Restorative proctocolectomy with ileal pouch anal anastomosis in obese patients

Impact of Obesity and Metabolic Syndrome on IBD Outcomes

PURPOSE OF REVIEW

The recent surge in inflammatory bowel disease (IBD) cases has paralleled a significant rise in obesity and metabolic comorbidities rates. In this article, we explore the potential influence of obesity and associated metabolic comorbidities on disease progression, complications, treatment response, surgical outcomes, health economics, and the potential impact of obesity treatment on the course of IBD.

FINDINGS

Contrary to visceral adiposity, obesity does not consistently result in an increased risk of IBD-related complications. Patients with IBD have a higher risk of acute arterial events, likely linked to systemic inflammation. Substantial evidence suggests that obesity has a negative impact on the response to IBD treatment, with this effect being most thoroughly studied in biologics and immunomodulators. The rates of overall complications and post-operative infections are higher in patients who are obese. There are limited but promising data regarding the impact of weight loss techniques, including exercise, medications, and bariatric interventions, on the outcomes in IBD. Both obesity and diabetes have adverse effects on the overall quality of life and place an increased financial burden on the IBD population. A growing body of evidence indicates a connection between obesity and associated metabolic comorbidities and negative outcomes in IBD, yet further efforts are required to fully understand this relationship.

Recommendations on the management of severe obesity in patients with inflammatory bowel disease of the Spanish Group on Crohn's Disease and Ulcerative Colitis (GETECCU), Spanish Society of Obesity (SEEDO), Spanish Association of Surgery (AEC) and Spanish Society of Digestive Endoscopy (SEED)

Obesity is a multifactorial, chronic, progressive and recurrent disease considered a public health issue worldwide and an important determinant of disability and death. In Spain, its current prevalence in the adult population is about 24% and an estimated prevalence in 2035 of 37%. Obesity increases the probability of several diseases linked to higher mortality such as diabetes, cardiovascular disease, hyperlipidemia, arterial hypertension, non-alcoholic fatty liver disease, several types of cancer, or obstructive sleep apnea. On the other hand, although the incidence of inflammatory bowel disease (IBD) is stabilizing in Western countries, its prevalence already exceeds 0.3%. Paralleling to general population, the current prevalence of obesity in adult patients with IBD is estimated at 15-40%. Obesity in patients with IBD could entail, in addition to its already known impact on disability and mortality, a worse evolution of the IBD itself and a worse response to treatments. The aim of this document, performed in collaboration by four scientific societies involved in the clinical care of severe obesity and IBD, is to establish clear and concise recommendations on the therapeutic possibilities of severe or typeIII obesity in patients with IBD. The document establishes general recommendations on dietary, pharmacological, endoscopic, and surgical treatment of severe obesity in patients with IBD, as well as pre- and post-treatment evaluation.

Obesity and novel management of inflammatory bowel disease

Obesity is prevalent within the inflammatory bowel disease (IBD) population, particularly in newly developed countries. Several epidemiological studies have suggested that 15%-40% of IBD patients are obese, and there is a potential role of obesity in the pathogenesis of IBD. The dysfunction of mesenteric fat worsens the inflammatory course of Crohn’s disease and may induce formation of strictures or fistulas. Furthermore, obesity may affect the disease course or treatment response of IBD. Given the increasing data supporting the pathophysiologic and epidemiologic relationship between obesity and IBD, obesity control is being suggested as a novel management for IBD. Therefore, this review aimed to describe the influence of obesity on the outcomes of IBD treatment and to present the current status of pharmacologic or surgical anti-obesity treatments in IBD patients.

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.

