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.

Treatment effect of ex vivo expanded allogeneic bone marrow-derived mesenchymal stem cells for the treatment of fistulizing Crohn's disease are durable at 12 months

BACKGROUND

Mesenchymal stem cells have been administered via direct injection to treat perianal Crohn's fistulizing disease. We herein sought to determine the safety and durability of treatment response to 12 months with 3 individual phase IB/IIA clinical trials of mesenchymal stem cells for refractory perianal, rectovaginal, and ileal pouch fistulas in the setting of Crohn disease.

METHODS

Three phase IB/IIA randomized placebo-controlled single-blinded clinical trials were performed for (1) perianal fistulas, (2) rectovaginal fistula, and (3) ileal pouch in situ with anovaginal and/or perianal fistulas. Bone marrow-derived mesenchymal stem cells (75 million in 7.5 mL) were injected at the time of exam under anesthesia on day 0 and month 3. Outcome measures were adverse events and combined clinical and pelvic magnetic resonance imaging healing at month 6 and month 12.

RESULTS

Across all 3 trials, 64 patients were enrolled; 49 were treatment and 15 were control. At 6 months, combined clinical and radiographic healing was achieved in 83.3%, 33.3%, and 30.8% of the perianal, rectovaginal, and pouch fistula treatment cohorts, respectively. At 12 months, the treatment response was durable, with 67.7% of perianal, 37.5% of rectovaginal, and 46.2% of peripouch fistulas maintaining complete clinical and radiographic healing. Two patients in the perianal fistula control cohort achieved combined clinical and radiographic healing at 12 months, whereas 0% of rectovaginal and pouch control patients healed.

CONCLUSION

Bone marrow-derived mesenchymal stem cells offer a safe and effective alternative treatment approach for severe perianal, rectovaginal, and peripouch fistulizing Crohn's disease. Treatment results are durable at 12 months.

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.

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.

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.

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.

A phase IB/IIA study of ex vivo expanded allogeneic bone marrow-derived mesenchymal stem cells for the treatment of rectovaginal fistulizing Crohn's disease

BACKGROUND

Crohn-related rectovaginal fistulas are notoriously difficult to treat. Studies of mesenchymal stem cells for the treatment of perianal Crohn fistulizing disease have largely excluded rectovaginal fistulas. The aim of this study was to determine the safety and efficacy of mesenchymal stem cells for refractory rectovaginal fistulizing Crohn disease.

METHODS

A phase IB/IIA randomized control trial was performed in a 3:1, single-blinded study. Patients included were adult women with an anovaginal/rectovaginal fistula in the setting of Crohn disease. Seventy-five million mesenchymal stem cells were administered with a 22G needle after curettage and primary closure of the fistula tract at day 0 and month 3. Adverse and serious adverse events were recorded at post-procedure day 1, week 2, week 6, month 3, month 6, and month 12, along with clinical healing, magnetic resonance imaging, and patient-reported outcomes.

RESULTS

A total of 19 patients were enrolled and treated-15 treatment and 4 control. There were no adverse or serious adverse events related to mesenchymal stem cell therapy. At 6 months, 50% of the treatment group and 0% of the control had complete clinical and radiographic healing; 91.7% of the treatment group had improvement at 6 months with only one patient having a lack of response, whereas only 50% of the control group had improvement at 6 months.

CONCLUSION

Bone marrow-derived mesenchymal stem cells offer a safe alternative treatment approach for rectovaginal fistulas in the setting of Crohn disease. Complete healing was achieved in half of the patients.

Preoperative Use of Multiple Advanced Therapies Is Not Associated With Endoscopic Inflammatory Pouch Diseases

BACKGROUND

Patients with an ileal pouch-anal anastomosis (IPAA) can experience pouch inflammation postoperatively. The use of antitumor necrosis factor (anti-TNF) biologics may be associated with pouch inflammation, but limited data exist on the impact of multiple advanced therapies on development of subsequent pouch inflammation. The aim of this study was to assess for an association between preoperative use of multiple advanced therapies and risk of endoscopically detected inflammatory pouch diseases (EIPDs).

METHODS

We performed a retrospective analysis of ulcerative colitis (UC) and indeterminate colitis (IBDU) patients who underwent an IPAA at a quaternary care center from January 2015 to December 2019. Patients were grouped based on number and type of preoperative drug exposures. The primary outcome was EIPD within 5 years of IPAA.

