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

AIM: Restorative proctocolectomy with transabdominal ileal pouch-anal anastomosis (abd-IPAA) has become the standard surgical treatment for medically refractory ulcerative colitis (UC). However, it requires a technically difficult distal anorectal dissection and anastomosis due to the bony confines of the deep pelvis. To address these challenges, the transanal IPAA approach (ta-IPAA) was developed. This novel approach may offer increased visibility and range of motion compared with abd-IPAA, although its postoperative benefits remain unclear. The aim of this work was to perform a systematic review and meta-analysis to compare and inform the frequency of postoperative outcomes between ta-IPAA and abd-IPAA for patients with UC. METHOD: Several databases were searched from inception until May 2022 for studies reporting postoperative outcomes of patients undergoing ta-IPAA. Reviewers, working independently and in duplicate, evaluated studies for inclusion and graded the risk of bias. Odds ratios (OR), mean differences (MD) and prevalence ratio (PR) and their corresponding 95% confidence intervals (CIs) were calculated using random-effects models. Sensitivity analysis was performed. RESULTS: Ten retrospective studies comprising 284 patients with ta-IPAA were included. Total mesorectal excision was performed in 61.8% of cases and close rectal dissection in 27.9%. There was no difference in the odds of Clavien-Dindo (CD) I-II complications, CD III-IV and anastomotic leak (OR 0.96, 95% CI 0.27-3.40; OR 1.18, 95% CI 0.65-2.16; OR 1.37, 95% CI 0.58-3.23; respectively) between ta-IPAA and abd-IPAA. The ta-IPAA pooled CD I-II complication rate was 18% (95% CI 5%-35%) and for CD III-IV 10% (95% CI 5%-17%), and the anastomotic leak rate was 6% (95% CI 2%-10%). There were no deaths reported. CONCLUSIONS: This meta-analysis compared the novel ta-IPAA procedure with abd-IPAA and found no difference in postoperative outcomes. While the need for randomized controlled trails and comparison of functional outcomes between both approaches remains, this evidence should assist colorectal surgeons to decide if ta-IPAA is a viable alternative.

Surgery for young onset diverticulitis: is it curative?

PURPOSE: Previously considered a disease of old age, diverticular disease is increasingly prevalent in younger populations. Guidelines on surgical resection have shifted from recommending resection for all young onset patients to an individualized approach. Therefore, we aim to determine demographics and outcomes including radiographic and surgical recurrence rates in patients < 40 years old undergoing resection for diverticular disease. METHODS: A retrospective, single center study was performed. All patients ≤ 39 years undergoing operative intervention for left-sided diverticular disease between Jan 2010 and July 2017 were included. Recurrence was determined by individual review of imaging and operative reports. RESULTS: Overall, 147 (n = 107/72.8% male, mean age = 34.93 ± 4.12 years) patients were included. The majority were ASA 1 or 2 (n = 41/27.9% and n = 82/55.8%). The most common surgical indication was uncomplicated diverticulitis (n = 77, 52.4%) followed by perforation (n = 26/17.7%). The majority (n = 108/73.5%) of cases were elective. Seventy-nine (57.3%) of all cases were performed laparoscopically. Primary anastomosis without diversion was the most common surgical outcome (n = 108/73.5%). Median length of stay was 5 (4, 7) days. There was no mortality. There were three (2.0%) intraoperative and 38 (25.9%) postoperative complications. The most common complication was anastomotic leak (n = 6/4.1%). The majority (n = 5) of leaks occurred after elective surgery. Two neoplastic lesions (1.3% of cohort) were found (1 adenoma with low-grade dysplasia/1 polyp cancer). Over a mean follow-up of 96 (74, 123) months, only 2 (1.3%) patients experienced a surgical or radiological recurrence. CONCLUSION: Both neoplasia and recurrence after resection for diverticular disease in young onset patients are rare. Leaks after primary anastomosis even in the elective setting warrant careful consideration of a defunctioning ileostomy.

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

BACKGROUND: We hypothesized that prolonging the interval to surgery in non-responders to neoadjuvant chemoradiation therapy (nCRT) could lead to worse oncologic outcomes. METHODS: Rectal adenocarcinoma patients with poor tumor response to nCRT (AJCC tumor regression grade 3) were selected. Oncologic outcomes were evaluated according to the time interval between completion of nCRT and surgery. RESULTS: Among 56 non-responders, 28 patients surgically treated ≥8 weeks after completion of nCRT had worse disease-free survival (31% vs. 49%, p â€‹= â€‹0.05) and worse overall survival (34% vs. 53%, p â€‹= â€‹0.02) compared to patients <8 weeks. Using the three different intervals (≥12 weeks, 6-12 weeks, and< 6 weeks), waiting longer was consistently associated with worse overall (23% vs. 48% vs. 63%, p â€‹= â€‹0.02) and worse cancer-specific survival (35% vs. 61% vs. 71%, p â€‹= â€‹0.04), respectively. CONCLUSION: For rectal cancer patients who are non-responders to nCRT, delay of surgery may lead to worse oncologic outcomes.