Obesity in inflammatory bowel disease: A review of its role in the pathogenesis, natural history, and treatment of IBD

In contrast to previous perceptions that inflammatory bowel disease (IBD) patients are generally malnourished and underweight, there is mounting evidence to suggest that rates of obesity in IBD now mirror that of the general population. IBD is an immune-mediated condition that appears to develop in individuals who have not only a genetic predisposition to immune dysregulation but also likely exposure to various environmental factors which further potentiate this risk. With the surge in obesity alongside the rising incidence of IBD, particularly in developing nations, the role that obesity may play, not only in the pathogenesis but also in the natural history of disease has become a topic of growing interest. Currently available data exploring obesity's impact on the natural history of IBD are largely conflicting, potentially limited by the use of body mass index as a surrogate measure of obesity at varying time points throughout the disease course. While there are pharmacokinetic data to suggest possible detrimental effects that obesity may have on the response to medical therapy, results in this realm are also inconsistent. Moreover, not only is it unclear whether weight loss improves IBD outcomes, little is known about the safety and efficacy of available weight-loss strategies in this population. For these reasons, it becomes increasingly important to further understand the nature of any interaction between obesity and IBD.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Primary fecal diversion and bowel dysfunction in restorative proctocolectomy for ulcerative colitis: a nationwide cross-sectional study

PURPOSE

The aim of this study was to explore the effects of primary fecal diversion on the risk of pouch dysfunction.

METHODS

Patients operated with an ileal pouch-anal anastomosis in Denmark in 2000-2010 were identified and validated bowel function questionnaires retrieved from a cross-sectional study. Multivariate logistic regression analysis was performed to determine the effect of primary fecal diversion on pouch dysfunction. A diagnostic or procedural code for intraabdominal abscesses and fistulas, occurring within 1 year after pouch creation, and anastomotic leakage or extremely early-onset pouchitis within 30 days of surgery defined a pelvic complication.

RESULTS

The questionnaire response rate was 85.6% (504 of 589), with no relevant differences in clinical characteristics between responders and non-responders. Pelvic complications, pouch failure, and death prior to the questionnaire date were more common for patients without primary fecal diversion. Among patients without primary fecal diversion, the prevalence of pouch dysfunction was 48% (95% CI: 34-62%), compared to 30% (95% CI: 26-35%) for those with [adjusted odds ratio = 2.23 (95% CI: 1.20-4.14)]. This difference was primarily caused by a higher risk of 'urgency', 'incomplete emptying', and a higher number of bowel movements per day.

CONCLUSION

Omission of primary fecal diversion in ileal pouch-anal anastomosis for ulcerative colitis may have a negative impact on bowel function. Prospective studies are warranted to elaborate these findings and to determine causality with pelvic complications.

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.

Exercise and Inflammatory Bowel Disease: Insights into Etiopathogenesis and Modification of Clinical Course

There is sparse information regarding exercise and inflammatory bowel disease (IBD). Furthermore, the importance of regular exercise in the optimal management of IBD has not received attention in guidelines and is often overlooked by practitioners. This article summarizes evidence regarding health benefits of exercise, guidelines regarding exercise in the general population and chronic inflammatory disorder populations, limitations regarding exercise capacity in patients with IBD, the association of lack of exercise with IBD pathogenesis, the role of exercise in beneficially modulating IBD clinical course, and extraintestinal benefits of exercise in patients with IBD.

Factors affecting pouch-related outcomes after restorative proctocolectomy

Purposes

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

Methods

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

Results

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

Conclusions

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

The influence of obesity and body mass index on the outcome of laparoscopic colorectal surgery: a systematic literature review

AIM

The relationship between obesity, body mass index (BMI) and laparoscopic colorectal resection is unclear. Our object was to assess systematically the available evidence to establish the influence of obesity and BMI on the outcome of laparoscopic colorectal resection.

METHOD

A search of PubMed/Medline databases was performed in May 2015 to identify all studies investigating the impact of BMI and obesity on elective laparoscopic colorectal resection performed for benign or malignant bowel disease. Clinical end-points examined included operation time, conversion rate to open surgery, postoperative complications including anastomotic leakage, length of hospital stay, readmission rate, reoperation rate and mortality. For patients who underwent an operation for cancer, the harvested number of lymph nodes and long-term oncological data were also examined.