RESULTS

Two hundred ninety-eight patients were included in this analysis. Most of these patients had UC (95.0%) and demonstrated pancolonic disease distribution (86.1%). The majority of patients were male (57.4%) and underwent surgery for medically refractory disease (79.2%). The overall median age at surgery was 38.6 years. Preoperatively, 68 patients were biologic/small molecule-naïve, 125 received anti-TNF agents only, and 105 received non-anti-TNF agents only or multiple classes. Ninety-one patients developed EIPD. There was no significant association between type (P = .38) or number (P = .58) of exposures and EIPD, but older individuals had a lower risk of EIPD (P = .001; hazard ratio, 0.972; 95% confidence interval, 0.956-0.989).

CONCLUSION

Development of EIPD was not associated with number or type of preoperative advanced therapies.

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.

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 ).

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.

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.

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.

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 ).

Future directions in imaging pouches

The sections of this special issue on the ileal pouch demonstrate that in the nearly 45 years since the ileal pouch has been utilized to treat patients with colitis and familial adenomatous polyposis, a substantial number of patients experience both short- and long-term morbidity and that imaging plays an important role in their management. Further, referral centers are encountering an increasing number of patients with pouch and peri-pouch complications and dysfunction. Many of these patients have had their pouches for years, and many have experienced a reduced quality of life as a result of their symptoms.As we look to the future, what are the specific questions that arise from this compilation of experience from institutions that see large numbers of patients with an ileal pouch? In what areas are we deficient? In what areas are we using the wrong methods? What should we be doing differently?

Clinical issues facing pouch patients: an introduction to a special issue on the ileal pouch

For over 40 years, restorative proctocolectomy has been used in patients with ulcerative colitis or familial adenomatous polyposis undergoing proctocolectomy. Radiologists are now encountering an increasing number of patients with an ileal pouch and therefore need to understand the clinical issues and concerns in these patients. This review is the introduction of a special issue on the ileal pouch and was written with both surgeon and gastroenterology input. The intent is to assist the radiologist in understanding the clinical questions posed by both the patients and their physicians. Subsequent sessions will address specific imaging modalities and techniques, how the gastroenterologists and surgeons address issues with these patients, and a final session summarizing the sessions and speculating on future investigations and approaches.

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.

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.

What are the outcomes in patients referred to a tertiary referral centre for Crohn's rectovaginal fistula surgery?

AIM

Rectovaginal fistulas in patients with Crohn's disease are challenging to manage, and surgical treatment remains the best option for achieving permanent closure of the fistula. Biologicals are now used routinely for patients with Crohn's disease. The aim of this study was to investigate the surgical procedures used by us to treat rectovaginal fistula in patients with Crohn's disease in the era of biologicals.

METHOD

Patients with Crohn's disease who underwent surgery for a rectovaginal fistula between 2010 and 2020 were included in this retrospective study and were identified from a prospectively maintained institutional database. Collected variables included demographics, perioperative and operative variables and data regarding medications used. Success of the procedure was defined as no symptoms at least 6 months after definitive repair and/or stoma closure.

RESULTS

Twenty patients (out of 80 referred for evaluation) underwent surgery with intent to close the fistula and had at least 6 months of follow-up. Mean age was 44 ± 12 years with a median follow-up duration of 33 months (range 6-130 months). Forty per cent of the patients had a history of at least two surgeries to close the fistula. The overall healing rate was 70% (14/20). The most performed procedure was a transanal rectal advancement flap (7/20), with a success rate of 85%.

CONCLUSION

Rectovaginal fistula in Crohn's disease is difficult to cure; according to our results almost half of these patients have multiple surgeries due to recurrence. Multiple procedures may be offered for this challenging problem in motivated patients. Perioperative diversion should be strongly considered.

Patient-Reported Outcomes in Colorectal Surgery

Given the increased life expectancy and improvements in the treatment of colorectal patients, the success of a treatment course can no longer be determined only by objective outcomes. Health care providers ought to take into consideration the impact an intervention will have on the quality of life of patients. Endpoints that take into account the patient's perspective are defined as patient-reported outcomes (PROs). PROs are assessed through patient-reported outcome measures (PROMs), usually in the form of questionnaires. PROs are especially important in colorectal surgery, whose procedures can often be associated with some degree of postoperative functional impairment. Several PROMs are available for colorectal surgery patients. However, while some scientific societies have offered recommendations, there is no standardization in the field and PROMs are seldom implemented in clinical practice. The routine use of validated PROMs can guarantee that functional outcomes are followed over time; this way, they can be addressed in case of worsening. This review will provide an overview of the most commonly used PROMs in colorectal surgery, both generic and disease specific, as well as a summary of the available evidence in support of their routine utilization.

