Risk factors for peristomal pyoderma gangrenosum complicating inflammatory bowel disease.

BACKGROUND AND AIMS: Risk factors for peristomal pyoderma gangrenosum (PPG) are not well defined. The aim of this study was to evaluate risk factors associated with development of PPG. METHODS: Both PPG patients and controls were obtained by searching a database of the Cleveland Clinic using the ICD-9 code from March 2005 to May 2011. The control group was selected by matching for underlying diseases and type of stoma in a ratio of 3:1. Univariate and multivariate analyses were performed. RESULTS: A total of 15 PPG cases and 45 controls were included. The mean age at the time of PPG diagnosis was 46.0 ± 14.4 years. The underlying disease was Crohn's disease in 7 patients (46.7%), ulcerative colitis in 7 (46.7%) and indeterminate colitis in 1 (6.7%). Eleven patients (73.3%) had end ileostomy, 3 (20.0%) had loop ileostomy and 1 (6.7%) had colostomy. Eleven patients (73.3%) had active intestinal disease. In multivariate analysis, female gender, the presence of concurrent autoimmune disorders, and a high body mass index (BMI) were significantly associated with the presence of PPG, with odds ratios of 8.385 (95% confidence interval [CI]: 1.496-46.982, p=0.015), 6.882 (95% CI:1.438-32.941, p=0.016), and 9.895 (95% CI: 1.970-43.704, p=0.005), respectively. After a median follow-up of 12.8 (interquartile range: 7.9-20.1) months with appropriate therapy, PPG healed in 8 patients (53.3%) and improved in 7 (46.7%) patients, after treatment. CONCLUSIONS: Female gender, the presence of autoimmune disorders and a high BMI appeared to be associated with an increased risk for the development of PPG in IBD patients.

Obstetric and cryptoglandular rectovaginal fistulas: long-term surgical outcome; quality of life; and sexual function.

PURPOSE: Rectovaginal fistula (RVF) repair can be challenging. Additionally, women may experience sexual dysfunction and psychosocial ramifications even after a successful repair. The aim of this study was to investigate variables looking for predictors of healing/failure and examine long-term quality-of-life (QOL) and sexual function in women with low RVF from obstetrical or cryptoglandular etiology METHODS: From June 1997-2009, 268 women underwent RVF repair. Of those, 100 with obstetric or cryptoglandular etiology agreed to participate in this study. Healing, type of procedure, use of seton or stoma, number of previous procedures, smoking, age, body mass index (BMI), dyspareunia, QOL using SF-12, FIQL, IBS-QOL, and female sexual function index was obtained from our prospective database and telephone contact. Fisher's exact test, chi-square test, and multivariable-logistic-regression model were used to identify the variables associated with healing/failure. RESULTS: Mean follow-up was 45.8 ± 39.2 months; mean age 42.8 ± 10.5 years; and BMI was 28.8 ± 7.6. Sixty (60%) fistulas were obstetric and 40 (40%) cryptoglandular and 68/100 patients (68%) healed. On multivariate analysis, treatment failure was related to a heavier BMI (p = 0.001) and number of repairs (p = 0.02). Looking at each type of repair, episioproctotomy had significant healing compared to the other choices (but was not significant on multivariate analysis). Forty-seven women were sexually active at follow-up and 12/47 (25.5%) reported dyspareunia. Fecal incontinence was reported preoperatively in 42 women, more often in those with obstetric-related RVF (76% vs. 24% p < 0.05). Healing was not affected by age, smoking, co-morbidities, preoperative seton, or stoma use. Fecal and sexual function and QOL were comparable between women with healed and unhealed RVF. CONCLUSION: Patients with higher BMI and more repairs had a decreased healing rate following RVF repair. Despite surgical outcome, QOL and sexual function were surprisingly similar regardless of fistula healing.

Colorectal surgeons: gender differences in perceptions of a career.

