent limitations that may impact results.

OBJECTIVE

This study aimed to compare the American College of Surgeons National Surgical Quality Improvement Program and the Nationwide Inpatient Sample, focusing on the similarities, differences, and limitations of both data sets.

DESIGN

All elective open and laparoscopic segmental colectomies from American College of Surgeons National Surgical Quality Improvement Program (2006-2013) and Nationwide Inpatient Sample (2006-2012) were reviewed. International Classification of Diseases, Ninth Revision, Clinical Modification coding identified Nationwide Inpatient Sample cases, and Current Procedural Terminology coding for American College of Surgeons National Surgical Quality Improvement Program. Common demographics and comorbidities were identified, and in-hospital outcomes were evaluated.

SETTINGS

A national sample was extracted from population databases.

PATIENTS

Data were derived from the Nationwide Inpatient Sample database: 188,326 cases (laparoscopic = 67,245; open = 121,081); and American College of Surgeons National Surgical Quality Improvement Program: 110,666 cases (laparoscopic = 54,191; open = 56,475).

MAIN OUTCOME MEASURES

Colectomy data were used as an avenue to compare differences in patient characteristics and outcomes between these 2 data sets.

RESULTS

Laparoscopic colectomy demonstrated superior outcomes compared with open; therefore, results focused on comparing a minimally invasive approach among the data sets. Because of sample size, many variables were statistically different without clinical relevance. Coding discrepancies were demonstrated in the rate of conversion from laparoscopic to open identified in the National Surgical Quality Improvement Program (3%) and Nationwide Inpatient Sample (15%) data sets. The prevalence of nonmorbid obesity and anemia from National Surgical Quality Improvement Program was more than twice that of Nationwide Inpatient Sample. Sepsis was statistically greater in National Surgical Quality Improvement Program, with urinary tract infections and acute kidney injury having a greater frequency in the Nationwide Inpatient Sample cohort. Surgical site infections were higher in National Surgical Quality Improvement Program (30-day) vs Nationwide Inpatient Sample (8.4% vs 2.6%; p < 0.01), albeit less when restricted to infections that occurred before discharge (3.3% vs 2.6%; p < 0.01).

LIMITATIONS

This is a retrospective study using population-based data.

CONCLUSION

This analysis of 2 large national databases regarding colectomy outcomes highlights the incidence of previously unrecognized data variability. These discrepancies can impact study results and subsequent conclusions/recommendations. These findings underscore the importance of carefully choosing and understanding the different population-based data sets before designing and when interpreting outcomes research.

Laparoscopy improves clinical outcome of gastrointestinal fistula caused by Crohn's disease

BACKGROUND

Benefits of laparoscopic surgery in the management of gastrointestinal fistula caused by Crohn disease need to be fully elucidated. We conducted this retrospective study to investigate the safety and feasibility and emphasize the advantages of laparoscopy compared with that of laparotomy for patients with gastrointestinal fistula caused by Crohn disease.

MATERIALS AND METHODS

A total of 1213 patients with gastrointestinal fistula in our center were screened, and 318 qualified patients were enrolled and divided into laparoscopy (n = 122) and laparotomy (n = 196) groups. Postoperative complications, length of hospital stay, systemic stress responses to surgery, postoperative mortality, and economic burden were collected and compared.

RESULTS

A total of 125 laparoscopic interventions were performed with a conversion rate of 20.0%. Fifteen versus 84 postoperative complications were obtained in laparoscopy and laparotomy groups, respectively (P = 0.0033). Total hospitalization was 22.7 d and 38.0 d in laparoscopy and laparotomy groups, respectively (P < 0.0001). Postoperative hospitalization was 10.9 d and 24.8 d in two groups, respectively (P < 0.0001). Elevation curve of serum C-reactive protein and procalcitonin in response to laparoscopy was significantly lower than that to laparotomy. Reduced postoperative mortality (P = 0.0292) and postoperative cost (P = 0.0292) were observed in laparoscopy instead of laparotomy group.

CONCLUSIONS

Laparoscopic approach is safe and feasible and could improve clinical outcome in gastrointestinal fistula patients with Crohn disease.