Prolonged diversion after ileal pouch-anal anastomosis: Is it safe to wait?

AIM

Diverting loop ileostomy reversal (DLI-R) is routinely performed from 2-6 months following ileal pouch-anal anastomosis (IPAA). The safety of delayed reversal after IPAA is not well-defined. The aim of this study was to determine if prolonged diversion is associated with adverse outcomes compared to routine closure.

METHODS

Adult patients undergoing primary IPAA with DLI from 2000 to 2021 were included in this retrospective cohort study from our institutional database. Patients were stratified into tertiles based on timing of reversal: Routine (56-116 days), Delayed (117-180 days), or Prolonged (>6 months). Univariate analysis compared categorical variables between groups. Patients reversed at <8 weeks were excluded.

RESULTS

In total, 2615 patients underwent DLI-R following IPAA (3-stage 61%, 2-stage 39%; mean age 39.9 years). DLI-R was performed as Routine, Delayed and Prolonged in 1908 (72.9%), 426 (16.4%) and 281 (10.8%), respectively. Overall, DLI-R related complications occurred in 12.4% (n = 324). The complication rate in the Routine group was 11% (n = 210), in the Delayed group was 12.2% (n = 52) and in the Prolonged group was 22.1% (n = 62). Reasons for prolonged diversion in the Prolonged group were complications at the time of IPAA in 207 (73.9%) or patient preference/scheduling in 73 (26.1%). DLI-R >6 months after IPAA due to complications had higher rates of overall complications following ileostomy reversal (OR 2.6, 95% CI 1.85-3.72, p < 0.001) whereas when DLI-R was delayed due to preference/scheduling outcomes were not different than the Routine group (p = 0.28).

CONCLUSION

Prolonged time to ileostomy reversal after IPAA is probably safe without increased risk of complications when due to patient preference.

Management and Outcomes of Ileal Pouch-Urethral Fistulas

OBJECTIVE

To describe a single-center experience with the management of ileal pouch-urethral fistulas (IPUF) following restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA).

METHODS

We retrospectively identified patients with documented IPUF managed at our institution from a urethral fistula cohort and analyzed their cases.

RESULTS

Thirteen patients who underwent surgeries for IPUF management from 2005-2022 were identified. Median age at IPAA was 29 years (range 11-53). Indications for IPAA included familial adenomatous polyposis (n=3) and ulcerative colitis (n=10). Median time from IPAA to fistula diagnosis was 15 years (range 0.5-38.5). Eleven patients were initially diverted with either loop (n=8) or end ileostomy (n=3). Overall, two patients had resolution of IPUF symptoms with a loop ileostomy alone and eight eventually underwent pouch excision with end ileostomy, one of which subsequently underwent redo IPAA. Seven patients were managed with primary closure of the urethral defect at the time of pouch excision, five of which also underwent gracilis muscle interposition. With a median follow-up of 4 years (range 0.3-13 years), all patients had resolution of their fistulae without any recurrences.

CONCLUSION

IPUFs are a rare complication after IPAA. In this cohort, all patients had their urinary tract preserved, but most ultimately had permanent fecal diversion. These results can help guide management of this complex issue.

Venous thromboembolism risk stratification for patients undergoing surgery for IBD using a novel six factor scoring system using NSQIP-IBD registry

BACKGROUND

Patients undergoing colorectal surgery for inflammatory bowel disease (IBD) are recognized to have an increased risk of venous thromboembolism (VTE). The aim of this study was to determine the perioperative risk factors for VTE and to create a predictive scoring system for VTE in the IBD cohort.

METHODS

The NSQIP-IBD Collaboration Registry from 2017 to 2020 was used to identify patients. Demographics, operative and outcomes data of IBD patients undergoing surgeries for IBD were analysed. A logistic multivariate regression model was performed using all significant variables to develop a predictive scoring system of VTE.

RESULTS

Five-thousand and three patients (51.9% male, mean age: 42.7, 42.7% ulcerative colitis) were included in the study. 125 (2.49%) developed VTE. On multivariate analysis ASA grade, ulcerative colitis, sepsis, serum sodium <139 mmol/L, an open abdomen and preoperative inter hospital transfer were associated with greater risk of VTE. Using these 6 significant factors, a risk model was constructed. The risk of VTE with one risk factor was 0.7% and 1.8% with two risk factors. The risk of VTE increased to 3.6% and 4.5% with three and four risk factors respectively. With five and six risk factors, the risk of VTE increased exponentially to 10.9% and 25% respectively.