PURPOSE: The outlook of surgeons is changing. There has been recent interest in looking at job perception towards general surgery, which further has been divided into looking at gender differences. METHODS: A questionnaire with nine sections/63 questions was mailed to all 1799 ASCRS members (244 women) who were on the ASCRS mailing list from the USA. The returned questionnaires were analyzed. RESULTS: A total of 498/1,799 (28%) were returned; 109/498 were female (22%), which represented 109/244 (45%) of the ASCRS female membership vs.389/1,655 (23%) of the ASCRS male membership. The mean age was 49 years (females 42 years, males 51 years, p < 0.001). Demographically significant findings were that more female colorectal surgeons (FCR) were single 12% vs. 2% (p < 0.001). Male colorectal surgeons (MCR) overall earned more than their female counterparts (p < 0.001) and 11% FCR's had a salary of >$350,000 vs. 33% MCR. More MCR found work atmosphere (p < 0.004) and casemix (p < 0.001) were satisfactory elements of their job. A majority of the colorectal surgeons polled, would not change their careers however more FCR (21%) than MCR (13%) would do so (p = 0.03). When queried specifically, FCR also indicated they affected the OR in a positive way (p < 0.001). FCR were more sensitive to their colleagues opinion of their capabilities (p < 0.001), MCR however felt that their colleagues had a high impression of their capabilities (p < 0.001). FCR agreed that women mentors were few because of lack of time (p < 0.001) and also felt their views were not considered when executive decisions were made (p < 0.001). CONCLUSIONS: Interestingly, proportionally more younger, single FCR than MCR returned the questionnaires. The significance of this finding is uncertain. Acknowledgment of these differences will promote more understanding and job satisfaction in both academic and private practice.

Analysis of function and predictors of failure in women undergoing repair of Crohn's related rectovaginal fistula.

PURPOSE: Crohn's-related rectovaginal fistulae have significant impact on quality of life including sexual function. The aim of this study was to obtain long-term follow-up of Crohn's related rectovaginal fistulae to assess variables that influence surgical success and determine its effects on quality of life and sexual function. METHODS: All women with Crohn's-related rectovaginal fistulas who underwent surgical repair from 1997 to 2007 were contacted for long-term follow-up. Variables assessed were age, body mass index, smoking, presence of active Crohn's disease, type of surgical procedure performed, use of perioperative seton or stoma, number of previous procedures, time interval between last repair and current repair, use of immunomodulators, and steroids. SF-12, Fecal Incontinence Quality-of-Life Scale, and Female Sexual Function Index were used to assess quality of life and sexual function. Multivariable logistic regression model was used to identify variables associated with surgical failure. RESULTS: Sixty-five women were identified at median follow-up of 44.6 months (interquartiles, 13.1-79.1) of which 30 patients (46.2%) were successfully healed. Methods of repair included advancement flap (n = 47), episioproctotomy (n = 8), colo-anal anastomosis (n = 7), and fibrin glue or plug (n = 3). Twenty-eight women (43.1%) were sexually active at follow-up, and of those, nine complained of dyspareunia, all within the unhealed group of patients. On multivariate analysis, only immunomodulators were associated with successful healing (p = 0.009). Smoking and steroids were associated with failure (p = 0.04). Sexual function and quality-of-life scores were comparable between healed and unhealed groups. CONCLUSIONS: Crohn's-related rectovaginal fistulae are difficult to treat. Healing increased with use of immunomodulators; however, smoking and steroids were predictors of failure. Dyspareunia was higher in unhealed women.

Factors associated with septic complications after restorative proctocolectomy.

OBJECTIVE: Few studies have evaluated factors that may be associated with the development of septic complications after restorative proctocolectomy. Therefore, the aim of this study is to evaluate preoperative and operative factors that might be associated with septic complications after restorative proctocolectomy. METHODS: Patients developing abdominal and pelvic septic complications after restorative proctocolectomy were identified from a prospective database. Patients with subclinical leaks and ileostomy closure leak were not included in the septic complication group. A multivariable logistic regression model for sepsis was constructed using a forward stepwise selection with entry criterion of P < 0.05. RESULTS: From 1983 to 2007, 3233 patients (56% male) were included in the database. Eight-four percent (2597) of patients underwent proximal diversion. Two hundred patients (6.2%) developed septic complications within 3 months of restorative proctocolectomy or within 3 months of ileostomy closure. On multivariate analysis, body mass index > 30 (P = 0.02, OR = 1.77), final pathologic diagnosis of ulcerative/indeterminate colitis (P = 0.02, OR = 2) or Crohn's disease (P = 0.02, OR = 3.6), intraoperative (P = 0.02, OR = 1.6), and postoperative transfusions (P = 0.01, OR = 1.9) were all independently associated with septic complications. We also demonstrated an independent association among individual surgeons (P = 0.04) with decreased septic complications. CONCLUSIONS: Body mass index greater than 30, final pathologic diagnosis of ulcerative/indeterminate colitis or Crohn's disease, intraoperative and postoperative transfusions, and surgeon were all independent factors associated with septic complications after restorative proctocolectomy.