RESULTS

Forty-five studies were analysed, the majority of which were level IV with only four level III (Oxford Centre for Evidence-based Medicine 2011) case-controlled studies. Thirty comparative studies containing 23 649 patients including 17 895 non-obese and 5754 obese showed no significant differences between the two groups with respect to intra-operative blood loss, overall postoperative morbidity, anastomotic leakage, reoperation rate, mortality and the number of retrieved lymph nodes in patients operated on for malignancy. Most studies, including 15 non-comparative studies, reported a longer operation time in patients who underwent a laparoscopic procedure with the BMI being an independent predictor in multivariate analyses for the operation time.

CONCLUSION

Laparoscopic colorectal resection is safe and technically and oncologically feasible in obese patients. These results, however, may vary outside of high volume centres of expertise.

Obesity and Sepsis

Obesity has reached epidemic proportions over the last few decades. Obesity is associated with increased morbidity and mortality in hypertension, cardiovascular diseases, stroke, and cancer and is feared to decrease overall life expectancy over the next few decades. There is a growing body of evidence suggesting that obesity is a chronic inflammatory disease. Obesity is becoming a cause of concern in critically ill patients as well. Sepsis is the number one cause of morbidity and mortality in noncoronary artery disease critical care units all over the world and is associated with a high cost of care. An increase in morbidity in obese septic patients compared with lean people is a cause of growing concern. Laboratory evidence suggests that there is exaggeration in the inflammatory and prothrombogenic phenotype assumed by obese compared with lean septic animals. The exact mechanisms underlying this phenomenon are unknown. This article reviews some of the pathophysiological processes responsible for the underlying inflammation in obesity and sepsis and reviews the literature for the association of the two.

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.

The role of bariatric surgery in morbidly obese patients with inflammatory bowel disease

BACKGROUND

Bariatric surgery is considered as being contraindicated for morbidly obese patients who also have inflammatory bowel disease (IBD). The aim of our study was to report the outcomes of bariatric surgery in morbidly obese IBD patients.

METHODS

The prospectively collected data of all the patients diagnosed as having IBD who underwent bariatric operations in 2 medical centers between October 2006 and January 2014 were retrieved and analyzed.

RESULTS

One male and 9 female morbidly obese IBD patients (8 with Crohn's disease and 2 with ulcerative colitis) underwent bariatric surgery. Their mean age was 40 years, and their mean body mass index was 42.6 kg/m2. Nine of them underwent a laparoscopic sleeve gastrectomy and 1 underwent a laparoscopic adjustable gastric band. Eight patients had obesity-related co-morbidities, including type 2 diabetes, hypertension, sleep apnea, osteoarthropathy, etc. After a median follow-up of 46 months (range 9-67), all of the patients lost weight, with an excess weight loss of 71%, and 10 out of 16 obesity-related co-morbidities were resolved. There was 1 complication not related to IBD, and no IBD exacerbation.

CONCLUSION

Bariatric surgery was safe and effective in our morbidly obese IBD patients. The surgical outcome in this selected patient group was similar to that of comparable non-IBD patients.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Considerations and complications in patients undergoing ileal pouch anal anastomosis

Total proctocolectomy with ileal pouch anal anastomosis (IPAA) preserves fecal continence as an alternative to permanent end ileostomy in select patients with ulcerative colitis and familial adenomatous polyposis. The procedure is technically demanding, and surgical complications may arise. This article outlines both the early and late complications that can occur after IPAA, as well as the workup and management of these potentially morbid conditions.

Influence of obesity on complications and costs after intestinal surgery

BACKGROUND

Obesity is a risk factor for many comorbid conditions that increase the cost of health care. We sought to examine the effect of obesity on surgical complications and cost in a group of patients undergoing intestinal surgery.