CONCLUSION

This study shows that there are cumulative risk factors which increase the risk of VTE after surgery for IBD. The risk increases exponentially with more than five risk factors, and extended chemoprophylaxis may not be enough in reducing this risk.

Is Endoscopic Submucosal Dissection for Colorectal Lesions Performed in the Endoscopy Suite Safe and Cost Saving?

BACKGROUND

We aimed to compare the outcomes and the cost differences of endoscopic submucosal dissection (ESD) procedures in the endoscopy suite (ES) versus the operating room (OR).

MATERIALS AND METHODS

The procedures in the OR were compared with procedures performed in the ES for demographics, lesion characteristics, procedure outcome, and procedure charges. The study included 163 procedures in the ES and 73 in the OR.

RESULTS

Both were similar in age, sex, body mass index, and intraprocedural and postoperative 30-day (late) complications. ES cases had significantly greater polyp size, were more commonly right-sided polyps, and had shorter hospital stays, with similar en bloc and margin-negative resection rates. The overall cost ratio of ESD procedures in ES to OR was 0.47 ( P <0.001).

CONCLUSIONS

Colorectal ESD procedures performed in the ES have similar efficacy and safety as those in the OR. Procedures performed in the ES were associated with a shorter length of stay and significant periprocedural cost savings.

A Phase IB/IIA study of allogeneic bone marrow derived mesenchymal stem cells for the treatment of refractory ileal anal anastomosis and peripouch fistulas in the setting of Crohn's disease of the pouch

BACKGROUND AND AIMS

Mesenchymal stem cells (MSCs) have been used for the treatment of perianal Crohn's fistulizing disease by direction injection. No studies to date have included patients with an ileal pouch anal anastomosis (IPAA) in situ.

METHODS

A phase IB/IIA randomized control trial of bone marrow derived allogeneic MSCs via direct injection to treat adult patients with a peripouch fistula(s) was conducted. 75 million MSCs were administered with a 22G needle; repeat injection at 3 months was given if complete clinical and radiographic healing were not achieved. Adverse and serious adverse events at post procedure day 1, week 2, week 6, month 3, month 6 and month 12 were assessed. Clinical healing, radiographic healing per pelvic MRI, and patient reported outcomes were assessed at the same time points.

RESULTS

A total of 22 patients were enrolled and treated; 16 were treatment and 6 were control. There were no adverse or serious adverse events related to MSC therapy. At six months, 31% of the treatment group and 20% of the control had complete clinical and radiographic healing. When stratifying the treatment group into perianal (n=7) and anovaginal (n=8) fistulas, 6 month healing in the treatment groups was 57% and 0%, respectively. The perianal Crohn's disease activity index (PCDAI), Wexner incontinence score, and VanAssche score all significantly decreased in treatment patients at six months; only the PCDAI decreased in the control group.

CONCLUSION

Bone marrow derived allogeneic MSCs offer a safe and effective alternative treatment approach for peripouch fistulas in the setting of a Crohn's like phenotype of the pouch.

Surgical Intervention is Effective for the Treatment of Crohn's related Rectovaginal Fistulas: Experience From A Tertiary Inflammatory Bowel Disease Practice

BACKGROUND AND AIMS

Rectovaginal fistula occurs in up to 10-20% of women with Crohn's disease, significantly affecting their quality of life. We sought to determine outcomes of single and repeat operative interventions.

METHODS

A retrospective review of all adult patients with a Crohn's related rectovaginal fistula who underwent an operation between 1995 to 2021 was performed. Data collected included patient demographics, Crohn's related medical treatment, surgical intervention, postoperative outcomes, and fistula outcomes.

RESULTS

A total of 166 patients underwent 360 operations; mean age was 42.8 (+/-13.2) years. Thirty-four (20.7%) patients were current and 58 (35.4%) former smokers. The most commonly performed procedure was a local approach (n=160, 44.5%) using fibrin glue, fistulotomy/fistulectomy or seton placement, followed by a transvaginal/transanal approach (n=113, 31.4%) with an advancement flap repair (including Martius advancement flap) and episoproctotomy, a transabdominal approach (n=98, 27.2%) including proctectomy or redo anastomosis and finally gracilis muscle interposition (n=8, 2.2%). The median number of operative interventions per patient was 2 (1.0-3.0) procedures. The overall fistula healing rate per patient was 71.7% (n=119) at a median follow-up of 5.5 (1.2-9.8) years. Factors that impaired healing included former smoking (OR 0.52 95%, CI 0.31 - 0.87, p=0.014) and seton insertion (OR 0.42 95%, CI 0.21-0.83, p=0.012).