The use of laparoscopy for T4a and T4b colon cancer: are we playing with fire?

BACKGROUND: The laparoscopic approach for colon cancer has become widely accepted. However, its safety for T4 tumors, and particularly for T4b tumors when local invasion to adjacent structures occurs, remains controversial. This study aimed to compare short and long-term outcomes in patients undergoing laparoscopic vs. open resection for T4a and T4b colon cancers. METHODS: A prospectively maintained, single-institution database was queried to identify patients with pathological stage T4a and T4b colon adenocarcinomas electively operated on between 2000 and 2012. Patients were divided into two groups based on the use of laparoscopy. Patient characteristics, perioperative, and oncologic outcomes were compared. RESULTS: One hundred and nineteen patients [41 laparoscopic (L), 78 open surgeries (O)] met the inclusion criteria. No difference was observed in age, gender, BMI, ASA, and procedure between groups. Tumors treated by L were smaller than O (p = 0.003). No difference was observed in morbidity, mortality, reoperation, or readmission between the groups. Length of hospital stay was shorter in L than O (6 vs. 9 days, p = 0.005). Conversion to open was necessary in 22% of all T4 tumors laparoscopic cases. However, when tumors were subdivided by pT4 classification, conversion was necessary for 4 of 34 (12%) pT4a patients vs. 5 of 7 (71%) pT4b patients (p = 0.003). In the pT4b cohort (n = 37), more tumors were treated by the open approach (30 vs. 7). For pT4b tumors, the R0 resection rate was 94% (86% in L vs. 97% in O, p = 0.249). The use of laparoscopy did not impact overall survival, disease-free survival, cancer-specific survival, or tumor recurrence overall in all T4 or T4a and T4b tumors. CONCLUSIONS: Laparoscopic surgery can be safely performed in pT4 tumors with similar oncologic outcomes as compared to open surgery. However, for pT4b tumors, the conversion rate is very high. The open approach may be preferable.

Initial Clinical Outcomes Using Umbilical Cord-Derived Tissue Grafts to Repair Anovaginal Fistula.