Does a laparoscopic approach affect the number of lymph nodes harvested during curative surgery for colorectal cancer?

BACKGROUND: This study aimed to assess the number of lymph nodes (LNs) harvested after laparoscopic and open colorectal cancer resections. METHODS: Between 1996 and 2007, 431 colorectal cancer patients underwent laparoscopic resection. During the periods of 1996-1997, 2002-2003, and 2006-2007, 243 patients undergoing laparoscopic colorectal cancer resection were matched 1-2 by age, operation, gender, operation date, body mass index (BMI), and tumor stage (TNM) to 486 patients undergoing open surgery. The numbers of examined and involved LNs were compared according to tumor location and year of surgery. RESULTS: Colorectal cancer resections (243 laparoscopic and 486 open procedures) were performed for 729 patients (447 men) with a mean age of 66.2 +/- 12.3 years and a mean BMI of 28.5 +/- 7.3. The mean number of LNs per case was 24.8 +/- 20.6. The number of LNs retrieved did not differ between laparoscopic and open surgery (p = 0.4). A significant difference was observed between the number of involved LNs retrieved laparoscopically (2.2 +/- 3.8) and the number retrieved by open surgery (1.6 +/- 4; p = 0.03). There were significant differences between the numbers of LNs retrieved from the right colon (28.1 +/- 14.6), left colon (24.5 +/- 17.6), and rectum (19.1 +/- 15.1) (p < 0.001). There were significantly fewer examined LNs in laparoscopic than in open cases during 2002 and 2003 (p = 0.003). CONCLUSION: Laparoscopic resection of colorectal cancer can achieve lymph node retrieval similar to that achieved by the open approach. In this era of new technology, laparoscopic lymph node harvest is becoming more optimized.

Wavefront analysis comparison of LASIK outcomes with the femtosecond laser and mechanical microkeratomes.

PURPOSE: To evaluate differences related to ocular aberrations after customized LASIK for myopia using three different microkeratomes. METHODS: Charts of 410 patients who underwent customized LASIK with the Alcon LADARVision4000 excimer laser were reviewed. Patients were stratified according to the device used to create the flap: Moria M2 microkeratome, Bausch & Lomb Hansatome microkeratome, or IntraLase laser. The difference between the wavefront pre- and postoperative value received a positive or a negative sign if the change occurred toward or away from zero, respectively, and it was compared to preoperative minus postoperative manifest refraction spherical equivalent (MRSE). RESULTS: Patients showed increase in the aberration level after LASIK with the three devices used in this study. IntraLase spherical aberration change tended to be better than mechanical microkeratomes for higher MRSE values (IntraLase compared to Hansatome, P < or = .023 for MRSE values > or = 4.00 diopters [D]; IntraLase compared to Moria, P < or = .015 for MRSE values > or = 2.00 D). For total aberrations, the improvement values for IntraLase tended to be higher than those for Moria (IntraLase compared to Moria, P < or = .021 for MRSE values > or = 3.00 D). For total higher order aberrations, IntraLase values tended to be better than Moria and Hansatome microkeratomes (IntraLase compared to Hansatome, P < or = .047 for MRSE values between 3.00 and 8.00 D; IntraLase compared with Moria, P < or = .002 for MRSE values > or = 2.00 D). Change in coma root-mean-square was similar for the three groups. CONCLUSIONS: The findings suggest the femtosecond laser provides a better platform for LASIK than the commonly used microkeratomes analyzed in this study.

Laparoscopic surgery for patients with Crohn's colitis: a case-matched study.

