Surgery for pouch inflow limb-related complications: Crohn's disease or something else?

PURPOSE: A total proctocolectomy with subsequent creation of an ileal-pouch, such as a J-pouch or a Kock pouch, has been the most common surgery performed for ulcerative colitis (UC). A small portion of these patients will develop complications with the inflow limb into the pouch requiring operative intervention. The objective was to establish a better understanding as to the pathological mechanism by which these pouch inflow limb problems develop. METHODS: This was a retrospective cohort study conducted at a single tertiary care inflammatory bowel disease (IBD) center. A database was created of all the patients who underwent pouch-related procedures, following completion of their original pouch, between 2006 and 2018. The patients requiring operative resection for inflow limb complications were identified among this cohort. Operative and pathological data were collected. RESULTS: One hundred seventy-eight UC patients underwent surgeries on their pouches between 2006 and 2018. Sixteen patients required operative resection for inflow limb problems. Reoperations for inflow limb problems included inflow limb resection with pouch excision (n = 4) and inflow limb resection with pouch revision (n = 12). The pathology findings of the inflow limb were consistent with Crohn's disease in 9 patients (56%). Two other patients (total 69%) were eventually diagnosed with Crohn's disease due to other pathological specimens or perianal pathology. The remaining patients had chronic, non-specific enteritis/serositis. CONCLUSIONS: A small proportion of pouch patients will eventually require surgery for inflow limb complications. Among these, there was a high rate of Crohn's disease of the inflow limb and overall change in diagnosis to Crohn's disease (Plietz et al. in Official Journal of the American College of Gastroenterology | ACG 114:S453, 2019).

Mouse vision: Variability and stability across the visual processing hierarchy.

The response of individual neurons to stable sensory input or behavioral output can change over time. A new study provides evidence from the mouse visual system that such drift does not follow the hierarchy of information flow across the brain.

Limited functional convergence of eye-specific inputs in the retinogeniculate pathway of the mouse.

Segregation of retinal ganglion cell (RGC) axons by type and eye of origin is considered a hallmark of dorsal lateral geniculate nucleus (dLGN) structure. However, recent anatomical studies have shown that neurons in mouse dLGN receive input from multiple RGC types of both retinae. Whether convergent input leads to relevant functional interactions is unclear. We studied functional eye-specific retinogeniculate convergence using dual-color optogenetics in vitro. dLGN neurons were strongly dominated by input from one eye. Most neurons received detectable input from the non-dominant eye, but this input was weak, with a prominently reduced AMPAR:NMDAR ratio. Consistent with this, only a small fraction of thalamocortical neurons was binocular in vivo across visual stimuli and cortical projection layers. Anatomical overlap between RGC axons and dLGN neuron dendrites alone did not explain the strong bias toward monocularity. We conclude that functional eye-specific input selection and refinement limit convergent interactions in dLGN, favoring monocularity.

Perfusion Assessment in Left-Sided/Low Anterior Resection (PILLAR III): A Randomized, Controlled, Parallel, Multicenter Study Assessing Perfusion Outcomes With PINPOINT Near-Infrared Fluorescence Imaging in Low Anterior Resection.