BACKGROUND: Perianal fistula is a debilitating disease and challenging condition to treat. Recently, the use of stem cells has been shown to improve healing of fistulas. OBJECTIVE: The aim was to examine the use of an umbilical cord-derived stem cell graft in a pilot study as a novel scaffold/stem inlay implanted into fistula repairs for anovaginal fistula to examine healing rates. DESIGN: This was a pilot study. SETTINGS: This study took place in a colorectal surgery practice. PATIENTS: Patients with anovaginal fistula consented to participate. Cryopreserved umbilical cord tissue graft with viable cells was incorporated as an inlay using a previously reported technique by the authors. Demographic data including history of previous repairs and IBD were included. All patients were followed for a minimum of 6 weeks. MAIN OUTCOME MEASURES: The primary measures were safety and efficacy of novel stem cell graft in the treatment of anovaginal fistula. RESULTS: From September 2017 to September 2019, 15 patients underwent anovaginal fistula repair. Three of these patients underwent a second repair, for a total of 18 repairs. No patient was intentionally diverted, but 3 patients presented for repair with a preexisting stoma. The majority of repairs were previous repair failures (12; 67%), and 7 repairs were performed on 5 patients with IBD. Median follow-up was 30 (6-104) weeks. The safety profile for cryopreserved umbilical cord tissue graft was excellent as no adverse events occurred. Overall complete healing rate was 39%, and 12 (67%) repairs resulted in improvement of symptoms. LIMITATIONS: This was a small pilot study. CONCLUSIONS: This is the largest series using cryopreserved umbilical cord graft for anovaginal fistula repair. The use of umbilical cord was safe and effective at closing defects. Randomized studies are necessary to determine added benefits over current standard of care. See Video Abstract at http://links.lww.com/DCR/B896 . RESULTADOS CLNICOS INICIALES DEL USO DE INJERTOS DE TEJIDO DERIVADO DE PLACENTA PARA REPARACIN DE FSTULAS ANOVAGINALES: ANTECEDENTES:La fístula perianal es una enfermedad debilitante y una afección difícil de tratar. Recientemente, se ha demostrado que el uso de células madre mejora la curación de las fístulas.OBJETIVO:Deseamos examinar el uso de un injerto de células madre derivadas de cordón umbilical en un estudio piloto como una nueva matriz/injerto de células madre implantado en reparaciones de fístula para fístula anovaginal para examinar las tasas de curación.DISEÑO:Este fue un estudio piloto.ESCENARIO:Este estudio se llevó a cabo en una clínica de cirugía colorrectal.PACIENTES:Se obtuvo consentimiento informado de pacientes con fístula anovaginal. El injerto de tejido de cordón umbilical criopreservado con células viables se incorporó como incrustación utilizando una técnica previamente informada por los autores. Se incluyeron datos demográficos que incluían antecedentes de reparaciones previas y enfermedad inflamatoria intestinal. Todos los pacientes fueron seguidos durante un mínimo de 6 semanas.PRINCIPALES MEDIDAS DE RESULTADO:Las principales medidas fueron la seguridad y la eficacia del nuevo injerto de células madre en el tratamiento de la fístula anovaginal.RESULTADOS:Desde 9/2017-9/2019, 15 pacientes fueron sometidas a reparación de fístula anovaginal. Tres de estos pacientes fueron sometidos a una segunda reparación, para un total de 18 reparaciones. Ningún paciente fue derivado intencionalmente mientras que 3 pacientes se presentaron para reparación con un estoma preexistente. La mayoría de las reparaciones fueron fallas de reparaciones previas (12, 67%) y se realizaron siete reparaciones en 5 pacientes con enfermedad inflamatoria intestinal (EII). La mediana de seguimiento fue de 30 semanas (6-104). El perfil de seguridad del injerto de tejido de cordón umbilical criopreservado fue excelente ya que no se produjeron efectos adversos. La tasa general de curación completa fue del 39% y 12 (67%) reparaciones dieron como resultado una mejoría de los síntomas.LIMITACIONES:Este fue un pequeño estudio piloto.CONCLUSIÓNES:Ésta es la serie más grande de utilización de injerto de cordón umbilical criopreservado para la reparación de una fístula anovaginal. La utilización del cordón umbilical resultó segura y eficaz para cerrar defectos. Se necesitan estudios aleatorizados para determinar los beneficios adicionales sobre el estándar de atención actual. Consulte Video Resumen en http://links.lww.com/DCR/B896 . (Traducción-Dr. Jorge Silva Velazco ).

A Novel Patient-like Swine Model of Perianal Crohn's Disease.

