Better characterization of operation for ulcerative colitis through the National surgical quality improvement program: A 2-year audit of NSQIP-IBD.

INTRODUCTION: There is little consensus of quality measurements for restorative proctocolectomy with ileal pouch-anal anastomosis(RPC-IPAA) performed for ulcerative colitis(UC). The National Surgical Quality Improvement Program(NSQIP) cannot accurately classify RPC-IPAA staged approaches. We formed an IBD-surgery registry that added IBD-specific variables to NSQIP to study these staged approaches in greater detail. METHODS: We queried our validated database of IBD surgeries across 11 sites in the US from March 2017 to March 2019, containing general NSQIP and IBD-specific perioperative variables. We classified cases into delayed versus immediate pouch construction and looked for independent predictors of pouch delay and postoperative Clavien-Dindo complication severity. RESULTS: 430 patients received index surgery or completed pouches. Among completed pouches, 46(28%) and 118(72%) were immediate and delayed pouches, respectively. Significant predictors for delayed pouch surgery included higher UC surgery volume(p = 0.01) and absence of colonic dysplasia(p = 0.04). Delayed pouch formation did not significantly predict complication severity. CONCLUSIONS: Our data allows improved classification of complex operations. Curating disease-specific variables allows for better analysis of predictors of delayed versus immediate pouch construction and postoperative complication severity. SHORT SUMMARY: We applied our previously validated novel NSIP-IBD database for classifying complex, multi-stage surgical approaches for UC to a degree that was not possible prior to our collaborative effort. From this, we describe predictive factors for delayed pouch formation in UC RPC-IPAA with the largest multicenter effort to date.

Elderly patients with inflammatory bowel disease: Updated review of the therapeutic landscape.

High-quality data remains scarce in terms of optimal management strategies in the elderly inflammatory bowel disease (IBD) population. Indeed, available trials have been mostly retrospective, of small sample size, likely owing to under-representation of such a population in the major randomized controlled trials. However, in the last five years, there has been a steady increase in the number of published trials, helping clarify the estimated benefits and toxicity of the existing IBD armamentarium. In the Everhov trial, prescription strategies were recorded over an average follow-up of 4.2 years. A minority of elderly IBD patients (1%-3%) were treated with biologics within the five years following diagnosis, whilst almost a quarter of these patients were receiving corticosteroid therapy at year five of follow-up, despite its multiple toxicities. The low use of biologic agents in real-life settings likely stems from limited data suggesting lower efficacy and higher toxicity. This minireview will aim to highlight current outcome measurements as it portends the elderly IBD patient, as well as summarize the available therapeutic strategies in view of a growing body of evidence.

Weak Cytotoxic T Cells Activation Predicts Low-Grade Dysplasia Persistence in Ulcerative Colitis.

INTRODUCTION: In patients with ulcerative colitis (UC), dysplasia develops in 10%-20% of cases. The persistence of low-grade dysplasia (LGD) in UC in 2 consecutive observations is still an indication for restorative proctocolectomy. Our hypothesis is that in the case of weak cytotoxic activation, dysplasia persists. We aimed to identify possible immunological markers of LGD presence and persistence. METHODS: We prospectively enrolled 112 UC patients who underwent screening colonoscopy (T0) who had biopsies taken from their sigmoid colon. Ninety of them had at least a second colonoscopy (T1) with biopsies taken in the sigmoid colon and 8 patients had dysplasia in both examinations suggesting a persistence of LGD in their colon. Immunohistochemistry and real time polymerase chain reaction for CD4, CD69, CD107, and CD8ß messenger RNA (mRNA) expression and flow cytometry for epithelial cells expressing CD80 or HLA avidin-biotin complex were performed. Non-parametric statistics, receiver operating characteristic curves analysis, and logistic multiple regression analysis were used. RESULTS: Thirteen patients had LGD diagnosed at T0. The mucosal mRNA expression of CD4, CD69, and CD8ß was significantly lower than in patients without dysplasia (P = 0.033, P = 0.046 and P = 0.007, respectively). A second colonoscopy was performed in 90 patients after a median follow-up of 17 (12-25) months and 14 of the patients were diagnosed with LGD. In these patients, CD8ß mRNA expression at T0 was significantly lower in patients without dysplasia (P = 0.004). A multivariate survival analysis in a model including CD8ß mRNA levels and age >50 demonstrated that both items were independent predictors of dysplasia at follow-up (hazard ratio [HR] = 0.47 [95% confidence interval [CI]: 0.26-0.86], P = 0.014, and HR = 13.32 [95% CI: 1.72-102.92], P = 0.013). DISCUSSION: These data suggest a low cytotoxic T cell activation in the colonic mucosa of UC patients who do not manage to clear dysplasia. Thus, low level of CD8ß mRNA expression in non-dysplastic colonic mucosa might be considered in future studies about the decision making of management of LGD in UC.

