Tofacitinib Is Associated With Increased Risk of Postoperative Venous Thromboembolism in Patients With Ulcerative Colitis

BACKGROUND

In 2019, the Food and Drug Administration issued a black box warning for increased risk of venous thromboembolism in patients with rheumatoid arthritis exposed to tofacitinib. There are limited data regarding postoperative venous thromboembolism risk in patients with ulcerative colitis exposed to tofacitinib.

OBJECTIVE

To assess whether preoperative exposure to tofacitinib is associated with increased odds of postoperative venous thromboembolism.

DESIGN

Retrospective review.

SETTINGS

Tertiary academic medical center.

PATIENTS

Consecutive patients exposed to tofacitinib within 4 weeks before total abdominal colectomy or total proctocolectomy, with or without ileostomy, from 2014 to 2021, matched 1:2 for tofacitinib exposure or no exposure.

INTERVENTION

Tofacitinib exposure versus no exposure.

MAIN OUTCOME MEASURES

Ninety-day postoperative venous thromboembolism rate.

RESULTS

Forty-two patients with tofacitinib exposure and 84 case-matched patients without tofacitinib exposure underwent surgery for medically refractory ulcerative colitis. Nine (22.0%) tofacitinib-exposed patients and 7 (8.5%) unexposed patients were diagnosed with venous thromboembolism within 90 days of surgery. In univariate logistic regression, patients exposed to tofacitinib had 3.01 times increased odds of developing venous thromboembolism within 90 days after surgery compared to unexposed patients ( p = 0.04; 95% CI, 1.03-8.79). Other venous thromboembolism risk factors were not significantly associated with venous thromboembolisms. Venous thromboembolisms in both groups were most commonly portomesenteric vein thromboses (66.7% in the tofacitinib-exposed group and 42.9% in the unexposed group) and were diagnosed at a mean of 23.2 days (range, 3-90 days) postoperatively in the tofacitinib-exposed group and 7.9 days (1-19 days) in the unexposed group. There were no statistically significant differences in location or timing between the 2 groups.

LIMITATIONS

Retrospective nature of the study and associated biases. Reliance on clinically diagnosed venous thromboembolisms may underreport the true incidence rate.

CONCLUSIONS

Tofacitinib exposure before surgery for medically refractory ulcerative colitis is associated with 3 times increased odds of venous thromboembolism compared with patients without tofacitinib exposure. See Video Abstract .

TOFACITINIB SE ASOCIA CON UN MAYOR RIESGO DE TROMBOEMBOLISMO VENOSO POSTOPERATORIO EN PACIENTES CON COLITIS ULCEROSA

ANTECEDENTES:En 2019, la FDA emitió una advertencia de recuadro negro sobre un mayor riesgo de tromboembolismo venoso en pacientes con artritis reumatoide expuestos a tofacitinib. Hay datos limitados sobre el riesgo de tromboembolismo venoso postoperatorio en pacientes con colitis ulcerosa expuestos a tofacitinib.OBJETIVO:Evaluar si la exposición preoperatoria a tofacitinib se asocia con mayores probabilidades de tromboembolismo venoso postoperatorio.DISEÑO:Revisión retrospectiva.LUGARES:Centro médico académico terciario.PACIENTES:Pacientes consecutivos expuestos a tofacitinib dentro de las 4 semanas previas a la colectomía abdominal total o proctocolectomía total, con o sin ileostomía, entre 2014 y 2021, emparejados 1:2 para exposición a tofacitinib o ninguna exposición.INTERVENCIÓN(S):Exposición a tofacitinib versus ninguna exposición.PRINCIPALES MEDIDAS DE RESULTADO:Tasa de tromboembolismo venoso posoperatorio a los 90 días.RESULTADOS:Cuarenta y dos pacientes con exposición a tofacitinib y 84 pacientes de casos similares sin exposición a tofacitinib se sometieron a cirugía por colitis ulcerosa médicamente refractaria. Nueve (22,0%) pacientes expuestos a tofacitinib y 7 (8,5%) pacientes no expuestos fueron diagnosticados con tromboembolismo venoso dentro de los 90 días posteriores a la cirugía. En la regresión logística univariada, los pacientes expuestos a tofacitinib tuvieron 3,01 veces más probabilidades de desarrollar un tromboembolismo venoso dentro de los 90 días posteriores a la cirugía en comparación con los no expuestos ( p = 0,04, IC del 95 %: 1,03-8,79). Otros factores de riesgo de tromboembolismo venoso no se asociaron significativamente con el tromboembolismo venoso. Los tromboembolismos venosos en ambos grupos fueron más comúnmente trombosis de la vena portomesentérica (66,7% en los expuestos a tofacitinib y 42,9% en los no expuestos) y se diagnosticaron en una media de 23,2 días (rango, 3-90 días) después de la operación en los expuestos a tofacitinib y 7,9 días. (1-19 días) en los grupos no expuestos, respectivamente. No hubo diferencias estadísticamente significativas en la ubicación o el momento entre los dos grupos.LIMITACIONES:Carácter retrospectivo del estudio y sesgos asociados. La dependencia de tromboembolismos venosos diagnosticados clínicamente puede subestimar la tasa de incidencia real.CONCLUSIONES:La exposición a tofacitinib antes de la cirugía para la colitis ulcerosa médicamente refractaria se asocia con probabilidades 3 veces mayores de tromboembolismo venoso en comparación con los pacientes sin exposición a tofacitinib. (Traducción-Dr. Mauricio Santamaria ).

Segmental Colectomy in Ulcerative Colitis

BACKGROUND

Segmental colectomy in ulcerative colitis is performed in select patients who may be at increased risk for postoperative morbidity.

OBJECTIVE

To identify ulcerative colitis patients who underwent segmental colectomy and assess their postoperative and long-term outcomes.

DESIGN

Retrospective case series.

SETTING

A tertiary-care inflammatory bowel disease center.

PATIENTS

Ulcerative colitis patients who underwent surgery between 1995 and 2022.

INTERVENTION

Segmental colectomy.

MAIN OUTCOME MEASURES

Postoperative complications, early and late colitis, metachronous cancer development, completion proctocolectomy-free survival rates and stoma at follow-up.

RESULTS

Fifty-five patients were included [20 (36.4%) female; 67.8 (57.4-77.1) years of age at surgery; body mass index 27.7 (24.2-31.1) kg/m2; median follow-up 37.3 months]. ASA score was III in 32 (58.2%) patients, 48 (87.3%) had at least one comorbidity, 48 (87.3%) had Mayo endoscopic subscore of 0-1. Patients underwent right hemicolectomy (28, 50.9%), sigmoidectomy (17, 30.9%), left hemicolectomy (6, 10.9%), low anterior resection (2, 3.6%), or a non-anatomic resection (2, 3.6%) for; endoscopically unresectable polyps (21, 38.2%), colorectal cancer (15, 27.3%), symptomatic diverticular disease (13, 23.6%), and stricture (6, 10.9%). Postoperative complications occurred in 16 (29.1%) patients [7 (12.7%) Clavien-Dindo Class III-V]. Early and late postoperative colitis rates were 9.1% and 14.5%, respectively. Metachronous cancer developed in 1 patient. 4 (7.3%) patients underwent subsequent completion proctocolectomy with ileostomy. Six (10.9%) patients had stoma at the follow-up. Two and 5-year completion proctocolectomy-free survival rates were 91% and 88%, respectively.

LIMITATIONS

Retrospective study, small sample size.

CONCLUSIONS

Segmental colectomy in ulcerative colitis is associated with low postoperative complication rates, symptomatic early colitis and late colitis rates, metachronous cancer development and the need for subsequent completion proctocolectomy. Therefore, it can be safe to consider select patients, such as the elderly with quiescent colitis and other indications for colectomy. See Video Abstract.

3-Dimensional Pouchography: A Proof-of-Concept Study of a Novel Technique for Visualizing Ileoanal Pouch Anatomy & Morphology in Normal and Mechanical Pouch Complication Patients

BACKGROUND

Herein, we present a proof-of-concept study of 3-dimensional (3D) pouchography using virtual and printed 3D models of ileal pouch-anal anastomosis (IPAA) in patients with normal pouches and in cases of mechanical pouch complications.

MATERIALS & METHODS

We performed a retrospective, descriptive case series of a convenience sample of 10 pouch patients with or without pouch dysfunction who had CT scans appropriate for segmentation were identified from our pouch registry. The steps involved in clinician-driven automated 3D reconstruction are presented.

RESULTS

Three patients who underwent CT imaging and were found to have no primary pouch pathology, and seven patients with known pouch pathology identifiable with 3D reconstruction including pouch strictures, megapouch, pouch volvulus, and twisted pouches underwent 3D virtual modeling; one normal and one twisted pouch were 3D printed. We discovered that 3D pouchography reliably identified staple lines (pouch body, anorectal circular and transverse, and tip of J), the relationship between staple lines, and variations in pouch morphology, and pouch pathology.

CONCLUSIONS

Three-dimensional reconstruction of IPAA morphology is highly feasible using readily available technology. In our practice, we have found 3D pouchography to be an extremely useful adjunct to diagnose various mechanical pouch complications and improve planning for pouch salvage strategies. Given its ease of use and helpfulness in understanding the pouch structure and function, we have started to routinely integrate 3D pouchography into our clinical pouch referral practice. Further study is needed to formally assess to value of this technique to aid in the diagnosis of pouch pathology.

Outcome of incidental versus preoperatively diagnosed colorectal cancer during total proctocolectomy with ileal pouch-anal anastomosis for inflammatory bowel disease

AIM

Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice for colorectal cancer (CRC) in inflammatory bowel disease. CRC may also be discovered incidentally at IPAA for other indications. We sought to determine whether incidentally found CRC at IPAA was associated with worse outcomes.

METHODS

Our institutional pouch registry (1983-2021) was retrospectively reviewed. Patients with CRC at pathology after IPAA were divided into two groups: a preoperative diagnosis (PreD) group and an incidental diagnosis (InD) group. Their long-term outcomes (overall survival, disease-free survival and pouch survival) were compared.

RESULTS

We included 164 patients: 53 (32%) InD and 111 (68%) PreD. There were no differences in cancer staging, differentiation and location. After a median follow-up of 11 (IQR 3-25) years for InD and 9 (IQR 3-20) years for the PreD group, deaths were 14 (26%) in the InD group and 18 (16%) in the PreD group. Pouch failures were five (9%) in the InD group and nine (8%) in the PreD group, of which two (5%) and four (4%) were cancer related. Ten-year overall survival was 94% for InD and 89% for PreD (P = 0.41), disease-free survival was 95% for InD and 90% for PreD (P = 0.685) and pouch survival was 89% for InD and 97% for PreD (P = 0.80). Pouch survival at 10 years was lower in rectal versus colon cancer (87% vs. 97%, P = 0.01). No difference was found in outcomes in handsewn versus stapled anastomoses.

CONCLUSION

Inflammatory bowel disease patients with incidentally found CRC during IPAA appear to have similarly excellent oncological and pouch outcomes to patients with a preoperative cancer diagnosis.

Transanal ileal pouch-anal anastomosis for inflammatory bowel disease: a systematic review and meta-analysis of short-term outcomes

AIM

Restorative proctocolectomy with transabdominal ileal pouch-anal anastomosis (abd-IPAA) has become the standard surgical treatment for medically refractory ulcerative colitis (UC). However, it requires a technically difficult distal anorectal dissection and anastomosis due to the bony confines of the deep pelvis. To address these challenges, the transanal IPAA approach (ta-IPAA) was developed. This novel approach may offer increased visibility and range of motion compared with abd-IPAA, although its postoperative benefits remain unclear. The aim of this work was to perform a systematic review and meta-analysis to compare and inform the frequency of postoperative outcomes between ta-IPAA and abd-IPAA for patients with UC.