CONCLUSION

Over two-thirds of Crohn's related rectovaginal fistulas can achieve closure with multiple surgical interventions. Smoking and seton usage negatively impact healing rates and should be avoided.

Pouch volvulus-why adhesions are not always the enemy

AIM

Minimally invasive approaches to proctocolectomy with ileal pouch anal anastomosis have become the standard of care with one benefit being the reduced risk of adhesion-related complications. However, a lack of pouch adherence to the pelvis can lead to increased mobility as well as volvulization, placing pouch viability at risk. We aimed to describe our institutional experience with pouch volvulus.

METHODS

Patients who presented with pouch volvulus from 1983 to 2020 were identified through a search of our pelvic pouch registry and enterprise-wide electronic medical record. Pouch volvulus was defined as a reducible rotation of the J-pouch on its mesenteric axis with evidence of a properly oriented ileo-anal anastomosis. Patients with 'twisted pouches' were excluded.

RESULTS

In total, 5760 patients underwent ileal pouch anal anastomosis from 1983 to 2020. Six patients (five women) were identified with a diagnosis of 'pouch volvulus' consistent with our definition. The six pouches were constructed utilizing laparoscopic techniques and the mean time from construction to volvulus was 2.36 years. All patients underwent urgent surgery, with a paucity of adhesions noted in five. Reduction and pouch pexy was performed in three and pouch excision in three, with immediate pouch reconstruction in two and end ileostomy creation in one. At a median follow-up of 9 months, pouch survival was 50%.

CONCLUSIONS

Pelvic pouches constructed using minimally invasive techniques may be at risk of volvulus due to reduced adhesion development. A high index of suspicion is warranted in pouch patients with obstructive symptomatology. CT imaging may be diagnostic, and prompt surgical intervention may facilitate pouch salvage.

Laparoscopic surgery for complex Crohn's disease: perioperative and long-term results from a propensity matched cohort

PURPOSE

Laparoscopic surgery for complicated Crohn's (CD) is often technically challenging. Previous studies are limited by the comparison of heterogeneous cohorts of patients undergoing laparoscopic vs open surgery. We aimed to compare perioperative and long-term outcomes of matched patients undergoing laparoscopic and open colonic and ileocolonic resection. Primary outcomes were operative time, blood loss, and complications. Long-term outcomes were subsequent intraabdominal CD surgery, incisional hernia repair, and stoma reversal rates.

METHODS

Laparoscopic and open CD patients were 1:1 propensity score matched on age, body mass index, sex, indication, ASA grade, prior abdominal surgery, and postoperative Crohn's medication use based on the laparoscopic approach.

RESULTS

A total of 906 patients underwent surgery for complex CD. After propensity matching, 386 were analyzed (193 open/193 lap, 51.3% male, mean age 33.9 + / - 12.6). Mean follow-up was 9.8 (range 7.9-12.1) years. Length of stay [(LOS) 6 (4, 8) vs 8 (5, 11) days, p < 0.001] and operative time [154 (110, 216) vs 176 (126, 239) min, p = 0.03] were shorter in the laparoscopic group. There was no difference in other complications or mortality. After adjusting for postoperative medications, no association was found between operative approach and subsequent intra-abdominal operation or incisional hernia repair. Laparoscopic patients were less likely to have postoperative sepsis [OR 0.40 (0.18, 0.91), p = 0.03].

CONCLUSION

In the setting of complicated Crohn's, in matched cohorts, laparoscopic surgery is associated with reduced operative times and LOS. Mortality, reoperation, and symptomatic hernia rates were equivalent to open surgery. Patients undergoing laparoscopic surgery are less likely to experience postoperative sepsis.

Analysis of Patterns of Compliance with Accreditation Standards of National Accreditation Program for Rectal Cancer

BACKGROUND

We identified commonly deficient standards across rectal cancer programs that underwent accreditation review by the National Accreditation Program for Rectal Cancer to evaluate for patterns of noncompliance.

STUDY DESIGN

With the use of the internal database of the American College of Surgeons, programs that underwent accreditation review from 2018 to 2020 were evaluated. The occurrence and frequency of noncompliance with the standards, using the 2017 standards manual, were evaluated. Programs were further stratified based on the year of review, annual rectal cancer volume, and Commission on Cancer classification.

RESULTS

A total of 25 programs with annual rectal cancer volume from 14 to more than 200 cases per year underwent accreditation review. Only 2 programs achieved 100% compliance with all standards. Compliance with standards ranged from 48% to 100%. The 2 standards with the lowest level of compliance included standard 2.5 and standard 2.11 that require all patients with rectal cancer to be discussed at a multidisciplinary team meeting before the initiation of definitive treatment and within 4 weeks after definitive surgical therapy, respectively. Patterns of noncompliance persisted when programs were stratified on the basis oof the year of survey, annual rectal cancer volume, and Commission on Cancer classification. The corrective action process allowed all programs to ultimately become successfully accredited.

