Functional Outcomes Following Laparoscopic Ileal Pouch-Anal Anastomosis in Patients with Chronic Ulcerative Colitis: Long-Term Follow-up of a Case-Matched Study.

BACKGROUND: Laparoscopic ileal pouch-anal anastomosis (L-IPAA) has been increasingly adopted over the last decade due to short-term patient-related benefits. Several studies have shown L-IPAA to be equivalent to open IPAA in terms of safety and short-term outcomes. However, few L-IPAA studies have examined long-term functional outcomes. We aimed to evaluate the long-term functional outcomes of L-IPAA as compared to open IPAA. METHODS: A previous case-matched cohort study at our institution compared short-term outcomes between L-IPAA and open IPAA from 1998 to 2004. For this study, we selected all patients from this case-matched cohort study with chronic ulcerative colitis (CUC) who had follow-up functional data of greater than 1 year. Functional data was obtained through prospective surveys, which were sent annually to all IPAA patients postoperatively. RESULTS: One hundred and forty-nine patients (58 L-IPAA, 91 open IPAA) with a median 8-year duration of follow-up were identified. There were no differences in demographics and long-term surgical outcomes between groups. Stapled anastomosis was more common in the laparoscopic group (91.4 versus 54.9%, p < 0.001). Stool frequency during daytime (>6 stools, L-IPAA 32.8%, open 49.4%, p = 0.048) and nighttime (>2 stools, L-IPAA 13.8%, open 30.6%; p = 0.024) was significantly lower in the L-IPAA group. Ability to differentiate gas from stool was not different (p = 0.13). Rate of complete continence was similar in L-IPAA and open groups (L-IPAA 36.2%, open 21.8%, p = 0.060). There was no difference in use of medication to control stools, perianal skin irritation, voiding difficulty, sexual problems, and occupational change between groups. Subgroup analysis to evaluate for any group differences attributable to anastomotic technique demonstrated only that stapled anastomoses lead to more perianal skin irritation in the L-IPAA group (L-IPAA = 60.4% versus open IPAA = 38.8%; p = 0.031). CONCLUSION: Overall, L-IPAA has comparable functional results to the open approach with slightly lower daytime and nighttime stool frequency. This difference may be attributed to a greater number of stapled anastomoses performed in the laparoscopic cohort.

Long-Term Outcome of IPAA in Patients Presenting with Fulminant Ulcerative Colitis: A Matched Cohort Study.

BACKGROUND: Studies reveal that ileal pouch-anal anastomosis (IPAA) has long-term success. These reports, however, use well-selected cohorts and exclude patients presenting with fulminant colitis (FC). Herein, we aimed to characterize long-term functional outcomes in patients with fulminant ulcerative colitis (UC) undergoing IPAA. METHODS: A prospective database identified patients who underwent IPAA between 1998 and 2008. Patients with FC and chronic UC were matched by age, gender, date of surgery, and follow-up duration. Clinical and laboratory parameters, immunomodulator use at the time of surgery, and functional outcomes were compared. RESULTS: Forty patients with FC and 73 patients with chronic UC were identified. Preoperative albumin, hemoglobin, leukocyte count, and steroid dose were significantly different for those with FC. Average survey follow-up was 5.2 years for FC and 6.7 years for chronic UC patients. Functional outcomes were not significantly different. The 3-year fistula-free rate was 91.4 versus 98.6 % and the 3-year stricture-free rate was 79.3 versus 87.2 % for FC versus chronic UC patients, respectively. CONCLUSION: Patients undergoing colectomy for FC secondary to UC have similar long-term functional outcomes after IPAA despite significantly worse presentation. This study confirms that IPAA is an appropriate and durable treatment for patients with FC.

Risk of neoplastic change in ileal pouches in familial adenomatous polyposis.