Technical Issues and Early Outcomes of Restorative Proctocolectomy for Familial Adenomatous Polyposis and Ulcerative Colitis: The Largest Romanian Single-Team Experience.

Background/ Aim: Restorative proctocolectomy (RPC) is a complex surgical procedure used to treat patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). The present study aims to assess the technical issues and early outcomes of RPC for FAP and UC, in a relatively large single-team series of patients. Patients and Methods: The data of all patients with RPC performed by a single surgical team between 1991 and 2018 were retrospectively assessed from a prospectively maintained electronic database. Results: The study group included 77 patients with RPC, and 70.1% have had FAP. The average number of RPC per year was 3.3 for the surgical team and 4.3 for the institution. A J pouch was performed in 93.5% of the patients. A hand-sewn reservoir was made in 76.6% of the patients. A hand-sewn ileal pouch-anal anastomosis was performed in 81.8% of the patients. A diverting ileostomy was performed in 92.2% of the patients. Mucosectomy was performed in 84.4% of the patients. The early morbidity rate was 36.4%, with severe complications rate of 13%. The main complications were pouch-related septic complications (18.2%), wound infections (9.1%), small-bowel obstruction (6.5%) and hemorrhage (6.5%). Conclusions: Although a RPC remains an uncommon surgical procedure in Romania, however, the early outcomes of the present series are comparable to those reported in high volume centers. Good outcomes after RPC can be obtained if such complex surgical procedures are performed by dedicated surgical teams, with high case-load.

Establishing Key Performance Indicators [KPIs] and Their Importance for the Surgical Management of Inflammatory Bowel Disease-Results From a Pan-European, Delphi Consensus Study.

BACKGROUND AND AIMS: Key performance indicators [KPIs] exist across a range of areas in medicine. They help to monitor outcomes, reduce variation, and drive up standards across services. KPIs exist for inflammatory bowel disease [IBD] care, but none specifically cover inflammatory bowel disease [IBD] surgical service provision. METHODS: This was a consensus-based study using a panel of expert IBD clinicians from across Europe. Items were developed and fed through a Delphi process to achieve consensus. Items were ranked on a Likert scale from 1 [not important] to 5 [very important]. Consensus was defined when the inter quartile range was ≤ 1, and items with a median score > 3 were considered for inclusion. RESULTS: A panel of 21 experts [14 surgeons and 7 gastroenterologists] was recruited. Consensus was achieved on procedure-specific KPIs for ileocaecal and perianal surgery for Crohn's disease, [N = 10] with themes relating to morbidity [N = 7], multidisciplinary input [N = 2], and quality of life [N = 1]; and for subtotal colectomy, proctocolectomy and ileoanal pouch surgery for ulcerative colitis [N = 11], with themes relating to mortality [N = 2], morbidity [N = 8], and service provision [N = 1]. Consensus was also achieved for measures of the quality of IBD surgical service provision and quality assurance in IBD surgery. CONCLUSIONS: This study has provided measurable KPIs for the provision of surgical services in IBD. These indicators cover IBD surgery in general, the governance and structures of the surgical services, and separate indicators for specific subareas of surgery. Monitoring of IBD services with these KPIs may reduce variation across services and improve quality.

[The technique of restorative proctocolectomy with ileal J­pouch : Standards and controversies]. / Technik der Proktokolektomie mit ileoanalem Pouch : Standards und Kontroverses.