BACKGROUND: Indocyanine green fluoroscopy has been shown to improve anastomotic leak rates in early phase trials. OBJECTIVE: We hypothesized that the use of fluoroscopy to ensure anastomotic perfusion may decrease anastomotic leak after low anterior resection. DESIGN: We performed a 1:1 randomized controlled parallel study. Recruitment of 450 to 1000 patients was planned over 2 years. SETTINGS: This was a multicenter trial. PATIENTS: Included patients were those undergoing resection defined as anastomosis within 10 cm of the anal verge. INTERVENTION: Patients underwent standard evaluation of tissue perfusion versus standard in conjunction with perfusion evaluation using indocyanine green fluoroscopy. MAIN OUTCOME MEASURES: Primary outcome was anastomotic leak, with secondary outcomes of perfusion assessment and the rate of postoperative abscess requiring intervention. RESULTS: This study was concluded early because of decreasing accrual rates. A total of 25 centers recruited 347 patients, of whom 178 were randomly assigned to perfusion and 169 to standard. The groups had comparable tumor-specific and patient-specific demographics. Neoadjuvant chemoradiation was performed in 63.5% of perfusion and 65.7% of standard (p > 0.05). Mean level of anastomosis was 5.2 ± 3.1 cm in perfusion compared with 5.2 ± 3.3 cm in standard (p > 0.05). Sufficient visualization of perfusion was reported in 95.4% of patients in the perfusion group. Postoperative abscess requiring surgical management was reported in 5.7% of perfusion and 4.2% of standard (p = 0.75). Anastomotic leak was reported in 9.0% of perfusion compared with 9.6% of standard (p = 0.37). On multivariate regression analysis, there was no difference in anastomotic leak rates between perfusion and standard (OR = 0.845 (95% CI, 0.375-1.905); p = 0.34). LIMITATIONS: The predetermined sample size to adequately reduce the risk of type II error was not achieved. CONCLUSIONS: Successful visualization of perfusion can be achieved with indocyanine green fluoroscopy. However, no difference in anastomotic leak rates was observed between patients who underwent perfusion assessment versus standard surgical technique. In experienced hands, the addition of routine indocyanine green fluoroscopy to standard practice adds no evident clinical benefit. See Video Abstract at http://links.lww.com/DCR/B560. VALORACIN DE LA IRRIGACIN DE LADO IZQUIERDO/RESECCIN ANTERIOR BAJA PILAR III UN ESTUDIO ALEATORIZADO, CONTROLADO, PARALELO Y MULTICNTRICO QUE EVALA LOS RESULTADOS DE LA IRRIGACIN CON PINPOINT IMGENES DE FLUORESCENCIA CERCANA AL INFRARROJO EN LA RESECCIN ANTERIOR BAJA: ANTECEDENTES:Se ha demostrado que la fluoroscopia con verde de indocianina mejora las tasas de fuga anastomótica en ensayos en fases iniciales.OBJETIVO:Nuestra hipótesis es que la utilización de fluoroscopia para asegurar la irrigación anastomótica puede disminuir la fuga anastomótica luego de una resección anterior baja.DISEÑO:Realizamos un estudio paralelo, controlado, aleatorizado 1:1. Se planificó el reclutamiento de 450-1000 pacientes durante 2 años.AMBITO:Multicéntrico.PACIENTES:Pacientes sometidos a resección definida como una anastomosis dentro de los 10cm del margen anal.INTERVENCIÓN:Pacientes que se sometieron a la evaluación estándar de la irrigación tisular contra la estándar en conjunto con la valoración de la irrigación mediante fluoroscopia con verde indocianina.PRINCIPALES VARIABLES EVALUADAS:El principal resultado fue la fuga anastomótica, y los resultados secundarios fueron la evaluación de la perfusión y la tasa de absceso posoperatorio que requirió intervención.RESULTADOS:Este estudio se cerró anticipadamente debido a la disminución de las tasas de acumulación. Un total de 25 centros reclutaron a 347 pacientes, de los cuales 178 fueron, de manera aleatoria, asignados a perfusión y 169 a estándar. Los grupos tenían datos demográficos específicos del tumor y del paciente similares. Recibieron quimio-radioterapia neoadyuvante el 63,5% de la perfusión y el 65,7% del estándar (p> 0,05). La anastomosis estuvo en un nivel promedio de 5,2 + 3,1 cm en perfusión en comparación con 5,2 + 3,3 cm en estándar (p> 0,05). Se reportó una visualización suficiente de la perfusión en el 95,4% de los pacientes del grupo de perfusión. El absceso posoperatorio que requirió tratamiento quirúrgico fue de 5,7% de los perfusion y en el 4,2% del estándar (p = 0,75). Se informó fuga anastomótica en el 9,0% de la perfusión en comparación con el 9,6% del estándar (p = 0,37). En el análisis de regresión multivariante, no hubo diferencias en las tasas de fuga anastomótica entre la perfusión y el estándar (OR 0,845; IC del 95% (0,375; 1,905); p = 0,34).LIMITACIONES:No se logró el tamaño de muestra predeterminado para reducir satisfactoriamente el riesgo de error tipo II.CONCLUSIÓN:Se puede obtener una visualización adecuada de la perfusión con ICG-F. Sin embargo, no se observaron diferencias en las tasas de fuga anastomótica entre los pacientes que se sometieron a evaluación de la perfusión versus la técnica quirúrgica estándar. En manos expertas, agregar ICG-F a la rutina de la práctica estándar no agrega ningún beneficio clínico evidente. Consulte Video Resumen en http://links.lww.com/DCR/B560. (Traducción-Dr Juan Antonio Villanueva-Herrero).

