Publications by authors named "Luca Stocchi"

124 Publications

SSAT PG/CME Committee Symposium Highlights: Perioperative Management-Best Practice in Surgical Quality and Safety.

J Gastrointest Surg 2021 02 8;25(2):339-350. Epub 2021 Jan 8.

Department of Surgery, Division of Colorectal Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, Suite MA, Duarte, CA, LP-2230, USA.

Perioperative management entails the multiple substeps in the performance of major abdominal surgery that are considered relevant for an optimal outcome. The PG/CME symposium of the SSAT 2018 provided a set of key talks that the authors subsequently summarized in the respective subsections of this summary article. Highlights topics included oral antibiotics and mechanical bowel prep, surgical site infections, DVT prophylaxis, enhanced recovery after surgery (ERAS), and narcotic-sparing pain management.
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http://dx.doi.org/10.1007/s11605-020-04839-5DOI Listing
February 2021

Meckel's Diverticulum Masquerading as Crohn Disease.

Inflamm Bowel Dis 2020 Oct;26(11):e150-e151

Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA.

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http://dx.doi.org/10.1093/ibd/izaa178DOI Listing
October 2020

No need to watch the clock: persistence during laparoscopic sigmoidectomy for diverticular disease.

Surg Endosc 2020 Jun 17. Epub 2020 Jun 17.

Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave/A30, Cleveland, OH, 44195, USA.

Background: Laparoscopic sigmoidectomy is the preferred approach in the elective surgical management of diverticulitis. However, it is unclear if the benefits of laparoscopy persist when operative times are prolonged. We aimed to investigate if the recovery benefits associated with laparoscopy are retained when operative times are long.

Methods: A retrospective review of a prospectively maintained database of patients who underwent elective laparoscopic sigmoidectomy from 2010-2015 at a single academic tertiary institution was performed. Operative times among laparoscopic completed cases were divided into quartiles, and patient outcomes were compared between the groups.

Results: A total of 466 patients (median age: 58 ± 11.6 years, 58% females) underwent sigmoidectomy: 430 completed laparoscopically and 36 (7.7%) converted. Median operative time in laparoscopically completed cases was 188 min (IQR 154-230). There were no differences in morbidity (P = 0.52) or readmission rates (P = 0.22) among the quartiles. The 2nd and 4th operative time quartiles were associated with significantly longer length of stay (LOS) when compared to the fastest quartile (P = 0.003 and P = 0.002, respectively), but there was no increase in LOS as operative times progressed between the 2nd, 3rd, and 4th quartiles. LOS after conversion was longer but did not reach statistical significance when compared to laparoscopically completed operations in the longest quartile (5.0 vs 6.5 days, P = 0.075) CONCLUSIONS: Our data do not support preemptive conversion of laparoscopic sigmoidectomy to avoid prolonged operative times. As long as progress is safely being made, surgeons are justified to continue pursuing laparoscopic completion.
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http://dx.doi.org/10.1007/s00464-020-07717-yDOI Listing
June 2020

Greater Peripouch Fat Area on CT Image Is Associated with Chronic Pouchitis and Pouch Failure in Inflammatory Bowel Diseases Patients.

Dig Dis Sci 2020 12 4;65(12):3660-3671. Epub 2020 Jun 4.

Department of Gastroenterology/Hepatology, The Cleveland Clinic Foundation, Cleveland, OH, USA.

Background: The causes of chronic antibiotic refractory pouchitis (CARP) and pouch failure in inflammatory bowel disease (IBD) patients remain unknown. Our previous small study showed peripouch fat area measured by MRI was associated with pouchitis.

Aims: To explore the relationship between peripouch fat area on CT imaging and pouch outcomes.

Methods: This is a historical cohort study. Demographic, clinical, and radiographic data of IBD patients with abdominal CT scans after pouch surgery between 2002 and 2017 were collected. Peripouch fat areas and mesenteric peripouch fat areas were measured on CT images at the middle pouch level.

Results: A total of 435 IBD patients were included. Patients with higher peripouch fat areas had a higher prevalence of CARP. Univariate analyses demonstrated that long duration of the pouch, high weight or body mass index, the presence of primary sclerosing cholangitis or other autoimmune disorders, and greater peripouch fat area or mesenteric peripouch fat area were risk factors for CARP. Multivariable analyses demonstrated that the presence of primary sclerosing cholangitis or autoimmuned disorders, and greater peripouch fat area (odds ratio [OR] 1.031; 95% confidence interval [CI] 1.016-1.047, P < 0.001) or mesenteric peripouch fat area were independent risk factors for CARP. Of the 435 patients, 139 (32.0%) had two or more CT scans. Multivariable Cox proportional hazard analyses showed that "peripouch fat area increase ≥ 15%" (OR 3.808, 95%CI 1.703-8.517, P = 0.001) was an independent predictor of pouch failure.

Conclusions: A great peripouch fat area measured on CT image is associated with a higher prevalence of CARP, and the accumulation of peripouch fat is a risk factor for pouch failure. The assessment of peripouch fat may be used to monitor the disease course of the ileal pouch.
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http://dx.doi.org/10.1007/s10620-020-06363-7DOI Listing
December 2020

When should we add a diverting loop ileostomy to laparoscopic ileocolic resection for primary Crohn's disease?

Surg Endosc 2020 May 28. Epub 2020 May 28.

Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.

Background: The aims of this study were to determine risk factors for morbidity associated with laparoscopic ileocolic resection (LICR) for Crohn's disease (CD) and whether the addition of a diverting ileostomy is associated with reduced morbidity.

Methods: Patients undergoing LICR for primary CD at our institution from 2005 to 2015 included in a prospectively maintained database were assessed. The decision to perform a diverting ileostomy was left at the discretion of the operating surgeon. Demographics, disease-related, and treatment-related variables were evaluated using univariate and multivariate analyses as possible factors associated with diverting ileostomy creation and 30-day perioperative septic complications (anastomotic leaks and/or abscess). Use of any immunosuppressive medication was defined as use of steroids, biologics, and immunomodulators either alone or in combination.

Results: For 409 patients, mortality was nil, overall morbidity rate was 40.6%, conversion rate 9.3%, and septic morbidity rate 7.6%. A diverting stoma was created in 22% of cases and was independently associated with BMI < 18.5 kg/m (P = 0.001), low serum albumin levels (P = 0.006), and longer operative time (P = 0.003). Use of any immunosuppressive medication was the only variable independently associated with septic complications, both in the overall population (OR 2.7, P = 0.036) and in the subgroup of undiverted patients (OR 3.1, P = 0.031). There was no association between septic morbidity and ileostomy creation, anastomotic configuration, penetrating disease, combined procedures (other resection or strictureplasty), BMI, albumin levels, and operative times.

Conclusions: LICR is safe in selected cases of complex penetrating disease, including when combined procedures are necessary. Our data are unable to prove that a diverting stoma is associated with reduced morbidity.
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http://dx.doi.org/10.1007/s00464-020-07670-wDOI Listing
May 2020

Redo IPAA After a Failed Pouch In Patients With Crohn's Disease: Is It Worth Trying?

Dis Colon Rectum 2020 06;63(6):823-830

Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio.

Background: In selected patients with ulcerative colitis and pelvic pouch failure, redo pouch is an option. However, it is unknown whether selected patients with Crohn's disease should be offered a chance to avoid permanent diversion after failure of IPAA.

Objective: The objective was to compare the outcomes of redo pouch for ulcerative colitis and Crohn's disease.

Design: This was a retrospective analysis of a prospectively maintained pouch database (1983-2017).

Settings: The setting was the Cleveland Clinic.