INTRODUCTION: Neoplastic change in ileal reservoirs after proctocolectomy has been reported in patients with familial adenomatous polyposis. We aim to determine the incidence and progression of neoplastic change in the ileal pouch of familial adenomatous polyposis patients at our institution. METHODS: A retrospective review of all patients who underwent proctocolectomy for familial adenomatous polyposis with construction of an ileal pouch from 1972 to 2007 was performed. Data and status at follow-up were retrieved from the Mayo Clinic Colorectal Surgery Pouch database. RESULTS: One hundred seventeen patients were identified with a median age of 26, 52 were male. Ileal reservoirs included J-pouch (a = 104), Kock pouch (n = 9), S-pouch (n = 3), and W-pouch (n = 1). Median follow-up was 125 months. Polyps were biopsied in 33 patients: non-dysplastic polyps (n = 2), low-grade dysplasia (n = 30), and adenocarcinoma (n = 1). No patients had high-grade dysplasia. Median time to development of dysplasia was 149 months. Adenocarcinoma developed in one patient after 284 months. Risk of dysplasia at 10, 20, and 25 years was 17, 45, and 69%, respectively. CONCLUSION: Though there is a high incidence of low-grade dysplasia in the ileal reservoir in familial adenomatous polyposis patients, high-grade dysplasia and cancer occur rarely. Patients with low-grade dysplasia may still necessitate regular follow-up.

New developments in colorectal surgery.

PURPOSE OF REVIEW: The field of colorectal surgery continues to move forward as technical innovations emerge and as surgeons ask critical questions. The results of subsequent investigations often lead to changes in practice. This review examines recent publications that describe these practice changes. RECENT FINDINGS: We identified and reviewed recent publications in the areas of rectal cancer controversies, genetic risk profiling, practice improvements, diverticulitis, enhanced recovery protocols, fecal incontinence, and single incision laparoscopic surgery. SUMMARY: New technologies and practice innovations will continue to enhance patient outcomes. Multiinstitutional studies, randomized when able, are necessary to further define the safety and efficacy of new surgical techniques and to further define best practices in colorectal surgery.

Recurrent pelvic surgery.

Recurrent pelvic surgery is technically challenging. This article discusses this complex topic in patients with both benign and malignant disease. Perspectives regarding a safe approach to patients who may require reoperative pelvic surgery are discussed with a focus on work-up, technical approach, and the importance of an experienced multidisciplinary team.

Uncomplicated diverticulitis, more complicated than we thought.

INTRODUCTION: The classification of complicated and uncomplicated diverticulitis has been used for many years. We note variations in the course of uncomplicated diverticulitis. We propose and describe three categories of uncomplicated diverticulitis. METHODS: A review was performed on 907 patients who underwent sigmoid resection for diverticulitis between January 1, 2005 and December 30, 2009 at Mayo Clinic, Rochester. Overall, 223 individuals were excluded as they were not uncomplicated diverticulitis. The remaining 684 patients were divided into three classifications as follows: 54 (7.9 %) atypical, 66 (9.6 %) chronic/smoldering, and 564 (82 %) acute resolving. Data elements abstracted included demographics, preoperative symptoms, imaging and endoscopy, operative and pathologic findings, postoperative complications, and resolution of symptoms. RESULTS: The 30-day complication rate of the atypical, chronic/smoldering, and acute groups was 26 %, 22 %, and 35 %, respectively. Resolution of symptoms for the atypical and chronic/smoldering groups was 93 % and 89 %, respectively. Only two patients in the acute resolving group required an operation for recurrence. CONCLUSION: A spectrum of clinical presentation for uncomplicated diverticulitis may require different approaches. A select group of patients with chronic/smoldering and atypical disease will continue to be burdened by symptoms. The success of surgical intervention was greater than 89 % in both groups with acceptable morbidity, and should remain an option.

Surgical site infection after breast surgery: impact of 2010 CDC reporting guidelines.