Hartmann's reversal: factors affecting complications and outcomes.

AIM: Hartmann's procedure is commonly performed emergently for infectious, inflammatory, or malignant processes. Most patients historically do not undergo reversal, and those who do have been found to suffer significant morbidity. The aim of this study was to study factors associated with complications after Hartmann's reversal and to provide information and guidance to surgeons. METHOD: A retrospective review of patients undergoing Hartmann's reversal between May 2002 and October 2017 was conducted at a tertiary medical center. Data included patient characteristics at the time of surgery and intra- and postoperative complications. Chi-square test was used for categorical variables. The Wilcoxon signed rank or t test where appropriate was used for multivariate analysis. RESULTS: Two hundred forty-nine patients were included. Mean age at reversal was 58.8 years, and 114 (58%) were male. Sixty-two (31.8%) patients experienced a major complication following reversal. Eight (4%) patients had an anastomotic leak. Thirteen (6.67%) patients had an intra-abdominal abscess which required either IR or operative drainage. Patients who experienced a major complication were more likely to have an ASA 4 at time of reversal (14.3% vs. 4.24%, p = 0.019), liver disease (6.6% vs. 0.8%, p = 0.021), and BMI < 30 (35% vs. 17.3%, p = 0.020). CONCLUSIONS: Nearly one-third of patients who had reversal surgery experienced a major complication. Four percent of patients undergoing reversal had an anastomotic leak, comparable to previously reported rates. Patients with ASA 4, liver disease, and BMI < 30 were at higher risk of a major complication following reversal. Patients who underwent laparoscopic reversal had no significant difference in outcomes. AIM: What does this paper add to the literature? The decision of whether to reverse a colostomy after Hartmann's procedure. Our study aims to identify risk factors associated with complications after Hartmann's reversal to better guide surgeon's facing the dilemma of whether or not to reverse the stoma.

Diverted versus undiverted restorative proctocolectomy for chronic ulcerative colitis: an analysis of long-term outcomes after pouch leak short title: outcomes after pouch leak.

BACKGROUND: The safety of undiverted restorative proctocolectomy (RPC) is debated. This study compares long-term outcomes after pouch leak in diverted and undiverted RPC patients. METHODS: Data were obtained from a prospectively maintained registry from a single surgical practice. One-stage and staged procedures with an undiverted pouch were considered undiverted pouches; all others were considered diverted pouches. The outcomes measured were pouch excision and long-term diversion defined as the need for loop ileostomy at 200 weeks after pouch creation. Regression models were used to compare outcomes. RESULTS: There were 317 diverted and 670 undiverted pouches, of which 378 were one-stage procedures. Pouch leaks occurred in 135 patients, 92 (13.7%) after undiverted, and 43 (13.6%) after diverted pouches. Eighty-six (64%) leaks were diagnosed within 6 months of pouch creation. Undiverted patients underwent more emergent procedures within 30 days of pouch creation (p < 0.01). Pouch excision occurred in 14 (33%) diverted patients and 13 (14%) undiverted patients (p = 0.01). Thirteen (32%) diverted patients and 18 (21%) undiverted patients (p = 0.17) had ileostomies at 200 weeks after surgery. In multivariable analyses, diverted patients had a higher risk of pouch excision (HR 3.67 p < 0.01), but similar rates of ileostomy at 200 weeks (HR 1.8, p = 0.19) compared to undiverted patients. CONCLUSIONS: Despite a likely selection bias in which "healthier" patients undergo an undiverted pouch, our data suggest that diversion does not prevent pouch excision and the need for long-term diversion after pouch leak. These findings suggest that undiverted RPC is a safe procedure in appropriately selected patients.