Patients: This study included patients who underwent redo pouch with a primary surgical specimen diagnosis of ulcerative or Crohn's colitis at the time of initial pouch.

Main Outcome Measures: Pouch failure was defined as either pouch excision or indefinite pouch diversion. Patient characteristics, perioperative and functional outcomes, pouch survival, and quality of life were compared according to the diagnosis.

Results: Of 422 patients, 392 had ulcerative colitis and 30 had Crohn's disease. Age and sex were comparable. The most common indications for redo pouch included anastomotic separation and fistulas (220 (56.1%) in ulcerative colitis and 21 (70%) in Crohn's disease). The majority of redo pouches required mucosectomy with handsewn anastomosis (310 (79%) in ulcerative colitis and 30 (100%) in Crohn's disease; p = 0.23). A new pouch was constructed in 160 patients (41%) with ulcerative colitis and repair of old pouch in 231 patients (59%) compared with 25 (83%) in Crohn's disease, who had creation of new pouch; only in 5 (17%) was the old pouch re-anastomosed. Stool frequency, seepage, and fecal urgency were comparable between groups. Cumulative 5-year pouch survival was longer in ulcerative colitis versus Crohn's disease (88% vs 55%; p = 0.008). Major causes of redo failure in Crohn's disease were pouch fistulas and/or strictures occurring after ileostomy closure. These were more common in Crohn's disease than in ulcerative colitis (p < 0.001).

Limitations: This was a retrospective design.

Conclusions: Redo pouch can be offered to selected patients with colonic Crohn's disease diagnosed at the time of their primary pouch. See Video Abstract at http://links.lww.com/DCR/B206. REHACER LA ANASTOMOSIS ILEOANAL CON RESERVORIO DESPUéS DE UN RESERVORIO ILEAL FALLIDO EN PACIENTES CON ENFERMEDAD DE CROHN: ¿VALE LA PENA INTENTARLO?: En pacientes seleccionados con colitis ulcerativa y falla del reservorio pélvico, rehacer el reservorio es una opción. Sin embargo, se desconoce si en los pacientes seleccionados con enfermedad de Crohn se debería ofrecer la oportunidad de evitar la derivación permanente después de la falla de la anastomosis ileoanal con reservorio ileal.El objetivo fue comparar los resultados de reservorios re-hechos en colitis ulcerosa y la enfermedad de Crohn.El escenario fue la Cleveland Clinic.Análisis retrospectivo de una base de datos de reservorios ileales mantenida prospectivamente (1983-2017).Este estudio incluyó a pacientes que se sometieron a cirugía para rehacer el reservorio ileal con un diagnóstico en el espécimen quirúrgico primario de colitis ulcerosa o de Crohn en el momento del reservorio inicial.La falla del reservorio se definió como la escisión del reservorio o la derivación indefinida del reservorio. Las características del paciente, los resultados perioperatorios y funcionales, la supervivencia del reservorio y la calidad de vida se compararon de acuerdo con el diagnóstico.De 422 pacientes, 392 tenían colitis ulcerativa y 30 tenían enfermedad de Crohn. La edad y el género fueron comparables. Las indicaciones más comunes para rehacer el reservorio incluyeron dehiscencia anastomótica y fístulas [220 (56,1%) en colitis ulcerosa y 21 (70%) en la enfermedad de Crohn]. La mayoría de los reservorios rehechos requirieron mucosectomía con anastomosis manual [310 (79%) en colitis ulcerosa y 30 (100%) en la enfermedad de Crohn, p = 0.23]. Se construyó un nuevo reservorio en 160 (41%) pacientes con colitis ulcerativa y se reparó el reservorio antiguo en 231 (59%) pacientes, en comparación con 25 (83%) en la enfermedad de Crohn, que requirieron creación de un nuevo reservorio, y solo 5 (17%) donde el reservorio antiguo se volvió a anastomosar. La frecuencia de las evacuaciones, el manchado fecal y la urgencia fecal fueron comparables entre grupos. La supervivencia acumulada del reservorio a 5 años fue mayor en la colitis ulcerativa frente a la enfermedad de Crohn (88% frente a 55%, p = 0.008). Las principales causas de falla del reservorio rehecho en la enfermedad de Crohn fueron las fístulas del reservorio y / o las estenosis que ocurrieron después del cierre de ileostomía. Estas fueron más comunes en la enfermedad de Crohn que en la colitis ulcerativa (p <0.001).Este fue un diseño retrospectivo.Rehacer el reservorio ileal se puede ofrecer a pacientes seleccionados con enfermedad de Crohn colónica diagnosticada en el momento de su reservorio primario. Consulte Video Resumen en http://links.lww.com/DCR/B206. (Traducción-Dr Jorge Silva Velazco).
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http://dx.doi.org/10.1097/DCR.0000000000001644DOI Listing
June 2020

Conditional Survival After IPAA for Ulcerative and Indeterminate Colitis: Does Long-term Pouch Survival Improve or Worsen With Time?

Dis Colon Rectum 2020 07;63(7):927-933

Department of Colon & Rectal Surgery, Cleveland Clinic, Cleveland, Ohio.

Background: Risk factors for pouch survival may or may not have a linear relationship with pouch loss over time. Conditional survival is a method to describe these nonlinear time-to-event relationships by reporting the expected survival at various time points.

Objective: The aim of this study was to calculate conditional pouch survival based on occurrence of risk factors for pouch loss.

Design: This was a retrospective study from an institutional database.

Settings: The study was conducted at the Cleveland Clinic Foundation.

Patients: Patients with ulcerative or indeterminate colitis who underwent index IPAA construction between 1986 and 2016 were included.

Main Outcome Measures: Patients were stratified based on postoperative anastomotic leak, abscess, or fistula occurrence. The Kaplan-Meier method with conditional survival was used to estimate overall and cause-specific survival at 10 years.

Results: A total of 3468 patients underwent IPAA during the study period. The overall 10-year pouch survival rate was 0.94 (95% CI, 0.93-0.95), and after 1 year the conditional pouch survival increased to 0.95 (95% CI, 0.94-0.96), after 3 years to 0.97 (95% CI, 0.96-0.98), and after 5 years to 0.98 (95% CI, 0.98-0.99). A total of 122 patients (3.5%) developed anastomotic leak, and the 10-year IPAA survival in patients with leak was 0.85 (95% CI, 0.77-0.93). In this group, after 1 year of pouch survival, the conditional pouch survival increased to 0.89 (95% CI, 0.82-0.96) and after 3 years to 0.98 (95% CI, 0.94-1.00). A similar pattern was seen for IPAA with postoperative abscess. The conditional survival curve was stable over time for patients with a fistula.

Limitations: This was a retrospective, single-institution study.