METHOD

Several databases were searched from inception until May 2022 for studies reporting postoperative outcomes of patients undergoing ta-IPAA. Reviewers, working independently and in duplicate, evaluated studies for inclusion and graded the risk of bias. Odds ratios (OR), mean differences (MD) and prevalence ratio (PR) and their corresponding 95% confidence intervals (CIs) were calculated using random-effects models. Sensitivity analysis was performed.

RESULTS

Ten retrospective studies comprising 284 patients with ta-IPAA were included. Total mesorectal excision was performed in 61.8% of cases and close rectal dissection in 27.9%. There was no difference in the odds of Clavien-Dindo (CD) I-II complications, CD III-IV and anastomotic leak (OR 0.96, 95% CI 0.27-3.40; OR 1.18, 95% CI 0.65-2.16; OR 1.37, 95% CI 0.58-3.23; respectively) between ta-IPAA and abd-IPAA. The ta-IPAA pooled CD I-II complication rate was 18% (95% CI 5%-35%) and for CD III-IV 10% (95% CI 5%-17%), and the anastomotic leak rate was 6% (95% CI 2%-10%). There were no deaths reported.

CONCLUSIONS

This meta-analysis compared the novel ta-IPAA procedure with abd-IPAA and found no difference in postoperative outcomes. While the need for randomized controlled trails and comparison of functional outcomes between both approaches remains, this evidence should assist colorectal surgeons to decide if ta-IPAA is a viable alternative.

Endorobotic submucosal dissection of rectal lesions using the single port robot DaVinci-SP: initial experience of the first 10 cases

BACKGROUND

Endoluminal surgery is increasingly recognized as a mode of treatment for colorectal neoplasms with the latest robotic single port platform Da Vinci-SP (Intuitive Surgical, Sunnyvale) facilitating submucosal dissection of benign rectal neoplasm.

METHOD

In this study, we present our initial experience with endorobotic submucosal dissection in the management of benign rectal neoplasms using the Da Vinci-SP (Intuitive Surgical, Sunnyvale) between 2020 and 2021. The primary endpoint was the successful completion of submucosal dissection.

RESULTS

During the study period, 10 patients underwent endorobotic submucosal dissection for benign rectal neoplasms. The median age of the patients was 68 (range: 59-78) years, and the mean BMI was 29.38 (range: 22.9-38.5). The mean size of the lesion was 42.3 mm (range: 20-65 mm) and was located 7.3 cm (mean) from the anal verge (range: 2-10 cm). The mean operative time was 91.3 minutes (range: 57-137 minutes). All 10 dissections were completed successfully en bloc. There were no intraoperative complications or mortality. All patients were discharged on the same day and commenced on a normal diet. Late bleeding was observed in one patient receiving anticoagulation, and one patient had urinary retention. Pathology revealed two adenocarcinomas, six tubulovillous adenomas, one tubular adenoma, and one sessile serrated adenoma. There was no recurrence in all other patients during the median follow-up of 6 months (range: 4-16 months).

CONCLUSIONS

Endorobotic submucosal dissection using a single-port robotic platform is safe and feasible for benign rectal mucosal neoplasms. The semiflexible platform offers an alternative to endoscopic submucosal dissection with favourable outcomes.

The role of advanced endoscopy in appendiceal polyp management and outcomes

BACKGROUND

Appendiceal orifice lesions are often managed operatively with limited or oncologic resections. The aim is to report the management of appendiceal orifice mucosal neoplasms using advanced endoscopic interventions.

METHODS

Patients with appendiceal orifice mucosal neoplasms who underwent advanced endoscopic resections between 2011 and 2021 with either endoscopic mucosal resection (EMR), endoscopic mucosal dissection (ESD), hybrid ESD, or combined endoscopic laparoscopic surgery (CELS) were included from a prospectively collected dataset. Patient and lesion details and procedure outcomes are reported.

RESULTS

Out of 1005 lesions resected with advanced endoscopic techniques, 41 patients (4%) underwent appendiceal orifice mucosal neoplasm resection, including 39% by hybrid ESD, 34% by ESD, 15% by EMR, and 12% by CELS. The median age was 65, and 54% were male. The median lesion size was 20 mm. The dissection was completed piecemeal in 49% of patients. Post-procedure, one patient had a complication within 30 days and was admitted with post-polypectomy abdominal pain treated with observation for 2 days with no intervention. Pathology revealed 49% sessile-serrated lesions, 24% tubular adenomas, and 15% tubulovillous adenomas. Patients were followed up for a median of 8 (0-48) months. One patient with a sessile-serrated lesion experienced a recurrence after EMR which was re-resected with EMR.

CONCLUSION

Advanced endoscopic interventions for appendiceal orifice mucosal neoplasms can be performed with a low rate of complications and early recurrence. While conventionally lesions at the appendiceal orifice are often treated with surgical resection, advanced endoscopic interventions are an alternative approach with promising results which allow for cecal preservation.

Factors associated with stoma closure after cytoreductive surgery

BACKGROUND

The rate of stoma closure after cytoreductive surgery (CRS) ​± ​hypethermic intraperitoneal chemotherapy (HIPEC) is reportedly low. This study aimed to assess predictors of stoma reversal.

METHODS

We retrospectively analyzed all patients who underwent CRS with temporary ostomy at our center between 2009 and 2021, and compared reversed versus non-reversed patients.

RESULTS

Out of 625 CRS, 72 (11.5%) patients were included (median age 62 years, 65% female, 75% with HIPEC): 53 (74%) achieved stoma closure. Reversed patients had less high grade tumors, more appendiceal mucinous neoplasms, less ovarian primaries, and more loop ileostomies. The most common reason for non-reversal was disease progression or death (14 cases, 74%). At multivariate analysis, low/intermediate grade tumor differentiation was associated with higher stoma closure rate.

CONCLUSION

In our study, 74% of patients achieved stoma closure after CRS with temporary ostomy. The strongest predictor of stoma closure was a low/intermediate grade tumor.

Safety & feasibility of targeted mesenteric approaches with Kono-S anastomosis and extended mesenteric excision in ileocolic resection and anastomosis in Crohn's disease

BACKGROUND

The mesentery has recently been implicated in the pathophysiology of Crohn's disease (CD), and several techniques have been developed to target the mesentery to reduce its influence on recurrence. We aimed to describe short-term safety and feasibility after these approaches.

METHODS

This is a comparative, retrospective, single-center cohort study of consecutive CD patients undergoing primary or redo ileocolic resection from 2015 to 2022 with Kono-S anastomosis (KSA), extended mesenteric excision (EME) only, or both: mesenteric excision and exclusion (MEE).

RESULTS

186 patients underwent KSA (n ​= ​74), EME (n ​= ​66), or MEE (n ​= ​46). The groups had comparable baseline characteristics. The MEE group operative time was longer (median: 187 vs. KSA 170, EME 152 ​min, p ​< ​0.01). Postoperatively, the groups had similar lengths of stay (median 4 days), readmissions (9.1 ​%), major postoperative complications (6.5 ​%), and anastomotic leaks (1.1 ​%).

CONCLUSION

Targeting the mesentery with novel surgical approaches for ileocolic Crohn's disease was safe and feasible for short-term follow-up.

Impact of neoadjuvant therapy on nodal harvest in clinical stage III rectal cancer: Establishing optimum cut-offs by disease response

INTRODUCTION

A minimum lymph node harvest (LNH) of 12 is the current standard for appropriate nodal staging in resectable rectal cancer. However, the rise of neoadjuvant chemoradiation (NCRT) and total neoadjuvant therapy (TNT) has been associated with decreasing number of LNH. We hypothesize that as tumor response to neoadjuvant therapy increases, the optimum for LNH to achieve appropriate nodal staging should decrease.

METHODS

Patients with clinical stage III rectal adenocarcinoma who underwent NCRT/TNT followed by resection were identified from the National Cancer Database. A JoinPoint regression analysis was used to determine the LNH for each tumor regression grade (TRG) category beyond which the rate of positive nodes does not significantly change.

RESULTS

Thirteen thousand four hundred and twenty-six patients met inclusion criteria. Of these, 2406 (17.9%) achieved TRG 0 or ypT0 and 8210 (61.2%) achieved ypN0. Collectively, 2043 patients (15.2%) were reported to have a pathologic complete response (ypT0 ypN0). Positive pathologic nodes were found in 15%, 23%, 31%, 54%, and 53% as ypT stage increased from ypT0 to ypT4, respectively. Similarly, ypN+ rates were 15%, 36%, 41%, and 55% in TRG 0-3. No JoinPoint was identified for TRG 0, whereas inflection points were found at 6-10 nodes for TRG1 (p = 0.002) and TRG 2 (p = 0.016), and at 11-15 nodes for TRG 3.

CONCLUSION

The benchmark of retrieving 12 nodes in resectable stage III rectal cancer is not consistently achieved after NCRT/TNT. We demonstrate that the LNH requirement to establish accurate pathologic nodal staging can vary depending on the tumor response to neoadjuvant therapies.

Perioperative outcomes of ileorectal anastomosis - an analysis of 823 patients

AIM

Ileorectal anastomosis (IRA) following total abdominal colectomy (TAC) allows for resortation of bowel continuity but prior studies have reported rates of anastomotic leak (AL) to be as high as 23%. We aimed to report rates of AL and complications in a large cohort of patients undergoing IRA. We hypothesized that AL rates were lower than previously reported and that selective use of diverting loop ileostomy (DLI) is associated with decreased AL rates.

METHOD

Patients undergoing TAC or end-ileostomy reversal with IRA, with or without DLI, between 1980 and 2021 were identified from a prospectively maintained institutional database and retrospectively analysed. Redo IRA cases were excluded. Short-term (30-day) surgical outcomes were collected using our database. AL was defined using a combination of imaging and, in the case of return to the operating room, intraoperative findings.

RESULTS

Of 823 patients in the study cohort, DLI was performed in 27% and performed more frequently for constipation and inflammatory bowel disease. The overall AL rate was 3% (1% and 4% in those with and without DLI, respectively) and diversion was found to be protective against leak (OR 0.28, 95% CI 0.08-0.94, p = 0.04). However, patients undergoing diversion had a higher overall rate of postoperative complications (51% vs. 36%, p < 0.001) including superficial wound infection, urinary tract infection, dehydration, blood transfusion and portomesenteric venous thrombosis (all p < 0.04).

CONCLUSION

Our study represents the largest series of patients undergoing IRA reported to date and demonstrates an AL rate of 3%. While IRA appears to be a viable surgical option for diverse indications, our study underscores the importance of careful patient selection and thoughtful consideration of staging the anastomosis and temporary faecal diversion when necessary.

Using Computed-Tomgraphy-Based Pelvimetry and Visceral Obesity Measurements to Predict Total Mesorectal Excision Quality for Patients Undergoing Rectal Cancer Surgery

BACKGROUND

A complete total mesorectal excision is the gold standard in curative rectal cancer surgery. Ensuring quality is challenging in a narrow pelvis, and obesity amplifies technical difficulties. Pelvimetry is the measurement of pelvic dimensions, but its role in gauging preoperatively difficulty of proctectomy is largely unexplored.

OBJECTIVE

To determine pelvic structural factors associated with incomplete total mesorectal excision following curative proctectomy and build a predictive model for total mesorectal excision quality.

DESIGN

Retrospective cohort study.

SETTING

A quaternary referral center database of patients diagnosed with rectal adenocarcinoma (2009-2017).

PATIENTS

Curative-intent proctectomy for rectal adenocarcinoma.

INTERVENTIONS

All radiological measurements were obtained from preoperative CT-images using validated imaging processing software tools. Completeness of total mesorectal excision was obtained from histology reports.

MAIN OUTCOME MEASURES

Ability of radiological pelvimetry and obesity measurements to predict total mesorectal excision quality.