BACKGROUND: Restorative proctocolectomy (RPC) is the standard of care in the case of medically refractory disease and in neoplasia in ulcerative colitis (UC). OBJECTIVES: This review aims at providing an overview of the current evidence on standards, innovations, and controversies with regard to the surgical technique of RPC. RESULTS: RPC is the standard of care in the surgical management of UC refractory to medical treatment and in neoplasia. Due to its simplicity and good functional outcomes, the J­pouch is the most used pouch design. RPC is usually performed as a two-stage procedure. In the presence of risk factors, a three-stage procedure should be performed. The technically more demanding mucosectomy and hand sewn anastomosis does not seem to result in a better oncologic outcome than stapled anastomosis. Functional results appear marginally better after stapled anastomosis, but the rectal cuff should not exceed 2 cm in this reconstruction. The laparoscopic approach is at least as good as the open approach. For the new, innovative surgical approaches such as robotics and transanal surgery, only feasibility but no advantages have yet been demonstrated. CONCLUSION: The evidence in regard to controversial points remains limited.

Patient and hospital factors associated with use of sphincter-sparing surgery for rectal cancer.

PURPOSE: Sphincter-sparing surgery for rectal cancer is associated with higher patient satisfaction, equivalent oncologic outcomes, and less morbidity than abdominoperineal resection. No national studies have explored trends in the use of sphincter-preserving rectal resection, while accounting for both hospital and patient factors. METHODS: This is a retrospective cohort study of 47,713 patients from the Nationwide Inpatient Sample who underwent surgery for rectal cancer from 1988 to 2006. Univariate analysis was used to identify patient and hospital factors associated with sphincter preservation. Logistic regression was performed to control for confounding variables. Trends in use of sphincter-sparing surgery over time were examined to identify hospital factors associated with higher rates of adoption. RESULTS: Patient demographics associated with sphincter preservation in multivariate analysis were age <60, female gender, and white race. Among hospital factors associated with sphincter preservation, the most important predictors were high procedural volume (odds ratio 1.55; 95% CI 1.33-1.79; P < .001), and urban location (odds ratio 1.26; 95% CI 1.33-1.40; P < .001). Although sphincter preservation increased over time in the entire cohort (35.4% in 1988 vs 60.5% in 2006), high-volume hospitals had significantly higher rates of sphincter preservation compared with the lowest-volume hospitals. CONCLUSIONS: Although rates of adoption of sphincter-sparing surgery were similar across hospital volume strata, overall rates of sphincter preservation were consistently higher in high-volume and urban hospitals, and among patients who are female, white, and younger. Further research is needed to determine whether these differences reflect disparities in quality of surgical care, or differences in referral patterns or case mix.

The role of pouch compliance measurement in the management of pouch dysfunction.

PURPOSE: Ileal pouch anal anastomosis is an established option for patients who require total proctocolectomy and restoration of bowel continuity. However, the functional results are not always good and low pouch compliance has been suggested as one possible cause. We aimed to review the results of pouch compliance tests over 11 years to assess whether measuring pouch compliance is a useful diagnostic tool to guide management of pouch dysfunction. METHODS: The results of pouch compliance tests performed between 1996 and 2007 together with the details of symptoms, treatments and outcome were reviewed. RESULTS: One hundred and forty-one pouch compliance tests were performed. There was no difference in pouch compliance between those with overt pathology (pouchitis, pelvic sepsis or anastomotic stricture) and those with idiopathic pouch dysfunction. In this second group, there was no difference in pouch compliance between patients with and without each of the symptoms of increased defaecatory frequency, incontinence and evacuation difficulties. The results of the compliance testing did not influence the clinical decision making on idiopathic pouch dysfunction (p=0.77) nor diverted pouches (p=0.07). CONCLUSIONS: Measuring pouch compliance does not offer new information accounting for idiopathic pouch dysfunction and has little influence on the clinical management.

[Organisation and early outcome of restorative proctocolectomy and ileal pouch-anal anastomosis]. / Organisation og tidlige operationsresultater efter ileo-pouch-anal-anastomose.