Assessment of Bowel End Perfusion After Mesenteric Division: Eye Versus SPY.

BACKGROUND: Anastomotic complications related to tissue ischemia cause morbidity in gastrointestinal (GI) surgery. Surgeons' standard practice to predict bowel perfusion is inspection of mesenteric perfusion before anastomosing bowel ends. Augmenting this assessment with fluorescent imaging is under study. A standardized system to evaluate this imaging has not yet been developed. This study compared the surgeon's intraoperative assessment to a novel GI-specific imaging analysis method. MATERIALS AND METHODS: Forty-nine consecutive patients undergoing open or laparoscopic-assisted bowel resections were enrolled. After mesenteric division, the surgeon marked the site for bowel transection. Near-infrared fluorescence imaging was performed on the marked bowel ends. Imaging analysis identified theoretical transection sites based on the quantification of arterial and microvascular inflow (Perfusion) and venous outflow (Timing). The primary outcome was the measured disparity between the site marked by the surgeon using current standard of care parameters and the imaging-determined site. No clinical outcomes were assessed. RESULTS: Seventy-two bowel end segments from 46 patients were analyzed. Disparity was found in 11 of 72 (15%) bowel end segments. In five (7%), the disparity was due to either Perfusion or Timing (single), and in six (8%), due to both Perfusion and Timing (combined). In the single disparity group, the median disparity distance was 2.0 cm by Perfusion and 4.0 cm by Timing, and in the combined group, 3.8 cm by Perfusion and 3.5 cm by Timing. Disparity (either single or combined) was in 25% of colon and 11.5% of small bowel (P = NS). Combined and single disparity had equivalent lengths of disparity distance (P = NS). CONCLUSIONS: Imaging coupled with this GI-specific analysis provides objective, real-time, and interpretable data of intramural blood supply. A 15% disparity rate from current clinical practice was observed.

High-yield in vitro recordings from neurons functionally characterized in vivo.

In vivo two-photon calcium imaging provides detailed information about the activity and response properties of individual neurons. However, in vitro methods are often required to study the underlying neuronal connectivity and physiology at the cellular and synaptic levels at high resolution. This protocol provides a fast and reliable workflow for combining the two approaches by characterizing the response properties of individual neurons in mice in vivo using genetically encoded calcium indicators (GECIs), followed by retrieval of the same neurons in brain slices for further analysis in vitro (e.g., circuit mapping). In this approach, a reference frame is provided by fluorescent-bead tracks and sparsely transduced neurons expressing a structural marker in order to re-identify the same neurons. The use of GECIs provides a substantial advancement over previous approaches by allowing for repeated in vivo imaging. This opens the possibility of directly correlating experience-dependent changes in neuronal activity and feature selectivity with changes in neuronal connectivity and physiology. This protocol requires expertise both in in vivo two-photon calcium imaging and in vitro electrophysiology. It takes 3 weeks or more to complete, depending on the time allotted for repeated in vivo imaging of neuronal activity.

Multicenter, Prospective, Longitudinal Study of the Recurrence, Surgical Site Infection, and Quality of Life After Contaminated Ventral Hernia Repair Using Biosynthetic Absorbable Mesh: The COBRA Study.

OBJECTIVE: The aim of the study was to evaluate biosynthetic absorbable mesh in single-staged contaminated (Centers for Disease Control class II and III) ventral hernia (CVH) repair over 24 months. BACKGROUND: CVH has an increased risk of postoperative infection. CVH repair with synthetic or biologic meshes has reported chronic biomaterial infections and high hernia recurrence rates. METHODS: Patients with a contaminated or clean-contaminated operative field and a hernia defect at least 9 cm had a biosynthetic mesh (open, sublay, retrorectus, or intraperitoneal) repair with fascial closure (n = 104). Endpoints included overall Kaplan-Meier estimates for hernia recurrence and postoperative wound infection rates at 24 months, and the EQ-5D and Short Form 12 Health Survey (SF-12). Analyses were conducted on the intent-to-treat population, and health outcome measures evaluated using paired t tests. RESULTS: Patients had a mean age of 58 years, body mass index of 28 kg/m, 77% had contaminated wounds, and 84% completed 24-months follow-up. Concomitant procedures included fistula takedown (n = 24) or removal of infected previously placed mesh (n = 29). Hernia recurrence rate was 17% (n = 16). At the time of CVH repair, intraperitoneal placement of the biosynthetic mesh significantly increased the risk of recurrences (P ≤ 0.04). Surgical site infections (19/104) led to higher risk of recurrence (P < 0.01). Mean 24-month EQ-5D (index and visual analogue) and SF-12 physical component and mental scores improved from baseline (P < 0.05). CONCLUSIONS: In this prospective longitudinal study, biosynthetic absorbable mesh showed efficacy in terms of long-term recurrence and quality of life for CVH repair patients and offers an alternative to biologic and permanent synthetic meshes in these complex situations.