RESULTS

Of the 410 cases meeting inclusion criteria, 362 had a complete total mesorectal excision (88%). A multivariable regression identified a deeper sacral curve (per 100 mm2 [OR: 1.14, 95% CI: 1.06-1.23, p < 0.001]), and greater transverse distance of pelvic outlet (per 10 mm [OR:1.41, 95% CI: 1.08-1.84, p = 0.012]) as independently associated with incomplete total mesorectal excision. An increased area of pelvic inlet (per 10 cm2); OR: 0.85, [95% CI: 0.75-0.97, p = 0.02] was associated with a higher rate of complete mesorectal excision. No difference in visceral obesity ratio and visceral obesity (ratio >0.4 vs.<0.4) between body mass index (<30 vs. ≥30) or sex was identified. A model was built to predict mesorectal quality using variables: depth of sacral curve, area of pelvic inlet and transverse distance of pelvic outlet.

LIMITATIONS

Retrospective analysis not controlled for choice of surgical approach.

CONCLUSIONS

Pelvimetry is predictive of total mesorectal excision quality in rectal cancer surgery and can alert surgeons preoperatively to cases of unusual difficulty. This predictive model may contribute to treatment strategy and aid in comparison of outcomes between traditional and novel techniques of total mesorectal excision. See Video Abstract.

Redo IPAA for long rectal cuff syndrome after ileoanal pouch for inflammatory bowel disease

ABTRACT

BACKGROUND: When constructing an ileal pouch-anal anastomosis (IPAA), the rectal cuff should ideally be 1-2 cm long to avoid subsequent complications.

METHODS

We identified patients from our IBD center who underwent redo IPAA for a long rectal cuff. Long rectal cuff syndrome (LRCS) was defined as a symptomatic rectal cuff ≥ 4 cm.

RESULTS

Forty patients met the inclusion criteria: 42.5% female, median age at redo surgery 42.5 years. The presentation was ulcerative proctitis in 77.5% of the cases and outlet obstruction in 22.5%. The index pouch was laparoscopically performed in 18 patients (45%). The median rectal cuff length was 6 cm. The pouch was repaired in 16 (40%) cases, whereas 24 (60%) required the creation of a neo-pouch. At the final pathology, the rectal cuff showed chronic active colitis in 38 (90%) cases. After a median follow-up of 34.5 (IQR 12-109) months, pouch failure occurred in 9 (22.5%) cases. The pouch survival rate was 78% at 3 years. Data on the quality of life were available for 11 (27.5%) patients at a median of 75 months after redo surgery. The median QoL score (0-1) was 0.7 (0.4-0.9).

CONCLUSION

LRCS, a potentially avoidable complication, presents uniformly with symptoms of ulcerative proctitis or stricture. Redo IPAA was restorative for the majority.

The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Third Time's the Charm? Indications and Outcomes for Redo-Redo Ileal Pouch-Anal Anastomosis

BACKGROUND

Up to 20% to 40% cases of redo ileal pouch anal anastomosis will result in pouch failure. Whether to offer a second redo procedure to maintain intestinal continuity remains a controversial decision.

OBJECTIVE

To report our institutional experience of second redo ileal pouch anal anastomosis procedures.

DESIGN

This was a retrospective review. Patient-reported outcomes were compared between patients undergoing second redos with those of patients undergoing first redos using propensity score matching to balance the 2 cohorts.

SETTINGS

Tertiary referral center.

PATIENTS

Patients who underwent second redo ileal pouch anal anastomosis procedures between 2004 and 2021.

INTERVENTIONS

Second redo ileal pouch anal anastomosis.

MAIN OUTCOME MEASURES

Pouch survival, patient-reported outcomes measured using the Cleveland Global Quality of Life survey.

RESULTS

Twenty-three patients were included (65% female), 20 (87%) with an index diagnosis of ulcerative colitis and 3 (13%) with indeterminate colitis. Final diagnosis was changed to Crohn's disease in 8 (35%) cases. The indication for pouch salvage was the same for the first and second redo in 21 (91%) cases: 20 (87%) patients had both redo ileal pouch anal anastomoses for septic complications. After a median follow up of 39 months (interquartile range, 18.5 - 95.5), pouch failure occurred in 8 (30%) cases (7 cases due to sepsis, of which 3 never had their stoma closed, and 1 case due to poor function); all patients who experience pouch failure underwent the second redo due to septic complications. Overall pouch survival at 3 years was 76%: 62.5% in patients with final diagnosis of Crohn's disease, versus 82.5% in ulcerative/indeterminate colitis (p = 0.09). Overall quality of life score (0 -1) was 0.6 (0.5 - 0.8). Quality of life and functional outcomes were comparable between first and second redos, except incontinence, which was higher in second redos.

LIMITATIONS

Single center retrospective review.

CONCLUSIONS

A second pouch salvage procedure may be offered with acceptable outcomes to selected patients with high motivation to keep intestinal continuity. See Video Abstract.

Ventral mesh rectopexy for recurrent rectal prolapse after Altemeier perineal proctosigmoidectomy: feasibility and outcomes

PURPOSE

Recurrence of rectal prolapse following the Altemeier procedure is reported with rates up to 40%. The optimal surgical management of recurrences has limited data available. Ventral mesh rectopexy (VMR) is a favored procedure for primary rectal prolapse, but its role in managing recurrences after Altemeier is unclear. VMR for recurrent prolapse involves implanting the mesh on the colon, which has a thinner wall, more active peristalsis, no mesorectum, less peritoneum available for covering the mesh, and potential diverticula. These factors can affect mesh-related complications such as erosion, migration, or infection. This study assessed the feasibility and perioperative outcomes of VMR for recurrent rectal prolapse after the Altemeier procedure.

METHODS

We queried our prospectively maintained database between 01/01/2008 and 06/30/2022 for patients who had experienced a recurrence of full-thickness rectal prolapse following Altemeier's perineal proctosigmoidectomy and subsequently underwent ventral mesh rectopexy.

RESULTS

Ten women with a median age of 67 years (range 61) and a median BMI of 27.8 kg/m2 (range 9) were included. Five (50%) had only one Altemeier, and five (50%) had multiple rectal prolapse surgeries, including Altemeier before VMR. No mesh-related complications occurred during a 65-month (range 165) median follow-up period. Three patients (30%) experienced minor postoperative complications unrelated to the mesh. Long-term complications were chronic abdominal pain and incisional hernia in one patient, respectively. One out of five (20%) patients with only one previous prolapse repair had a recurrence, while all patients (100%) with multiple prior repairs recurred.

CONCLUSION

Mesh implantation on the colon is possible without adverse reactions. However, high recurrence rates in patients with multiple previous surgeries raise doubts about using VMR for secondary or tertiary recurrences.

The mode of delivery does not influence the occurrence of post-partum perianal disease flares in patients with inflammatory bowel disease

INTRODUCTION

Perianal disease occurs in up to 34% of inflammatory bowel disease (IBD) patients. An estimated 25% of women will become pregnant after the initial diagnosis, thus introducing the dilemma of whether mode of delivery affects perianal disease. The aim of our study was to analyze whether a cesarean section (C-section) or vaginal delivery influence perianal involvement. We hypothesized the delivery route would not alter post-partum perianal manifestations in the setting of previously healed perianal disease.

METHODS

All consecutive eligible IBD female patients between 1997 and 2022 who delivered were included. Prior perianal involvement, perianal flare after delivery and delivery method were noted.

RESULTS

We identified 190 patients with IBD who had a total of 322 deliveries; 169 (52%) were vaginal and 153 (48%) were by C-section. Nineteen women (10%) experienced 21/322 (6%) post-partum perianal flares. Independent predictors were previous abdominal surgery for IBD (OR, 2.7; 95% CI, 1-7.2; p = 0.042), ileocolonic involvement (OR, 3.3; 95% CI, 1.1-9.4; p = 0.030), previous perianal disease (OR, 22; 95% CI, 7-69; p < 0.001), active perianal disease (OR, 96; 95% CI, 21-446; p < 0.001) and biologic (OR, 4.4; 95% CI,1.4-13.6; p < 0.011) or antibiotic (OR, 19.6; 95% CI, 7-54; p < 0.001) treatment. Negative association was found for vaginal delivery (OR, 0.19; 95% CI, 0.06-0.61; p < 0.005). Number of post-partum flares was higher in the C-section group [17 (11%) vs. 4 (2%), p = 0.002].

CONCLUSIONS

Delivery by C-section section was not protective of ongoing perianal disease activity post-delivery, but should be recommended for women with active perianal involvement.

Epidemiology and age-related trends in surgical outcomes for sigmoid volvulus: a 17-year analysis

BACKGROUND

Sigmoid volvulus, a gastrointestinal disorder characterized by twisted bowel, often requires medical intervention, either through endoscopic or surgical means, to avoid potentially severe outcomes. This study examined the challenges elderly patients face in undergoing surgical treatment, encompassing both mortality and morbidity. Furthermore, it aimed to determine how medical practices and outcomes have changed over a period of 17 years.

METHODS

We utilized data from the National Surgical Quality Improvement Project, which covers the period from 2005 to 2021, to identify patients who underwent left hemicolectomy for colonic volvulus. The patients were categorized into three age groups: < 60 years, 60-75 years, and > 75 years. We performed a meticulous logistic regression analysis, carefully adjusted for risk factors, to compare mortality, morbidity, and types of surgical treatment administered among the different age groups.

RESULTS

Our study included 6775 patients. The breakdown of the patient population was as follows: 2067 patients were < 60 years of age, 2239 were between 60 and 75 years of age, and 2469 were > 75 years of age. The elderly cohort, those aged above 75 years, were predominantly male, had lower BMIs, underwent fewer laparoscopic surgeries, required more diverting stomas and end-ostomies, and had longer hospital stays. Notably, the elderly population faced a mortality risk that was 5.67 times (95% CI 3.64, 9.20) greater than that of their youngest counterparts, with this risk increasing by 10% (95% CI 1.06, 1.14) for each additional year of age. Furthermore, the odds of mortality associated with emergency surgery were 1.63 times (95% CI 1.21, 2.22) higher than those associated with elective surgery. The postoperative morbidity odds were also elevated for emergency surgeries, 1.30 times (95% CI 1.08, 1.58) greater than that for elective cases. Over the 17-year period, we observed a decline in mortality rates, an increase in the utilization of laparoscopic procedures, and overall stability of morbidity rates.

CONCLUSION

Our findings highlight the increased vulnerability of patients over 75 years of age, who are not only at an elevated risk of mortality compared to their younger counterparts, but also a continuously increasing risk with age. By focusing on elective surgeries for younger patients and minimizing emergency surgeries for the elderly, it may be possible to reduce the mortality risk associated with surgical interventions in this population.

Salvage Surgery: An Effective Therapy in the Management of Ileoanal Pouch Prolapse

BACKGROUND

Restorative proctocolectomy with IPAA is the surgical treatment of choice for patients requiring surgery for IBD and, less frequently, for other pathologies. Pouch prolapse is a rare complication that compromises pouch function and negatively affects patients' quality of life.

OBJECTIVE

This study aimed to describe our experience from a single high-volume center in this infrequent condition.

DESIGN

Restrospective cohort study of a prospectively maintained, Institutional Review Board-approved database.

SETTINGS

All consecutive eligible patients with IPAA and pouch prolapse were identified from 1990 to 2021.

PATIENTS

Patients with full-thickness prolapse treated by pouch pexy were included.

INTERVENTIONS

Pouch pexy (with/without mesh).

MAIN OUTCOME MEASURES

Success rate of pouch pexy, defined as no recurrence of prolapse.

