DECIDE: Delphi Expert Consensus Statement on Inflammatory Bowel Disease Dysplasia Shared Management Decision-Making.

BACKGROUND AND AIMS: Inflammatory bowel disease colitis-associated dysplasia is managed with either enhanced surveillance and endoscopic resection or prophylactic surgery. The rate of progression to cancer after a dysplasia diagnosis remains uncertain in many cases and patients have high thresholds for accepting proctocolectomy. Individualised discussion of management options is encouraged to take place between patients and their multidisciplinary teams for best outcomes. We aimed to develop a toolkit to support a structured, multidisciplinary and shared decision-making approach to discussions about dysplasia management options between clinicians and their patients. METHODS: Evidence from systematic literature reviews, mixed-methods studies conducted with key stakeholders, and decision-making expert recommendations were consolidated to draft consensus statements by the DECIDE steering group. These were then subjected to an international, multidisciplinary modified electronic Delphi process until an a priori threshold of 80% agreement was achieved to establish consensus for each statement. RESULTS: In all, 31 members [15 gastroenterologists, 14 colorectal surgeons and two nurse specialists] from nine countries formed the Delphi panel. We present the 18 consensus statements generated after two iterative rounds of anonymous voting. CONCLUSIONS: By consolidating evidence for best practice using literature review and key stakeholder and decision-making expert consultation, we have developed international consensus recommendations to support health care professionals counselling patients on the management of high cancer risk colitis-associated dysplasia. The final toolkit includes clinician and patient decision aids to facilitate shared decision-making.

A prospective case control study of functional outcomes and related quality of life after colectomy for neoplasia.

AIM: Our aim was to assess bowel function and its effect on overall quality of life (QOL) when compared to healthy controls after colectomy. METHODS: Patients undergoing resection of colorectal neoplasia were recruited pre-operatively and followed up at 6 and 12 months, to assess 'early' bowel function. Patients who underwent surgery 2 to 4 years previously were recruited for assessment of 'intermediate' bowel function. Healthy relatives were recruited as controls. The Memorial Sloan-Kettering Cancer Centre and EQ-5D questionnaires were used to assess bowel function and QOL, respectively. Statistical assessment included regression analyses, parametric and non-parametric tests. The association between QOL and Memorial Sloan-Kettering Cancer Centre (MSKCC) scores was evaluated using Spearman's rank correlation. RESULTS: Ninety-one patients were recruited for assessment of 'early' and 85 for 'intermediate' bowel function. There were 85 controls. Patients had a significantly higher number of bowel movements at each follow-up (p < 0.001). At 12 months after surgery, patients reported difficulty with gas-stool discrimination. The 'intermediate' group were found to have lower scores for flatus control (<0.001) and total frequency score (p 0.03), indicating worse function. Patients with higher total MSKCC scores, no symptoms of urgency and those able to control flatus reported better QOL (p 0.006, 0.007 and 0.005, respectively) at 6 and 12 months. Gas-stool differentiation and complete evacuation correlated with better QOL in the 'intermediate' bowel function group (p 0.02 and 0.02, respectively). CONCLUSION: Colonic resection adversely affects elements of bowel function up to 4 years after surgery. Good colonic function, represented by higher MSKCC scores, correlates with better QOL.

To divert or not to divert: A retrospective analysis of variables that influence ileostomy omission in ileal pouch surgery.