METHODS

Using the Veterans Affairs Surgical Quality Improvement Program (VASQIP), which includes clinical data abstracted from medical records for Veterans Affairs (VA) surgical patients, and the VA Decision Support System, which provides the costs of individual patient encounters on the basis of relative values assigned to intermediate products, we examined surgical complications and costs of care in 4,881 patients undergoing intestinal surgery in 2006. Patients were classified into 4 groups based on body mass index (BMI): malnourished (<18), normal weight (18-30), obesity class I to II (30-40), and obesity class III (>40). Patient endpoints included the occurrence of any complication and surgical costs incurred within 30 days of surgery. Endpoints were compared across the 4 BMI categories in unadjusted analyses and risk-adjusted analyses and hospital-level variation using multivariable models.

RESULTS

After controlling for patient risk factors and hospital-level variation, patients in obesity class I to II were 1.21 times more likely to have any complication and patients in obesity class III were 1.41 times more likely to have any complication when compared with normal-weight patients. Similarly, patients in obesity class I to II were 1.44 times more likely to develop a wound complication compared with normal-weight patients, and patients in class III were 1.84 times more likely to develop a wound complication and 1.55 times more likely to develop a respiratory complication compared with normal-weight patients. In contrast, costs were greatest for malnourished patients at $45,000 compared with normal-weight patients at $37,000. However, after controlling for patient risk factors and variation in costs attributable to the admitting hospital, there were no significant cost differences between the 4 BMI categories.

CONCLUSIONS

Obesity leads to increased wound and respiratory complications in intestinal surgery. Nevertheless, obesity alone is not an independent risk factor for increased costs in intestinal surgery.

Inflammatory bowel disease in the obese patient

Obesity is becoming increasingly more common among patients with inflammatory bowel disease. In this review, we will explore the epidemiological trends of inflammatory bowel disease, the complex interplay between the proinflammatory state of obesity and inflammatory bowel disease, outcomes of surgery for inflammatory bowel disease in obese as compared with non-obese patients, and technical concerns pertaining to restorative proctocolectomy and ileoanal pouch reservoir, stoma creation and laparoscopic surgery for inflammatory bowel disease in obese patients.

Computed tomography volumetric fat parameters versus body mass index for predicting short-term outcomes of colon surgery

BACKGROUND

At present, the impact of obesity on short-term outcomes of general surgery remains controversial, especially in the field of laparoscopy. Most studies on the subject have used the body mass index (BMI) to define obesity without distinguishing between visceral and subcutaneous storage. Computed tomography (CT) volumetric analysis permits accurate evaluation of site-specific volume of adipose tissue. The purpose of this study was to compare CT volumetric fat parameters and the BMI for predicting short-term outcomes of colon surgery.

METHODS

A retrospective analysis was conducted of 231 consecutive patients undergoing elective colon resection, with open or laparoscopic technique, from January 2007 to April 2009. CT volumetric quantification of abdominal visceral and subcutaneous adipose tissue was performed. Intraoperative and perioperative data were collected.

RESULTS

A total of 187 patients were enrolled. BMI showed a direct correlation with fat volumetric parameters but not with the visceral/subcutaneous fat ratio. Operating time was correlated with subcutaneous fat storage and BMI in the laparoscopic right colectomy subgroup. No associations were found with the conversion rate. Length of the hospital stay was correlated with the visceral/subcutaneous fat ratio in the laparoscopic left colectomy subgroup. Whereas the overall postoperative complication rate and mortality were not associated with fat parameters, the postoperative surgical complication rate was associated with visceral volumetric parameters in the laparoscopic left colectomy subgroup.

CONCLUSIONS

Short-term outcomes of colon surgery are better predicted by fat volumetric parameters than by the BMI. This study has provided new elements for discussion on the impact of visceral and subcutaneous adiposity in laparoscopic and traditional colon surgery.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN, SETTING, AND PATIENTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Restorative proctectomy with ileal pouch-anal anastomosis in obese patients

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Effect of Retroperitoneal Fat Mass on Surgical Outcomes in Patients Performing Laparoscopic Adrenalectomy: The Effect of Fat Tissue in Adrenalectomy