INTRODUCTION: Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) has become the operation of choice for patients with ulcerative colitis and familial polyposis. However, the procedure is complex with a long learning curve, and carries a risk of both early and late complications. The purpose of this study was to evaluate the early outcomes (within 30 days after surgery) and organisation of IPAA surgery in Denmark between January 2001 and December 2005. MATERIALS AND METHODS: IPAA patients >18 years old were drawn from the Danish National Patient Registry from 2001 through 2005. Hospital stay and the primary operation were recorded as well as re-operations and readmissions within the first 30 postoperative days. Mortality was recorded from the National Civic Register. RESULTS: 385 patients underwent IPAA surgery during the study period (77/year) in six centres. One centre performed 31% of the operations. The mean postoperative hospital stay (primary - and readmission within 30 days) was 13.5 days. 24% were readmitted within 30 days and 8% were re-operated. The mortality rate was 0.3%. CONCLUSION: Based upon the limited number of operations, the high risk of early readmissions and re-operations, the well-known steep learning curve and the potential improvement with the technically demanding laparoscopic technique, a reorganisation of the procedure to fewer centres is suggested.

Systematic reviews and meta-analyses in coloproctology: interpretation and potential pitfalls.

A systematic review (SR) is the unbiased appraisal of systematically identified relevant studies. Implicit in its definition is a robust and scientifically valid process, and when performed as such, SR is an important clinical research tool and influence in health policy decision-making. This educational paper outlines that, from the original prototype based on randomized trials, there are now many other types of SRs including those based on: nonrandomized comparative studies, observational studies, prognostic studies, and studies of diagnostic and screening tools. While each of these has a similar 'anatomy' or format, at an individual class level, there are principles specific to each SR type. Several examples from the coloproctology literature are used as case-studies to illustrate potential pitfalls, and upon re-analysis, often reverse or attenuate the conclusions stated in the original publication. These examples serve to emphasize the need for health professionals to understand the process of SR and meta-analysis so that we all arrive at appropriate interpretations to the benefit of our patients.

Results at up to 20 years after ileal pouch-anal anastomosis for chronic ulcerative colitis.

BACKGROUND: Ileal pouch-anal anastomosis (IPAA) is performed routinely for chronic ulcerative colitis. METHODS: Using data from a prospective database and annual standardized questionnaires, functional outcome, complications and quality of life (QoL) after IPAA were assessed. RESULTS: Some 1885 IPAA operations were performed for chronic ulcerative colitis over a 20-year period (mean follow-up 11 years). The mean age at the time of IPAA was 34.1 years, increasing from 31.2 years (1981-1985) to 36.3 years (1996-2000). The overall rate of pouch success at 5, 10, 15 and 20 years was 96.3, 93.3, 92.4 and 92.1 per cent respectively. Mean daytime stool frequency increased from 5.7 at 1 year to 6.4 at 20 years (P < 0.001), and also increased at night (from 1.5 to 2.0; P < 0.001). The incidence of frequent daytime faecal incontinence increased from 5 to 11 per cent during the day (P < 0.001) and from 12 to 21 per cent at night (P < 0.001). QoL remained unchanged and 92 per cent remained in the same employment. Seventy-six patients were eventually diagnosed with indeterminate colitis and 47 with Crohn's disease. CONCLUSION: IPAA is a reliable surgical procedure for patients requiring proctocolectomy for chronic ulcerative colitis and indeterminate colitis. The clinical and functional outcomes are excellent and stable for 20 years after operation.

Revolution and evolution: 30 years of ileoanal pouch surgery.

Ileal pouch-anal anastomosis (IPAA) has become the standard of care for the 25% of patients with ulcerative colitis who ultimately require colectomy. IPAA is favored by patients because it avoids the necessity for a long-term stoma. This review examines how 3 decades of experience with IPAA has molded current practice, highlighting 5- and 10-year follow-up of large series to determine durability and functional performance, in addition to causes of failure and the management of complications.

Pilot study of the quality initiative in rectal cancer strategy.