HYPOTHESIS: A model could be developed to identify patients who can safely undergo restorative proctocolectomy (RPC) without proximal diversion. DESIGN: Logistic regression analysis was used to identify independent factors favoring omission of ileostomy at the time of RPC. A propensity nomogram was developed and validated using measures of calibration, discrimination, and subgroup analysis. SETTING: Two tertiary referral centers. PATIENTS: A total of 4013 patients undergoing RPC between January 1977 and December 2005 were included in the study sample. MAIN OUTCOME MEASURE: The decision to omit loop ileostomy at the time of RPC. RESULTS: After study group exclusions, proximal diversion was performed in 3196 of 3733 patients (85.6%) undergoing RPC; 45.4% of 3733 patients were women. The mean (SD) age at surgery was 37.4 (12.8) years. Ulcerative colitis was the indication for RPC in 2304 patients (61.7%) and familial adenomatous polyposis in 364 patients (9.8%), and a J pouch was performed in 2657 patients (71.2%). The following were found to be associated with ileostomy omission: stapled anastomosis (odds ratio [OR], 6.4), no preoperative corticosteroid use (OR, 3.2), familial adenomatous polyposis diagnosis (OR, 2.6), cancer diagnosis (OR, 3.4), female sex (OR, 1.6), and age at surgery younger than 26 years (OR, 2.1) (P < .01 for all). The model discriminated well (area under the receiver operating characteristic curve, 74.9%), with no significant differences between observed and expected outcomes (P = .49). Omission of proximal diversion demonstrated no significant effect on postoperative adverse events, although it was associated with a 2-day increase in the median length of hospital stay (P < .01). CONCLUSION: Incorporation of a 5-point nomogram in the preoperative assessment of patients undergoing RPC may aid clinicians in identifying a select group of patients who may be candidates for ileostomy omission during RPC.

An assessment of between-recti distance and divarication in patients with and without abdominal aortic aneurysm.

INTRODUCTION: The study assessed whether there is a greater incidence of divarication of the recti and whether between-recti distance is greater in patients with abdominal aortic aneurysm (AAA). PATIENTS AND METHODS: The study consisted of two parts: a radiological and a clinical assessment. All patients with a confirmed AAA on computerised tomography were included and compared with patients in whom AAA was excluded with imaging. Between-recti distance was measured using a computerised image viewer and clinical divarication was assessed by a surgical registrar or consultant. RESULTS: In the radiological part of the study, 108 patients with AAA were compared with 84 with colorectal cancer. Median between-recti distance was 38 mm (range, 25-59 mm) in the AAA group and 27 mm (range, 20-44.5 mm) in the non-AAA group (P=0.006). AAA diameter did not correlate with between-recti distance. The clinical study included 50 patients (25 AAA). The groups were well matched, with only a greater incidence of diabetes in the AAA group (20% vs 0%; P=0.018). AAA patients were more likely to have clinically detected divarication of the recti (76% vs 36%; P=0.004). CONCLUSIONS: Patients with AAA have greater radiological and clinical evidence of divarication. It is suggested that patients with divarication be screened for AAA.

Laparoscopic splenectomy and diaphragmatic rupture repair in a 27-week pregnant trauma patient.

Report of a 27-week pregnant woman having diaphragmatic rupture and intrathoracic ruptured spleen is presented. She was managed by laparoscopic reduction of the intrathoracic viscus, with repair of the defect and splenectomy.

The National Bowel Cancer Project: social deprivation is an independent predictor of nonrestorative rectal cancer surgery.

PURPOSE: This study was designed to assess the impact of social deprivation on rates of abdominoperineal excision of the rectum in the United Kingdom. METHODS: Data were extracted from the Association of Coloproctology of Great Britain and Ireland Colorectal Cancer Database (2000-2005). Social deprivation was assessed by using the Index of Multiple Deprivation (2004) score. Logistic regression was performed to identify independent predictors of nonrestorative surgery. RESULTS: A total of 12,128 patients underwent anterior resection or abdominoperineal excision for Dukes A-C cancer in 101 centers; 2,625 patients (21.6 percent) underwent abdominoperineal excision (median, 20.8 (interquartile range, 16.5-27.9) percent per unit). Abdominoperineal excision rates decreased from 24.3 to 18.2 percent (P < 0.001) and varied between the least and most deprived groups from 18 to 26.4 percent, respectively (P < 0.001). Independent predictors of abdominoperineal excision were: year of surgery (odds ratio = 0.855 per year increase, P < 0.001), female vs. male gender (odds ratio = 0.82, P < 0.001), use of neoadjuvant radiotherapy (odds ratio = 2.4, P < 0.001), and social deprivation (most vs. least deprived: odds ratio = 1.638, P < 0.001). CONCLUSIONS: Abdominoperineal excision rates vary considerably between centers. Gender and deprivation status independently predict formation of a permanent stoma. These results have important implications for intercenter comparisons of surgical quality and may suggest inequalities in health care provision.

Comparison of outcomes after restorative proctocolectomy with or without defunctioning ileostomy.