Background: Obesity and visceral fat are thought to be the most important factors influencing the technical difficulty during open and laparoscopic surgery. The authors aimed to investigate the effect of retroperitoneal fat mass on surgical outcomes in patients undergoing laparoscopic adrenalectomy. Patients and methods: This prospective study included 51 consecutive patients who underwent lateral transabdominal laparoscopic adrenalectomy. Body mass index (BMI) and retroperitoneal fat area (RFA)/adrenal mass area (AMA) ratio were calculated. Results: There was a positive correlation between BMI and operating time and postoperative complications and hospital stay. According to 2-way analysis of variance, only RFA/AMA ratio ( P = .0001) was found to significantly correlate with operating time, whereas BMI did not significantly correlate with operating time ( P = .51). In patients with high BMI, high RFA indicated longer operating time and higher complication rate, whereas low RFA was associated with significantly shorter operating time and decreased risk of complications. Conclusion: Retroperitoneal fat mass is a more useful parameter than BMI for predicting the surgical outcomes of laparoscopic adrenalectomy.

Obesity Exacerbates Sepsis-Induced Inflammation and Microvascular Dysfunction in Mouse Brain

OBJECTIVE

Obese patients with sepsis have higher morbidity and mortality than lean counterparts, but the mechanisms involved are unknown. The authors examined the inflammatory and thrombogenic responses of the cerebral microvasculature to sepsis induced by cecal ligation and perforation in obese and lean wild-type mice.

METHODS

Leukocyte and platelet adhesion in cerebral microvasculature and behavioral responses were measured in wild-type and obese mice 4 h postperforation. P-selectin expression in different vascular beds was assessed 6 h postperforation. The effects of immunoblockade of P-selectin, ICAM-1, and CD18 on leukocyte and platelet recruitment were evaluated in obese septic animals.

RESULTS

Cerebral venules of obese and wild-type mice assumed a proinflammatory and prothrombogenic phenotype 4 h post-perforation, with greatly exaggerated responses in obese mice compared to the lean counterparts. These enhanced responses were attenuated by blocking P-selectin, CD18, or ICAM-1. Obese mice also exhibited a more profound behavioral deficit after sepsis, which appears to be unrelated to the recruitment of leukocytes and platelets. Cecal ligation and perforation-induced P-selectin expression was greater in obese mice compared with lean counterparts.

CONCLUSIONS

These findings suggest that the increased morbidity to sepsis in obesity may result from exaggerated microvascular inflammatory and thrombogenic responses that include the activation of endothelial cells with subsequent expression of adhesion molecules, such as P-selectin.

Exercise and inflammatory bowel disease

Crohn's disease and ulcerative colitis are both idiopathic inflammatory bowel diseases (IBDs) that affect 0.5% of Canadians. As yet, there is no known cure for either disease, and symptoms are treated with an array of medicines. The objective of the present review was to present the role of exercise and its impact on all facets of IBD. Exercise has been speculated to be protective against the onset of IBD, but the literature is inconsistent and weak. Preliminary studies reveal that exercise training may be beneficial to reduce stress and symptoms of IBD. Current research also recommends exercise to help counteract some IBD-specific complications by improving bone mineral density, immunological response, psychological health, weight loss and stress management ability. However, the literature advises that some patients with IBD may have limitations to the amount and intensity of exercise that they can perform. In summary, exercise may be beneficial to IBD patients, but further research is required to make a convincing conclusion regarding its role in the management of IBD and to help establish exercise regimens that can account for each IBD patient's unique presentation.

Complications and functional results after ileoanal pouch formation in obese patients

OBJECTIVE

Ileoanal pouch formation (IPAA) can be technically challenging in obese patients, and there is little data evaluating results after the procedure in these patients. We compare outcomes for patients with a body mass index (BMI) > or =30 undergoing IPAA when compared with those for patients with BMI <30.

METHODS

Retrospective analysis of prospectively accrued data for patients with BMI > or =30 undergoing IPAA. Patient and disease-related characteristics, complications, long-term function, and quality of life (QOL) using the Cleveland Global Quality of Life scale (CGQL) were determined for this group of patients (group B) and compared with those for patients with BMI <30 (group A). Kruskal-Wallis and Wilcoxon rank sum tests were used to compare quantitative or ordinal data and chi-square or Fisher's exact tests for categorical variables. Long-term mortality and complication rates were estimated using the Kaplan-Meier method with group comparisons performed using log rank tests.