Conclusions: Overall conditional pouch survival improved over time for patients with postoperative anastomotic leak and abscess. These novel findings can be useful to counsel patients regarding expectations for long-term pouch survival even if they develop leaks and abscesses. See Video Abstract at http://links.lww.com/DCR/B217. SUPERVIVENCIA CONDICIONAL DESPUÉS DE ANASTOMOSIS CON BOLSA ÍLEO ANAL, PARA COLITIS ULCERATIVA E INDETERMINADA: ¿LA SOBREVIDA DE LA BOLSA A LARGO PLAZO, MEJORA O EMPEORA CON EL TIEMPO?: Los factores de riesgo para la sobrevida de la bolsa, pueden o no tener una relación lineal con la pérdida de la bolsa y con el tiempo. La supervivencia condicional es un método para describir estas relaciones no lineales de tiempo, hasta el evento informando la supervivencia esperada en varios puntos de tiempo.El objetivo de este estudio fue calcular la supervivencia condicional de la bolsa, en función de aparición de factores de riesgo para la pérdida de bolsa.Estudio retrospectivo de una base de datos institucional.Cleveland Clinic Foundation.Pacientes con colitis ulcerativa o indeterminada, sometidos a una anastomosis de bolsa íleo anal, de 1986 a 2016.Los pacientes fueron estratificados en función de la fuga anastomótica postoperatoria, absceso o aparición de fístula. El método de Kaplan Meier con supervivencia condicional, se utilizó para estimar la supervivencia general y la causa específica a los 10 años.Un total de 3.468 pacientes fueron sometidos a anastomosis ileal con bolsa anal durante el período de estudio. La tasa de supervivencia global de la bolsa a 10 años, fue de 0,94 (0,93 a 0,95), y después de 1 año, la supervivencia condicional de la bolsa aumentó a 0,95 (0,94 a 0,96), después de 3 años a 0,97 (0,96 a 0,98) y después de 5 años a 0.98 (0.98 - 0.99). Un total de 122 (3,5%) pacientes desarrollaron fuga anastomótica, y la supervivencia de la anastomosis de bolsa íleo anal a 10 años en pacientes con fuga fue de 0,85 (IC del 95%: 0,77 a 0,93). En este grupo, después de 1 año de supervivencia de la bolsa, la supervivencia condicional de la bolsa aumentó a 0,89 (IC del 95%: 0,82 a 0,96), y después de 3 años a 0,98 (IC del 95%: 0,94 a 1). Se observó un patrón similar para la anastomosis de bolsa íleo anal con absceso postoperatorio. La curva de supervivencia condicional fue estable en el tiempo para los pacientes con una fístula.Estudio retrospectivo, de una sola institución.La supervivencia condicional global de la bolsa, mejoró con el tiempo para pacientes con fuga anastomótica postoperatoria y absceso. Estos nuevos hallazgos pueden ser útiles para aconsejar a los pacientes con respecto a las expectativas de supervivencia de la bolsa a largo plazo, incluso si desarrollan fugas y abscesos. Consulte Video Resumen http://links.lww.com/DCR/B217. (Traducción-Dr Fidel Ruiz Healy).
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http://dx.doi.org/10.1097/DCR.0000000000001629DOI Listing
July 2020

Mesenteric excision surgery or conservative limited resection in Crohn's disease: study protocol for an international, multicenter, randomized controlled trial.

Trials 2020 Feb 21;21(1):210. Epub 2020 Feb 21.

Center for Inflammatory Bowel Diseases, Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China.

Background: The structures of the mesentery including adipose tissue, nerves, and lymphatics play an important role in the pathogenesis and disease progression of Crohn's disease (CD). Conventional surgical resection for CD usually does not involve resecting the mesentery en bloc with the specimen. This contrasts with complete mesocolic excision (CME) in colorectal cancer, which involves radical resection of the mesentery. Preliminary evidence from smaller studies suggests that applying the principle of mesocolic excision to CD surgery may reduce the risk of postoperative recurrence. This randomized controlled trial is designed to test whether applying the principles of mesocolic excision to CD results in reduced postoperative recurrence. It also aims to evaluate intra- and postoperative morbidity between the two approaches.

Methods: This international, multicenter, randomized controlled trial will randomize patients (n = 116) scheduled to undergo primary ileocolic resection to either receive extensive mesenteric excision (EME) or conventional ileocolic resection with limited mesenteric excision (LME). Five sites will recruit patients in three countries. In the EME group, the mesentery is resected following CME, while avoiding the root region, i.e., 1 cm from the root of the ileocolic artery and vein. In the LME group, the mesentery is retained, i.e., "close shave" or < 3 cm from the border of bowel. The primary end point will be surgical recurrence after surgery. The secondary end points will be the postoperative endoscopic and clinical recurrence, and intra- and postoperative morbidity. Demographics, risk factors, laboratory investigations, endoscopy, postoperative prophylaxis and imaging examination will be assessed. Analysis of the primary outcome will be on an intention-to-treat basis.

Discussion: If mesocolic excision in CD reduces postoperative disease recurrence and does not increase morbidity, this trial has the potential to change practice and reduce recurrence of CD after surgical resection.

Trial Registration: Clinical Trials.gov, ID: NCT03769922. Registered on February 27, 2019.
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http://dx.doi.org/10.1186/s13063-020-4105-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7035646PMC
February 2020

Multivariate Prediction of Intraoperative Abandonment of Ileal Pouch Anal Anastomosis.

Dis Colon Rectum 2020 05;63(5):639-645

Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida.

Background: Restorative total proctocolectomy with IPAA may not be feasible in some patients because of technical intraoperative limitations.

Objective: This study aimed to assess preoperative predictors for intraoperative IPAA and review management.

Design: This is a retrospective review.

Setting: This study was conducted at Cleveland Clinic between January 2010 and May 2018.

Patients: Patients ≥18 years of age who underwent ileoanal pouch surgery were included. Patients with successful pouch creation as planned were grouped as "successful IPAA creation." Operative reports of patients who underwent alternative procedures were reviewed to identify cases when the pouch was preoperatively planned but intraoperatively abandoned (IPAA-abandoned group). Multivariate logistic regression models were developed to determine predictors of intraoperative pouch abandonment. We also reviewed the management of patients in whom the initial pouch creation failed.

Main Outcome Measures: The primary outcomes measured were preoperative predictors for intraoperative ileoanal pouch abandonment.

Results: A total of 1438 patients were offered an ileoanal pouch; 21 (1.5%) experienced pouch abandonment due to inadequate reach (n = 17) and other technical reasons (n = 4). These patients underwent alternative procedures such as end or loop ileostomy with/without proctectomy. Multivariate logistic regression analysis indicated male sex (OR, 6.021; 95% CI, 1.540-23.534), BMI (OR, 1.217; 95% CI, 1.114-1.329), and a 2-stage procedure (OR, 14.510; 95% CI, 4.123-51.064) as independent factors associated with intraoperative abandonment of pouch creation. Alternative procedures were total proctocolectomy with end ileostomy (n = 14) and total abdominal colectomy with end ileostomy without proctectomy (n = 7). Ultimately, pouch creation was achieved in 6 of 21 patients after a median interval of 8.8 (range, 4.1-34.8) months. All patients had intentional weight loss before a reattempt and total abdominal colectomy with end ileostomy without proctectomy as their initial procedure.

Limitations: This study was limited by its retrospective nature.