OBJECTIVE: To evaluate postoperative adverse events and functional outcomes of patients undergoing restorative proctocolectomy with or without proximal diversion. DATA SOURCES: The literature was searched by means of MEDLINE, Embase, Ovid, and Cochrane databases for all studies published from 1978 through July 15, 2005. STUDY SELECTION: Comparative (randomized and nonrandomized) studies evaluating outcomes after restorative proctocolectomy with or without ileostomy were included. DATA EXTRACTION: Three authors independently extracted data by using operative variables, early and late adverse events, and functional outcomes between the 2 groups. Trials were assessed by means of the modified Newcastle-Ottawa Score. Random-effects meta-analytical techniques were used for analysis. DATA SYNTHESIS: The review included 17 studies comprising 1486 patients (765 without ileostomy and 721 with ileostomy). There were no significant differences in functional outcomes between the 2 groups. The development of pouch-related leak was significantly higher in the no-ileostomy group (odds ratio, 2.37; P = .002). Small-bowel obstruction was more common in the stoma group but was not statistically significant (odds ratio, 0.65). The development of anastomotic stricture favored the no-stoma group (odds ratio, 0.31; P = .045). On sensitivity analysis, pelvic sepsis was significantly less common in patients whose ileostomies were defunctioned; however, this finding was not mirrored by a significant difference in ileal pouch failure in this subgroup. CONCLUSIONS: Restorative proctocolectomy without a diverting ileostomy resulted in functional outcomes similar to those of surgery with proximal diversion but was associated with an increased risk of anastomotic leak. Diverting ileostomy should be omitted in carefully selected patients only.

The impact of technical factors on outcome of restorative proctocolectomy for familial adenomatous polyposis.

PURPOSE: This study was designed to assess the impact of technical factors on functional outcomes and complications in patients undergoing restorative proctocolectomy for familial adenomatous polyposis. METHODS: This was a descriptive study on 189 patients undergoing restorative proctocolectomy in a single tertiary referral center between 1977 and 2003. Primary outcomes were major complications, pouch function, and neoplastic transformation in the anal transitional zone. RESULTS: Pouch construction was J-reservoir (60 percent), W-reservoir (34 percent), or S-reservoir (6 percent), with double-stapled (31 percent) or handsewn anastomosis with mucosectomy (69 percent). Overall pouch survival was 96 percent at five years and 89 percent at ten years, with no differences according to pouch design or anastomotic technique. The incidence of pelvic sepsis was unaffected by anastomotic technique (stapled vs. handsewn; 12 vs. 13 percent) or type of reservoir (J- vs. W- vs. S-pouch; 16 vs. 9 vs. 10 percent). Fistula formation was independent of anastomotic technique (stapled vs. handsewn; 8 vs. 8 percent) and type of reservoir (J- vs. W- vs. S-pouch; 9 vs. 7 vs. 0 percent). The night-time and 24-hour bowel frequencies were similar with the two anastomotic techniques and types of reservoirs. The incidence of polyps at the anal transitional zone was lower with handsewn than with stapled anastomosis (19 vs. 38 percent; P=0.047). CONCLUSIONS: Restorative proctocolectomy in patients with familial adenomatous polyposis has good functional outcomes and an acceptable rate of complications, which are independent of choice of technique. Handsewn ileoanal anastomosis with mucosectomy seems to reduce the incidence of subsequent neoplasia in the anal transitional zone but does not eliminate the risk of cancer.

Comparison of outcomes following ileostomy versus colostomy for defunctioning colorectal anastomoses.