RESULTS

There were 345 patients (median BMI 32.7) in group B and 1,671 patients in group A. When the cumulative risk of complications over 15 years was compared, group B patients had a significantly higher chance of getting a complication (94.9% vs 88%, p = 0.006). The rates of pelvic sepsis (6.7% vs 5.3%, p = 0.3), pouchitis (58.1 vs 54.4%, p = 0.9), pouch failure (6% vs 4.5%, p = 0.9), and hemorrhage (5.6% vs 4.8%, p = 0.7) were similar for group B and group A. Group B patients, however, had a significantly higher risk of the development of wound infection (18.8% vs 8.1%, p < 0.001) and anastomotic separation (10.4% vs 5.4%, p < 0.001), whereas group A patients had a higher rate of development of obstruction over time (26.7% vs 22.3%, p = 0.02). Long-term outcome including QOL and function after 15 years was comparable between groups.

CONCLUSIONS

Although technically demanding, IPAA can be undertaken in obese patients with acceptable morbidity. Good long-term functional results and QOL that is comparable to nonobese patients may be anticipated.

Surgery for ulcerative colitis

Ulcerative colitis is an inflammatory condition of unknown aetiology affecting all or part of the rectum and colon. The mainstay of treatment is medical but there are specific indications for surgical intervention. This article reviews the evolution of surgical management and in particular compares outcome from proctocolectomy and pouch surgery. A number of factors determining choice of procedure are examined, including elective or emergency presentation, patient selection, technical issues, morbidity and quality of life. Emphasis is made regarding a full explanation of these factors so that the patient is fully involved in the final decision regarding choice of procedure.

The impact of obesity on outcome after major colorectal surgery

PURPOSE

There is an epidemic of obesity in the Western world and its associated substantial morbidity and mortality. This review examines the data on the impact of obesity on perioperative morbidity and mortality specifically in the context of colorectal surgery.

METHODS

MEDLINE, PUBMED, and the Cochrane library were searched for relevant articles. A manual search for other pertinent papers also was performed.

RESULTS

There is good evidence that obesity is a risk factor for wound infection after colorectal surgery. Obesity may increase the risk of wound dehiscence, incisional site herniation, and stoma complications. Obesity is linked to anastomotic leak, and obese patient undergoing rectal resections may be at particular risk. There is little data on the impact of obesity on pulmonary and cardiovascular complications after colorectal surgery. Operation times are longer for rectal procedures in obese patients, but hospital stay is not prolonged. Obese patients undergoing laparoscopic colorectal surgery are at increased risk of conversion to an open procedure.

CONCLUSIONS

Obesity has a negative impact on outcome after colorectal surgery. To further clarify the impact of obesity on surgical outcome, it is recommended that future studies examine grades of obesity and include measures of abdominal obesity.

Challenges of laparoscopic colectomy in the obese patient: a review

BACKGROUND

Perioperative care of clinically severely obese patients presents numerous unique challenges. These patients have distinctive issues with regard to cardiovascular, pulmonary, and thromboembolic complications. In addition, hospital equipment must be able to accommodate the body habitus of this population.

METHODS

A Medline search using the terms "morbid obesity," "colon resection," "obesity comorbidities," "laparoscopic colectomy," "perioperative challenges," and "risk factors" was performed for English-language articles. Further references were obtained through cross-referencing the bibliography cited in each publication.

RESULTS

The authors discussed the most relevant challenges surgeons encounter in the perioperative setting when treating obese patients.

COMMENTS

The management of the morbidly obese patient requires meticulous preoperative, intraoperative, and postoperative care. Colorectal surgeons should be familiar with obesity-related problems when treating colorectal disease processes in this patient population. The associated comorbid illnesses in this population, as well as the technical difficulties regularly posed by them, make laparoscopic colectomy a more challenging procedure than normally encountered in the nonobese patient population.

