Three-stage Laparoscopic Ileal Pouch-anal Anastomosis Is the Best Approach for High-risk Patients with Inflammatory Bowel Disease: An Analysis of 185 Consecutive Patients.

BACKGROUND: There are very few studies and no consensus concerning the choice between two- and three-stage ileal pouch-anal anastomosis [IPAA] in inflammatory bowel diseases [IBD]. This study aimed to compare operative results between both surgical procedures. METHODS: Only patients who underwent a laparoscopic IPAA for IBD were included. They were divided into two groups: two-stage [IPAA and stoma closure] [Group A] and three-stage IPAA [subtotal colectomy, IPAA, stoma closure] [Group B]. RESULTS: From 2000 to 2015, 185 patients (107 men, median age of 42 [range, 15-78] years) were divided into Groups A [n = 82] and B [n = 103]. Patients in Group B were younger than in Group A (39 [15-78] vs 43 [16-74] years; p = 0.019), presented more frequently with Crohn's disease [16% vs 5%; p < 0.04], and were more frequently operated in emergency for acute colitis [37% vs 1%; p < 0.0001]. Cumulative operative time and length of stay were significantly longer in Group B (580 [300-900] min, and 19 [13-60] days) than in Group A (290 [145-490] min and 10 [7-47] days; p < 0.0001). Cumulative postoperative morbidity, delay for stoma closure, and function were similar between the two groups. Long-term morbidity was similar between Group A [13%] and Group B [21%; p = 0.18]. CONCLUSIONS: Our study suggested that postoperative morbidity was similar between two- and three-stage laparoscopic IPAA. It suggested that the three-stage procedure is probably safer for high-risk patients [ie in acute colitis].

When is the best time for temporary stoma closure in laparoscopic sphincter-saving surgery for rectal cancer? A study of 259 consecutive patients.

BACKGROUND: There is no consensus regarding the best timing for temporary stoma closure after proctectomy for rectal cancer, especially if the patient requires adjuvant chemotherapy. This study aimed to assess whether the timing of stoma closure could influence postoperative morbidity. METHODS: Patients with rectal cancer undergoing laparoscopic proctectomy with temporary stoma were included and divided into three groups according to the delay of stoma closure after proctectomy: ≤60 days (Group A), 61-90 days (Group B), and >90 days (Group C). RESULTS: From 2008 to 2013, 259 patients (146 men, median age 61 years) were divided into Groups A (n = 65), B (n = 115), and C (n = 79). At the time of stoma closure, seven (11%) patients received adjuvant chemotherapy in Group A versus 42 (37%) in Group B (p = 0.0002) and 24 (30%) in Group C (p = 0.004), and peristomal hernia was noted in four patients (6%) in Group A versus 14 (12%) in Group B and 21 (27%) in Group C (p < 0.0001). Although overall postoperative morbidity was similar between groups, anastomotic leakage (at the stoma closure site) was noted in one patient in Group A versus zero in Group B versus four in Group C (p = 0.03). Median hospital stay was 5 days in Group A versus 6 in Group B versus 6 in Group C (p = 0.004). CONCLUSIONS: Our results suggested that timing of temporary stoma closure can influence postoperative morbidity. Best results were obtained if stoma closure was performed before 90 days, even during adjuvant chemotherapy. There is no benefit in delaying stoma closure after completion of adjuvant chemotherapy.

Short-term induction of thrombocytopenia delays periodontal healing in rats with periodontal disease: participation of endostatin and vascular endothelial growth factor.

BACKGROUND AND OBJECTIVE: Platelets contain factors, including VEGF and endostatin, that can modulate the healing process. We evaluated the effects of severe thrombocytopenia on periodontal healing in rats and determined the contribution of VEGF and endostatin to the healing process. MATERIAL AND METHODS: Rats were distributed into three test groups and two control groups. Cotton ligatures were placed at the gingival margin level of the lower first molar in the test groups. Sham-operated rats and rats in one of the periodontitis groups were killed 15 days later. Rats in the remaining two periodontitis groups had the ligatures removed in order to study the spontaneous recovery from the periodontal disease 15 days later, and these rats were treated with rabbit antiplatelet serum, in order to induce thrombocytopenia, or normal rabbit serum. An additional group without ligatures received antiplatet serum in the same period. RESULTS: After ligature removal, rats treated with normal rabbit serum showed reduced myeloperoxidase activity, decreased alveolar bone loss and increased numbers of blood vessels. Thrombocytopenia caused a delay in alveolar bone regeneration, a decrease in the number of vessels and a modest decrease in myeloperoxidase activity. In the rats with periodontitis, serum endostatin concentrations were slightly decreased and serum VEGF remained unchanged compared with sham-operated animals. After ligature removal, a significant VEGF increase and endostatin decrease were observed in the rats treated with normal rabbit serum. Thrombocytopenia led to a dramatic fall in both VEGF and endostatin concentrations. CONCLUSION: Thrombocytopenia leads to a delay of periodontal healing in the situation of experimental periodontitis, which might be mediated in part by a decrease in the serum concentration of VEGF and endostatin derived from the platelets. However, other factors derived from the platelets may also have contributed to a delay of periodontal healing in the rats with thrombocytopenia.