BACKGROUND: Perianal Crohn's disease is associated with poor outcomes and high medical costs. It is notoriously difficult to treat despite therapeutic advancements for luminal disease. A large animal model that mimics human perianal disease is needed to test innovative therapies. OBJECTIVE: This study aimed to create a swine model that replicates the inflammatory component and therapeutic challenges found in patients with perianal Crohn's disease. DESIGN: This was an animal preclinical study. SETTINGS: The experiments were performed at the animal laboratory at the Johns Hopkins University. PATIENTS: Four sus scrufus female pigs were included in the study. INTERVENTIONS: Four female pigs underwent creation of 3 surgical perianal fistulas each, 1 rectovaginal and 2 perianal. Size 24 French setons were placed to maintain patency of the fistula tracts for 4 weeks. After removal of the setons, trinitrobenzene sulfonic acid was administered into the fistula tract to create and maintain local inflammation mimicking perianal Crohn's disease. MAIN OUTCOMES MEASURES: An MRI was obtained to assess the fistulas and the pigs were euthanized to review histopathology. RESULTS: Three inflammatory chronic fistula tracts were successfully created in each pig as confirmed by MRI and examination under anesthesia. This is the first report of maintaining patent fistulas in swine 2 weeks after removal of setons. For the first time, we reported that 2 pigs developed branching fistulas and small abscesses reminiscent of human perianal Crohn's disease. The corresponding histopathologic examination found significant chronic active inflammation on standard hematoxylin and eosin staining. LIMITATIONS: The fistulas were surgically induced and did not occur naturally. CONCLUSIONS: A chronic perianal fistula model in pigs that strongly resembles human perianal Crohn's disease was successfully created. This model can be used to test novel therapeutics and techniques to pave the path for human trials. See Video Abstract at http://links.lww.com/DCR/B969 . UN NUEVO MODELO PORCINO SIMILAR A UN PACIENTE DE LA ENFERMEDAD DE CROHN PERIANAL ANTECEDENTES: La enfermedad de Crohn perianal se asocia con malos resultados y altos costos médicos. Es notoriamente difícil de tratar a pesar de los avances terapéuticos para la enfermedad luminal. Se precisa de un modelo animal grande que imite la enfermedad perianal humana para probar terapias innovadoras.OBJETIVO:Nuestro objetivo de este estudio fue crear un modelo porcino que replique el componente inflamatorio y los desafíos terapéuticos que se encuentran en los pacientes con enfermedad de Crohn perianal.DISEÑO:Este fue un estudio preclínico en animales.AJUSTES:Los experimentos se realizaron en el laboratorio de animales de la Universidad Johns Hopkins.PACIENTES:Se incluyeron en el estudio cuatro cerdas sus scrofa.INTERVENCIONES:Cuatro cerdas fueron sometidas a la creación de 3 fístulas perianales quirúrgicas cada una: 1 recto vaginal y 2 perianales. Se colocaron sedales de 24 French para mantener la permeabilidad de los trayectos fistulosos durante 4 semanas. Tras el retiro de los sedales, se administró ácido trinitrobenceno sulfónico en el trayecto de la fístula para crear y mantener la inflamación local simulando la enfermedad de Crohn perianal.PRINCIPALES MEDIDAS DE RESULTADOS:Se obtuvo una resonancia magnética para evaluar las fístulas y los cerdos fueron sacrificados para revisar la histopatología.RESULTADOS:Se crearon de manera exitosa tres trayectos fistulosos inflamatorios crónicos en cada cerdo, confirmados por imágenes de resonancia magnética y examen bajo anestesia. Este es el primer informe de preservación de fístulas permeables en cerdos 2 semanas tras el retiro de los setones. Por primera vez, informamos que dos cerdos desarrollaron fístulas ramificadas y pequeños abscesos que recuerdan a la enfermedad de Crohn perianal humana. El examen histopatológico correspondiente encontró una significativa inflamación crónica activa en la tinción estándar de hematoxilina y eosina.LIMITACIONES:Las fístulas se indujeron quirúrgicamente y no se produjeron de forma natural.CONCLUSIONES:Se logro recrear con éxito un modelo de fístula perianal crónica en cerdos que se asemeja mucho a la enfermedad de Crohn perianal humana. Este modelo se puede utilizar para probar nuevas terapias y técnicas para allanar el camino para los ensayos en humanos. Consulte Video Resumen en http://links.lww.com/DCR/B969 . (Traducción-Dr Osvaldo Gauto).

Effect of Incisional Negative Pressure Wound Therapy on Surgical Site Infections in High-Risk Reoperative Colorectal Surgery: A Randomized Controlled Trial.