INTRODUCTION: Total mesorectal excision vs. traditional surgical techniques may lead to improved rates of permanent colostomy, local tumor recurrence, and survival for patients undergoing major rectal cancer operations. We developed the surgeon-directed, multipronged Quality Initiative in Rectal Cancer strategy to encourage surgeons to use total mesorectal excision techniques. METHODS: The Quality Initiative in Rectal Cancer strategy interventions included a workshop, an operative demonstration of total mesorectal excision, and a postoperative questionnaire. The design of the strategy was informed by the industrial theory principles of continuous quality improvement. We assessed the logistics of implementing the strategy and the attitudes of surgeons toward the strategy through a pilot study at three community hospitals in the Central-West region of Ontario. RESULTS: Seventeen of 19 surgeons participated in a workshop, and 12 of 17 workshop participants received at least one operative demonstration of total mesorectal excision. Ten of 11 surgeons who completed a postoperative questionnaire indicated their traditional approach to rectal cancer surgery varied with that of the operative demonstration. The attitudes of surgeons toward the Quality Initiative in Rectal Cancer strategy were positive. For the time periods before and after the pilot study, there was a trend toward a lower rate of permanent colostomy among patients treated by surgeons who participated in both the workshop and an operative demonstration of total mesorectal excision. CONCLUSION: The Quality Initiative in Rectal Cancer strategy may be an effective method of introducing optimal rectal cancer surgery techniques to a large group of practicing surgeons.

Continent diversions: the new gold standards of ileoanal reservoir and neobladder.

In recent decades, surgical treatment of familial adenomatous polyposis, chronic ulcerative colitis, and muscle-invasive bladder cancer has undergone a revolution. Specifically, ileoanal reservoir and neobladder have become the new "gold standard" of definitive surgical therapy for these disorders. This article discusses issues in surgical construction, indications, contraindications, perioperative care concepts, and nursing and health professional implications related to these two procedures. These interventions include screening candidates for ileoanal reservoir or neobladder to rule out Crohn's disease or metastatic cancer and educating candidates for continent diversions about the proposed procedure(s) and associated events, potential complications, postoperative exercise, sexual health and function issues, and the benefits of support group participation so they can gain a realistic understanding of ultimate functional outcomes. Questions for future research are addressed.

Surgeon influenced variables in resectional rectal cancer surgery.

PURPOSE: Surgeon influenced variables in rectal cancer surgery were assessed. METHODS: The literature was reviewed to discuss technical and educational issues that may affect the outcome of surgery for rectal cancer. Particular attention was paid to recently debated topics such as adjuvant therapy, colonic J-pouches, total mesorectal excision, and surgeons' training. RESULTS: In some selected cases, transanal techniques with or without neoadjuvant or adjuvant therapy have improved the success of local excision. The biology of rectal cancer has begun to be understood. However, until a more complete understanding with an appreciation of therapeutic implications has been arrived at, surgeon influenced variables will continue to be of paramount importance. Multiple studies have shown tremendous surgeon variability in the outcome after rectal cancer surgery. Some of the variables that have been shown to be important include tumor-free distal and lateral margins, a total mesorectal excision, and an appropriate anastomosis. It has been well demonstrated that proctectomy with straight coloanal anastomosis compromises function as compared with preoperative levels or healthy controls. These deficiencies are further exacerbated by adjuvant therapy. Significant functional improvements, particularly in the first 12 to 24 months after surgery, have been achieved with use of colonic J-pouch. CONCLUSION: There are many ways by which the surgeon can optimize curative resection for rectal cancer. Appropriate distal and tumor-free lateral margins with total mesorectal excision should be the goals for all tumors in the lower two-thirds of the rectum. Reconstruction should be performed, whenever technically possible, by a colonic J-pouch. Surgeons should be cognizant of their own practice patterns, volume, capabilities, and very importantly results. These results should be audited frequently and willingly shared with patients.

Audit of single-stage proctocolectomy for Crohn's disease: postoperative complications and recurrence.