CONCLUSION

During this initial phase of the National Accreditation Program for Rectal Cancer accreditation, the majority of programs undergoing review did not achieve 100% compliance and went through a corrective action process. Although the minimal multidisciplinary team meeting attendance requirements were simplified in the 2021 revised standards, noncompliance related to presentation of all patients at the multidisciplinary team meeting before and after definitive treatment highlights the need for programs seeking accreditation to implement optimized and standardized workflows to achieve compliance.

Excisional haemorrhoidectomy: is it safe in patients with an ileal pouch-anal anastomosis?

AIM

Excisional haemorrhoidectomy in patients with ulcerative colitis (UC), especially those undergoing an ileal pouch-anal anastomosis (IPAA), remains controversial. The aim of our study was to determine the safety of excisional haemorrhoidectomy in UC patients with and without an IPAA.

METHOD

A retrospective review of all adult UC patients undergoing excisional haemorrhoidectomy between 1 January 1995 and 1 January 2019 at a tertiary inflammatory bowel disease referral centre was performed. Data collected included patient demographics, clinical characteristics of UC, prior surgical intervention for UC (colectomy, IPAA) and complications after haemorrhoidectomy.

RESULTS

Forty-one adult patients [50% male; median age 52 (range 25-79) years] with UC underwent excisional haemorrhoidectomy between 1 January 1995 and 1 January 2019. The majority (n = 23) had not previously undergone surgery for UC. However, eight had already undergone construction of an IPAA at the time of haemorrhoidectomy, seven had IPAA at the time of haemorrhoidectomy and three had an IPAA constructed subsequent to haemorrhoidectomy. Two (4.9%) patients need to go back to theatre for postoperative bleeding. There were no further 30-day complications or long-term nonhealing of the surgical site. There were no pouch complications in those who had haemorrhoidectomy at the time of IPAA construction or in the presence of an IPAA.

CONCLUSION

Our data suggest that excisional haemorrhoidectomy may be performed safely in carefully selected UC patients with symptomatic haemorrhoids with or without IPAA and even at the time of IPAA construction.

Excisional Hemorrhoidectomy: Safe in Patients With Crohn's Disease?

INTRODUCTION

Due to concerns over wound healing, hemorrhoidectomy in patients with Crohn's disease (CD) remains controversial. We sought to ascertain safety and efficacy of excisional hemorrhoidectomy in CD.

METHODS

A retrospective review of all adult CD patients undergoing excisional hemorrhoidectomy between January 1, 1995, and January 1, 2019, at 2 IBD referral centers was performed. Data collected included patient demographics, clinical characteristics of CD (anorectal symptoms; prior nonoperative hemorrhoidal therapy; presence of other perianal disease; and activity, duration, and anatomic location of CD), and postoperative complications including bleeding, wound healing, and need for further therapy or surgical intervention after surgery.

RESULTS

A total of 36 adult patients with Crohn's disease with symptomatic hemorrhoidal disease were included. The study cohort included 16 males (44%), and median age was 49 (range, 21 to 77) years. Predominant symptoms included pain (n = 16; 44%), prolapse (n = 8; 22%), and bleeding (n = 12; 33%). Sixteen patients (44%) had nonoperative therapy before surgery. Twenty-four patients (67%) had other perianal disease. At the time of hemorrhoidectomy, 9 patients (25%) were exposed to corticosteroids, 8 patients (25%) to immunomodulators, and 9 patients (25%) to biologics. During a median follow-up time of 31.5 (range, 1 to 255) months after hemorrhoidectomy, 4 patients (11%) had complications (1 developed a stricture, 1 developed a perianal abscess/fistula, 1 had a nonhealing wound, and 1 had hemorrhoidal recurrence).

CONCLUSION

Our data suggest that excisional hemorrhoidectomy may be performed safely in CD patients who have failed nonoperative hemorrhoidal therapy without concern for de novo perianal disease or need for proctectomy.Hemorrhoidal disease is common in patients with Crohn's disease. This study sought to understand the outcomes of surgically treating hemorrhoids in patients with Crohn's disease.

A narrative celebrating the recent contributions of women to colorectal surgery

BACKGROUND

To interview extraordinary women who have made recent significant contributions to the field of colorectal surgery.