BACKGROUND: Reported surgical site infection (SSI) rates after breast operations ranges 0.8-26 % in the literature. The aims of the present study were to characterize SSI after breast/axillary operations and determine the impact on the SSI rate of the 2010 Centers for Disease Control and Prevention (CDC) reporting guidelines that now specifically exclude cellulitis. METHODS: Retrospective chart review identified 368 patients with 449 operated sides between July 2004 and June 2006. SSI was defined by CDC criteria: purulent drainage (category 1), positive aseptically collected culture (category 2), signs of inflammation with opening of incision and absence of negative culture (category 3), and physician diagnosis of infection (category 4). The impact of excluding cellulitis was assessed. RESULTS: Prior CDC reporting guidelines revealed that among 368 patients, 32 (8.7 %) experienced SSI in 33 (7.3 %) of 449 operated sides. Of these, 11 (33 %) met CDC criteria 1-3, while 22 (67 %) met CDC criterion 4. Excluding cellulitis cases per 2010 CDC SSI reporting guidelines eliminates 21 of the 22 infections previously meeting CDC criterion 4. Under the new reporting guidelines, the SSI rate is 12 (2.7 %) of 449 operated sides. SSI rates varied by procedure, but these differences were not statistically significant. CONCLUSIONS: Cellulitis after breast and axillary surgery is much more common than other criteria for SSI, and SSI rates are reduced almost threefold if cellulitis cases are excluded. Recently revised CDC reporting guidelines may result in underestimates of the clinical burden of SSI after breast/axillary surgery.

Prophylactic resection, uncomplicated diverticulitis, and recurrent diverticulitis.

The classifications of acute uncomplicated diverticulitis and complicated diverticulitis have served us well for many years. However, in recent years, we have noted the prevalence of variations of uncomplicated diverticulitis, which have not precisely fit under the classification of 'acute resolving uncomplicated diverticulitis', which manifests itself with the typical left lower quadrant pain, fever, diarrhea, elevated white blood count, and CT findings, such as stranding, and which resolves fairly promptly and completely on oral antibiotic therapy. For these other variations, we would suggest we use the term chronic diverticulitis, as a subset of uncomplicated diverticulitis, meaning there is no abscess, stricture, or fistula, but the episode does not respond to the usual antibiotic treatment, and there is a rebound symptomatology once the treatment has stopped, or there is continuing subliminal inflammation that continues, typically, for several weeks after the initial episode without complete resolution. This variation could also be termed 'smoldering' diverticulitis. A second variation of uncomplicated diverticulitis should be termed atypical diverticulitis, since this variant does not manifest all of the usual components of acute diverticulitis, particularly an absence of fever, and even white blood count elevation, and there may be a lack of diagnostic evidence of acute diverticulitis. This diagnosis must be compared with diarrhea-predominant irritable bowel syndrome, and it is sometimes very difficult to distinguish between these two entities. The character of the pain in irritable bowel syndrome is typically cramping intermittently, compared with the more constant pain in smoldering diverticulitis. In our study by Horgan, McConnell, Wolff and coworkers, 5% of 930 patients who underwent sigmoid resection fit into this category of atypical uncomplicated diverticulitis. These 47 patients all had diverticulosis, and 76% that had surgery had evidence of acute and chronic inflammation, and 15% had an unsuspected pericolonic abscess. There was no mortality and a low complication mortality rate (4.2%). Complete resolution of symptoms was achieved in 76.5 with 80% being pain free. Therefore, this is mostly a diagnosis of exclusion, and clinicians must be careful to perform a thorough workup and evaluation before proceeding to surgery with this as a diagnosis. Ischemic colitis is also in the differential diagnosis, and many patients who have diverticulitis, have irritable bowel syndrome as well, so caution must be used in predicting positive outcomes after surgery in these patients.

15-year experience with surgical treatment of duodenal carcinoma: a comparison of periampullary and extra-ampullary duodenal carcinomas.

BACKGROUND: The aim of our study was to compare the outcomes of periampullary and extra-ampullary duodenal adenocarcinomas and segmental duodenal resection versus pancreatoduodenectomy and to evaluate prognostic factors. METHODS: We performed a retrospective review of all adults treated for duodenal adenocarcinoma by operative resection at a large tertiary referral center from 1994 to 2009. RESULTS: One hundred twenty-four patients had an operation for duodenal adenocarcinoma over a 15-year period (periampullary, n = 25, and extra-ampullary, n = 99). Ninety-nine patients (80%) underwent curative resection, including 24 (96%) with periampullary and 75 (76%) with extra-ampullary carcinomas. The average number of lymph nodes sampled was eight with segmental resection and 12 with pancreatoduodenectomy (p < 0.001). Five-year overall survivals were 37% for the entire cohort (n = 124), 37% in the extra-ampullary group, and 38% in the periampullary group. Tumor size (p = 0.20), positive nodes (p = 0.60), segmental resection versus pancreatoduodenectomy (p = 0.55), adjuvant therapy (p = 0.23), and R(1) versus R(0) resection (p = 0.21) were not associated with survival. In contrast, advanced T stage and pathologic grade were associated with poor survival. CONCLUSION: Extra-ampullary and periampullary duodenal adenocarcinomas have similar survival after resection. For distal duodenal tumors, survival is improved by curative resection without being compromised by limited resection. The number of lymph nodes sampled was significantly less with segmental resection than pancreatoduodenectomy.