BACKGROUND: Colorectal resections have relatively high rates of surgical site infections causing significant morbidity. Incisional negative pressure wound therapy was introduced to improve wound healing of closed surgical incisions and to prevent surgical site infections. OBJECTIVE: This randomized controlled trial aimed to investigate the effect of incisional NPWT on superficial surgical site infections in high-risk, open, reoperative colorectal surgery. DESIGN: This was a single-center randomized controlled trial conducted between July 2015-October 2020. Patients were randomly assigned to incisional negative pressure wound therapy or standard gauze dressing with a 1:1 ratio. A total of 298 patients were included. SETTINGS: This study was conducted at the colorectal surgery department of a tertiary-level hospital. PATIENTS: This study included patients older than 18 years who underwent elective reoperative open colorectal resections. Patients were excluded who had open surgery within the past 3 months, who had active surgical site infection, and who underwent laparoscopic procedures. MAIN OUTCOME MEASURES: The primary outcome was superficial surgical site infection within 30 days. Secondary outcomes were deep and organ-space surgical site infections within 7 days and 30 days, postoperative complications, and length of hospital stay. RESULTS: A total of 149 patients were included in each arm. The mean age was 51 years, and 49.5% were women. Demographics, preoperative comorbidities, and preoperative albumin levels were comparable between the groups. Overall, most surgeries were performed for IBD, and 77% of the patients had an ostomy fashioned during the surgery. No significant difference was found between the groups in 30-day superficial surgical site infection rate (14.1% in control versus 9.4% in incisional negative pressure wound therapy; p = 0.28). Deep and organ-space surgical site infections rates at 7 and 30 days were also comparable between the groups. Postoperative length of stay and complication rates (Clavien-Dindo grade) were also comparable between the groups. LIMITATIONS: The patient population included in the trial consisted of a selected group of high-risk patients. CONCLUSIONS: Incisional negative pressure wound therapy was not associated with reduced superficial surgical site infection or overall complication rates in patients undergoing high-risk reoperative colorectal resections. See Video Abstract at http://links.lww.com/DCR/B956 . EFECTO DE LA TERAPIA DE HERIDA INSICIONAL CON PRESIN NEGATIVA EN INFECCIONES DEL SITIO QUIRRGICO EN CIRUGA COLORRECTAL REOPERATORIA DE ALTO RIESGO UN ENSAYO CONTROLADO ALEATORIZADO: ANTECEDENTES:Las resecciones colorrectales tienen tasas relativamente altas de infecciones del sitio quirúrgico que causan una morbilidad significativa. La terapia de heridas incisionales con presión negativa se introdujo para mejorar la cicatrización de las heridas de incisiones quirúrgicas cerradas y para prevenir infecciones del sitio quirúrgico.OBJETIVO:El objetivo de este ensayo controlado y aleatorizado fue investigar el efecto de la terapia de herida incisional con presión negativa en infecciones superficiales del sitio quirúrgico en cirugía colorrectal re operatoria, abierta y de alto riesgo.DISEÑO:Ensayo controlado y aleatorizado de un solo centro entre julio de 2015 y octubre de 2020. Los pacientes fueron aleatorizados para recibir tratamiento para heridas incisionales con presión negativa o vendaje de gasa estándar en una proporción de 1:1. Se incluyeron un total de 298 pacientes.AJUSTE:Este estudio se realizó en el departamento de cirugía colorrectal de un hospital de tercer nivel.PACIENTES:Se incluyeron pacientes mayores de 18 años que se fueron sometidos a resecciones colorrectales abiertas, re operatorias y electivas. Se excluyeron aquellos pacientes que tuvieron cirugía abierta en los últimos 3 meses, con infección activa del sitio quirúrgico y que fueron sometidos a procedimientos laparoscópicos.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue infección superficial del sitio quirúrgico dentro de los 30 días. Los resultados secundarios fueron infecciones del sitio quirúrgico profundas y del espacio orgánico dentro de los 7 y 30 días, las complicaciones posoperatorias y la duración de la estancia hospitalaria.RESULTADOS:Se incluyeron un total de 149 pacientes en cada brazo. La edad media fue de 51 años y el 49,5% fueron mujeres. La demografía, las comorbilidades preoperatorias y los niveles de albúmina preoperatoria fueron comparables entre los grupos. En general, la mayoría de las cirugías fueron realizadas por enfermedad inflamatoria intestinal y al 77 % de los pacientes se les confecciono una ostomía durante la cirugía. No hubo diferencias significativas entre los grupos en la tasa de infección del sitio quirúrgico superficial a los 30 días (14,1 % en el control frente a 9,4 % en el tratamiento de herida incisional con presión negativa, p = 0,28). Las tasas de infecciones del sitio quirúrgico profundas y del espacio orgánico a los 7 y 30 días también fueron comparables entre los grupos. La duración de la estancia postoperatoria y las tasas de complicaciones (Clavien-Dindo Graduacion) también fueron comparables entre los grupos.LIMITACIONES:La población de pacientes incluida en el ensayo consistió en un grupo seleccionado de pacientes de alto riesgo.CONCLUSIONES:Video Resumen en http://links.lww.com/DCR/B956 . (Traducción-Dr. Osvaldo Gauto ).

Redo Continent Ileostomy in Patients With IBD: Valuable Lessons Learned Over 25 Years.