Fistula-Associated Anorectal Cancer in the Setting of Crohn's Disease.

BACKGROUND: Cancer arising from perianal fistulas in patients with Crohn's disease is rare. There are only a small series of articles that describe sporadic cases of perianal cancer in Crohn's disease fistulas. Therefore, there are no clear guidelines on how to appropriately screen patients at risk and choose proper management. OBJECTIVE: The purpose of this study was to describe patients diagnosed with cancer in perianal fistulas in the setting of Crohn's disease. DESIGN: The study involved an institutional review board-approved retrospective review of medical charts of patients with perianal Crohn's disease. The data extracted from patient charts included demographic and clinical characteristics. SETTINGS: Patients seen at the Mount Sinai Medical Center were included. PATIENTS: We identified patients who were diagnosed with perianal cancer in biopsies of fistula tracts. MAIN OUTCOME MEASURES: We observed the number of patients with Crohn's disease who had fistulas, cancer in fistula tract, and time to diagnosis. RESULTS: The charts of 2382 patients with fistulizing perianal Crohn's disease were reviewed. Cancer in a fistula tract was diagnosed in 19 (0.79%) of these patients, 9 with squamous-cell carcinoma and 10 with adenocarcinoma. The majority of the 19 patients (68%) had symptoms typical of perianal fistula. The mean time from diagnosis of Crohn's disease to fistula diagnosis and from fistula diagnosis to cancer diagnosis was 19.4 and 6.0 years. In 5 patients (26%), cancer was not diagnosed in the first biopsy obtained from the fistula tract. LIMITATIONS: This is a retrospective chart review of a rare outcome; the results may not be generalizable. CONCLUSIONS: Routine biopsies of long-standing fistula tracts in patients with Crohn's disease should be strongly considered and may yield an earlier diagnosis of cancer in the fistula tracts.

Adhesive Small Bowel Obstruction: Early Operative versus Observational Management.

We assessed the nonoperative and operative management of adhesive small bowel obstruction (ASBO) and compared complication rates and surgical outcomes. ASBO is a common complication of abdominopelvic surgery. Although patients may respond to nonoperative management, many require surgery. We retrospectively studied patients admitted to Mount Sinai Hospital with a diagnosis of complete ASBO to determine outcomes of nonoperative management. Patients admitted with complete ASBO from 2001 to 2011 were included. Patients with no previous abdominopelvic surgery, surgery within the six weeks preceding admission and obstruction due to other identifiable causes, such as incarcerated hernia, were excluded. Complication rates and outcomes were compared between patients managed with immediate surgery and those managed initially with nonoperative strategies. Of 460 patients admitted with complete ASBO, 106 (23.0%) had surgery within 24 hours of admission. At surgery, 20 (18.9%) had ischemic bowel and 8 (7.5%) had perforations. The remaining 354 patients had a trial of nonoperative management lasting at least 24 hours. Of 354 patients managed initially without surgery, 100 (28.2%) patients were discharged without operative intervention during their index admissions. Among the patients having surgery more than 24 hours after admission, indications for surgery were generally failure to resolve, worsening clinical status, and change in imaging findings. Of those patients observed for at least 24 hours, 40 (15.7%) were found to have ischemic bowel and 5 (2.0%) had perforation at surgery. Rates of bowel resection, stoma creation and postoperative complications were similar for the immediate and delayed surgery groups. Among the delayed surgery group, 71 (28.0%) required a bowel resection and 11 (4.3%) stoma creation. Twenty one per cent had postoperative complications, most commonly ileus. There were no statistically significant differences in the outcomes between immediate and delayed groups regardless of duration of delay. Among patients observed with complete ASBO, 24.6 per cent of patients with adhesive obstruction resolved without surgery or readmission. Delaying operative management did not affect surgical findings or complication rates.