Neoadjuvant treatment of duodenal adenocarcinoma: a rescue strategy.

AIM: To evaluate the role of neoadjuvant chemoradiation therapy and rescue surgery in the management of unresectable or recurrent duodenal adenocarcinoma. METHODS: Retrospective review of all adults treated with neoadjuvant therapy and rescue surgery for locally unresectable or locally recurrent duodenal adenocarcinoma from 1994 to 2010. RESULTS: Ten patients received various forms of neoadjuvant therapy prior to operative exploration for potential resection. Six patients presented with locally unresectable disease, while four had local recurrences. Six patients had vascular encasement, three had retroperitoneal extension with vascular invasion, and one had invasion of surrounding organs. Of the six patients with locally advanced disease, preoperative therapy consisted of chemotherapy alone (3) or chemoradiotherapy (3). Of the four patients with local recurrences, preoperative therapy consisted of chemotherapy alone (1), chemoradiotherapy alone (1), chemoradiotherapy after chemotherapy (1), and chemoradiotherapy followed by combination chemotherapy (1). Nine of ten patients became resectable after neoadjuvant therapy. Clinically, two patients had complete responses, and four had partial responses. Histopathology revealed complete pathologic response in two patients and near-complete pathologic response in one (<1 mm of residual disease). Currently, five patients are alive (range 18-83 months postoperatively). All have no evidence of disease. CONCLUSION: Neoadjuvant therapy may convert locally unresectable duodenal adenocarcinoma to resectable disease with subsequent prolonged survival.

Complications associated with postoperative antibiotic prophylaxis after breast surgery.

BACKGROUND: Evidence supports single-dose preoperative antibiotic (ABX) prophylaxis for breast surgery; however, limited data exist regarding the incidence and type of antibiotic complications postoperatively. METHODS: Breast/axillary surgeries between July 2004 and June 2006 were reviewed. Complications were analyzed by antibiotic group: preoperative prophylaxis, postoperative prophylaxis, and therapeutic intent. The Fisher exact test was used to compare complication rates. RESULTS: A total of 389 patients underwent breast/axillary surgeries during the study period. A total of 363 (93%) patients received ABX: 353 (91%) received a single preoperative dose, 91 (23%) received postoperative ABX prophylaxis, and 76 (201%) received ABX for therapeutic intent. Among patients receiving ABX, 15 (4%) had an ABX-related complication. The ABX-related complication rate was significantly higher among those receiving postoperative prophylaxis (5.5%; 5 of 91) compared with those receiving preoperative ABX alone (0%; 0 of 214) (P = .002). CONCLUSIONS: Drug-related complications were uncommon with preoperative ABX prophylaxis. Considering the potential complications of ABX after breast surgery, the use of postoperative prophylaxis should be reexamined.

Impact of neoadjuvant chemotherapy with FOLFOX/FOLFIRI on disease-free and overall survival of patients with colorectal metastases.

STUDY AIMS: To determine if neoadjuvant FOLFOX/FOLFIRI is associated with improved disease-free survival (DFS) or overall survival (OS) in patients with colorectal metastases (CRM) to the liver. METHODS: Ninety-nine patients (from 457 eligible) with CRM that underwent hepatic resection during 2000 to 2005 were included. Group 1 (n = 44) patients received neoadjuvant FOLFOX/FOLFIRI, and Group 2 (n = 55) did not receive neoadjuvant therapy. RESULTS: There were 58% men. The median age for Group 1 was 58 and Group 2, 64 (p = 0.03). OS for Group 1 at 1, 3, and 5 years was 93%, 62%, and 51%, respectively, with a median OS of 5.8 years. In Group 2 survival at 1l, 3, and 5 years was 90%, 63%, and 45%, respectively, with a median OS of 3.7 years (HR 1.06, p = 0.87). The DFS for Group 1 at 1, 3, and 5 years was 51%, 20%, and 20%, with a median DFS of 1.1 years and Group 2 at 1, 3, and 5 years was 58%, 32%, and 32% (median DFS-1.2 years; HR = 1.24, p = 0.45). CONCLUSIONS: Neoadjuvant FOLFOX/FOLFIRI was employed more frequently in younger patients with CRM; however, neoadjuvant chemotherapy for CRM was not significantly associated with an increase in OS or DFS, despite additional adjuvant therapy.