DESIGN

The authors asked some of the many extraordinary women who have made significant contributions to the field of colorectal surgery to answer several questions. These women were selected from many potential candidates based upon their extraordinary recent contributions to the field of colorectal surgery. These thought leaders were asked about their contributions to colorectal surgery, their mentors, whether they had any women as role models, and, lastly, what they would tell their younger selves. The study was structured to recognize these women for their remarkable recent contributions to colorectal surgery, and we wished to encourage women to pursue leadership in colorectal surgery including the allied fields of colorectal pathology and colorectal imaging. Furthermore, the authors hoped to inspire male colorectal surgeons to actively mentor and help the career development of women colorectal surgeons. The potential limitations of the study include the fact that there are many more well-deserving women who could have been included in the sample survey but, because of space constraints, were not invited.

CONCLUSION

Women in colorectal surgery and in the allied specialties of colorectal pathology and colorectal radiology have made many recent major significant contributions to colorectal surgery. The expectation is that the volume and frequency of such contributions as well as the number of women making these contributions should further significantly increase with time.

Issues in Standardizing Psychometric Tests for Children who are Blind

The School of Education, University of Birmingham, England, is attempting to standardize a new psychometric assessment tool—a tactile speed-of-information processing test—for blind children. This article discusses some of the issues and difficulties that have been encountered and presents implications for the future direction of psychometric testing of children who are blind.

Small bowel adenocarcinoma in Crohn's disease: a rare but devastating complication

BACKGROUND

Small bowel adenocarcinoma (SBA) remains a rare entity but occurs at increased frequency in the setting of chronic Crohn's disease (CD). Our aim was to study the presentation, diagnosis and prognosis of SBA in patients undergoing surgery for CD at a single institution.

METHODS

We reviewed the medical records of all patients with CD complicated by adenocarcinoma of the small bowel from 2000 to 2017. Descriptive statistics and Kaplan-Meier overall survival estimates were calculated.

RESULTS

In total, 22 patients (14 males) with CD (median duration of Crohn's diagnosis 32 years) were diagnosed with SBA and underwent surgical resection (8 isolated small bowel resections, 12 ileocolic resections, and 2 total proctocolectomies). The median patient age at the time of diagnosis was 54 years (range 22-82 years). A total of 17 patients (77%) underwent cross-sectional CT imaging within 3 months of surgery, a cancer diagnosis was suggested in only one patient. In one other patient, SBA was diagnosed preoperatively on endoscopic biopsy of the terminal ileum. The remaining patients were operated on for obstruction (n = 17), abscess or fistulizing disease (n = 2), and sigmoid cancer (n = 1). For these 20 (90%) patients not suspected to have SBA on preoperative assessment, 5 (25%) were diagnosed intraoperatively on frozen section and 15 (75%) were unexpectedly diagnosed postoperatively on final pathology. T staging was characterized by more advanced tumors (T4: 59%, T3: 27%, T2: 9%, and T1: 5%). Nine patients (41%) had nodal involvement and five patients (23%) had hepatic and/or peritoneal carcinomatosis. The 1-, 3-, and 5-year survival estimates for our cohort were 84%, 30%, and 10%, respectively. Median survival was 30.5 months with median follow-up of 23 months (range 6-84 months).

CONCLUSIONS

SBA in the setting of CD is most commonly found incidentally after surgical resection for benign indications. As such, any suspicious finding at the time of surgery in a patient with chronic CD should warrant careful investigation with frozen section and/or resection. Prognosis for CD complicated by SBA remains poor even in the modern era.

Performance of Blind Children on Digit-Span Tests

This article reports the results of digit-span tests that were administered to 314 children who are blind. The results showed that gender, first language, and educational setting had no effect on the children's scores and that the congenitally totally blind children scored higher than did the sighted children, whereas those who had had some sight did not.

The ACS National Surgical Quality Improvement Program-Inflammatory Bowel Disease Collaborative: Design, Implementation, and Validation of a Disease-specific Module

BACKGROUND

Surgery for inflammatory bowel disease (IBD) involves a complex interplay between disease, surgery, and medications, exposing patients to increased risk of postoperative complications. Surgical best practices have been largely based on single-institution results and meta-analyses, with multicenter clinical data lacking. The American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) has revolutionized the way in which large-volume surgical outcomes data have been collected. Our aim was to employ the ACS-NSQIP to collect disease-specific variables relevant to surgical outcomes in IBD.