BACKGROUND: Patients with IBD with continent ileostomies may require revision surgeries. There remains a paucity of data regarding outcomes after redo continent ileostomy. OBJECTIVE: This study aimed to evaluate patient outcomes after redo continent ileostomy. DESIGN: Retrospective cohort study. SETTINGS: This study was conducted at a high-volume, specialized colorectal surgery department. PATIENTS: We identified patients who underwent redo continent ileostomy (defined as neo-pouch construction or major operations changing the pouch configuration) for IBD between 1994 and 2020. MAIN OUTCOME MEASURES: The main outcomes measured were patient demographics, short- and long-term outcomes, and quality of life. RESULTS: A total of 168 patients met inclusion criteria; 102 (61%) were female, the mean age was 51 years (±13.1), and the mean BMI was 24.4 (±3.9). The median time between primary and redo continent ileostomy was 16.8 years. One hundred twenty-two patients (73%) who underwent redo surgery had ulcerative colitis, 36 (21%) had Crohn's disease, and 10 (6%) had indeterminate colitis. Slipped nipple valve and valve stricture were the most common indications for redo continent ileostomy (86%). After a median follow-up of 4 years, 48 patients (29%) required a subsequent reoperation and 27 (16%) had pouch failure requiring pouch excision. The pouch survival rate was 89% at 3 years, 84% at 5 years, and 79% at 10 years. On univariate analysis, a shorter interval between the primary and redo continent ileostomy was associated with long-term pouch failure ( p = 0.003). Cox regression multivariate analysis confirmed that a shorter interval between surgeries was independently associated with pouch failure ( p = 0.014). The mean Cleveland Clinic Global Quality of Life score was 0.61 (± 0.23) among the 70 patients who responded to the questionnaire. LIMITATIONS: The main limitations were that this was a retrospective, single-center study and that it had a low response rate for the Global Quality of Life questionnaire. CONCLUSIONS: Redo continent ileostomy surgery is associated with a long-term pouch retention rate of 79% and satisfactory quality of life. Therefore, redo surgery should be offered to patients who are motivated to keep their continent ileostomy. See Video Abstract at http://links.lww.com/DCR/C87 . REHACER LA ILEOSTOMA CONTINENTE EN PACIENTES CON ENFERMEDAD INFLAMATORIA INTESTINAL VALIOSAS LECCIONES APRENDIDAS DURANTE AOS: ANTECEDENTES:Los pacientes con enfermedad inflamatoria intestinal con ileostomías continentes pueden requerir cirugías de revisión. Sigue habiendo escasez de datos con respecto a los resultados después de volver a realizar la ileostomía continente.OBJETIVO:Evaluar los resultados después de rehacer la ileostomía continente.DISEÑO:Estudio de cohorte retrospectivo.ESCENARIO:Departamento especializado en cirugía colorrectal de alto volumen.PACIENTES:Identificamos pacientes que se sometieron a una nueva ileostomía continente (definida como construcción de una nueva bolsa u operaciones mayores que cambian la configuración de la bolsa) por enfermedad inflamatoria intestinal entre 1994 y 2020.PRINCIPALES MEDIDAS DE RESULTADO:Datos demográficos de los pacientes, resultados a corto y largo plazo y calidad de vida.RESULTADOS:Un total de 168 pacientes cumplieron con los criterios de inclusión; 102 (61%) eran mujeres, la edad media fue de 51 años (±13,1) y el IMC medio fue de 24,4 (±3,9). La mediana de tiempo entre la ileostomía primaria y la nueva ileostomía continente fue de 16,8 años. Ciento veintidós pacientes (73%) que se sometieron a una nueva cirugía tenían colitis ulcerosa, 36 (21%) tenían enfermedad de Crohn y 10 (6%) tenían colitis indeterminada. El deslizamiento de la válvula del pezón y la estenosis de la válvula fueron las indicaciones más comunes para rehacer la ileostomía continente (86%). Después de una mediana de seguimiento de 4 años, 48 (29%) pacientes requirieron una reintervención posterior y 27 (16%) tuvieron falla de la bolsa que requirió la escisión de la bolsa. La tasa de supervivencia de la bolsa fue del 89 % a los 3 años, del 84% a los 5 años y del 79% a los 10 años. En el análisis univariable, un intervalo de tiempo más corto entre la ileostomía continente primaria y la nueva se asoció con falla de la bolsa a largo plazo (p = 0,003). El análisis multivariable de regresión de Cox confirmó que el intervalo más corto entre cirugías se asoció de forma independiente con el fracaso de la bolsa (p = 0,014). La puntuación media de la Calidad de Vida Global fue de 0,61 (± 0,23) entre los 70 pacientes que respondieron al cuestionario.LIMITACIONES:Estudio retrospectivo de un solo centro. Baja tasa de respuesta al cuestionario de Calidad de Vida.CONCLUSIÓN:La cirugía de ileostomía continente se asocia con una tasa de retención de la bolsa a largo plazo del 79% y una calidad de vida satisfactoria. Por lo tanto, se debe ofrecer una nueva cirugía a los pacientes que están motivados para mantener su ileostomía continente. Consulte Video Resumen en http://links.lww.com/DCR/C87 . (Traducción-Dr. Felipe Bellolio ).

Targeted lateral pelvic lymph node excision in the setting of total neoadjuvant therapy for rectal cancer.

Targeted lateral pelvic node dissection in the era of total neoadjuvant therapy.