Care of the Obese PatientWith an Ostomy

Obesity has become the number one health problem in the United States. The patients who is obese and undergoing a surgical procedure that results in the formation of fecal or urinary diversion requires advanced skills of a multidisciplinary healthcare team. Patients who are obese carry a high risk of wound and cardiopulmonary complications and often present a serious challenge in terms of stoma creation and management. The purpose of this article is to examine the risk factors that face the patient who is obese and undergoing stoma surgery, the challenges of stoma creation, and the resultant stoma management problems.

Impact of obesity on resource utilization for general surgical procedures

OBJECTIVE

To determine the impact of the obesity epidemic on workload for general surgeons.

SUMMARY BACKGROUND DATA

In 2001, the prevalence of obesity in the United States reached 26%, more than double the rate in 1990. This study focuses on the impact of obesity on surgical practice and resource utilization.

METHODS

A retrospective analysis was done on patients undergoing cholecystectomy, unilateral mastectomy, and colectomy from January 2000 to December 2003 at a tertiary care center. The main outcome variables were operative time (OT), length of stay (LOS), and complications. The key independent variable was body mass index. We analyzed the association of obesity status with OT, LOS, and complications for each surgery, using multivariate regression models controlling for surgeon time-invariant characteristics.

RESULTS

There were 623 cholecystectomies, 322 unilateral mastectomies, and 430 colectomies suitable for analysis from 2000 to 2003. Multivariable regression analyses indicated that obese patients had statistically significantly longer OT (P < 0.01) but not longer LOS (P > 0.05) or more complications (P > 0.05). Compared with a normal-weight patient, an obese patient had an additional 5.19 (95% confidence interval [CI], 0.15-10.24), 23.67 (95% CI, 14.38-32.96), and 21.42 (95% CI, 9.54-33.30) minutes of OT with respect to cholecystectomy, unilateral mastectomy, and colectomy. These estimates were robust in sensitivity analyses.

CONCLUSIONS

Obesity significantly increased OT for each procedure studied. These data have implications for health policy and surgical resource utilization. We suggest that a CPT modifier to appropriately reimburse surgeons caring for obese patients be considered.

Laparoscopic restorative proctocolectomy

Background

Restorative proctocolectomy is increasingly being performed using minimally invasive surgery. In published series laparoscopically assisted techniques have usually included a suprapubic incision to enable major parts of the operation to be done openly.

Methods

Fifty consecutive patients with familial adenomatous polyposis or ulcerative colitis underwent laparoscopic restorative proctocolectomy using only a small perumbilical incision of 4 cm or less for vascular dissection and pouch formation; all other steps were performed entirely laparoscopically. Logistic regression was used for statistical analysis.

Results

In four patients (8 per cent) the operation was converted to an open procedure. The diagnosis of ulcerative colitis was associated with a higher overall rate of complications (P = 0·011), and an increased body mass index (BMI) with a higher rate of major complications (P = 0·050). The occurrence of wound infection was related to the diagnosis of ulcerative colitis (P = 0·049). Conversion resulted in greater blood loss (P = 0·004), but not in a higher complication rate. No patient required a blood transfusion. Patients with an increased BMI and those taking immunosuppressive therapy had a longer hospital stay (P = 0·043).

Conclusion

Laparoscopic restorative proctocolectomy is technically feasible. Patients with ulcerative colitis and increased BMI have a higher risk of complications. This minimally invasive technique may reduce the need for perioperative blood transfusion.

