The SAGES MASTERS program presents: the 10 seminal articles for the Laparoscopic Right Colectomy Pathway.

BACKGROUND: As one of the 12 clinical pathways of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program, the Colorectal Pathway intends to deliver didactic content organized along 3 levels of performance (competency, proficiency and mastery) each represented by an anchoring procedure (laparoscopic right colectomy, laparoscopic left/sigmoid colectomy, and intracorporeal anastomosis during minimally invasive (MIS) ileocecal or right colon resection). In this article, the SAGES Colorectal Task Force presents focused summaries of the top 10 seminal articles selected for laparoscopic right colectomy which surgeons should be familiar with. METHODS: Using a systematic literature search of Web of Science, the most cited articles on laparoscopic right colectomy were identified, reviewed, and ranked by the SAGES Colorectal Task Force and invited subject experts. Additional articles not identified in the literature search were included if deemed impactful by expert consensus. The top 10 ranked articles were then summarized, with emphasis on relevance and impact in the field, findings, strengths and limitations, and conclusions. RESULTS: The top 10 seminal articles selected for the laparoscopic right colectomy anchoring procedure include articles on surgical techniques for benign and malignant disease, with anatomical and video illustrations, comparative outcomes of laparoscopic vs open colectomy, variations in technique with impact on clinical outcomes, and assessment of the learning curve. CONCLUSIONS: The top 10 seminal articles selected for laparoscopic right colectomy illustrate the diversity both in content and format of the educational curriculum of the SAGES Masters Program to support practicing surgeon progression to mastery within the Colorectal Pathway.

Robotic ileocolic resection with intracorporeal anastomosis for Crohn's disease.

The robotic platform can overcome limitations of the laparoscopic approach, particularly in the facilitation of intracorporeal anastomosis creation. We aim to share our institutional experience with robotic ileocolic resection for Crohn's disease (CD) and compare it to a laparoscopic cohort. We identified patients who underwent ileocolic resection for CD with a purely robotic (R) or laparoscopic (L) approach between February 2015 and 2018. Chart review was performed and preoperative, intraoperative, and postoperative data was collected. A total of 47 patients with a mean age of 35.2 years old were identified and 61% were female. Seventy percent [n = 33, (23 females, 69.6%)] of the cases were performed robotically and 30% of the cases [n = 14, (6 females, 42.8%)] were performed laparoscopically. The groups were well matched for age, gender, BMI as well as disease related factors (CD duration; clinical classification and location), perioperative immunosuppression, and surgical history. Time to bowel function was shorter by about 1 day in the robotic group (R: 1.9 ± 0.88 days vs. L: 2.7 ± 0.8 days, p = 0.003). Mean operative time was longer in the robotic group by 51 min and this difference was significant (p = 0.03), however 30.3% of patients underwent ureteral stent placement, which can account for added time in robotic cases. There were less conversions in the robotic group [R: 1(4.3%) vs. L: 1(7%)], but this was not significant. There were no intraoperative complications in either group. Complication (L: 21.4% vs. R: 15.1%, p = 0.605) and reoperation rates (L: 0% vs. R: 3.03%, p = 0.429) were similar. Robotic ileocolic resection for Crohn's disease is as safe and feasible as the laparoscopic approach. This was accomplished with no leaks, major morbidity or mortality and comparable length of stay, with 1 day shorter return of bowel function, and with a lower overall complication rate. The robotic approach offers advantages in Crohn's disease which should be studied further in prospective studies.

Crohn's Disease of the Esophagus, Duodenum, and Stomach.

Upper gastrointestinal Crohn's is an under-reported, under-recognized phenotype of Crohn's disease. Routine screening in the pediatric population has shown a higher prevalence compared with adults; however, most adult patients remain asymptomatic with respect to upper gastrointestinal Crohn's disease. For the patients who are symptomatic, medical treatment is the first line of management, except for cases of obstruction, perforation, or bleeding. Though most patients respond to medical therapy, mainly steroids, with the addition of immunomodulators and more recently biologics agents, surgical intervention is usually required only for obstructing gastroduodenal disease secondary to strictures. Strictureplasty and bypass are safe operations with comparable morbidity, although bypass has higher rates of dumping syndrome and marginal ulceration in the long term. Rare cases of gastroduodenal fistulous disease from active distal disease may involve the stomach or duodenum, and esophageal Crohn's disease can fistulize to surrounding structures in the mediastinum which may require the highly morbid esophagectomy.