PURPOSE: This study was undertaken to review our overall experience of single-stage proctocolectomy for Crohn's disease. METHODS: One hundred three patients who underwent single-stage proctocolectomy for Crohn's disease between 1958 and 1997 were reviewed. Factors affecting the incidence of recurrence were examined using a multivariate analysis. RESULTS: Principal indications for proctocolectomy were chronic colitis (49 percent), acute colitis (37 percent), and anorectal disease (14 percent). The commonest postoperative complication was delayed perineal wound healing (n = 36; 35 percent), followed by intra-abdominal sepsis (17 percent) and stomal complications (15 percent). In 23 patients the perineal wound healed between three and six months after proctocolectomy, whereas in 13 patients the wound remained unhealed for more than six months. There were two hospital deaths (2 percent) caused by sepsis. The 5-year, 10-year, and 15-year cumulative reoperation rates for small-bowel recurrence were 13, 17, and 25 percent, respectively, after a median follow-up of 18.6 years. From a multivariate analysis, factors affecting reoperation rate for recurrence were gender (male; hazard ratio 2.4 vs. female; P = 0.03) and age at operation (< or =30 years; hazard ratio 2.6 vs. >30 years; P = 0.04). The following factors did not affect the reoperation rate: duration of symptoms, smoking habits, associated perforating disease, coexisting small-bowel disease, postoperative complications, and medical treatment. CONCLUSIONS: Proctocolectomy for Crohn's disease is associated with a high incidence of complications, particularly delayed perineal wound healing. Proctocolectomy carries a low recurrence rate in the long term. However, young male patients are at high risk of recurrence.

Colonic J-pouch as a neorectum: functional assessment.

BACKGROUND: Sphincter-saving procedures are now commonly used for low rectal cancer but straight colo-anal anastomosis seemed to produce poor functional outcome. The present study was therefore carried out to compare and contrast the functional outcome of colonic J-pouch and straight colo-anal anastomosis. METHODS: The clinical and functional outcome of 17 patients having a colonic J-pouch-anal anastomosis and 10 patients having a straight colo-anal anastomosis were compared. They were compared in terms of age, sex, distal resection margin, Dukes stage, histological grade, morbidity/mortality and postoperative anal function. RESULTS: There was better bowel function in patients having J-pouch-anal anastomosis, especially in the early period after closure of the covering stoma. Bowel frequency in those patients who had a J-pouch anastomosis was much less compared to those patients in the straight colo-anal group in the 1st and possibly the 2nd year. There was a period of adaptation for the straight colo-anal group which led to a bowel frequency approaching that of the J-pouch group over 1-2 years. Differences in urgency, faecal continence, evacuation function, the use of drugs to slow bowel frequency and ability to discriminate between flatus and faeces were found to favour the J-pouch group in the first postoperative year. The difference between the two groups diminished after that because the straight group improved, especially by the end of the 2nd year. During the study period, there were no constipation problems in the J-pouch group, as noted in some other studies. This was probably associated with the 6-cm length chosen for the pouch. CONCLUSIONS: The use of colonic J-pouch resulted in a significant decrease in stool frequency and more satisfactory anal function for the first postoperative year. This difference lessened during the second postoperative year. There was no demonstrable difficulty with rectal evacuation in the pouch patients.

Surgical management of total ulcerative colitis and familial adenomatous polyposis.

Total ulcerative colitis (UC) and familial adenomatous polyposis (FAP) are two major diseases that require total removal of the colorectal mucosa. To provide a high quality of postoperative life, various surgical techniques have been used. However, results were far from ideal. Since 1978, we have worked on the ileoanal anastomosis (IAA) technique to achieve both radical removal of the mucosa and preservation of natural anal function. From 1979 to 1991, a total of 155 patients were treated by IAA. To evaluate the surgical results, these patients were divided into three groups: the Tokyo series (49 cases, 1979-1983), Hyogo I series (49 cases 1983-1988) and Hyogo II series (57 cases, 1989-1991). The success rates in terms of preservation of anal continence were: 58% (UC) and 78% (FAP) in the Tokyo series, 84% (UC) and 96% (FAP) in the Hyogo I series and 92% (UC) and 100% (FAP) in the Hyogo II series. The surgical time and blood loss were significantly reduced in the later series. Of the 82 patients followed up for 6 mo in the two Hyogo series, anal continence was normal or nearly normal in 54 patients, with only minor leakage at night in 22 patients. Septic complications in the pelvic caused the majority of surgical failures. We conclude that improved IAA techniques can achieve total removal of the colorectal mucosa and preserve anal function in more than 90% of patients with UC or FAP. However, the skill of an experienced surgeon is still required to achieve this goal. The long-term outcome of anal function after such procedures needs further evaluation.