Risk factors for mortality and morbidity after elective sigmoid resection for diverticulitis: prospective multicenter multivariate analysis of 582 patients

The prevalence of diverticular disease of the colon is increasing in occidental countries. It would be useful to further decrease the mortality and morbidity after elective sigmoid resection (ESR) for diverticulitis. The aim of this study was to identify modifiable preoperative and intraoperative risk factors for mortality and morbidity after ESR for diverticulitis. A database of 2615 patients who underwent a colon or rectal resection with primary anastomosis between 1985 to 1998 has been constructed from prospective randomized studies published by a French surgical group. Of those patients, 582 had undergone ESR for diverticulitis, and they constitute the population of the present study. A total of 46 potential preoperative and intraoperative risk factors for mortality and morbidity have been studied by univariate and multivariate analysis. The operative mortality for our series was 1.2%, and the overall morbidity was 24.9%. The multivariate analysis revealed two statistically significant independent risk factors of mortality: age >75 (odds-ratio=7.9; 95% confidence interval [CI 1.7-36.6]; p=0.01) and obesity (odds-ratio=5.2; 95% CI [1.1-27.9]; p=0.04). The abdominal morbidity (AM) was 6.5% (38/582). The absence of antimicrobial prophylaxis administration with ceftriaxone was the only significant risk factor for AM in multivariate analysis (p=0.003; odds-ratio=2; 95% CI [1.1-4]). The extraabdominal morbidity (EAM) was 18.4% (107/582). Both chronic pulmonary disease (p=0.008; odds-ratio=2.9; 95% CI [1.4-6]; p=0.008) and cirrhosis (odds-ratio=12; 95% CI [1.2-120]) proved to be significant risk factors for EAM. Weight control prior to surgery, routine administration of prophylactic preoperative antibiotics, and preoperative optimization of the respiratory status of patients with chronic pulmonary disease could decrease the postoperative mortality and morbidity associated with ESR for diverticulitis.

Laparoscopically assisted colectomy and ileoanal pouch procedure with and without protective ileostomy

BACKGROUND

Apart from an obviously better cosmetic situation, there is controversy on the actual benefit of laparoscopic and laparoscopically assisted techniques in restorative proctocolectomy. The need for a protective ileostomy remains unclear.

METHODS

Fifty-nine consecutive patients with ulcerative colitis and familial polyposis were included in this prospective cohort study. The colon was mobilized laparoscopically with a four-trocar technique, facilitating vascular dissection, rectal resection, and ileoanal pouch construction to be done through a Pfannenstiel incision. A protective ileostomy was constructed only in patients where the operation was difficult or where the anastomosis was under tension. Intra- and postoperative data were recorded; statistical analyses were performed by exact logistic regression.

RESULTS

Laparoscopic mobilisation was successful in 54 patients (91.2%). Two patients had to be primarily converted because of exceeding the set time limit; 3 other patients had to have an additional median laparotomy. These 5 patients all had an increased body mass index (BMI), which was a statistically significant risk factor for failure of the laparoscopic technique. 18.6% of patients developed major complications (n = 11). Nine patients required secondary ileostomies; all of them either were under high dose immunosuppressants (n = 5) or had an increased BMI (average 28.42 kg/m2). Failure of the laparoscopic technique was associated with major complications.

CONCLUSION

Laparoscopically assisted restorative proctocolectomy is technically feasible; an increased BMI is a relevant risk factor for failure. The minimally invasive approach probably does not reduce the need for a protective ileostomy in selected patients. The selection criteria for the addition or omission of a protective ileostomy in minimally invasive restorative proctocolectomy remain to be clearly defined.

Surgical treatment of inflammatory bowel disease

Appropriate surgical management of Crohn disease is predicated on multiple variables, but stricturoplasty is generally reserved for small bowel disease, whereas resection is utilized in ileocolonic inflammation and favored for large bowel disease. Laparoscopic resection is becoming increasingly useful and justified for ileocolic resections, and segmental resection should be strongly considered for limited large bowel inflammation. Some centers are also using a laparoscopic approach for the surgical treatment of acute or chronic ulcerative colitis, although the benefits are less apparent. Proctocolectomy with ileostomy or ileal pouch-anal anastomosis returns the patient's quality of life to a level comparable to that enjoyed by the general population. Creation of a pouch is performed in most instances, but early complications may warrant pouch revision and later complications, such as pouchitis, can mandate pouch excision.