Conclusions: Ileoanal pouch abandonment is rare and can be mitigated by initial total abdominal colectomy and weight loss. Male, obese patients are at a higher risk of failure. Intraoperative assessment of ileoanal pouch feasibility should occur before rectal dissection. See Video Abstract at http://links.lww.com/DCR/B156. PREDICCIÓN MULTIVARIANTE DEL ABANDONO INTRAOPERATORIO DE LA ANASTOMOSIS ANAL CON BOLSA ILEAL: La proctocolectomía total restaurativa con anastomosis de bolsa ileoanal puede no ser posible en algunos pacientes debido a limitaciones técnicas intraoperatorias.Evaluar los predictores preoperatorios para el abandono intraoperatorio de la bolsa ileoanal y revisar el manejo.Revisión retrospectiva.Cleveland Clinic entre Enero de 2010 y mayo de 2018.Pacientes > 18 años que se sometieron a cirugía de bolsa ileoanal. Los pacientes con una creación exitosa de la bolsa según lo planeado se agruparon como "creación exitosa de anastomosis de bolsa ileoanal". Se revisaron los informes operativos de los pacientes que se sometieron a procedimientos alternativos para identificar los casos en que la bolsa se planificó preoperatoriamente pero se abandonó intraoperatoriamente (grupo de "anastomosis anal de bolsa ileoanal abandonada"). Se desarrollaron modelos de regresión logística multivariante para determinar los predictores del abandono intraoperatorio de la bolsa. También revisamos el manejo de pacientes que fallaron en la creación inicial de la bolsa.Predictores preoperatorios para el abandono intraoperatorio de la bolsa ileoanal.A un total de 1438 pacientes se les ofreció una bolsa ileoanal; 21 (1.5%) experimentaron abandono de la bolsa debido a un alcance inadecuado (n = 17) y otras razones técnicas (n = 4). Estos pacientes se sometieron a procedimientos alternativos como ileostomía final o de asa con / sin proctectomía. El análisis de regresión logística multivariante indicó género masculino (OR, 6.021; IC 95%, 1.540-23.534), índice de masa corporal (OR, 1.217; IC 95%, 1.114-1.329) y procedimiento en 2 etapas (OR, 14.510; IC 95%, 4.123-51.064) como factores independientes asociados con el abandono intraoperatorio de la creación de la bolsa. Los procedimientos alternativos fueron la proctocolectomía total con ileostomía final (n = 14) y la colectomía abdominal total con ileostomía final sin proctectomía (n = 7). Finalmente, la creación de la bolsa se logró en 6/21 pacientes después de un intervalo medio de 8.8 (rango, 4.1-34.8) meses. Todos los pacientes tuvieron pérdida de peso intencional antes de la reintenta y colectomía abdominal total con ileostomía final sin proctectomía como procedimiento inicial.Naturaleza retrospectiva.El abandono de la bolsa ileoanal es raro y puede mitigarse mediante la colectomía abdominal total inicial y la pérdida de peso. Los pacientes masculinos y obesos tienen un mayor riesgo de fracaso. La evaluación intraoperatoria de la viabilidad de la bolsa ileoanal debe ocurrir antes de la disección rectal. Consulte Video Resumen en http://links.lww.com/DCR/B156. (Traducción-Dr. Yesenia Rojas-Kahlil).
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May 2020

Lower peripouch fat area is related with increased frequency of pouch prolapse and floppy pouch complex in inflammatory bowel disease patients.

Int J Colorectal Dis 2020 Apr 4;35(4):665-674. Epub 2020 Feb 4.

Department of Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA.

Background: Pouch prolapse is a rare pouch complication which often leads to pouch failure in inflammatory bowel disease (IBD) patients. Its exact cause remains unknown. Floppy pouch complex (FPC) was defined as the presence of any one of the following pouch disorders: pouch prolapse, afferent limb syndrome (ALS), redundant loop, and pouch folding. We aimed to explore the role of peripouch fat area in the occurrence of pouch prolapse and FPC.

Methods: Pouch patients with available pouchoscopy and abdominal CT scans who were followed up between 2011 and 2017 in Cleveland Clinic were reviewed. Peripouch fat was measured on CT images.

Results: Of the 93 included patients, 31 were females; 87 had J pouches and 6 had S pouches. The median duration of pouch was 8.0 (interquartile range [IQR] 5.0-16.5) years. A total of 18 cases (19.4%, 18/93) were identified as FPC, including 12 pouch prolapse, 5 ALS, 1 redundant loop, and 3 pouch folding. Patients with pouch prolapse had lower peripouch fat area (13.6 (9.3-18.5) vs. 27.6 (11.0-46.2)cm, P = 0.022) than those without. Patients with FPC had lower peripouch fat area (15.4 (11.4-20.6) vs. 27.6 (11.0-46.9)cm, P = 0.040) than those without. Univariate and multivariate analyses demonstrated that lower peripouch fat area, lower weight, and family history of IBD were independent predictors of pouch prolapse and FPC.

Conclusions: A lower peripouch fat area was observed in inflammatory bowel disease patients with pouch prolapse and FPC. Longitudinal studies are needed to further elucidate the role of peripouch fat in the pathogenesis of pouch prolapse and FPC.
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http://dx.doi.org/10.1007/s00384-019-03469-xDOI Listing
April 2020

Saline versus Lactated Ringer's Solution: The Saline or Lactated Ringer's (SOLAR) Trial.

Anesthesiology 2020 04;132(4):614-624

From the Department of General Anesthesiology (K.M., A.T., W.A.S.E., K.R., S.B., A.G.K., M.R.R., T.K., G.R.B., A.K.) Department of Outcomes Research (K.M., A.T., N.M., C.M., K.R., H.E., B.C., I.S., G.R.B., D.C., E.J.M., A.K., D.I.S.) Department of Quantitative Health Sciences (N.M., C.M., E.J.M.) Department of Orthopedic Surgery (C.H.-R.), Cleveland Clinic, Cleveland, Ohio the Division of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, Florida (L.S.) the Division of Anesthesia, Critical Care, and Pain Management, Tel-Aviv Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel (B.C.) the Department of Anesthesia, St. Elizabeth's Medical Center, Boston, Massachusetts (I.S.).

Background: Both saline and lactated Ringer's solutions are commonly given to surgical patients. However, hyperchloremic acidosis consequent to saline administration may provoke complications. The authors therefore tested the primary hypothesis that a composite of in-hospital mortality and major postoperative complications is less common in patients given lactated Ringer's solution than normal saline.

Methods: The authors conducted an alternating cohort controlled trial in which adults having colorectal and orthopedic surgery were given either lactated Ringer's solution or normal saline in 2-week blocks between September 2015 and August 2018. The primary outcome was a composite of in-hospital mortality and major postoperative renal, respiratory, infectious, and hemorrhagic complications. The secondary outcome was postoperative acute kidney injury.

Results: Among 8,616 qualifying patients, 4,187 (49%) were assigned to lactated Ringer's solution, and 4,429 (51%) were assigned to saline. Each group received a median 1.9 l of fluid. The primary composite of major complications was observed in 5.8% of lactated Ringer's versus 6.1% of normal saline patients, with estimated average relative risk across the components of the composite of 1.16 (95% CI, 0.89 to 1.52; P = 0.261). The secondary outcome, postoperative acute kidney injury, Acute Kidney Injury Network stage I-III versus 0, occurred in 6.6% of lactated Ringer's patients versus 6.2% of normal saline patients, with an estimated relative risk of 1.18 (99.3% CI, 0.99 to 1.41; P = 0.009, significance criterion of 0.007). Absolute differences between the treatment groups for each outcome were less than 0.5%, an amount that is not clinically meaningful.

Conclusions: In elective orthopedic and colorectal surgery patients, there was no clinically meaningful difference in postoperative complications with lactated Ringer's or saline volume replacement. Clinicians can reasonably use either solution intraoperatively.
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http://dx.doi.org/10.1097/ALN.0000000000003130DOI Listing
April 2020

Impact of preoperative duration of ulcerative colitis on long-term outcomes of restorative proctocolectomy.

Int J Colorectal Dis 2020 Jan 23;35(1):41-49. Epub 2019 Nov 23.

Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue, A30, Cleveland, Ohio, 44195, USA.

Background: It is unknown if ulcerative colitis (UC) duration has an impact on outcomes of ileal pouch anal anastomosis (IPAA). The aim of the study was to compare the long-term IPAA outcomes based on preoperative UC duration.

Methods: All patients with pathologically confirmed UC who underwent IPAA were included from a prospectively maintained pouch database (1983-2017).Patient's cohort was stratified according to UC duration:< 5 years,5-10 years,10-20 years,> 20 years. UC duration was defined as time interval from date of preoperative diagnosis to colectomy date. The main outcome was Kaplan-Meier pouch survival. Secondary outcomes were pouch function and quality of life.