BACKGROUND: The present study evaluated outcomes of patients undergoing proximal diversion using either a loop ileostomy or loop colostomy following distal colorectal resection for malignant and non-malignant disease. METHODS: A literature search of the Medline, Ovid, Embase and Cochrane databases was performed to identify studies published between 1966 and 2006, comparing loop ileostomy and loop colostomy to protect a distal colorectal anastomosis. A random effect meta-analytical technique was used and sensitivity analysis performed on studies published since 2000, higher quality papers, those reporting on 70 or more patients, and those reporting outcomes following colorectal cancer resections. RESULTS: Seven studies, including three randomised controlled trials, satisfied the inclusion criteria. Outcomes of a total of 1,204 patients were analysed, of whom 719 (59.7%) underwent defunctioning loop ileostomy. High stoma output was more common following ileostomy formation (OR = 5.39, 95% CI: 1.11, 26.12, P = 0.04), but wound infections following their reversal were significantly fewer (OR = 0.21, 95% CI: 0.07, 0.62, P = 0.004). Overall complications were less frequent for ileostomy patients in the subgroup of high quality studies (OR = 0.22, 95% CI: 0.08, 0.59, P = 0.003). CONCLUSION: The results of this meta-analysis suggest that ileostomy may be preferable to colostomy when used to defunction a distal colorectal anastomosis. Wound infections following stoma reversal were reduced, as were overall stoma-related complications and incisional hernia following stoma reversal for ileostomy patients in high quality studies.

Comparison of short-term outcomes of laparoscopic vs open approaches to ileal pouch surgery.

AIMS: The present meta-analysis compared short-term outcomes between patients undergoing laparoscopic and open restorative proctocolectomy. METHODS: A literature search of Medical Literature Analysis and Retrieval System Online, Ovid, Excerpta Medica and Cochrane databases was performed to identify studies published between 1990 and 2006 comparing laparoscopic and open restorative proctocolectomy. A random-effect meta-analytical technique was used, and sensitivity analysis was performed on studies published since 2001, higher-quality papers, those reporting on more than 30 patients and those with matching of patient characteristics. RESULTS: Ten studies satisfied the selection criteria, including outcomes on 329 patients, 168 (51.1%) of whom underwent laparoscopic resection. Operative time was significantly longer in the laparoscopic group by 86 min (p<0.001) and throughout the subgroup analysis, but this finding was associated with significant heterogeneity. Operative blood loss was less in the laparoscopic group by 84 ml. There was no significant difference in post-operative adverse events between the groups. A statistically significant reduction in length of post-operative stay was observed for laparoscopic patients in high-quality studies and those reporting on more than 30 patients by 1.1 days (p=0.02 in both subgroups) and studies published in or since 2001 by 3.0 days (p=0.004) but not overall. CONCLUSION: Laparoscopic ileal pouch surgery was associated with longer operative time, lower blood loss, shorter length of hospital stay and similar short-term adverse events compared with open surgery. Comparative data on quality of life and long-term outcomes are currently unavailable. The potential advantage of laparoscopic ileal pouch surgery remains to be established.

The effect of Crohn's disease on outcomes after restorative proctocolectomy.

PURPOSE: This study was designed to compare postoperative adverse events and functional outcomes after ileal pouch-anal anastomosis between patients with Crohn's disease and those with non-Crohn's disease diagnoses. METHODS: A literature search was performed to identify studies published between 1980 and 2005 comparing outcomes of patients undergoing ileal pouch-anal anastomosis for Crohn's disease, ulcerative colitis, and indeterminate colitis. Random-effect, meta-analytical techniques were used and sensitivity analysis was performed. RESULTS: Ten studies comprising 3,103 patients (Crohn's disease=225; ulcerative colitis=2,711; indeterminate colitis=167) were included. Patients with Crohn's disease developed more anastomotic strictures than non-Crohn's disease diagnoses (odds ratio, 2.12; P=0.05) and experienced pouch failure more frequently than patients with ulcerative colitis (Crohn's disease vs. ulcerative colitis: 32 vs. 4.8 percent, P<0.001; Crohn's disease vs. indeterminate colitis: 38 vs. 5 percent, P<0.001). Urgency was more common in Crohn's disease compared with non-Crohn's disease: 19 vs. 11 percent (P=0.02). Incontinence occurred more frequently in Crohn's disease compared with non-Crohn's disease patients: 19 vs. 10 percent (odds ratio, 2.4; P=0.01). Twenty-four-hour stool frequency did not differ significantly between Crohn's disease, ulcerative colitis, or indeterminate colitis. Patients with isolated colonic Crohn's disease were not significantly at increased risk of postoperative complications or pouch failure (P=0.06). CONCLUSIONS: Patients with Crohn's disease undergoing ileal pouch-anal anastomosis should be appropriately counseled toward poorer functional outcomes and higher failure compared with non-Crohn's disease patients. It maybe possible to preoperatively select patients with isolated colonic Crohn's disease who may benefit from ileal pouch-anal anastomosis with acceptable adverse outcomes.