RESULTS

A total of 4791 patients underwent IPAA; 7 (0.1%) were diagnosed with full-thickness prolapse. An additional 18 patients who underwent IPAA and had full-thickness prolapse were referred from outside institutions. Among 25 included patients, 16 (64.0%) were women, and the overall mean age was 35.6 ± 13.4 years. The time interval from initial pouch formation to prolapse was 4.2 (interquartile range, 1.1-8.5) years. Nine patients (36.0%) underwent previous treatment for prolapse. All patients presented with symptoms and physical examination compatible with full-thickness prolapse. Twenty patients (80.0%) underwent surgical pouch pexy without mesh and 5 (20.0%) had pouch pexy with mesh placement. A diverting ileostomy was performed in 1 patient (4.0%) before pouch pexy and in 8 patients (32.0%) at the time of surgical prolapse correction. After surgery, recurrent prolapse was noted in 3 patients (12.0%) at a median of 6.9 (interquartile range, 5.2-8.3) months.

LIMITATIONS

Retrospective study, small sample size thus prone to selection, and referral biases, which may limit the generalizability of our findings.

CONCLUSION

Pouch prolapse can be effectively treated with salvage surgery. Surgical intervention is safe and provides acceptable outcomes. See Video Abstract.

CIRUGA DE RESCATE UNA TERAPIA EFICAZ EN EL MANEJO DEL PROLAPSO DE LA BOLSA ILEOANAL

ANTECEDENTES:La proctocolectomía restauradora con anastomosis reservorio ileoanal es el tratamiento quirúrgico de elección para aquellos pacientes que requieren cirugía por enfermedad inflamatoria intestinal y, con menor frecuencia, por otras patologías. El prolapso de la bolsa es una complicación rara que compromete la función de la bolsa y afecta de manera negativa la calidad de vida de los pacientes.OBJETIVO:Describir nuestra experiencia de un solo centro de alto volumen en esta condición poco frecuente.DISEÑO:Estudio de cohorte retrospectivo de una base de datos mantenida prospectivamente aprobada por el IRB.AJUSTES/PACIENTES:Fueron identificados y elegibles de manera consecutiva todos los pacientes con anastomosis de bolsa ileoanal y prolapso de bolsa entre 1990 y 2021. Se incluyeron pacientes con prolapso de bolsa de espesor total tratados con pexia.INTERVENCIONES:Pexia de la bolsa (con/sin malla).PRINCIPALES MEDIDAS DE RESULTADO:Tasa de éxito de la pexia de la bolsa, definida como ausencia de recurrencia del prolapso.RESULTADOS:Un total de 4.791 pacientes fueron sometidos a anastomosis de bolsa ileoanal; siete (0,1%) fueron diagnosticados con prolapso de espesor total. Otros 18 pacientes con anastomosis de reservorio ileoanal fueron derivados de instituciones externas. De entre los 25 pacientes incluidos, 16 (64,0 %) eran mujeres y la edad media promedio fue de 35,6+/-13,4 años. El intervalo de tiempo desde la creación inicial de la bolsa hasta el prolapso fue de 4,2 (IQR 1,1-8,5) años. Nueve (36,0 %) pacientes fueron sometidos a tratamiento previo para el prolapso (fisioterapia n = 4, pexia de la bolsa n = 2, pexia de la bolsa con malla n = 2, resección de la mucosa n = 1). Todos los pacientes presentaron síntomas y exploración física compatibles con prolapso de espesor total. Veinte (80,0%) pacientes se sometieron a pexia de bolsa quirúrgica sin malla y cinco (20,0%) se sometieron a pexia de bolsa con colocación de malla. Se realizó una ileostomía de derivación en un (4,0%) paciente antes de la pexia de la bolsa y en ocho (32,0%) pacientes en el momento de la corrección quirúrgica del prolapso. Posterior a la cirugía, se observó prolapso recurrente en tres pacientes (12,0 %) con una mediana de 6,9 (IQR 5,2-8,3) meses.LIMITACIONES:Estudio retrospectivo, pequeño tamaño de muestra, por lo tanto, propenso a sesgos de selección y referencia que pueden limitar la generalización de nuestros hallazgos.CONCLUSIÓN:El prolapso de la bolsa ileoanal puede tratarse de manera efectiva mediante la cirugía de rescate. La intervención quirúrgica es segura y proporciona resultados aceptables. (Traducción-Dr. Mauricio Santamaria ).

Assessing prognostic factors of long-term survival after surgery for colorectal gastrointestinal stromal tumours

AIM

Due to their rarity, the management of colorectal gastrointestinal stromal tumours (CR GISTs) is still under debate. The aim of this study was to assess prognostic factors.

METHOD

We performed a retrospective review of patients who underwent surgery with curative intent for CR GIST at our centre from 2002 to 2019. Factors associated with overall (OS) and recurrence-free survival (RFS) were analysed.

RESULTS

Fifty-six patients were included [median age 63 years, 29 (52%) female, 30 (54%) Miettinen high-risk, 40 (71%) with rectal GIST]. Nineteen (34%) patients received perioperative (neoadjuvant and/or adjuvant) imatinib. All cases of colonic GIST had an R0 resection, compared with 28 (70%) of rectal GISTs. After a median follow-up of 97 months (interquartile range 48-155 months), 14 (25%) deaths and 14 (25%) recurrences occurred. In the high-risk cohort, factors associated with improved RFS were R0 resection (OR 0.19, 95% CI 0.1-0.5, p = 0.002) and perioperative imatinib (OR 0.33, 95% CI 0.42-0.97, p = 0.04). Patients who had received perioperative imatinib had longer RFS (60% vs. 11% at 5 years, p = 0.006) but not OS. In rectal GISTs, 5-year OS was 85% for R0 and 70% for R1 resections (p = 0.164) and 5-year RFS was 85% for R0 and 12% for R1 resection (p < 0.001). When stratifying patients by perioperative imatinib, there were no differences in OS or RFS in the R0 or R1 groups.

CONCLUSION

Perioperative imatinib and R0 resection were associated with improved RFS in high-risk patients with CR GIST. In patients with rectal GIST, R1 resection was associated with worse RFS irrespective of perioperative imatinib treatment.

Surgical Options for the Treatment of Perianal and Anovaginal Fistulas in the Setting of Ileoanal Pouch Crohn's Disease: Experience of a Tertiary Center

BACKGROUND

The leading cause of pouch failure following ileal pouch-anal anastomosis are peri-pouch fistulas and pelvic sepsis.

OBJECTIVE

Determine the overall efficacy of current surgical therapy for the treatment of perianal and anovaginal fistulizing disease related to Crohn's disease phenotype of the pouch.

DESIGN

Retrospective cohort study of a prospectively maintained, IRB-approved database.

SETTINGS/PATIENTS

Ninety-one (2.3%) patients of 3058 patients with an original diagnosis of ulcerative colitis who underwent proctocolectomy with ileal pouch-anal anastomosis between 2000 and 2021 at the Cleveland Clinic and underwent postoperative surgery for Crohn's-related perianal disease.

INTERVENTIONS

Two hundred thirty-one operations for perianal or anovaginal fistula(s).

MAIN OUTCOME AND MEASURES

Healing rate of surgical therapy for peri-pouch fistulizing disease, impact of recurrent interventions on outcomes, and predictors of surgical failure.

RESULTS

Overall mean age was 39.1 (± 11.6) years, with a BMI of 25.3 (± 6.3) kg/m2. More than half of the patients were female (n = 52, 57.1%). Sixty-three patients (69.2%) had a perianal fistula, 25 (27.5%) had an anovaginal fistula, and 3 (3.3%) patients had both. Overall success rate for healing was 59.3% (n = 54/91) at a mean follow-up of 6.4 (± 4.8) years. Seventeen (18.7%) patients underwent a concomitant diverting loop ileostomy. Among them, eight (47.0%) patients had the ileostomy closure after a mean time of 9.7 (± 2.8) months. In the multivariable logistic regression model, patients who had seton insertions in any operation were significantly less likely to heal (OR 0.11 95%, CI 0.03-0.43, p = 0.001). Overall pouch failure rate was 12.1%.

LIMITATIONS

Retrospective single-center study which lacks a control arm and consistent long-term follow-up specific to a population-based dataset.

CONCLUSIONS

Pouch patients who develop perianal disease are difficult to treat, sometimes requiring pouch excision. However, when medical treatment alone is not effective, a multidisciplinary approach including surgical intervention can result in complete fistula healing in more than half of the cases.

Turnbull-Cutait Pull-Through Procedure Is an Alternative to Permanent Ostomy in Patients With Complex Pelvic Fistulas

BACKGROUND

A permanent stoma is frequently recommended in the setting of complex or recurrent rectovaginal fistulas because of the high failure rate of reconstructive procedures. The Turnbull-Cutait pull-through procedure is a salvage operation for motivated patients desiring to avoid permanent fecal diversion.

OBJECTIVE

To analyze the cure rates of complex rectovaginal fistulas after the Turnbull-Cutait pull-through procedure based on cause.

DESIGN

After the institutional review approval board, a retrospective review of women who underwent the procedure (1993-2018) for a rectovaginal fistula was conducted. Patients' demographics, cause, and postoperative outcomes were analyzed.

SETTING

Colorectal surgery department at a tertiary center in the United States.

PATIENTS

Adult women with a rectovaginal fistula who underwent a colonic pull-through procedure were included.

MAIN OUTCOME MEASURES

Recurrence after the colonic pull-through procedure.

RESULTS

There were 81 patients who underwent colonic pull-through; of those, 26 patients had a rectovaginal fistula, had a median age of 51 (43-57) years, and had a mean BMI of 28 ± 3.2 kg/m 2 . A total of 4 patients (15%) had a recurrence and 85% of the patients healed. Ninety-three percent of the patients healed after the prior anastomotic leak. Patients with a Crohn's disease-related fistula had a 75% cure rate. The Kaplan-Meier analysis showed a cumulative incidence of recurrence of 8% (95% CI, 0%-8%) within 6 months after surgery and 12% at 12 months.

LIMITATIONS

Retrospective design.

CONCLUSIONS

The Turnbull-Cutait pull-through procedure may be the last option to preserve intestinal continuity and successfully treat rectovaginal fistulas in 85% of cases.

EL PROCEDIMIENTO PULLTHROUGH DE TURNBULLCUTAIT ES UNA ALTERNATIVA A LA OSTOMA PERMANENTE EN PACIENTES CON FSTULAS PLVICAS COMPLEJAS

ANTECEDENTES:Con frecuencia se recomienda un estoma permanente en el contexto de una fístula rectovaginal compleja o recurrente debido a la alta tasa de fracaso de los procedimientos reconstructivos. El procedimiento de extracción de Turnbull-Cutait es una operación de rescate para pacientes motivados que desean evitar la desviación fecal permanente.OBJETIVO:Analizar las tasas de curación de la fístula rectovaginal compleja después del procedimiento de extracción de Turnbull-Cutait según la etiología.DISEÑO:Después de la junta de aprobación de revisión institucional, se realizó una revisión retrospectiva de mujeres que se sometieron a un procedimiento (1993-2018) por fístula rectovaginal. Se analizaron los datos demográficos, la etiología y los resultados posoperatorios de los pacientes.AJUSTE:Departamento de cirugía colorrectal en un centro terciario en los Estados Unidos.PACIENTES:Mujeres adultas con fístula rectovaginal que se sometieron a extracción del colon.RESULTADO PRINCIPAL:recurrencia después de la extracción del colon.RESULTADOS:Hubo 81 pacientes que tenían extracción colónica, de esas 26 fístulas rectovaginales con una mediana de edad de 51 (43 - 57) años, y un índice de masa corporal promedio de 28 ± 3,2 kg/m2. Un total de 4 (15%) pacientes tuvieron una recurrencia y el 85% de los pacientes se curaron. El noventa y tres por ciento de los pacientes se curaron después de la fuga anastomótica previa. Los pacientes con fístula relacionada con EC tuvieron una tasa de curación del 75%. El análisis de Kaplan Meier mostró una incidencia acumulada de recurrencia del 8% [95% intervalo de confianza 0%-18%] dentro de los 6 meses posteriores a la cirugía y del 12% a los 12 meses.LIMITACIONES:Diseño retrospectivo.CONCLUSIONES:El procedimiento de extracción de Turnbull-Cutait puede ser la última opción que se puede ofrecer para preservar la continuidad intestinal y tratar la fístula rectovaginal con éxito en el 85% de los casos. (Traducción-Yesenia.Rojas-Khalil).