Results: Out of 4502 IPAAs (1983-2016), 2797 patients were included. Treated with biologics versus 12% with UC duration > 20 years were 41% patients with UC duration < 5 years. Treated with steroids compared to shortest (34%,p < 0.001) were 54% patients with the longest disease. A total of 65% of patients with shortest disease had IPAAs performed mostly in 3 stages. Anastomotic separation and pelvic sepsis were more prevalent among shortest compared to longest disease groups. Rates of pouch-targeted fistulas, anastomotic strictures, and pouchitis were highest in longest disease group. Pouch survival was similar between groups. Multivariate analysis did not show a significant association between UC duration and pouch failure [1.05(0.97-1.1), p = 0.23].Longer UC duration was associated with increased odds of pouchitis [1.2(1.1, 1.3), p < 0.001]. Biologics agents were shown to be protective against pouchitis.

Conclusions: Preoperative UC duration does not increase pouch failure risk. Longer preoperative UC duration increases the pouchitis risk. Biologic agents and three-staged IPAA are protective against pouchitis and septic complications in long-term among patients with UC.
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http://dx.doi.org/10.1007/s00384-019-03449-1DOI Listing
January 2020

Parenteral Nutrition Instead of Early Reoperation in the Management of Early Postoperative Small Bowel Obstruction.

J Gastrointest Surg 2020 01 26;24(1):109-114. Epub 2019 Aug 26.

Digestive Diseases and Surgery Institute, Cleveland Clinic, 9500 Euclid Ave Desk A100, Cleveland, OH, 44195, USA.

Background: In majority of patients, early postoperative small bowel obstruction (EPSBO) resolves with nasogastric decompression and bowel rest alone, while in some patients, symptoms persist without urgent indications for surgery. The purpose of this study was the evaluation of home parenteral nutrition (HPN) instead of elective surgery as an initial approach to persistent EPSBO.

Methods: Patients developing EPSBO prescribed HPN without reoperation within 6 weeks after index intestinal surgery were identified from an institutional HPN registry and retrospectively compared with patients undergoing reoperation for EPSBO within the same time period.

Results: Thirty-four patients for the HPN group and 27 patients in elective reoperative (REOP) group met the inclusion criteria. In the HPN group, mean interval between surgery and PN initiation was 11 days. HPN duration ranged from 17 to 244 days with a median of 60 days. Thirty-one patients (91%) successfully recovered bowel function and resumed enteral nutrition without reoperation, while 3 patients required reoperation > 6 weeks after index surgery due to HPN failure. In the REOP group, mean interval between index surgery and reoperation was 17 days. At reoperation, 12 patients required bowel resection, 5 having incidental enterotomies, and 3 required new stoma creation. Postoperatively, 2 patients developed enterocutaneous fistulas, 1 experienced an anastomotic leak, and another had fascial dehiscence.

Conclusion: HPN is a safe alternative to elective surgery in clinically stable patients with persistent EPSBO. This approach avoids hazardous reoperation during the recovery phase when adhesions are at their worst.
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http://dx.doi.org/10.1007/s11605-019-04347-1DOI Listing
January 2020

Does laparoscopic ileal pouch-anal anastomosis reduce infertility compared with open approach?

Surgery 2019 10 14;166(4):670-677. Epub 2019 Aug 14.

Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH.

Background: The aim of this study was to assess the association of the mode of surgery on female fertility after restorative proctocolectomy with ileal pouch-anal anastomosis.

Methods: All female patients aged 18 to 44 years who underwent restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis, familial adenomatous polyposis, or Crohn's disease at the Cleveland Clinic Ohio or the Cleveland Clinic Florida from 1983 to 2012 were sent a standardized fertility questionnaire. Infertility was defined as lack of pregnancy after 1 year of unprotected sexual intercourse. Patients who had attempted to conceive after restorative proctocolectomy with ileal pouch-anal anastomosis were compared based on the surgical approach: laparoscopic ileal pouch-anal anastomosis versus open ileal pouch-anal anastomosis.

Results: A total of 890 female patients were surveyed, of which 519 (58.3%) responded. Of these, 161 (31%) had attempted pregnancy after surgery: 18 (12%) had laparoscopic ileal pouch-anal anastomosis and 143 (88%) had open ileal pouch-anal anastomosis. There were no significant differences regarding demographics between groups. There was no difference in reported infertility rates (61.1% vs 65%, respectively, P = 0.69) between the laparoscopic ileal pouch-anal anastomosis and open ileal pouch-anal anastomosis groups. The median time to pregnancy (3.5 months vs 9 months, respectively, log-rank P = 0.01) was reduced in patients who underwent laparoscopic ileal pouch-anal anastomosis compared with those who underwent open ileal pouch-anal anastomosis.

Conclusion: Postoperative infertility rates were higher after ileal pouch-anal anastomosis regardless of mode of surgery. However, laparoscopy was associated with a significantly reduced time to conceive compared with the open approach.
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http://dx.doi.org/10.1016/j.surg.2019.04.045DOI Listing
October 2019

Do Patients With Inflammatory Bowel Disease Benefit from an Enhanced Recovery Pathway?

Inflamm Bowel Dis 2020 02;26(3):476-483

Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH, USA.

Background: Enhanced recovery pathways (ERPs) have been shown to reduce length of stay (LOS), complications, and costs after colorectal surgery; yet, little data exists regarding patients with inflammatory bowel disease (IBD). We hypothesized that implementation of ERP for IBD patients is associated with shorter LOS and improved economic outcomes.

Methods: An IRB-approved prospective clinical database was used to identify consecutive patients from 2015 to 2017. Patients were grouped as "pre-ERP" and "post-ERP" based on the date of implementation of a comprehensive ERP. Ileostomy closures, redo pouch operations, and outpatient operations were excluded. The relationship between ERP, LOS, and secondary outcomes was assessed using univariate and multivariate analysis.

Results: Overall, a total of 671 patients were included: 345 (51.4%) with Crohn's disease (CD) and 326 (48.6%) with ulcerative colitis (UC). Of these, 425 were pre-ERP (63.4%), and 246 were post-ERP (36.6%). The groups did not differ in terms of age, gender, American Society of Anesthesiologist (ASA) scores, comorbidities, estimated blood loss, or ostomy construction. The post-ERP group had a significantly higher mean body mass index (BMI), more patients with CD, longer operative time, and more minimally invasive surgery (MIS; all P < 0.05). The post-ERP group had a significantly shorter LOS (6 vs 4.5 days, median), whereas mean hospital costs decreased by 15.7%. There was no difference in readmissions or complications. On multivariate analysis, MIS and ERP use were both associated with a shorter LOS.

Conclusion: Inflammatory bowel disease patients benefit from the use of ERP, demonstrating decreased LOS and costs without an increase in complications and readmissions. Enhanced recovery pathways should be routinely implemented in this often challenging patient population.
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February 2020

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

J Crohns Colitis 2019 Jul;13(7):856-863

Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA.

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.
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http://dx.doi.org/10.1093/ecco-jcc/jjz004DOI Listing
July 2019

Diverticular Colovaginal Fistulas: What Factors Contribute to Successful Surgical Management?

Dis Colon Rectum 2019 09;62(9):1079-1084

Department of Colon and Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio.

Background: Diverticular disease is the leading cause of colovaginal fistulas. Surgery is challenging given the inflammatory process that makes dissection difficult. To date, studies are small and include fistula secondary to multiple etiologies.