A prospective, multicenter, randomized, controlled study of non-cross-linked porcine acellular dermal matrix fascial sublay for parastomal reinforcement in patients undergoing surgery for permanent abdominal wall ostomies.

BACKGROUND: A large proportion of patients with a colostomy or an ileostomy develop parastomal hernias. The placement of a reinforcing material at the stoma site may reduce parastomal hernia incidence. OBJECTIVE: We aimed to assess the safety and efficacy of stoma reinforcement with sublay placement of non-cross-linked porcine-derived acellular dermal matrix at the time of stoma construction. DESIGN: This is a randomized, patient- and third-party assessor-blind, controlled trial. SETTINGS: This study took place in colorectal/general surgery institutions. INTERVENTIONS: Patients were prospectively randomly assigned to undergo standard end-stoma construction with or without porcine-derived acellular dermal matrix reinforcement. PATIENTS: Patients undergoing construction of a permanent stoma were eligible. A total of 113 patients (59 men, 54 women; mean age, 60 years; mean BMI, 25.4 kg/m) participated: 58 controls and 55 with reinforcement. MAIN OUTCOMES MEASURES: The incidence of parastomal hernia, safety, and stoma-related quality of life were assessed. RESULTS: Intraoperative complications and blood loss were similar between groups. Quality-of-life scores were similar through 24 months of follow-up. At 24 months of follow-up, the incidence of parastomal hernias was similar for both groups (12.2% of the porcine-derived acellular dermal matrix group and 13.2% of controls). LIMITATIONS: Study limitations include the inclusion of ileostomy and colostomy patients, open and laparoscopic techniques, and small numbers of patients at follow-up. CONCLUSIONS: Safety and quality-of-life data from this randomized control trial show similar outcomes in both groups. Prosthetic reinforcement of stomas was safe, but it did not significantly reduce the incidence of parastomal hernia formation. CLINICAL TRIAL REGISTRATION: Identification no. NCT00771407.

High rates of metachronous colon cancer or dysplasia after segmental resection or subtotal colectomy in Crohn's colitis.

BACKGROUND: In ulcerative colitis, total proctocolectomy is the treatment of choice for patients with colonic dysplasia or cancer because of the high risk for metachronous neoplasia. It is unknown whether patients with Crohn's disease and colon cancer or dysplasia have a similar risk. METHODS: We retrospectively reviewed the charts of 75 patients treated at our center from 2001 to 2011 with Crohn's disease and colon cancer who underwent segmental resection or subtotal colectomy (STC). We then identified the presence or absence of subsequent colon cancer or dysplasia in these patients during the follow-up (0-19 years). RESULTS: Of the 64 patients with colon cancer, 25 had at least 1 metachronous cancer (39%). The mean time to a new cancer was 6.8 years. Eighty-five percent of patients (21/25) were undergoing annual screening colonoscopy. Of the 11 patients with dysplasia, 5 (46%) had a new dysplasia. Mean time to a new dysplastic lesion was 5.0 years. Nineteen of the 47 patients (40%) who had a segmental resection for colon cancer developed metachronous cancer and 6/17 patients (35%) with a STC had metachronous cancer. Two of the 4 patients (50%) with STC for dysplasia (50%) had a new dysplasia and 3/7 patients (43%) with segmental resection had a new dysplasia. There was no significant difference (P = 0.61) between recurrence rates in patients with segmental resection versus STC. CONCLUSIONS: The high rate of metachronous colon cancer after surgical resection suggests that total proctocolectomy should be considered. Larger studies are required to determine if the same is true for dysplasia.

Immunosuppressive therapy does not increase operative morbidity in patients with Crohn's disease.