Ileal Pouch-anal Anastomosis in Primary Sclerosing Cholangitis-inflammatory Bowel Disease (PSC-IBD): Long-term Pouch and Liver Transplant Outcomes

OBJECTIVE

To compare the effect of liver transplantation (LT) on ileal pouch-anal anastomosis (IPAA) outcomes in patients with primary sclerosing cholangitis and inflammatory bowel disease (PSC-IBD).

BACKGROUND

Patients with PSC-IBD may require both IPAA for colitis and LT for PSC.

METHODS

Patients with PSC-IBD from out institutional pouch registry (1985-2022) were divided according to LT status and timing of LT (before and after IPAA) and their outcomes analyzed.

RESULTS

A total of 160 patients were included: 112 (70%) nontransplanted at last follow-up; 48 (30%) transplanted, of which 23 (14%) before IPAA and 25 (16%) after. Nontransplanted patients at IPAA had more laparoscopic procedures [37 (46%) vs 8 (18%), P =0.002] and less blood loss (median 250 vs 400 mL, P =0.006). Morbidity and mortality at 90 days were similar. Chronic pouchitis was higher in transplanted compared with nontransplanted patients [32 (67%) vs 51 (45.5%), P =0.03], but nontransplanted patients had a higher rate of chronic antibiotic refractory pouchitis. Overall survival was similar, but nontransplanted patients had more PSC-related deaths (12.5% vs 2%, P =0.002). Pouch survival at 10 years was 90% for nontransplanted patients and 100% for transplanted patients (log-rank P =0.052). Timing of LT had no impact on chronic pouchitis, pouch failure, or overall survival. PSC recurrence was 6% at 10 years. For transplanted patients, graft survival was similar regardless of IPAA timing.

CONCLUSIONS

In patients with PSC-IBD and IPAA, LT is linked to an increased pouchitis rate but does not affect overall and pouch survival. Timing of LT does not influence short-term and long-term pouch outcomes.

Defining the safety of early ileostomy closure after ileal pouch anal anastomosis

PURPOSE

The safety of early ileostomy reversal after ileal pouch anal anastomosis (IPAA) has not been established. Our hypothesis was that ileostomy reversal before 8 weeks is associated with negative outcomes.

METHODS

This was a retrospective cohort study from a prospectively maintained institutional database. Patients who underwent primary IPAA with ileostomy reversal between 2000 and 2021 from a Pouch Registry were stratified on the basis of timing of reversal. Those reversed before 8 weeks (early) and those reversed from 8 weeks to 116 days (routine) were compared. The primary outcome was overall complications according to timing and reason for closure.

RESULTS

Ileostomy reversal was performed early in 92 patients and routinely in 1908. Median time to closure was 49 days in the early group and 93 days in the routine group. Reasons for early reversal were stoma-related morbidity in 43.3% (n = 39) and scheduled closure in 56.7% (n = 51). The complication rate in the early group was 17.4% versus 11% in the routine group (p = 0.085). When early patients were stratified according to reason for reversal, those reversed early for stoma-related morbidity had an increased complication rate compared to the routine group (25.6% vs. 11%, p = 0.006). Patients undergoing scheduled reversal in the early group did not have increased complications (11.8% vs. 11%, p = 0.9). There was a higher likelihood of pouch anastomotic leak when reversal was performed early for stoma complications compared to routinely (OR 5.13, 95% CI 1.01-16.57, p = 0.049).

CONCLUSIONS

Early closure is safe but could be delayed in stoma morbidity as patients may experience increased complications.

Incidental Dysplasia During Total Proctocolectomy With Ileoanal Pouch: Is It Associated With Worse Outcomes?

BACKGROUND

Patients with inflammatory bowel disease (IBD) are at increased risk of colorectal cancer. In cases of invisible or nonendoscopically resectable dysplasia found at colonoscopy, total proctocolectomy with ileal pouch anal anastomosis can be offered with good long-term outcomes; however, little is known regarding cancer-related outcomes when dysplasia is found incidentally after surgery on final pathology.

METHODS

Using our prospectively collected pouch registry, we identified patients who had preoperative colonic dysplasia or dysplasia found only after colectomy. Patients with cancer preoperatively or after colectomy were excluded. Included patients were divided into 3 groups: PRE (+preoperative biopsy, negative final pathology), BOTH (+preoperative biopsy and final pathology), and POST (negative preoperative biopsy, +final pathology). Long-term outcomes in the 3 groups were assessed.

RESULTS

In total, 517 patients were included: PRE = 125, BOTH = 254, POST = 137. After a median follow-up of 12 years (IQR 3-21), there were no differences in overall, disease-free, or pouch survival between groups. Cancer/dysplasia developed in 11 patients: 3 (2%) in the PRE, 5 (2%) in the BOTH, and 3 (2%) in the POST group. Only 1 cancer-related death occurred in the entire cohort (PRE group). Disease-free survival at 10 years was 98% for all groups (P = .97). Pouch survival at 10 years was 96% for PRE, 99% for BOTH, and 97% for POST (P = .24).

CONCLUSIONS

The incidental finding of dysplasia on final pathology after proctocolectomy was not associated with worsened outcomes compared with preoperatively diagnosed dysplasia.

Stricturing Crohn's Disease Single-Cell RNA Sequencing Reveals Fibroblast Heterogeneity and Intercellular Interactions

BACKGROUND & AIMS

Fibroblasts play a key role in stricture formation in Crohn's disease (CD) but understanding its pathogenesis requires a systems-level investigation to uncover new treatment targets. We studied full-thickness CD tissues to characterize fibroblast heterogeneity and function by generating the first single-cell RNA sequencing (scRNAseq) atlas of strictured bowel and providing proof of principle for therapeutic target validation.

METHODS

We performed scRNAseq of 13 fresh full-thickness CD resections containing noninvolved, inflamed nonstrictured, and strictured segments as well as 7 normal non-CD bowel segments. Each segment was separated into mucosa/submucosa or muscularis propria and analyzed separately for a total of 99 tissue samples and 409,001 cells. We validated cadherin-11 (CDH11) as a potential therapeutic target by using whole tissues, isolated intestinal cells, NanoString nCounter, next-generation sequencing, proteomics, and animal models.

RESULTS

Our integrated dataset revealed fibroblast heterogeneity in strictured CD with the majority of stricture-selective changes detected in the mucosa/submucosa, but not the muscle layer. Cell-cell interaction modeling revealed CXCL14+ as well as MMP/WNT5A+ fibroblasts displaying a central signaling role in CD strictures. CDH11, a fibroblast cell-cell adhesion molecule, was broadly expressed and up-regulated, and its profibrotic function was validated using NanoString nCounter, RNA sequencing, tissue target expression, in vitro gain- and loss-of-function experiments, proteomics, and knock-out and antibody-mediated CDH11 blockade in experimental colitis.

CONCLUSIONS

A full-thickness bowel scRNAseq atlas revealed previously unrecognized fibroblast heterogeneity and interactions in CD strictures and CDH11 was validated as a potential therapeutic target. These results provide a new resource for a better understanding of CD stricture formation and open potential therapeutic developments. This work has been posted as a preprint on Biorxiv under doi: 10.1101/2023.04.03.534781.

The Learning Curve for Advanced Endoscopy for Colorectal Lesions: A Surgeon's Experience at a High-Volume Center

BACKGROUND

Advanced endoscopy can be used for the complete removal of large colorectal polyps. To date, few surgeons perform advanced endoscopy, and it is unknown how many procedures are needed to reach proficiency.

OBJECTIVE

This study aimed to determine the learning curve for colorectal advanced endoscopy.

DESIGN

Retrospective.

SETTING

Tertiary referral center.

PATIENTS

We queried a prospectively maintained institutional database of advanced endoscopy performed by a high-volume colorectal surgeon between 2011 and 2018.

MAIN OUTCOME MEASURES

Advanced endoscopy characteristics were compared for 6 chronological intervals. Primary end points were the rates of complications and polyp recurrence. Secondary end point was the change in polyp removal rate (mm/h) over time.

RESULTS

A total of 207 patients underwent advanced endoscopy for a single colorectal polyp. The median polyp size was 30 (4-70) mm, 61.5% were located in the right colon, and 8.8% were malignant. The mean procedure time was 77 (range, 16-320) minutes. Immediate colon resection occurred in 25 patients because of suspicion of cancer or concern for perforation and was excluded from the learning curve analysis. The remaining 182 advanced endoscopy procedures were divided into intervals of 30 procedures. The median removal rate was highest in the last interval and in the endoscopy suite. A removal rate of 30 mm/h was achieved after performing 100 cases. The complication rate (bleeding or return to operating room) was 12.1% and was similar across intervals. The readmission rate was 11.5%, and 6.6% of 6-month follow-up colonoscopies showed polyp recurrence at the resection site.

LIMITATIONS

Retrospective design and single surgeon.

CONCLUSION

The learning curve for achieving proficiency with advanced endoscopy in the colon and rectum required a minimum of 100 cases with a low complication rate, low polyp recurrence rate, high en bloc resection rate, and a polyp removal rate of 30 mm/h. See Video Abstract at http://links.lww.com/DCR/C162 .LA CURVA DE APRENDIZAJE DE LA ENDOSCOPIA AVANZADA PARA LESIONES COLORRECTALES: LA EXPERIENCIA DE UN CIRUJANO EN UN CENTRO DE ALTO VOLUMENANTECEDENTES:La endoscopia avanzada se puede utilizar para la extirpación completa de pólipos colorrectales grandes. Hasta la fecha, pocos cirujanos realizan endoscopia avanzada y se desconoce cuántos procedimientos se necesitan para alcanzar la competencia.OBJETIVO:Determinar la curva de aprendizaje de la endoscopia colorrectal avanzada.DISEÑO:Retrospectivo.AJUSTE:Centro de referencia terciario.PACIENTES:Consultamos una base de datos institucional mantenida prospectivamente de endoscopia avanzada realizada por un cirujano colorrectal de alto volumen entre 2011 y 2018.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon las características de la endoscopia avanzada en seis intervalos cronológicos. Los puntos finales primarios fueron las tasas de complicaciones y recurrencia de pólipos. El criterio de valoración secundario fue el cambio en la tasa de eliminación de pólipos (mm/h) a lo largo del tiempo.RESULTADOS:Un total de 207 pacientes se sometieron a una endoscopia avanzada por un solo pólipo colorrectal. La mediana del tamaño de los pólipos fue de 30 (4-70) mm, el 61,5% se ubicaron en el colon derecho y el 8,8% fueron malignos. El tiempo medio del procedimiento fue de 77 (rango: 16-320) minutos. La resección inmediata del colon ocurrió en 25 pacientes debido a la sospecha de cáncer o preocupación por la perforación y fueron excluidos del análisis de la curva de aprendizaje. Los restantes 182 procedimientos de endoscopia avanzada se dividieron en intervalos de 30 procedimientos. La mediana de la tasa de extirpación fue más alta en el último intervalo y en la sala de endoscopia. Se logró una tasa de extirpación de 30 mm/hr después de realizar 100 casos. La tasa de complicaciones (sangrado o retorno al quirófano) fue del 12,1% y fue similar en todos los intervalos. La tasa de reingreso fue del 11,5% y el 6,6% de las colonoscopias de seguimiento a los 6 meses mostraron recurrencia de pólipos en el sitio de la resección.LIMITACIONES:Diseño retrospectivo, cirujano único.CONCLUSIÓN:La curva de aprendizaje para lograr el dominio de la endoscopia avanzada en el colon y el recto requiere un mínimo de 100 casos con una baja tasa de complicaciones, baja tasa de recurrencia de pólipos, alta tasa de resección en bloque y una tasa de eliminación de pólipos de 30 mm/h. Consulte el Video Resumen en http://links.lww.com/DCR/C162 . (Traducción-Dr. Yesenia.Rojas-Khalil ).