INTRODUCTION: The purpose of this study was to compare short and long-term outcomes of laparoscopic colectomy with open colectomy in patients with Crohn's disease confined to the colon. MATERIALS AND METHODS: We reviewed all patients undergoing laparoscopic colectomy for Crohn's disease at our institution between 1994 and 2005. Laparoscopic colectomies were matched to open colectomies by patient age, gender, American Society of Anesthesiologists score, type, and year of surgery. We excluded patients with concomitant small bowel disease. RESULTS: Twenty-seven laparoscopic cases were matched with 27 open cases. There were seven conversions (26%). There was no mortality. Median operative times were significantly longer after laparoscopic colectomy (240 vs 150 min, P < 0.01), and estimated blood loss was comparable (325 vs 350 ml, P = 0.4). Postoperative complications were similar. Laparoscopic colectomies had shorter median length of stay (5 vs 6 days, P = 0.07) and median time to first bowel movement (3 vs 4 days, P = 0.4). When overall length of stay included 30-day readmissions, the difference in favor of laparoscopy became statistically significant (P = 0.02). Recurrent disease requiring surgery was decreased after laparoscopy, although median follow-up was significantly shorter. CONCLUSION: Laparoscopic colectomy is a safe and acceptable option for patients with Crohn's colitis. Longer follow-up is needed to accurately establish recurrence rates.

CT enterography for Crohn's disease: accurate preoperative diagnostic imaging.

PURPOSE: CT enterography (CTE) is a technique that provides detailed images of the small bowel by using a low Hounsfield unit oral contrast media. This study was designed to correlate CTE findings with operative findings in patients with Crohn's disease. METHODS: We performed a retrospective study of all patients with Crohn's disease of the small bowel or colon, who had CTE and subsequent small bowel or colon surgery within three months after the CT examination. CTE findings of stricture, fistula, inflammatory mass, abscess, and combinations of these abnormalities were compared with operative findings. Specialist radiologists and fellowship-trained colorectal surgeons participated in the study. The Fisher's exact test or chi-squared tests were used with respect to categorical data, and the Wilcoxon's rank-sum test was used for quantitative data. RESULTS: In 36 patients, the presence or absence of stricture, fistula, abscess, or inflammatory mass was correctly determined by CTE in 100, 94, 100, and 97 percent, respectively. The accuracy for stricture or fistula number was 83 and 86 percent, respectively. There were nine patients with multiple disease phenotypes identified on CTE of which eight were confirmed at surgery. CTE overestimated or underestimated the extent of disease in 11 patients (31 percent). CONCLUSIONS: CTE is an accurate preoperative diagnostic imaging study for small-bowel Crohn's disease. The ability of this imaging study to detect both luminal and extraluminal pathology is a distinct advantage of CTE compared with small-bowel contrast studies.

Perioperative resting pressure predicts long-term postoperative function after ileal pouch-anal anastomosis.

The purpose of this study was to determine whether perioperative manometry is useful in predicting long-term functional status after ileal pouch-anal anastomosis (IPAA). Prospectively collected perioperative anal manometry data from 1439 patients undergoing IPAA from 1986 to 2000 were compared to postoperative functional status at various time intervals from 6 months to 8 years after IPAA. A validated questionnaire was used to obtain information regarding restrictions of diet, work, social and sexual activity, urgency, fecal seepage or incontinence, energy level, satisfaction with surgery, and quality of life. The presence of seepage and the degree of incontinence were compared to the patient's perceived quality of life, health, energy level, and satisfaction with surgery. Low (<40 mm Hg) pre- and postoperative resting pressures were associated with increased seepage, pad use, and incontinence. Patients with low resting pressures also reported diminished quality of life, health, energy level, and satisfaction with surgery. There was a significant association (P < 0.001) between seepage and degree of incontinence and quality of health, quality of life, energy level, and level of satisfaction with surgery. Perioperative resting anal sphincter pressures greater than 40 mm Hg are associated with significantly better function and quality of life after ileal IPAA. Improved functional outcome is associated with better quality-of-life outcomes. Low preoperative resting pressures do not preclude successful outcome after IPAA.