Need for a revised staging consensus in medullary thyroid carcinoma.

HYPOTHESIS: Assessing prognosis for medullary thyroid cancer remains challenging and inexact. We hypothesize that the 1997 TNM staging criteria, especially for stage IV, are more accurate than the current 2002 staging system. DESIGN: Retrospective cohort study. SETTING: Tertiary referral center. PATIENTS: One hundred seventy-three patients surgically treated for medullary thyroid cancer from January 1, 1980, to December 31, 2007. MAIN OUTCOME MEASURES: Patients were staged according to 1997 and 2002 TNM criteria and according to treatment result: biochemically cured (normal calcitonin level); clinically cured (elevated calcitonin level but no evidence of disease by imaging); or not cured. Survival was calculated from initial surgery to death or last follow-up. Analysis used McNemar test to compare paired proportions and Kaplan-Meier estimation with log-rank tests. RESULTS: A significantly higher proportion of patients were classified as having stage IV cancer using 2002 criteria compared with 1997 criteria (33% vs 7%, respectively; P < .001). Stage IV, 5-year overall survival was 82% (95% confidence interval, 72%-93%) with 2002 criteria vs 46% (95% confidence interval, 22%-93%) with 1997 criteria. Despite 15 of 36 clinically cured patients (42%) being classified as having stage IV cancer (13 patients with stage IVa cancer, 2 patients with stage IVb cancer) by the 2002 criteria, the observed overall survival of the clinically cured group at 5, 10, and 15 years was 100%, 100%, and 79%, respectively (P = .7 compared with those biochemically cured). CONCLUSIONS: The current 2002 TNM staging for medullary thyroid cancer appears inadequate, especially for patients with stage IV cancer. Elevated but stable calcitonin levels often do not portend unfavorable outcome. Patients with lymph node metastases, irrespective of their location, but without distant disease would seem best classified as having stage III cancer.

Postoperative prophylactic antibiotics and surgical site infection rates in breast surgery patients.

BACKGROUND: A single preoperative prophylactic dose of an intravenous antibiotic with antistaphylococcal activity is standard of care for breast and axillary surgical procedures. Some surgeons also prescribe postoperative prophylaxis for all patients with drains to prevent infection despite its lack of proven efficacy. METHODS: A retrospective chart review of patients with breast and/or axillary surgical procedures between July 2004 and June 2006 were included. Data were collected on patient demographics, procedure types, and use of prophylactic antibiotics. Surgical site infection (SSI) was defined by means of Centers for Disease Control and Prevention criteria, including patients meeting the physician diagnosis criterion if an antibiotic was prescribed for a clinical diagnosis of cellulitis. chi(2) and Fisher's exact tests were used to compare SSI rates. RESULTS: Three hundred fifty-three patients with 436 surgical sites who received either preoperative or both pre- and postoperative antibiotic were analyzed. Overall, the SSI rate was 7.8% (34 of 436 surgical sites). Eighty-five patients (24%) with 127 surgical sites were provided both preoperative and postoperative prophylactic antibiotics. The SSI rates did not differ statistically (P = .67) for the groups that did (95% confidence interval, 4.8-15.0; 11 of 127 surgical sites, 8.7%) and did not receive postoperative antibiotic prophylaxis (95% confidence interval, 5.0-11.0; 23 of 309, 7.4%). CONCLUSIONS: Although the overall number of patients who developed SSI was relatively small, there was no reduction in the SSI rate among those who received postoperative antibiotic prophylaxis. Because of the potential adverse events associated with antibiotic use, further evaluation of this practice is required.