GOALS: The aim of this study was to examine the impact of immunosuppressive therapy on the morbidity of intestinal surgery in patients with Crohn's disease. BACKGROUND: An increasing number of immunomodulating agents are being used in the treatment of Crohn's disease. The effect of these medications on surgical morbidity is controversial. STUDY: We performed a retrospective review of our prospectively maintained database of patients with Crohn's disease who underwent intestinal surgery between June 1999 and May 2010. The effect of perioperative immunomodulation on postoperative outcomes, specifically anastomotic complications, was evaluated. Predictors of postoperative morbidity among demographic and surgical variables were identified. Length of hospitalization and rate of hospital readmission were compared between groups. Comparisons were made using Student t test and Fisher exact test. RESULTS: One hundred ninety-six intestinal procedures were performed. One hundred twenty-seven (64.8%) of these were performed among patients who received perioperative immunomodulation. Forty-six (23.5%) procedures were in patients who received >1 immunomodulating medication perioperatively. Complications occurred in 45 (23.0%) cases. There were 20 (10.2%) anastomotic complications, including 8 (4.1%) intra-abdominal abscesses, 8 (4.1%) anastomotic leaks, and 4 (2%) enterocutaneous fistulas. Preoperative treatment with steroids (P=0.21), 6-MP (P=0.10), and anti-tumor necrosis factor biologics (P=1.0) was not associated with increased postoperative anastomotic complications. Combination immunosuppressive therapy also did not increase morbidity (P=0.39). CONCLUSIONS: In our series, single agent and combination immunosuppressive therapy given around the time of intestinal surgery did not increase the incidence of surgical complications in patients with Crohn's disease.

The clinical impact of preoperative percutaneous drainage of abdominopelvic abscesses in patients with Crohn's disease.

PURPOSE: Although image-guided percutaneous drainage is increasingly being used to treat Crohn's disease-related abdominopelvic abscesses, surgery is seldom avoided. The aim of this study was to compare outcomes following the treatment of intra-abdominal Crohn's abscesses with percutaneous drainage followed by surgery to those after surgery alone. METHODS: We retrospectively reviewed the charts of patients treated for Crohn's-related abdominopelvic abscesses at Mount Sinai Medical Center between April 2001 and June 2010. Patients who underwent drainage followed by surgery were compared to those who underwent surgery alone. Differences in operative and postoperative outcomes were compared. RESULTS: Seventy patients with Crohn's disease-related abdominopelvic abscesses were identified, 38 (54%) of whom underwent drainage before surgery. Percutaneous drainage was technically successful in 92% of patients and clinically successful in 74% of patients. No differences in rate of septic complications (p = 0.14) or need for stoma creation (p = 0.78) were found. Patients who underwent percutaneous drainage had greater overall hospital lengths of stay (mean 15.8 versus 12.2 days, p = 0.007); 8.6% of patients had long-term postponement of surgery after percutaneous drainage. CONCLUSIONS: In our series, the treatment of Crohn's abscesses with percutaneous drainage prior to surgery did not decrease the rate of postoperative septic complications.

Modified Rives-Stoppa technique for repair of complex incisional hernias in 59 patients.

Incisional hernias develop in 2% to 11% of patients who undergo laparotomy. Prosthetic mesh repair provides more strength, tension-free closure, and decreased recurrence rates as compared to primary tissue repairs. Complications-fistula formation, adhesions, skin erosion, and seroma/abscess formation-however, include increased rates of infection, sometimes requiring complete mesh removal. The Rives-Stoppa repair for complex incisional hernias confers the benefits of prosthetic repair and lower recurrence rates, but decreases certain complications by preventing direct mesh contact with the bowel. A total of 89 consecutive patients (mean age, 58.1) underwent a modified Rives-Stoppa repair for purposes of this review, all the patients who lost to follow-up before 6 months postoperatively were excluded from the study. Of the remaining 59 patients, 32.2% (n = 19) had expanded polytetrafluoroethylene mesh, and 67.8% (n = 40) had polypropylene mesh. Average range of follow-up was 40.0 months. Hernia recurred in 1 patient (1.7%). Infection requiring explantation of the prosthesis occurred in 3 patients (5.1%). The Rives-Stoppa repair is reportedly the best open technique for complex incisional hernias with comparatively lower recurrence rates. Additionally, patients with inflammatory bowel disease (64.4% of our series), who often require later reoperation for their primary disease, may benefit from this technique of herniorrhaphy where no interface exists between intrabdominal contents and the prosthesis. This lack of interface decreases intrabdominal adhesions and facilitates re-entry if future surgery is needed for inflammatory bowel disease.