Objective: The objectives of this study were to examine surgical outcomes of diverticular colovaginal fistulas and to identify variables associated with successful closure.

Design: This was a retrospective study of a prospectively maintained clinical database.

Settings: The study was conducted at a single tertiary referral center.

Patients: Women with diverticular colovaginal fistulas, who underwent surgical repair with intent to close the fistula, were included.

Interventions: Repair of colovaginal fistula through minimally invasive or open techniques was involved.

Main Outcome Measures: Successful closure of fistula, defined as resolution of symptoms and no stoma, was measured.

Results: Fifty-two patients underwent surgical treatment of diverticular colovaginal fistula, 23 (44%) of whom underwent a minimally invasive approach (conversion rate of 22%). Ostomy construction and omental pedicle flaps were used in 28 (54%) and 38 patients (73%). Surgery was successful in 47 patients (90%). Accounting for secondary operations, ultimate success and failure rates were 49 (94.0%) and 3 (5.7%). There was no difference in postoperative morbidity between the 2 groups (5 patients with Clavien-Dindo III/IV complications in the success group versus 2 patients in the failure group; 10.6% vs 40.0%; p = 0.44). Failure to achieve fistula closure was not associated with perioperative variables, age, BMI, diabetes mellitus, ASA grade, steroid use, previous abdominal surgery or hysterectomy, use of omentoplasty, or ostomy. Patients who failed were more likely to be smokers (60.0% vs 12.8%; p = 0.03).

Limitations: Limitations include the retrospective design and lack of power.

Conclusions: Surgery is effective in achieving successful closure of diverticular colovaginal fistula. Smokers should be encouraged to stop before embarking on an elective repair. Although the use of fecal diversion and omental pedicle flaps did not correlate with success, they should be used when clinically appropriate. See Video Abstract at http://links.lww.com/DCR/A983. FÍSTULAS COLOVAGINALES DIVERTICULARES ¿QUÉ FACTORES CONTRIBUYEN AL ÉXITO DEL TRATAMIENTO QUIRÚRGICO?: La enfermedad diverticular es la causa principal de fístulas colovaginales. La cirugía es un reto dado el proceso inflamatorio que dificulta la disección. Hasta la fecha, los estudios son pequeños e incluyen fístulas secundarias a múltiples etiologías.

Objetivo: 1) Examinar los resultados quirúrgicos de las fístulas colovaginales diverticulares; 2) Identificar variables asociadas a un cierre exitoso. DISEÑO:: Estudio retrospectivo de una base de datos clínicos prospectivamente mantenida. CONFIGURACIÓN:: Centro de referencia superior.

Pacientes: Mujeres con fístulas colovaginales diverticulares, que se sometieron a una reparación quirúrgica con la intención de cerrar la fístula.

Intervenciones: Reparación de la fístula colovaginal mediante técnicas mínimamente invasivas o abiertas.

Medidas De Resultados Principales: Cierre exitoso de la fístula definida como resolución de los síntomas y sin estoma.

Resultados: Cincuenta y dos pacientes se sometieron a tratamiento quirúrgico de la fístula colovaginal diverticular, 23 (44%) de los cuales se sometieron a un acceso mínimamente invasivo (tasa de conversión del 22%). La construcción de la ostomía y los pedículos omentales se utilizaron en 28 (54%) y 38 pacientes (73%), respectivamente. La cirugía fue exitosa en 47 pacientes (90%). Tomando en cuenta las operaciones secundarias, las tasas finales de éxito y fracaso fueron 49 (94.0%) y 3 (5.7%). No hubo diferencias en la morbilidad postoperatoria entre los dos grupos (5 pacientes con complicaciones de Clavien-Dindo III / IV en el grupo de éxito versus a 2 pacientes en el grupo de fracaso, 10.6% versus a 40.0%; p = 0.44). El fracaso para lograr el cierre de la fístula no se asoció con variables perioperatorios, edad, IMC, diabetes, grado ASA, uso de esteroides, cirugía abdominal previa o histerectomía, uso de omentoplastia u ostomía. Los pacientes que fracasaron eran más propensos a ser fumadores (60.0% versus a 12.8%; p = 0.03).

Limitaciones: Las limitaciones incluyen el diseño retrospectivo y la falta de poder.

Conclusiones: La cirugía es efectiva para lograr el cierre exitoso de la fístula colovaginal diverticular. Se debe aconsejar a los fumadores a parar de fumar antes de embarcarse en una reparación electiva. Mientras el uso de desviación fecal y pedículos omentales no se correlacionó con el éxito, deberían utilizarse cuando sea clínicamente apropiado. Consulte el Video del Resumen en http://links.lww.com/DCR/A983.
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September 2019

Predictors of one-year outcomes following the abdominoperineal resection.

Am J Surg 2019 07 29;218(1):119-124. Epub 2018 Aug 29.

Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA. Electronic address:

Purpose: This study aimed to determine one-year outcomes and the impact of various factors on the need for readmission and reoperation following abdominoperineal resection (APR).

Method: A multivariate logistic regression analysis was conducted to determine predictors of readmission and/or reoperation within one year of APR performed between January-2000 and December-2013.

Results: 536 patients were analyzed for whom the most common indication for surgery was rectal cancer(86.4%). Within one year of operation, 14.2% (n = 76) of patients have major (grade III/IV of Clavien-Dindo [CD]) and 26.1%(n = 140) of patients have minor complications (grade I/II of CD). Respective major and minor perineal wound complication(PWC) rates were 10.4% and 5.6%.Readmission and reoperation rates within 90 days following discharge were 25% and 8.8%, respectively. While PWC (n = 53,39.2%) and small bowel obstruction(n = 23,17%) were the most common causes of readmission within 90 days,PWC(n = 20,23.3%) and distant metastasis(n = 20,23.3%) were the main causes of long-term readmission(90-day to 1 year).

Conclusion: Perineal wound complications were the most common cause of readmission and reoperation within one year of APR. Well-coordinated efforts aimed at decreasing the perineal wound morbidity may impact the need for readmission and reoperation.
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http://dx.doi.org/10.1016/j.amjsurg.2018.08.021DOI Listing
July 2019

Outcome Comparison of Single-port Versus Multiport Versus Under Direct View Completion Proctectomy With Ileal-Pouch Anal Anastomosis for Patients With Ulcerative Colitis.

Surg Laparosc Endosc Percutan Tech 2019 Oct;29(5):373-377

Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH.

Purpose: Whether the reported theoretical benefits of single-port laparoscopic (SPL) approach can be converted to superior clinical outcomes is still unknown for ulcerative colitis (UC) patients undergoing second-stage proctectomy. This study aimed to compare the short-term postoperative and long-term pouch-related functional outcomes of SPL, multiport laparoscopic (MPL), and direct view (DV) completion proctectomy with ileal-pouch anal anastomosis (CP/IPAA).

Materials And Methods: Patients who underwent either SPL, MPL, or under DV CP/IPAA for UC between August 2009 and August 2014 were identified from an institutional review board-approved, prospectively maintained institutional database and reviewed. Demographics, patient characteristics, short-term and long-term complications, and morbidity were compared between the 3 groups. Multivariate logistic or Cox regression analysis was conducted for covariate adjustments.

Results: Groups (SPL: n=36; MPL: n=67; DV: n=97) were comparable in terms of preoperative characteristics and demographics except for age. The SPL group was associated with reduced estimated blood loss, reduced length of stay compared with the MPL and DV groups, and shorter operating time compared with the MPL group (P<0.001). Similar short-term postoperative and long-term pouch-related functional outcomes were noted without significant differences in quality of life scores among the 3 groups.