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

PURPOSE: Laparoscopic surgery for complicated Crohn's (CD) is often technically challenging. Previous studies are limited by the comparison of heterogeneous cohorts of patients undergoing laparoscopic vs open surgery. We aimed to compare perioperative and long-term outcomes of matched patients undergoing laparoscopic and open colonic and ileocolonic resection. Primary outcomes were operative time, blood loss, and complications. Long-term outcomes were subsequent intraabdominal CD surgery, incisional hernia repair, and stoma reversal rates. METHODS: Laparoscopic and open CD patients were 1:1 propensity score matched on age, body mass index, sex, indication, ASA grade, prior abdominal surgery, and postoperative Crohn's medication use based on the laparoscopic approach. RESULTS: A total of 906 patients underwent surgery for complex CD. After propensity matching, 386 were analyzed (193 open/193 lap, 51.3% male, mean age 33.9 + / - 12.6). Mean follow-up was 9.8 (range 7.9-12.1) years. Length of stay [(LOS) 6 (4, 8) vs 8 (5, 11) days, p < 0.001] and operative time [154 (110, 216) vs 176 (126, 239) min, p = 0.03] were shorter in the laparoscopic group. There was no difference in other complications or mortality. After adjusting for postoperative medications, no association was found between operative approach and subsequent intra-abdominal operation or incisional hernia repair. Laparoscopic patients were less likely to have postoperative sepsis [OR 0.40 (0.18, 0.91), p = 0.03]. CONCLUSION: In the setting of complicated Crohn's, in matched cohorts, laparoscopic surgery is associated with reduced operative times and LOS. Mortality, reoperation, and symptomatic hernia rates were equivalent to open surgery. Patients undergoing laparoscopic surgery are less likely to experience postoperative sepsis.

Restorative proctocolectomy with ileal pouch-anal anastomosis in elderly patients - is advanced age a contraindication?

AIM: We aimed to determine pouch function and retention rate for restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) in elderly patients. METHODS: We identified patients over 50 years old subjected to IPAA for confirmed pathological UC from 1980 until 2016. Patients were grouped according to age: 50-59, 60-69 and 70+ years. Short and long-term outcomes and quality of life (QOL) were compared among the groups. RESULTS: Six hundred and one patients were identified (399 (66.4%) between 50-59 181 (30.1%) between 60-69, and 21 (3.5%) over 70 years of age). More males were in the 70+ arm, and more two-stage procedures were performed in this group. Wound infection increased with age (P = 0.023). There was a trend of more fistula and pouchitis in the 70+ patients (P = 0.052 and P = 0.055, respectively). Pouch failure rate increased with age, and it was statistically significant in the 70+ cohort (P = 0.015). Multivariate stepwise logistic regression showed that pelvic sepsis (HR 4.8 (95% CI 1.5-15.4), P = 0.009), fistula (HR 6.0 (95% CI 1.7-21.5), and mucosectomy with handsewn anastomosis (HR 4.5 (95% CI 1.4-14.7)), were independently associated with pouch failure. No difference was observed in the QOL among the groups, but pouch function was better for patients younger than 60 years. CONCLUSION: In elderly patients with UC, IPAA may be offered with reasonable functional outcomes, and ileal pouch retention rates, as an alternative to the permanent stoma. Stapled anastomosis increases the chance of pouch retention and should be recommended as long as the distal rectum does not carry dysplasia.

A Novel Validated Breast Aesthetic Scale.

BACKGROUND: Breast aesthetics impacts patients' quality of life after breast reconstruction, but patients and surgeons frequently disagree on the final aesthetic evaluation. The need for a comprehensive, validated tool to evaluate breast aesthetics independently from the patient motivated this study. METHODS: The 13-item Validated Breast Aesthetic Scale was developed after several internal meetings, and worded to be understood by a nonspecialist. Three items are common for both breasts, with the remaining being side-specific. To test the internal consistency of the scale subitems, postoperative photographs after different breast reconstruction techniques were graded by a six-member panel. To test interrater and intrarater correlation across time, four physicians evaluated the results of abdominally based breast reconstructions following nipple-sparing mastectomies. RESULTS: Graded aesthetic outcomes of 53 patients showed that the Cronbach alpha of the subitems of the scale was 0.926, with no single item that, if excluded, would increase it. Twenty-two patients underwent aesthetic outcomes grading at four different time points. The mean overall appearance was 3.71 ± 0.62. The mean grade for overall nipple appearance was 4.0 ± 0.57. The coefficient alpha of the panel overall aesthetic grade across different time points was 0.957; whereas intragrader reliability for graders 1 through 4 individually showed alpha coefficients of 0.894, 0.9, 0.898, and 0.688, respectively. Similar results were found for the other items of the scale. CONCLUSIONS: The proposed aesthetic scale evaluates different aspects of the breast reconstruction aesthetic result with excellent internal consistency among its subitems. Grading by a gender-balanced, diverse four-member panel using postoperative photographs showed higher reliability and reproducibility compared to single graders.

Right colon, left colon, and rectal cancer have different oncologic and quality of life outcomes.