Robotic transanal minimally invasive rectal mucosa harvest.

INTRODUCTION: Buccal mucosal grafts (BMG) are traditionally used in urethral reconstruction. There may be insufficient BMG for applications requiring large grafts, such as urethral stricture after gender-affirming phalloplasty. Rectal mucosa in lieu of BMG avoids oral impairment, while potentially affording less postoperative pain and larger graft dimensions. Transanal minimally invasive surgery (TAMIS) using laparoscopic instruments has been described. Due to technical challenges of harvesting a sizable graft within the rectal lumen, we adopted a new robotic approach. We demonstrate the feasibility and safety of a novel technique of Robotic TAMIS (R-TAMIS) in the harvest of rectal mucosa for the purpose of onlay graft urethroplasty. METHODS: Six patients (ages 28-60) presenting with urethral stricture and one vaginal stricture underwent robotic rectal mucosal harvest. The procedure, which was first studied on an inanimate bovine colon model, was performed under general anesthesia in lithotomy position using the GelPOINTTM Path Transanal Access. Mucosa was harvested robotically after submucosal hydrodissection. Graft size harvested correlated with surface area needed for urethral or vaginal reconstruction. Following specimen retrieval, flexible sigmoidoscopy confirmed hemostasis. The graft was placed as an onlay for urethroplasty. RESULTS: There were no intraoperative or postoperative complications. Mean graft size was 11.4 × 3.0 cm. All reconstructions had excellent graft take. All patients recovered without morbidity or mortality. They reported minimal postoperative pain and all regained bowel function on postoperative day one. Patients with prior BMG harvests subjectively self-reported less postoperative pain and greater quality of life. There have been no long-term complications at a median follow-up of 17 months. CONCLUSIONS: To our knowledge, this is the first use of R-TAMIS for rectal mucosa harvest. Our preliminary series indicates this approach is feasible and safe, constituting a promising minimally invasive technique for urethral reconstruction. Prospective studies evaluating graft outcomes and donor site morbidity with more long-term follow-up are needed.

Multi-Institutional Outcomes of Minimally Invasive Harvest of Rectal Mucosa Graft for Anterior Urethral Reconstruction.

PURPOSE: We report multi-institutional outcomes in patients who underwent urethroplasty with a rectal mucosa graft. MATERIALS AND METHODS: We used the TURNS (Trauma and Urologic Reconstructive Network of Surgeons) database to identify patients who underwent urethral reconstruction with transanal harvest of a rectal mucosa graft. We reviewed preoperative demographics, stricture etiology, previous management and patient outcomes. RESULTS: We identified 13 patients from April 2013 to June 2017. Median age at surgery was 54 years. The stricture etiology was lichen sclerosus in 6 of 13 patients (46%), idiopathic in 2 (15%), hypospadias in 1 (7%), prior gender confirming surgery in 3 (23%) and rectourethral fistula after radiation for prostate cancer in 1 (7%). Prior procedures included failed urethroplasty with a buccal mucosa graft in 9 of 13 patients (69%), direct vision internal urethrotomy in 2 (15%) and none in 2 (15%). Median stricture length was 13 cm. Stricture location in the 9 cisgender patients was panurethral in 5 (56%), bulbopendulous in 2 (22%) and bulbar in 2 (22%). It was located at the junction of the fixed urethra extending into the neophallus in all 3 patients (100%) who underwent prior gender confirming surgery. Mean rectal mucosa graft length for urethroplasty was 10.6 cm (range 3 to 16). Repair types included dorsal or ventral onlay, or 2-stage repair. Stricture recurred at a median followup of 13.5 months in 2 of 13 patients (15%). Postoperative complications included glans dehiscence, urethrocutaneous fistula and compartment syndrome in 1 patient each (7%). No rectal or bowel related complications were reported. CONCLUSIONS: Urethral reconstruction with a transanal harvested rectal mucosa graft is a safe technique when a buccal mucosa graft is unavailable or not indicated.