Conclusions: SPL CP/IPAA for UC can be safely performed with superior short-term outcomes such as reduced intraoperative blood loss and length of hospital stay compared with MPL and under direct view approaches, and shorter operating time compared with MPL.
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http://dx.doi.org/10.1097/SLE.0000000000000674DOI Listing
October 2019

Endoscopic stricturotomy versus ileocolonic resection in the treatment of ileocolonic anastomotic strictures in Crohn's disease.

Gastrointest Endosc 2019 08 30;90(2):259-268. Epub 2019 Jan 30.

Interventional Inflammatory Bowel Disease (i-IBD) Unit and Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA.

Background And Aims: Endoscopic stricturotomy (ESt) is a novel technique in the treatment of anastomotic strictures in Crohn's disease (CD). The aim of this study was to compare the outcome of patients with ileocolonic anastomotic stricture treated with ESt versus ileocolonic resection (ICR).

Methods: This historical cohort study included consecutive CD patients with ileocolonic anastomotic stricture treated with ESt or ICR from 2010 to 2017. The primary outcomes were surgery-free survival and postprocedural adverse events.

Results: Thirty-five patients treated with ESt and 147 patients treated with ICR were analyzed. Median follow-up was .8 years (interquartile range [IQR], .2-1.7) and 2.2 years (IQR, 1.2-4.4) in the ESt and ICR groups, respectively (P < .001). Subsequent stricture-related surgery was needed in 4 patients (11.3%) receiving ESt and in 15 patients (10.2%) receiving ICR (P = .83). Kaplan-Meier analysis also showed no statistical difference regarding surgery-free survival between the 2 groups (P = .24). Procedure-related major adverse events were documented in 5 of 49 patients (10.2% per procedure) undergoing ESt and 47 patients (31.9%) undergoing ICR (P = .003). Risk factors for decreased surgery-free survival on multivariate analysis included preprocedural corticosteroids (hazard ratio [HR], 2.8; 95% confidence interval [CI], 1.0-8.1), multiple strictures (HR, 4.9; 95% CI, 1.7-14.2), and increased disease-related hospitalizations (HR, 4.0; 95% CI, 1.2-13.0).

Conclusions: With the limitation of a shorter follow-up, ESt achieved comparable surgery-free survival with a decreased morbidity when compared with ICR.
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August 2019

What Is the Best Surgical Treatment of Pouch-Vaginal Fistulas?

Dis Colon Rectum 2019 05;62(5):595-599

Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio.

Background: Pouch-vaginal fistula is a debilitating condition with no single best surgical treatment described. Closure of these fistulas can be incredibly difficult, and transanal, transabdominal, and transvaginal approaches have been reported with varying success rates. Recurrence is a major problem and could eventually result in repeat redo pouch or permanent diversion.

Objective: The aim of our study was to investigate healing rates for procedures done for pouch-vaginal fistula closure.

Design: This is a retrospective analysis of a prospectively maintained database complemented by chart review.

Settings: This study reports data of a tertiary referral center.

Patients: Patients who underwent surgery for pouch-vaginal fistula from 2010 to 2017 were identified. Patients who underwent surgery with intent to close the fistula were included, and patients who had inadequate follow-up to verify fistula status were excluded.

Interventions: Patients included underwent surgery to close pouch-vaginal fistula.

Main Outcome Measures: Success of the surgery was the main outcome measure. Success was defined as procedures with no reported recurrence of fistula on last follow-up.

Results: A total of 70 patients underwent surgery with an intent to close the pouch-vaginal fistula, 65 of whom had undergone index IPAA for ulcerative colitis, but 13 of these patients later had the diagnosis changed to Crohn's disease. Thirty-nine patients (56%) had a fistula originating from anal transition zone to dentate line to the vagina (not at the pouch anastomosis). In the total group of 70 patients, our successful closure rate was 39 (56%) of 70. Procedures with the highest success rates were perineal ileal pouch advancement flap and redo IPAA (61% and 69%).

Limitations: The retrospective nature and small number of cases are the limitations of the study.

Conclusions: Although numerous procedures may be used in an attempt to close pouch-vaginal fistula, pouch advancement and redo pouch were the most successful in closing the fistula. See Video Abstract at http://links.lww.com/DCR/A841.
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May 2019

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

Inflamm Bowel Dis 2019 07;25(8):1383-1389

Cleveland Clinic, Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland, Ohio, USA.

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.
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July 2019

Surgical outcomes of patients treated with ustekinumab vs. vedolizumab in inflammatory bowel disease: a matched case analysis.

Int J Colorectal Dis 2019 Mar 10;34(3):451-457. Epub 2018 Dec 10.

Department of Colorectal Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA.

Aim: The association between preoperative use of monoclonal antibodies in inflammatory bowel disease (IBD) patients and postoperative complications is controversial, especially for the latest approved biologics, ustekinumab and vedolizumab, where data is limited. We hypothesized that ustekinumab-treated patients would have a similar overall postoperative complication rate as vedolizumab-treated patients. The aim of this study was to compare postoperative complications in patients receiving preoperative ustekinumab vs. vedolizumab.

Methods: We queried our IRB-approved prospective database to identify Crohn's patients who underwent colorectal surgery and pretreatment with ustekinumab or vedolizumab within 12 weeks of surgery. Ustekinumab-treated patients were matched to vedolizumab-treated patients based on sex, age ± 5 years, date of operation ± 3 years, and type of surgery. Paired univariate analysis and conditional logistic regression of the matched pairs were performed. Our primary outcome was the short-term postoperative complication rate. Secondary outcomes included infectious complications, readmission, reoperation, and length of stay.

Results: A total of 103 patients with Crohn's disease (CD) met the inclusion criteria (mean age 38.7 ± 13.4 years; male 51.2%). Overall, 30 patients received preoperative ustekinumab and 73 vedolizumab. In the univariate analysis, vedolizumab-treated patients had a higher postoperative complication rate (p = 0.009) and ileus rate (p = 0.015). After matching, 26 matched pairs were compared and logistic regression models demonstrated no significant difference in the primary outcome.

Conclusions: For our limited experience, the choice of preoperative biologic treatment between ustekinumab and vedolizumab should not be influenced by fear of surgical complications.
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March 2019

Factors associated with noncomplete mesorectal excision following surgery for rectal adenocarcinoma.

Am J Surg 2019 03 14;217(3):465-468. Epub 2018 Nov 14.

Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA. Electronic address:

Background: The completeness of the resected mesorectum is a quality metric in rectal cancer surgery and has been related to oncological outcomes. Our aim was to identify variables associated with non-complete mesorectal excision and determine any effect on overall survival.

Methods: Consecutive patients who underwent curative intent surgery for rectal adenocarcinoma (2009-2016) were identified from a prospectively-maintained institutional database. Patients were grouped according to their mesorectal grade: complete, near-complete and incomplete. Multivariate analysis was performed to identify the association between various patient, disease and surgeon-related characteristics and mesorectal grading. Log-rank tests were used to evaluate any difference in overall survival between the groups.

Results: 689 patients met inclusion criteria. Demographics and perioperative variables were comparable between the groups. On multivariate analysis, abdominoperineal resection, and involved circumferential resection margin were significantly associated with non-complete mesorectum. Finally, patients with non-complete mesorectal grading have approximately twice the hazard of death compared to those with complete mesorectal grading.

Conclusions: Several factors are associated with a non-complete mesorectal excision. Non-complete mesorectal grade is associated with decreased survival.
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http://dx.doi.org/10.1016/j.amjsurg.2018.10.051DOI Listing
March 2019

Impact of the extraction-site location on wound infections after laparoscopic colorectal resection.