Neoadjuvant Immune Checkpoint Inhibition Improves Organ Preservation in T4bM0 Colorectal Cancer With Mismatch Repair Deficiency: A Retrospective Observational Study

BACKGROUND

Colorectal cancer with mismatch repair deficiency is usually less aggressive and associated with a lower risk of distant metastasis. Immune checkpoint inhibition, rather than traditional chemoradiotherapy, has shown great advantages in treating such patients.

OBJECTIVE

This study aimed to verify the hypothesis that locally very advanced (T4b) colorectal cancer without distant metastases might present with higher probability of mismatch repair deficiency and be more sensitive to neoadjuvant immune checkpoint inhibition.

DESIGN

This study was designed as a single-center retrospective observational study.

SETTINGS

The study was conducted in a tertiary referral center in China.

PATIENTS

The study included patients who were clinically diagnosed with T4bM0 colorectal cancer from 2008 to 2019.

MAIN OUTCOME MEASURES

Clinicopathological characteristics, mismatch repair status, and survival outcomes of patients with mismatch repair deficiency were analyzed.

RESULTS

A total of 268 patients were included. The incidence of patients with mismatch repair deficiency in the T4bM0 population was 27.6% (75/268), with 84.0% (63/75) in the colon and 16.0% (12/75) in the rectum. For tumors located in the proximal colon, 45.0% (50/111) exhibited mismatch repair deficiency, whereas the incidence of mismatch repair deficiency in sigmoid colon cancer and rectal cancer was only 15.9% (25/157). Neoadjuvant immune checkpoint inhibition significantly reduced the open surgery rate ( p = 0.000) and multivisceral resection rate ( p = 0.025). The pathological complete remission rate in the neoadjuvant immune checkpoint inhibition group was significantly higher than that in neoadjuvant chemoradiotherapy/chemotherapy group (70.0% vs 0%; p = 0.004). No tumor downstaging was observed after neoadjuvant chemotherapy. Neoadjuvant immune checkpoint inhibition provided significantly better disease-free survival ( p = 0.0078) and relatively longer overall survival ( p = 0.15) than other groups.

LIMITATIONS

This study is limited by the possible selection bias and small sample size.

CONCLUSIONS

Our data depicted the high incidence of mismatch repair deficiency in T4bM0 mismatch repair deficiency and the effectiveness of the neoadjuvant immune checkpoint inhibition group in organ preservation. Precision oncology requires identification of the protein status of mismatch repair at initial diagnosis to make a rational treatment decision for these patients. See Video Abstract at http://links.lww.com/DCR/B952 .

LA INHIBICIN DEL PUNTO DE CONTROL INMUNITARIO NEOADYUVANTE MEJORA LA PRESERVACIN DE RGANOS EN EL CNCER COLORRECTAL TBM CON DEFICIENCIA DE REPARACIN DE ERRORES DE COINCIDENCIA UN ESTUDIO OBSERVACIONAL RETROSPECTIVO

ANTECEDENTES:Los pacientes con cáncer colorrectal con deficiencia en la reparación de desajustes suelen (dMMR) ser menos agresivos y se asocian con un menor riesgo de metástasis a distancia. La inhibición del punto de control inmunitario, en lugar de la quimiorradioterapia tradicional, ha mostrado grandes ventajas en el tratamiento de estos pacientes.OBJETIVO:Este estudio tuvo como objetivo verificar nuestra hipótesis de que el CCR localmente muy avanzado (T4b) sin metástasis a distancia podría presentarse con una mayor probabilidad de dMMR y ser más sensible a la inhibición del punto de control inmunitario neoadyuvante.DISEÑO:Este estudio fue diseñado como un estudio observacional retrospectivo de un solo centro.CONFIGURACIÓN:El estudio se realizó en un centro de referencia terciario en China.PACIENTES:Se incluyeron pacientes con diagnóstico clínico de CCR T4bM0 desde 2008 hasta 2019.PRINCIPALES MEDIDAS DE RESULTADO:Se analizaron las características clinicopatológicas, el estado de MMR y los resultados de supervivencia de los pacientes con dMMR.RESULTADOS:Se incluyeron un total de 268 pacientes. La incidencia de dMMR en la población T4bM0 fue del 27,6% (75/268), con un 84,0% (63/75) en colon y un 16,0% (12/75) en recto. Para los tumores ubicados en el colon proximal, el 45,0% (50/111) exhibió dMMR, mientras que la incidencia de dMMR en el cáncer de colon sigmoideo y el cáncer de recto fue solo del 15,9% (25/157). La inhibición del punto de control inmunitario neoadyuvante redujo significativamente la cirugía abierta y la tasa de resección multivisceral ( p = 0,000 y p = 0,025, respectivamente). La tasa de PCR en el grupo de inhibición del punto de control inmunitario neoadyuvante fue significativamente mayor que en el grupo de quimiorradioterapia/quimioterapia neoadyuvante (70,0% frente a 0%, p = 0,004). No se observó reducción del estadio del tumor después de la quimioterapia neoadyuvante. La inhibición del punto de control inmunitario neoadyuvante proporcionó una supervivencia sin enfermedad significativamente mejor ( p = 0,0078) y una supervivencia general relativamente más larga ( p = 0,15) que otros grupos.LIMITACIONES:Este estudio está limitado por el posible sesgo de selección y el pequeño tamaño de la muestra.CONCLUSIONES:Nuestros datos representan la alta incidencia de dMMR en T4bM0 CRC y la eficacia del grupo de inhibición del punto de control inmunitario neoadyuvante en la preservación de órganos. La oncología de precisión requiere la identificación del estado de la proteína MMR en el diagnóstico inicial para tomar una decisión de tratamiento racional para estos pacientes especiales. Consulte el Video Resumen en http://links.lww.com/DCR/B952 . (Traducción-Dr. Yesenia Rojas-Khalil ).

Clinical Outcomes of Patients with Brain Metastases from Colorectal Cancer Treated with Stereotactic Radiosurgery

PURPOSE/OBJECTIVE(S)

Prior studies have demonstrated that brain metastases from gastrointestinal (GI) primary cancers have a poorer response to stereotactic radiosurgery (SRS) when compared to patients with other primary sites, with reported local control of 62-74%. We report our institutional outcomes for patients with colorectal primary cancer who were treated with SRS for brain metastases.

MATERIALS/METHODS

Patients with colorectal primary cancer who underwent SRS for brain metastases between 1989 and 2021 were retrospectively reviewed from a single institutional IRB-approved database. The primary endpoint was local failure (LF) and secondary endpoint was overall survival (OS). LF was estimated using the Cumulative Incidence Function with death as a competing risk. Survival analysis was performed using the Kaplan-Meier Method. Predictors of cumulative incidence of LF were assessed using competing risk regression.

RESULTS

The study population comprised of 109 patients with primary colorectal adenocarcinoma with 207 brain metastases. The median follow-up was 5.2 months (range: 0.4-124 months) and median OS was 5.8 months (range: 0.5-71.2 months). Fifty-two patients (48%) were male and median Karnofsky Performance Status at the time of treatment was 80 (range: 40-100). The median tumor diameter was 1.55 cm (range: 0.17-5.48 cm). The median prescription dose and number of fractions were 24 Gy (range: 11-36 Gy) and 1 fraction (range: 1-3 fractions), respectively. The cumulative incidence of LF at 3, 6, and 12 months was 9.7% (95% CI: 6.1-14%), 22% (95% CI: 16-28%), and 25% (95% CI: 20-31%), respectively. Overall survival at 3, 6, and 12 months was 81% (95% CI: 76-87%), 49% (95% CI: 42-56%) and 24% (95% CI: 18-31%), respectively. On univariate analysis, age was a significant predictor (HR = 0.96, 95% CI: 0.94-0.98), p < 0.001) of LF. Tumor size (HR = 0.80, p = 0.13) and prescription dose (HR = 1.02, p = 0.54) did not predict for LF.

CONCLUSION

To our knowledge, this is the largest series of patients with brain metastases from colorectal primary cancer treated with SRS. Compared to historical data, LF and OS in our cohort of patients was favorable. Our data confirms relatively higher rates of LF when compared to brain metastases from other primary disease sites. Further studies are warranted to identify factors that predict for LF following SRS and to develop models that predict which patients with colorectal brain metastases may be at higher risk of failure.

Redo ileal pouch-anal anastomosis for early versus late sepsis-related pouch failure

BACKGROUND

Pouch failure after restorative proctocolectomy with ileal pouch-anal anastomosis occurs in 5% to 15% of cases, mostly due to septic complications. We aimed to determine if the timing of pouch failure impacted long-term outcomes for redo ileal pouch-anal anastomosis after sepsis-related complications.

METHOD

We retrospectively analyzed our prospectively collected institutional pouch database. Patients who underwent redo ileal pouch-anal anastomosis for septic complications between 1988 and 2020 were divided into an early (pouch failure within 6 months of stoma closure after index operation, or stoma never closed) and a late failure group (pouch failure after 6 months of stoma closure). The primary endpoint was pouch survival.

RESULTS

In total, 335 patients were included: 241 (72%) in the early and 94 (28%) in the late failure group. The most common indication for failure was an anastomotic leak in the early failure group (163, 68%) and fistula in the late failure group (59, 63%), P < .001. Pouch survival at 3, 5, and 10 years was 77%, 75%, and 72% for the early and 79%, 75%, and 68% for the late failure group (P = .94). The most common reason for redo pouch failure was fistula in both groups. Quality of life was similar in both groups. In multivariate analysis, the only factor associated with pouch failure was the final diagnosis of Crohn's disease.

CONCLUSION

Outcomes after redo ileal pouch-anal anastomosis were comparable between patients with early and late sepsis-related index pouch failure, with acceptable rates of long-term pouch survival and good quality of life.

Long-term Outcomes of Straight Ileoanal Anastomoses Converted to Ileal Pouch Anal Anastomoses

BACKGROUND

While ileal pouch anal anastomosis (IPAA) is the recommended way to restore intestinal continuity after total proctocolectomy, straight ileoanal anastomoses (SIAA) are still selectively performed, especially in the pediatric population. In case of SIAA failure, conversion to IPAA is possible, but reports on its outcomes are scarce.

METHODS

We retrospectively analyzed our prospectively collected database on pelvic pouches, and identified patients with a SIAA that was converted to IPAA. Our aim was long-term functional outcomes.

RESULTS

Twenty-three patients were included (14 females, median age at SIAA 15 years, median age at conversion to IPAA 19 years). The indication for SIAA was ulcerative colitis in 17 (74%) cases, indeterminate colitis in 2 (9%) cases, and familial adenomatous polyposis in 4 (17%) cases. The indication for IPAA conversion was incontinence/poor quality of life in 12 (52%) cases, sepsis in 8 (35%) cases, anastomotic stricture in 2 (9%) cases, and prolapse in one (4%) case. The majority were diverted at IPAA conversion (22, 96%). Three (13%) patients never had stoma closure, due to patient wishes, failed healing of vaginal fistula, and pelvic sepsis, respectively. After a median follow up of 109 months (28-170), pouch failure occurred in 5 additional patients. Overall pouch survival was 71% at 5 years. Median quality of life was 8/10, of health 8/10, and of energy 7/10. Median satisfaction with surgery was 9.5/10.

CONCLUSION

Conversion of SIAA to IPAA leads to acceptable long-term outcomes and good quality of life, and can safely be offered to patients with problems related to SIAA.

LEVEL OF EVIDENCE

IV.

Salvage surgery is an effective alternative for J-pouch afferent limb stricture treatment

BACKGROUND

Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice for patients requiring surgery for inflammatory bowel disease. A stricture located at the inlet of the afferent limb can lead to small bowel obstruction in a limited number of patients with a pelvic pouch. This paper aims to examine our experience with afferent limb stricture surgical correction when other endoscopic treatment methods have failed to control obstructive symptoms.