Small bowel adenocarcinoma in Crohn's disease.

BACKGROUND: An association between small bowel adenocarcinoma and Crohn's disease (CD) is well-established. We present our recent experience with this entity in order to further elucidate its clinicopathological features and update our series from 1991. METHODS: A retrospective review was undertaken of all surgical patients with small bowel adenocarcinoma and CD seen at our institution between 1993 and 2009. Follow-up was assessed until time of death or by interview with survivors. Survival was calculated based on TNM (tumor extent, lymph node status, metastases staging) staging and comparing between our current and previous series. RESULTS: Twenty-nine patients (ten females and 19 males) were identified and followed for a median of 2 years. The median age at onset of CD symptoms was 25, and the median age at cancer diagnosis was 55.4, for a mean interval of 25.3 years. Twenty-two cancers were ileal and five were jejunal. There were no cancers in excluded intestinal loops. Significant differences in 2-year survival were determined for: node-negative (79.3%, 95%CI 58.3-100%) versus node-positive cancers (49% %, 95%CI 20.0-78.0%), and for localized (92.3%, 95%CI 77.8-100%) versus metastatic disease (33.3%, 95%CI 6.6-60%). Overall 36-month survival was 69.3% (95%CI 51.5-87.1%) compared to 40% among those without excluded loops in our series from 1991. Sixteen patients had long periods of quiescent disease before diagnosis (7-45 years), and 16 required surgery for bowel obstruction that was refractory to medical management. Adequate information was not retrievable for three patients. CONCLUSIONS: A comparison to our previous series reveals similar clinical characteristics and a high rate of node-positive cancer at diagnosis. Our findings also confirm two important clinical indicators of malignancy: recrudescent symptoms after long periods of relative quiescence and small bowel obstruction that is refractory to medical therapy.

Gastrointestinal recovery after laparoscopic colectomy: results of a prospective, observational, multicenter study.

BACKGROUND: Although evidence suggests that laparoscopic colectomy (LC) results in faster gastrointestinal (GI) recovery than open bowel resection, previous studies were performed at single institutions or generally not controlled for diet introduction or perioperative care, making the results difficult to interpret. A prospective, observational, multicenter study was planned to investigate GI recovery, length of hospital stay (LOS), and postoperative ileus (POI)-related morbidity after LC. METHODS: Patients scheduled to undergo LC or hand-assisted laparoscopic (HAL) bowel resection and to receive opioid-based postoperative intravenous patient-controlled analgesia were enrolled in 16 U.S. centers. The study design was similar to that for trials of alvimopan phase 3 open laparotomy bowel resection using a standardized accelerated postoperative care pathway. The primary end points were time to upper and lower GI recovery (GI-2: toleration of solid food and bowel movement) and postoperative LOS. The secondary end points included POI-related morbidity (postoperative nasogastric tube insertion or investigator-assessed POI resulting in prolonged hospital stay or readmission), conversion rate, and protocol-defined prolonged POI (GI-2 > 5 postoperative days). RESULTS: In this study, 148 patients received hemicolectomy by the LC (42 left and 67 right) or HAL (39 left) approach. The conversion rate was 18.8% (25.4% LC left, 17.3% HAL left, 15% LC right). The mean time to GI-2 recovery was 4.4 days, and the mean postoperative LOS was 4.9 days, neither of which varied substantially by surgical approach. Prolonged POI occurred for 15 patients (10.1%), and POI-related morbidity occurred for 17 patients (11.5%). No patients were readmitted because of POI, whereas 3 patients (2%) were readmitted for all other causes. CONCLUSIONS: Mean GI recovery and LOS after LC were accelerated compared with those for patients in open laparotomy bowel resection clinical trials or those reported in large hospital databases (0.7 and 1.7-2.2 days, respectively). Overall POI-related morbidity was similar between the open bowel resection and LC populations, demonstrating that POI continues to present with important morbidity regardless of the surgical approach.