PURPOSE: Colorectal cancer patients are commonly considered a single entity in outcomes studies. This is particularly true for quality of life (QOL) studies. This study aims to compare oncologic and QOL outcomes between right colon, left colon, and rectal cancer in patients operated on in a single high-volume institution. METHODS: A prospectively maintained database was queried to identify patients with pathological stages I-III colorectal adenocarcinoma electively operated on with curative intent between 2000 and 2010. Patient characteristics, perioperative and oncologic outcomes, and QOL were compared according to cancer location. RESULTS: Two-thousand sixty-five (606 right colon cancer [RCC], 366 left colon cancer [LCC], and 1093 rectal cancer [RC]) patients met the inclusion criteria. LCC had better overall survival (OS) and disease-free survival (DFS) in the non-adjusted analysis (p < 0.001) and better OS in multivariate analysis adjusted by age, gender, ASA, chemotherapy, and pathological stage (p = 0.024). Although RCC had worse OS and DFS in non-adjusted survival analysis than LCC and RC, when adjusted for the factors above, RCC had better survival outcomes than RC, but not LCC. COX regression analysis showed age (p < 0.001), gender (p = 0.016), ASA (p < 0.001), pathological stage (p < 0.001), adjuvant chemotherapy (p = 0.043), and cancer location (p = 0.024) were independently associated with OS. Age (p < 0.001), gender (p = 0.030), ASA (p = 0.004), and pathological stage (p < 0.001) were independently associated with DFS. Patients with RC reported more sexual dysfunction and work restrictions than colon cancers (p = 0.015 and p < 0.001, respectively). CONCLUSION: In an adjusted multivariate analysis, colon cancers demonstrated better survival outcomes when compared to rectal cancers.

Does CO2 pneumoperitoneum in laparoscopy interfere with collagen deposition in abdominal surgical wounds?

Purpose To determine by histomorphometric analysis whether CO2 pneumoperitoneum interferes with collagen deposition in surgical wounds in the aponeurosis of rats. Methods This experiment involved 80 male Wistar rats, randomly allocated into four groups according to pneumoperitoneum period (PRE: 30 min preoperatively; POST: 30 min postoperatively; PP: 30 min pre- and postoperatively; C: control group). CO2 pneumoperitoneum was insufflated to 5 mmHg of pressure. A laparotomy was performed; 1 cm of the left colon was then resected, and an end-to-end anastomosis was performed to simulate surgical trauma, after which the abdominal wall was closed. On postoperative days 7 or 14, a sample of the abdominal wall was collected, stained with picrosirius red and observed under polarized light in an optical microscope. The amount of collagen was estimated by computerized histomorphometric analysis. Results There were no significant differences in collagen deposition between the control and experimental groups on postoperative days 7 (p=0.720) or 14 (p=0.933). The amount of collagen increased as expected in all groups between postoperative days 7 and 14 (p=0.0003). Conclusion At 5 mmHg, CO2 pneumoperitoneum does not interfere with collagen deposition in abdominal wall surgical wounds in rats.

Factors Influencing the Aesthetic Outcome and Quality of Life After Breast Reconstruction: A Cross-sectional Study.

BACKGROUND: The most important purpose of reconstruction is to increase or restore the patient's quality of life (QOL). The purpose of our study was to evaluate the QOL and aesthetic outcomes of patients after autologous versus implant-based breast reconstruction. METHODS: Patients who underwent breast reconstruction between 2009 and 2011 were included. The Breast-Q, a validated breast reconstruction QOL questionnaire, was used along with postoperative photographs panel analyses using a multiparameter breast-specific aesthetic outcome scale and retrospective evaluation of demographic and treatment data. RESULTS: Of 820 patients, 261 complete questionnaires were evaluated. On the multivariable linear regression, the "satisfaction with breasts" was positively influenced by autologous and bilateral reconstructions, whereas radiation therapy (RTx), the time between the reconstruction and the questionnaire, and the number of surgeries due to complications were negative factors (adjusted R = 0.183; P < 0.001). The same factors influenced the "satisfaction with the outcomes." The mean "overall breast appearance" was also positively influenced by autologous and bilateral reconstructions, and RTx and the total number of surgeries were negative predictive factors (adjusted R = 0.311, P < 0.001). CONCLUSIONS: The aesthetic result and QOL after breast reconstruction for breast cancer treatment are positively influenced by the use of autologous tissue and bilaterality. Factors that negatively influenced the aesthetic result and the QOL include use of RTx, a higher number of surgeries needed for the reconstruction, reoperations due to complications, higher body mass index, and a longer time elapsed between reconstruction and the questionnaire.