METHODS

All consecutive eligible patients with ileal pouch-anal anastomosis and afferent limb stricture were identified from our institutional review board-approved database from 1990 to 2021. Patients surgically treated with excision and reimplantation/strictureplasty of afferent limb stricture were included in this study.

RESULTS

Twenty patients met our inclusion criteria. Fifteen (75%) were female, and the overall mean age was 41 ± 10.3 years at afferent limb stricture surgery. The interval from ileal pouch-anal anastomosis formation to surgery for afferent limb stricture was 13.5 ± 6.7 years. Nine (45%) underwent strictureplasty, and 11 (55%) had resection and reimplantation of the afferent limb into the pouch. Before afferent limb stricture surgery, 3 (15%) required a diverting ileostomy for their obstructive symptoms. An additional 12 (60%) had a stoma constructed during afferent limb stricture surgery, and 5 had a strictureplasty and no stoma. Postoperatively, 1 patient (5%) had a leak at the afferent limb stricture repair site. All patients had their ileostomy closed 3.2 (2.99-3.6) months after surgery. Long-term after afferent limb stricture surgery, recurrent small bowel obstruction symptoms recurred in 7 (35%) patients 3.9 (2.6-5.8) years later.

CONCLUSION

Afferent limb stricture can be treated effectively with salvage surgery. The surgical intervention appears durable and provides an acceptable outcome for their obstructive symptoms.

Redo Ileocolic Resection Is Not an Independent Risk Factor for Anastomotic Leak in Recurrent Crohn's Disease

BACKGROUND

Redo ileocolic resection for recurrent Crohn's disease is associated with increased technical complexity and higher complication rates compared to primary resection. Literature concerning redo surgery for recurrent Crohn's disease is scarce and it is controversial whether a redo is a risk factor for postoperative anastomotic leak.

OBJECTIVE

This study aimed to hypothesized that redo ileocolic resection for Crohn's disease is an independent risk factor for anastomotic leak.

DESIGN

Retrospective, case-control study from 1994 to 2019 with multivariate analysis and propensity score weighting.

SETTING

Quaternary, IBD-referral center.

PATIENTS

Adult patients aged >18 years were included in the study.

INTERVENTIONS

Primary or redo ileocolic resection with an anastomosis, with or without diverting ileostomy.

MAIN OUTCOME MEASURES

Thirty-day anastomotic leak rate.

RESULTS

A total of 991 patients (56% primary and 44% redo ileocolic resections) were included. Patients who underwent redo resection were significantly older with more comorbidities, fewer medications, and less fistulizing disease compared to the primary group. On univariate analysis, patients who underwent redo resection had more overall complications (50.5% vs 36.2%, p < 0.001), and the cumulative number of prior ileocolic resections was significantly associated with increased risk for overall morbidity ( p < 0.001). There were 31 (3%) anastomotic leaks; leak rates did not differ between groups ( p = 0.60). Multivariable analysis indicated that extensive adhesiolysis ( p < 0.001), ileostomy omission ( p = 0.009), and intraoperative abscess/fistula ( p = 0.02) were independently associated with leaks but not redo resection ( p = 0.27). Patients with 0, 1, 2, or 3 of these risk factors had observed leak rates of 1.1%, 1.3%, 6.0%, and 11.6.% ( p = 0.03), respectively.

LIMITATIONS

The limitations of this study were selection bias, referral bias, and single quaternary center.

CONCLUSIONS

Compared to primary procedures, redo ileocolic resection for recurrent Crohn's disease is associated with increased overall morbidity but not anastomotic leak. See Video Abstract at http://links.lww.com/DCR/C132 .

LA RESECCIN ILEOCLICA REHECHA NO ES UN FACTOR DE RIESGO INDEPENDIENTE DE FUGA ANASTOMTICA EN LA ENFERMEDAD DE CROHN RECURRENTE

ANTECEDENTES:La resección ileocólica para la enfermedad de Crohn recurrente se asocia con una mayor complejidad técnica y mayores tasas de complicaciones en comparación con la resección primaria. La literatura sobre la reintervención quirúrgica para la enfermedad de Crohn recurrente es escasa y es controvertido si una redo es un factor de riesgo para la fuga anastomótica posoperatoria.OBJETIVO:Tenemos la hipótesis de que rehacer la resección ileocólica para la enfermedad de Crohn es un factor de riesgo independiente para la fuga anastomótica.DISEÑO:Estudio retrospectivo de casos y controles de 1994 a 2019 con análisis multivariado y ponderación de puntuación de propensión.AJUSTE:Centro de referencia de enfermedad inflamatoria intestinal de cuarto nivel.PACIENTES:Pacientes adultos >18 años.INTERVENCIONES:Resección ileocólica primaria o rehecha con una anastomosis, con o sin derivación de ileostomía.PRINCIPALES MEDIDAS DE RESULTADO:Tasa de fuga anastomótica a los 30 días.RESULTADOS:Se incluyeron un total de 991 pacientes (56% resecciones primarias y 44% resecciones ileocólicas rehechas). Los pacientes de reintervención eran significativamente mayores con más comorbilidades, menos medicamentos y menos enfermedad fistulizante en comparación con el grupo primario. En el análisis univariado, los pacientes reoperados tuvieron más complicaciones generales (50,5% frente a 36,2%, p < 0,001) y el número acumulado de resecciones ileocólicas previas se asoció significativamente con un mayor riesgo de morbilidad general ( p < 0,001). Hubo 31 (3%) fugas anastomóticas; las tasas de fuga no difirieron entre los grupos ( p = 0,6). El análisis multivariado indicó que la adhesiolisis extensa ( p < 0,001), la omisión de ileostomía ( p = 0,009) y el absceso/fístula intraoperatorios ( p = 0,02) se asociaron de forma independiente con fugas, pero no con nueva resección ( p = 0,27). Los pacientes con 0, 1, 2 o 3 de estos factores de riesgo observaron tasas de fuga del 1,1%, 1,3%, 6,0% y 11,6% ( p = 0,03), respectivamente.LIMITACIONES:Sesgo de selección, Sesgo de referencia, un centro de cuarto nivelCONCLUSIÓN:En comparación con los procedimientos primarios, la resección ileocólica para la enfermedad de Crohn recurrente se asocia con una mayor morbilidad general, pero no con una fuga anastomótica. Consulte Video Resumen en http://links.lww.com/DCR/C132 . (Traducción-Dr. Mauricio Santamaria ).

A Phase IB/IIA Study of Ex Vivo Expanded Allogeneic Bone Marrow-Derived Mesenchymal Stem Cells for the Treatment of Perianal Fistulizing Crohn's Disease

BACKGROUND

Mesenchymal stem cells have been used for the treatment of perianal Crohn's fistulizing disease by direct injection. However, no studies to date have included patients with proctitis, anal canal involvement, and multiple branching tracts.

OBJECTIVE

This study aimed to determine safety and efficacy of mesenchymal stem cells for refractory perianal Crohn's disease.

DESIGN

Phase IB/IIA randomized controlled trial.

SETTINGS

Tertiary IBD referral center.

PATIENTS

Adult Crohn's disease patients with perianal fistulizing disease.

INTERVENTION

Seventy-five million mesenchymal stem cells were administered with a 22-G needle by direct injection after curettage and primary closure of the fistula tract. A repeat injection of 75 million mesenchymal stem cells at 3 months was given if complete clinical and radiographic healing were not achieved.

MAIN OUTCOMES MEASURES

Adverse and serious adverse events occurred at postprocedure day 1, week 2, week 6, month 3, month 6, and month 12. Clinical healing, radiographic healing per MRI, and patient-reported outcomes were collected at the same time points.

RESULTS

A total of 23 patients were enrolled and treated; 18 were treatment patients and 5 were control. There were no adverse or serious adverse events reported related to mesenchymal stem cell therapy. At 6 months, 83% of the treatment group and 40% of the control group had complete clinical and radiographic healing. The perianal Crohn's disease activity index, Wexner incontinence score, and VanAssche score had all significantly decreased in treatment patients at 6 months; none significantly decreased in the control group.

LIMITATIONS

Single institution and single blinded.

CONCLUSIONS

Bone marrow-derived mesenchymal stem cells offer a safe and effective alternative treatment approach for severe perianal fistulizing Crohn's disease. See Video Abstract at http://links.lww.com/DCR/C128 .

UN ESTUDIO DE FASE IB/IIA DE CLULAS MADRE MESENQUIMALES DERIVADAS DE MDULA SEA ALOGNICA EXPANDIDA EX VIVO PARA EL TRATAMIENTO DE LA ENFERMEDAD DE CROHN FISTULIZANTE PERIANAL

ANTECEDENTES:Las células madre mesenquimales se han utilizado para el tratamiento de la enfermedad fistulizante de Crohn perianal mediante inyección dirigida. Sin embargo, ningún estudio hasta la fecha ha incluido pacientes con proctitis, afectación del canal anal y vías de ramificación múltiples.OBJETIVO:Determinar la seguridad y eficacia de las células madre mesenquimales para la enfermedad de Crohn perianal refractaria.DISEÑO:Ensayo de control aleatorizado de fase IB/IIA.AJUSTES:Centro de referencia de enfermedad inflamatoria intestinal terciaria.PACIENTES:Pacientes adultos con enfermedad de Crohn con enfermedad fistulizante perianal.INTERVENCIÓN:Se administraron 75 millones de células madre mesenquimales con una aguja 22G mediante inyección directa después del legrado y cierre primario del trayecto de la fístula. Se administró una inyección repetida de 75 millones de células madre mesenquimales a los 3 meses si no se lograba una curación clínica y radiográfica completa.PRINCIPALES MEDIDAS DE RESULTADOS:eventos adversos y adversos graves en el día 1, la semana 2, la semana 6, el mes 3, el mes 6 y el mes 12 después del procedimiento. Curación clínica, curación radiográfica por imagen de resonancia magnética y resultados informados por el paciente en los mismos puntos de tiempo.RESULTADOS:Un total de 23 pacientes fueron reclutados y tratados; 18 fueron de tratamiento y 5 de control. No se informaron eventos adversos o adversos graves relacionados con la terapia con células madre mesenquimales. A los seis meses, el 83 % del grupo de tratamiento y el 40 % del control tenían una curación clínica y radiográfica completa. El índice de actividad de la enfermedad de Crohn perianal, la puntuación de incontinencia de Wexner y la puntuación de VanAssche habían disminuido significativamente en los pacientes de tratamiento a los seis meses; ninguno disminuyó significativamente en el grupo de control.LIMITACIONES:Institución única y simple ciego.CONCLUSIONES:Las células madre mesenquimales derivadas de la médula ósea ofrecen un d tratamiento alternativo seguro y eficaz para la enfermedad de Crohn fistulizante perianal grave. Consulte Video Resumen en http://links.lww.com/DCR/C128 . (Traducción-Dr Yolanda Colorado ).

Word of caution: Rectal cancer without response to neoadjuvant treatment - Do not wait for surgery

BACKGROUND

We hypothesized that prolonging the interval to surgery in non-responders to neoadjuvant chemoradiation therapy (nCRT) could lead to worse oncologic outcomes.

METHODS

Rectal adenocarcinoma patients with poor tumor response to nCRT (AJCC tumor regression grade 3) were selected. Oncologic outcomes were evaluated according to the time interval between completion of nCRT and surgery.

RESULTS

Among 56 non-responders, 28 patients surgically treated ≥8 weeks after completion of nCRT had worse disease-free survival (31% vs. 49%, p ​= ​0.05) and worse overall survival (34% vs. 53%, p ​= ​0.02) compared to patients <8 weeks. Using the three different intervals (≥12 weeks, 6-12 weeks, and< 6 weeks), waiting longer was consistently associated with worse overall (23% vs. 48% vs. 63%, p ​= ​0.02) and worse cancer-specific survival (35% vs. 61% vs. 71%, p ​= ​0.04), respectively.