Factors Associated with Short-Term Morbidity in Patients Undergoing Colon Resection for Crohn's Disease.

BACKGROUND: Patients undergoing colon resection for Crohn's disease are at risk of developing postoperative complications. The aim of this study is to identify factors associated with short-term (30-day) morbidity in patients undergoing colon resection for Crohn's disease from a national database. METHODS: Patients who underwent colon resection for Crohn's disease in 2015 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The groups were classified based on presence of postoperative 30-day complications. The overall morbidity was calculated by including patients who had at least one postoperative complication. Demographics, preoperative, and operative factors were assessed and compared between the two groups. Further multivariate logistic regression analysis was conducted. RESULTS: A total of 1643 patients met the inclusion criteria [mean age of 41.2 (± 15.5) years, 871 (53%) female]. Sixty percent (n = 993) of the procedures were performed laparoscopically and 128 (12.8%) cases were converted to open. Ninety-five patients (5%) underwent emergent resections. Thirty percent (n = 507) of patients had at least one postoperative complication within 30 days of surgery. Ileus (16%), transfusion (7%), and organ-space surgical site infection (6%) were the most common morbidities. Independent risk factors for postoperative morbidity were male gender (p = 0.01), open surgery (p = 0.002), preoperative severe anemia (p = 0.001), and preoperative weight loss (p = 0.04). CONCLUSION: Approximately one third of the patients who undergo colon resection for Crohn's disease experience postoperative complications. Preoperative optimization of nutrition and anemia may improve outcomes. Laparoscopic technique appears to be the preferred surgical treatment option for resection when feasible.

Granulomatous enterocolitis associated with Hermansky-Pudlak syndrome.

BACKGROUND: Hermansky-Pudlak syndrome (HPS) is a rare autosomal recessive disorder. It consists of a triad of tyrosinase-positive oculocutaneous albinism (Ty-pos OCA), bleeding diathesis resulting from platelet dysfunction, and systemic complications associated with accumulation of ceroid lipofuscin. Many patients are from a small area in northwestern Puerto Rico. HPS has been associated with granulomatous enterocolitis in up to 20% of affected patients. It is not known whether this granulomatous colitis is a part of the syndrome, or represents an independent but associated process, such as Crohn's disease. This colitis can be severe, and has been reported to be poorly responsive to medical therapies including sulfasalazine, mesalamine, steroids, and metronidazole. CASE REPORT: We report a series of four patients with refractory enterocolitis in the setting of HPS who were treated at Mount Sinai Hospital between 1998 and 2005. A trial of infliximab was attempted in all four, and produced a complete response in two. CONCLUSIONS: Many phenotypic and pathologic similarities exist between granulomatous enterocolitis in HPS and Crohn's disease. However, it is unclear whether the granulomatous enterocolitis in HPS is because of ceroid deposition or reflects the coexistence of Crohn's disease and HPS. The occurrence of ileal involvement and perianal fistulization in our cases suggests that in at least some instances, HPS and Crohn's disease are truly associated.

Restorative proctocolectomy and ileal pouch-anal anastomosis for ulcerative colitis after liver transplant for primary sclerosing cholangitis: case report and review of literature.

Primary sclerosing cholangitis (PSC) is present in 5 per cent of patients with ulcerative colitis (UC). Conversely, as many as 90 per cent of patients with PSC have been found to have UC. The accepted treatment for advanced PSC is orthotopic liver transplant, and the treatment of ulcerative colitis with concomitant PSC is restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). A small number of studies have shown that there is an increased risk of pouchitis in UC patients with PSC after ileal pouch-anal anastomosis. We report a case of a 45-year-old male who underwent a two-stage restorative proctocolectomy with IPAA after previous orthotopic liver transplant for PSC. We have reviewed the available literature concerning restorative proctocolectomy after liver transplantation, giving special attention to postoperative complications and subsequent development of pouchitis. It is important to be aware of the possibility of increased risk for development of pouchitis and to follow these patients closely to prevent complications.