STUDY DESIGN

A collaborative of 13 high-volume IBD surgery centers was convened to collect 5 IBD-specific variables in NSQIP. Variables included biologic and immunomodulator medications usage, ileostomy utilization, ileal pouch anastomotic technique, and colonic dysplasia/neoplasia. A sample of the Surgical Clinical Reviewer collected data was validated by a colorectal surgeon at each institution, and kappa's agreement statistics generated.

RESULTS

Over 1 year, data were collected on a total of 956 cases. Overall, 41.4% of patients had taken a biologic agent in the 60 days before surgery. The 2 most commonly performed procedures were laparoscopic ileocolic resections (159 cases) and subtotal colectomies (151 cases). Overall, 56.8% of cases employed an ileostomy, and 134 ileal pouches were constructed, of which 92.4% used stapled technique. A sample of 214 (22.4%) consecutive cases was validated from 8 institutions. All 5 novel variables were shown to be reliably collected, with excellent agreement for 4 variables (kappa ≥ 0.70) and very good agreement for the presence of colonic dysplasia (kappa = 0.68).

CONCLUSION

We report the results of the initial year of implementation of the first disease-specific collaborative within NSQIP. The selected variables were demonstrated to be reliably collected, and this collaborative will facilitate high-quality, large case-volume research specific to the IBD patient population.

High-Risk Ileocolic Anastomoses for Crohn's Disease: When Is Diversion Indicated?

BACKGROUND AND AIMS

Patients with Crohn's disease undergoing ileocolectomy and primary anastomosis are often at increased risk of anastomotic leak. We aimed to determine whether diverting ileostomy was protective against anastomotic leak after ileocolic resection for Crohn's disease using a large international registry.

METHODS

We analysed the National Surgical Quality Improvement Program Colectomy Module from 2012 to 2016. Multivariable logistic regression analysis and propensity-score matching were used to identify independent risk factors for leak, and to test the hypothesis that diverting ileostomy was protective against anastomotic leakage.

RESULTS

A total of 4172 [92%] patients underwent primary anastomosis, and 365 [8%] underwent anastomosis plus ileostomy. The leak rates in the two groups were 4.5% and 2.7%, [p = 0.12], respectively. Multivariate analysis indicated ileostomy omission, emergency surgery, smoking, inpatient status, wound classification 3 or 4, weight loss, steroid use, and prolonged operative time were independently associated with leak. Patients with 0-6 risk factors had leak rates of 1.6%, 2.7%, 4.3%, 6.7%, 8.8%, 11.5%, and 14.3% [p ≤ 0.001], respectively. Following propensity-score matching, ileostomy reduced the risk of leak rate by 55% [p = 0.005]. Patients with primary anastomosis who leaked most frequently required reoperation [57.8%], but anastomosis plus ileostomy patients who leaked most frequently were managed by percutaneous drainage [70%], p = 0.04.

CONCLUSIONS

After ileocolic resection for Crohn's disease, anastomotic leak may be predicted by simple addition of risk factors. We found that diverting ileostomy mitigated against leak, reducing both the leak rate and the likelihood of unplanned reoperations. Faecal diversion should be considered when ≥3 risk factors are present.

Postoperative Steroid Taper Is Associated With Pelvic Sepsis After Ileal Pouch-anal Anastomosis

OBJECTIVE

We hypothesized that postoperative oral steroid taper after ileal pouch-anal anastomosis for inflammatory bowel disease would not be associated with pelvic septic complications.

BACKGROUND

Recent data has emphasized the possible association between biologic medication use and pelvic sepsis following ileal pouch-anal anastomosis. Limited contemporary data exist examining the effects of steroid use on these complications.

METHODS

Consecutive patients undergoing ileal pouch-anal anastomosis for inflammatory bowel disease at a single institution from January 2009 to December 2013 were included. Factors associated with anastomotic leak and pelvic sepsis were assessed using univariate and multivariate analysis.

RESULTS

A total of 686 patients were included (mean age 39.5 years, 59% males). Postoperative oral steroid taper was associated with both anastomotic leak and pelvic sepsis on univariate analysis. Stress dose intravenous steroid use was not associated with complications. Multivariate analysis indicated total proctocolectomy (odds ratio [OR] 2.2; confidence interval [CI] 1.01-4.7, P = 0.047), and postoperative oral steroid taper (OR 2.3; CI 1.06-5.1; P = 0.035) as independent factors significantly associated with pelvic sepsis.

CONCLUSIONS

Prolonged postoperative oral steroid taper after ileal pouch-anal anastomosis should be avoided. If preoperative steroid weaning is not possible before a planned total proctocolectomy and ileal pouch-anal anastomosis, patients should undergo an initial total abdominal colectomy.