CONCLUSION

For rectal cancer patients who are non-responders to nCRT, delay of surgery may lead to worse oncologic outcomes.

Does the age of ulcerative colitis diagnosis impact outcomes of restorative proctocolectomy?

BACKGROUND

Ulcerative colitis (UC) can be diagnosed at a variety of different ages. We evaluated if age of ulcerative colitis (UC) diagnosis impacts outcomes of restorative proctocolectomy (RP) with ileal pouch-anal anastomosis (IPAA).

METHODS

A prospectively maintained pouch database (1983-2020) was queried to identify patients undergoing an RP for UC. The cohort was stratified based on bimodal disease presentation into 2 groups: the early adulthood group (19-30 years old) and the mid/late adulthood group (40-70 years old). Patients' demographics, postoperative complications, functional (stool number, seepage), and quality of life (QoL) rates were compared between the groups.

RESULTS

A total of 628 patients with an age range of 19-30 years old (18.1 ± 2.2 at the time of diagnosis, 24.2 ± 10.5 at the time of IPAA) and 706 patients with an age range of 40-70 years old (45 ± 3.0 at time of diagnosis, 52.3 ± 9.4 at time of IPAA) were identified. Older patients had longer disease duration, higher BMI, lower biologic use, and greater one-/two-staged IPAA, with 20% hand sewn anastomosis and 16.5% of S pouch configuration compared to younger ones. No difference was observed in anastomotic separation, pelvic sepsis, fistulas, or pouch failure in follow-up. Postoperatively, older patients more frequently developed bowel obstructions, strictures, and pouchitis, in addition to higher rates of seepage (p < 0.05). QoL was comparable between groups.

CONCLUSION

While IPAA retention rates are comparable between different age cohorts, older age at diagnosis and IPAA construction is associated with higher rates of pouchitis, bowel obstruction, anastomotic strictures, and worse functional outcome. Quality of life is similar in those who retain their ileal pouch on the long-term.

Prospective randomized comparison of three-dimensional (3D) versus conventional laparoscopy in total colectomy for ulcerative colitis

BACKGROUND

3D laparoscopy has been proposed with the aim of improving the depth perception and overall operative performance. To aim of this study is to compare 3D laparoscopy with conventional 2D laparoscopy in terms of operative time and visual parameters.

METHODS

This is a prospective, randomized, single-center trial designed to determine 10% reduction in the mean operative time. Ulcerative colitis patients >18 years of age who underwent laparoscopic total abdominal colectomy with end ileostomy between 2015 and 2020 were included. Patients were randomized into 3D and 2D laparoscopy groups. Duration of operation and surgeons' evaluation of the visualization system were the primary outcomes.

RESULTS

Fifty-three subjects (26 in 2D, 27 in 3D group) were included in the analysis, with 56% being male. Mean age and body mass index were 40 (16.3) years and 23.5 (4.7) kg/m2 , respectively. Twenty-five subjects underwent single port laparoscopic surgery, of whom 13 were in 3D and 12 in 2D group. Mean operative time was 75.3 (30.8) versus 82.7 (38.6) minutes (P = 0.4) for 3D and 2D groups, respectively. Operative times spent for individual steps were comparable. Post-operative minor complications (8 in 3D versus 8 in 2D, P = 1) and median number of times for scope maintenance were also similar between the groups. 69% of the visual evaluation survey results favoured 3D over 2D (P = 0.014).

CONCLUSION

Three-dimensional laparoscopy for total colectomy in ulcerative colitis patients is safe and feasible option providing better visualization with no difference in operative time.

Top Colorectal Articles from 2021 to Inform Your Cancer Practice

Multimodality treatment for locally advanced rectal cancer is the standard of care. Treatments include surgery, radiation, and chemotherapy, with medical therapies now being favored in the neoadjuvant setting. Various regimens continue to be studied and defined in prospective randomized trials. The PRODIGE 23 and RAPIDO trials showed improved disease-free survival and pathologic complete response rates for split chemotherapy/radiation treatment and short-course radiation with consolidation chemotherapy, respectively; both compared with traditional neoadjuvant long course chemoradiation, surgery, and adjuvant chemotherapy. Furthermore, new regimens are yielding a higher rate of complete clinical response, allowing for non-operative management. Circulating tumor DNA provides a potential novel option for monitoring response to treatment and rectal cancer surveillance. This manuscript summarizes some of the key clinical trials and studies that are defining clinical practice.

Idiopathic myointimal hyperplasia of the mesenteric veins: A systematic review of surgical management

BACKGROUND

Idiopathic myointimal hyperplasia of the mesenteric veins is an extremely rare non-thrombotic mesenteric veno-occlusive disease. The management of idiopathic myointimal hyperplasia of the mesenteric veins is not well-established, and although surgery is the mainstay of treatment, the optimal operation remains unclear. Therefore, we aimed to perform a systematic review to assess the various surgical procedures and associated outcomes for patients with idiopathic myointimal hyperplasia of the mesenteric veins.

METHODS

A systematic search for articles published from 1946 to April 2022 in MEDLINE, EMBASE, Cinahl, Scopus, Web of Science, and Cochrane Library databases is reported. In addition, we report 4 cases of idiopathic myointimal hyperplasia of the mesenteric veins managed at our institution until March 2023.

RESULTS

A total of 53 studies and 88 patients with idiopathic myointimal hyperplasia of the mesenteric veins were included. Most (82%) were male patients, with a mean age of 56.6 years old. The majority (99%) of patients required surgery. Most reports described the involvement of the rectum and sigmoid colon (81%). The most common surgical procedures were Hartmann's procedure (24%) and segmental colectomy (19%); completion proctectomy with ileal pouch-anal anastomosis was performed in 3 (3.4%) cases. In 6 (6.8%) cases, idiopathic myointimal hyperplasia of the mesenteric veins was suspected preoperatively and managed with elective surgery. Four (4.5%) complications were reported. Nearly all (99%) patients achieved remission with surgical intervention.

CONCLUSION

Idiopathic myointimal hyperplasia of the mesenteric veins is a rare pathologic entity infrequently suspected preoperatively and typically diagnosed after surgical resection. Surgical resection with Hartmann's procedure or segmental colectomy was most commonly performed, with completion proctectomy and ileal pouch-anal anastomosis reserved for cases of extensive rectal involvement. Surgical resection was safe and effective, with a low risk of complications and recurrence. Surgical decision-making should be based on the extent of the disease at the time of presentation.

Impact of Total Neoadjuvant Therapy on Postoperative Outcomes After Proctectomy for Rectal Cancer

BACKGROUND

Total neoadjuvant therapy is an alternative to neoadjuvant chemoradiation alone for rectal cancer and has the benefits of more completion of planned therapy, increased downstaging, earlier treatment of micrometastases, and assessment of chemosensitivity; however, it may increase surgical complications, especially with increased radiation-to-surgery interval.

OBJECTIVE

The study aimed to determine the impact of total neoadjuvant therapy on postoperative complications compared with neoadjuvant chemoradiation alone.

DESIGN

Retrospective cohort study.

SETTINGS

Single tertiary referral center.

PATIENTS

The patient included was a stage II/III rectal cancer patient who underwent total neoadjuvant therapy or long-course neoadjuvant chemoradiation followed by surgical resection from 2018-2020.

MAIN OUTCOME MEASURES

The main outcome measures included severe postoperative complications (Clavien-Dindo grade ≥3).

RESULTS

Of 181 patients, 86 (47.5%) underwent total neoadjuvant therapy and 95 (52.5%) underwent neoadjuvant chemoradiation. There was no difference in severe postoperative complications or any complications. There was also no difference in the rate of complete total mesorectal excision or negative circumferential margin. Total neoadjuvant therapy had a mean operative time of 355.5 minutes and estimated blood loss of 263.6 mL compared with 326.7 minutes and 297.5 mL in the neoadjuvant chemoradiation group. Total neoadjuvant therapy patients had a lower mean lymph node yield than neoadjuvant chemoradiation patients. On multivariable analysis, total neoadjuvant therapy was associated with increased operative time (OR, 1.19; p < 0.001) and estimated blood loss (OR, 1.22; p < 0.001) and decreased lymph node yield (OR, 0.67; p < 0.001). There was no difference in severe complications or any complications.

LIMITATIONS

Selection bias uncontrolled by modeling.

CONCLUSIONS

We found no difference in risk of postoperative complications between patients who received total neoadjuvant therapy vs neoadjuvant chemoradiation. Total neoadjuvant therapy patients had longer operations and greater estimated blood loss. This may be a reflection of increased operative difficulty because of increased radiation-to-surgery interval and/or the effects of chemotherapy; however, the absolute differences were small and, therefore, should be interpreted cautiously. See Video Abstract at http://links.lww.com/DCR/C44 .

IMPACTO DE LA TERAPIA NEOADYUVANTE TOTAL EN LOS RESULTADOS POSOPERATORIOS DESPUS DE UNA PROCTECTOMA POR CNCER DE RECTO

ANTECEDENTES:La terapia neoadyuvante total es una alternativa a la quimiorradiación neoadyuvante sola para el cáncer de recto y tiene los beneficios de una mayor finalización de la terapia planificada, mayor reducción del estadiage, tratamiento más temprano de las micrometástasis y evaluación de la quimiosensibilidad; sin embargo, puede aumentar las complicaciones quirúrgicas, especialmente con un mayor intervalo entre la radiación y la cirugía.OBJETIVO:Determinar el impacto de la terapia neoadyuvante total sobre las complicaciones posoperatorias en comparación con la quimiorradiación neoadyuvante sola.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:Centro único de referencia terciario.PACIENTES:Paciente con cáncer de recto en estadio II/III que se sometieron a terapia neoadyuvante total o quimiorradiación neoadyuvante de larga duración seguida de resección quirúrgica entre 2018 y 2020.PRINCIPALES MEDIDAS DE RESULTADO:Complicaciones postoperatorias graves (grado de Clavien-Dindo ≥3).RESULTADOS:De 181 pacientes, 86 (47,5%) se sometieron a terapia neoadyuvante total y 95 (52,5%) se sometieron a quimiorradioterapia neoadyuvante. No hubo diferencia en las complicaciones postoperatorias graves o cualquier otra complicación. Tampoco hubo diferencia en la tasa de escisión mesorrectal total completa o margen circunferencial negativo. La terapia neoadyuvante total tuvo un tiempo operatorio promedio de 355,5 minutos y una pérdida de sangre estimada de 263,6 ml en comparación con 326,7 minutos y 297,5 ml en el grupo de quimiorradiación neoadyuvante. Los pacientes con terapia neoadyuvante total tuvieron una media de ganglios linfáticos más bajo en comparación con los pacientes con quimiorradioterapia neoadyuvante. En el análisis multivariable, la terapia neoadyuvante total se asoció con un mayor tiempo operatorio (OR = 1,19, p < 0,001) y pérdida de sangre estimada (OR = 1,22, p < 0,001) y menor cantidad los ganglios linfáticos (OR = 0,67, p < 0,001). No hubo diferencia en las complicaciones graves o cualquier complicación.LIMITACIONES:Sesgo de selección no controlado por modelado.CONCLUSIONES:No encontramos diferencias en el riesgo de complicaciones postoperatorias entre los pacientes que recibieron terapia neoadyuvante total versus quimiorradiación neoadyuvante. Los pacientes con terapia neoadyuvante total tuvieron operaciones más prolongadas y una mayor pérdida de sangre estimada. Esto puede ser un reflejo de una mayor dificultad quirúrgica como resultado de un mayor intervalo entre la radiación y la cirugía y/o los efectos de la quimioterapia; sin embargo, las diferencias absolutas fueron pequeñas y, por lo tanto, deben interpretarse con cautela. Consulte Video Resumen en http://links.lww.com/DCR/C44 . (Traducción- Dr. Francisco M. Abarca-Rendon ).