Am J Surg 2019 03 29;217(3):502-506. Epub 2018 Oct 29.

Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA.

Background: The purpose of this study was to determine the impact of the incision used for specimen extraction on wound infection during laparoscopic colorectal surgery.

Methods: All patients undergoing elective laparoscopic colorectal resection in a single specialized department from 2000 to 2011 were identified from a prospectively maintained institutional database. Specific extraction-sites and other relevant factors associated with wound infection rates were evaluated with univariate and multivariate analyses.

Results: 2801 patients underwent specimen extraction through infra-umbilical midline (N = 657), RLQ/LLQ (N = 388), stoma site (N = 58), periumbilical midline (N = 629), Pfannenstiel (N = 789) and converted midline (N = 280). The overall wound infection rate was 10% and was highest in converted midline (14.6%) and Pfannenstiel (11.4%) incisions, while the lowest rate was associated with RLQ/LLQ (N = 13, 3.3%). Independent factors associated with wound infection were increased BMI (p < 0.001), extraction site location (p = 0.006), surgical procedure (p = 0.020, particularly left-sided colectomy and total proctocolectomy), diagnosis (p < 0.001, particularly sigmoid diverticulitis and inflammatory bowel disease), intraabdominal adhesions (p = 0.033) and intrabdominal rather than pelvic procedure (p = 0.005).

Conclusions: A RLQ/LLQ extraction site is associated with the most reduced risk of wound infection in laparoscopic colorectal surgery.
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http://dx.doi.org/10.1016/j.amjsurg.2018.10.034DOI Listing
March 2019

Is the Neutrophil-to-Lymphocyte Ratio Associated With Increased Morbidity After Colorectal Surgery?

Surg Laparosc Endosc Percutan Tech 2019 Feb;29(1):36-39

Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH.

Purpose: We aimed to evaluate the association between preoperative and postoperative neutrophil-to-lymphocyte ratio (NLR) and 30-day postoperative complications after colorectal surgery.

Methods: Patients undergoing elective colorectal surgery between January, 2010 and December, 2014 were identified. Patients who had preoperative and postoperative days 1 and 2 (Postoperative day [POD]-1, POD-2) NLR were included in the study. Primary study outcomes were optimal NLR cutoff values at preop, POD-1, and POD-2.

Results: A total of 1328 patients met the inclusion criteria. Of those, 518 (39%) patients experienced at least one postoperative complication. Sex (P<0.001), diabetes mellitus (DM) (P<0.001), diagnosis (P=0.001), operation type (P=0.03), and open surgery (P<0.001) were statistically associated with higher NLR (POD-1, P=0.02; POD2, P=0.01). DM (OR, 1.97; 95%CI, 1.27-3.08; P=0.003] and NLR on POD-2≥9.2 (OR, 1.43; 95%CI, 1.03-1.98; P=0.02) were significantly related to postoperative complications.

Conclusions: NLR may provide clinicians with an additional tool for identifying patients at high risk for postoperative complications after elective colorectal surgery. Routine use of NLR may lead to early intervention and potentially improve the management of complications after colorectal surgery.
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http://dx.doi.org/10.1097/SLE.0000000000000588DOI Listing
February 2019

Reply.

Clin Gastroenterol Hepatol 2018 10;16(10):1683-1684

Department of Colorectal Surgery and Center for Inflammatory Bowel Disease, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio.

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http://dx.doi.org/10.1016/j.cgh.2018.06.032DOI Listing
October 2018

Extended Venous Thromboembolism Prophylaxis After Elective Surgery for IBD Patients: Nomogram-Based Risk Assessment and Prediction from Nationwide Cohort.

Dis Colon Rectum 2018 Oct;61(10):1170-1179

Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio.

Background: Identification of risk factors for postoperative venous thromboembolism is an important step to reduce the morbidity associated with this potentially preventable complication after elective surgery for patients with IBD.

Objective: This study aimed to determine the risk factors for 30-day venous thromboembolism after abdominal surgery for patients with venous thromboembolism, identify potential indications for extended thromboprophylaxis, and develop a nomogram for prediction of risk.

Design: This is a retrospective cohort study from a prospectively collected database.

Setting: The American College of Surgeons National Surgical Quality Improvement Program Participant User File from 2005 to 2016 was used for data analysis.

Patients: All patients with IBD undergoing elective abdominopelvic bowel surgery were included.

Main Outcome Measures: The primary outcomes were the incidence of in-hospital and postdischarge venous thromboembolism within 30 days of the index abdominopelvic surgery.

Results: A total of 24,182 patients met the inclusion criteria. Thirty-day total and postdischarge rates of venous thromboembolism were 2.5% (n = 614) and 1% (n =252). Forty-one percent (252/614) of venous thromboembolism events occurred after hospital discharge. Univariate analysis assessed 37 variables for association with study outcomes. On multivariate logistic regression analysis, older age, steroid use, bleeding disorders, open surgery, hypertension, longer operative time, and preoperative hospitalization were associated with venous thromboembolism before discharge and also postoperative transfusion, steroid use, pelvic and enterocutaneous fistula surgery, and longer operative time were associated with venous thromboembolism after discharge. A nomogram was constructed for each outcome, translating multivariate model parameter estimates into a visual scoring system where the estimated probability of venous thromboembolism can be calculated.

Limitations: This study was limited by its retrospective nature and the limitations inherent to a database.

Conclusion: Given the higher risk of venous thromboembolism in patients with IBD after elective abdominopelvic surgery compared with other indications, an accurate prediction of venous thromboembolism before and after discharge using the proposed nomogram can facilitate decision making for individualized extended thromboprophylaxis in the preoperative setting as a screening tool. See Video Abstract at http://links.lww.com/DCR/A711.
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http://dx.doi.org/10.1097/DCR.0000000000001189DOI Listing
October 2018

Impact of omentoplasty on anastomotic leak and septic complications after low pelvic anastomosis: a study from the NSQIP database.

Int J Colorectal Dis 2018 Dec 31;33(12):1733-1739. Epub 2018 Aug 31.

Section of Biostatistics, Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA.

Purpose: The role of omentoplasty in the prevention of anastomotic leak (AL) in colorectal surgery is controversial. The aim of this study was to evaluate the impact of omentoplasty on AL and septic complications after low pelvic anastomosis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

Methods: The ACS-NSQIP database was queried for patients who underwent segmental colectomy with low pelvic anastomosis by using 2012 targeted colectomy participant use data file. Patients were divided into two groups according to omentoplasty versus no-omentoplasty formation. AL and surgical site infections (SSIs) within postoperative 30 days were compared between the groups.

Results: A total of 2891 patients (1447 [50.1%] males) with a mean age of 60.2 ± 13.0 years met the inclusion criteria. There were 86 (2.9%) and 2805 (97.1%) patients in the omentoplasty and no-omentoplasty group, respectively. In the multivariate analysis, omentoplasty neither reduced AL (p = 0.83; OR = 0.88, 95% CI, 0.21-2.44) nor organ/space SSIs (p = 0.08; OR = 2.14, 95% CI, 0.91-4.41). Also, this technique did not play any role in reducing AL and organ/space SSI rates regardless of diversion with the exception of its association with higher organ/space SSIs in patients without diverting stoma (9.2% vs 3.8%, p = 0.04). No differences were detected between the groups with respect to the management strategies for AL (p = 0.22).

Conclusions: Omentoplasty did not decrease AL and septic complications after low pelvic anastomosis and had no impact on the postoperative management of AL.
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http://dx.doi.org/10.1007/s00384-018-3151-2DOI Listing
December 2018