Meta-analysis of clinical outcome after first and second liver resection for colorectal metastases.

BACKGROUND: The perioperative risk and long-term survival benefit of repeat hepatectomy for patients with liver metastases from colorectal cancer, compared with that of a first liver resection, has been reported with varying results in the literature. METHODS: The literature was searched using Medline, Embase, Ovid, and Cochrane databases for all studies published from 1992 to 2006. Two authors independently extracted data using the following outcomes: postoperative complications and mortality; disease recurrence; and long-term survival. Trials were assessed using the modified Newcastle-Ottawa Score. Random-effect meta-analytical techniques were used for analysis. RESULTS: Twenty-one studies met the inclusion criteria, comprising 3,741 patients. The use of adjuvant chemotherapy was similar in both groups (odds ratio [OR] = 0.97; 95% confidence interval [CI] = 0.54, 1.74; P = .92), as was the number of hepatic nodules present at the time of first or second resection (weighted mean difference [WMD] = 0.18; 95% CI = -0.22, 0.57; P = .380). Wedge resection was carried out less often at first hepatectomy (39% vs 46%; OR = 0.66; 95% CI = 0.44, 1.00; P = .05). There was significantly less blood loss in patients undergoing first versus second hepatectomy (WMD = 238 ml; 95% CI = 90, 385; P = .002). There was no difference in perioperative morbidity (OR = 1.01; 95% CI = 0.65, 1.55; P = .98), mortality (OR = 1.01; 95% CI = 0.18, 5.72; P = .99) or long-term survival (HR = 0.90; 95% CI = .66, 1.24; P = .530) between groups. CONCLUSIONS: Repeat hepatectomy for patients with colorectal cancer metastases is safe and provides survival benefit equal to that of a first liver resection.

A comparison of adverse events and functional outcomes after restorative proctocolectomy for familial adenomatous polyposis and ulcerative colitis.

PURPOSE: Restorative proctocolectomy is the procedure of choice for patients undergoing proctocolectomy for familial adenomatous polyposis or ulcerative colitis. This meta-analysis was designed to identify differences in adverse events and functional outcomes between these two groups. METHODS: Studies published between 1986 and 2003 that compared outcomes between patients with familial adenomatous polyposis and ulcerative colitis were included. Meta-analytical techniques using random effect models were used to compare short-term and long-term adverse events as well as functional outcomes between the groups. RESULTS: Nineteen studies comprising 5,199 patients (familial adenomatous polyposis, 782; ulcerative colitis, 4,417) were analyzed. There were no significant differences in immediate postoperative adverse events between the two groups. Pouch-related fistulation was significantly increased in the ulcerative colitis group (10.5 percent vs. familial adenomatous polyposis 4.8 percent; odds ratio 2.31; P < 0.001). There was no significant difference in pouch failure between the two groups (ulcerative colitis 5.8 percent vs. familial adenomatous polyposis 4.5 percent; odds ratio 1.22; P = 0.43). The incidence of pouchitis was significantly greater in the ulcerative colitis group (30.1 vs. 5.5 percent; odds ratio 6.44; P < 0.001). Patients with familial adenomatous polyposis had a significant advantage in stool frequency with one less motion per 24 hours (95 percent confidence interval, 0.21-1.76; P = 0.01). CONCLUSIONS: In contrast to studies reporting similar outcomes for patients undergoing restorative proctocolectomy for familial adenomatous polyposis or ulcerative colitis, the present meta-analysis suggested that patients with ulcerative colitis are at greater risk of pouch-related fistulation and pouchitis. Although there was an increase in the 24-hour stool frequency in the ulcerative colitis group, this may be accounted for by the younger age at surgery in the familial adenomatous polyposis group.

A comparison of hand-sewn versus stapled ileal pouch anal anastomosis (IPAA) following proctocolectomy: a meta-analysis of 4183 patients.

OBJECTIVE: Using meta-analytical techniques, the study compared postoperative adverse events and functional outcomes of stapled versus hand-sewn ileal pouch-anal anastomosis (IPAA) following restorative proctocolectomy. BACKGROUND: The choice of mucosectomy and hand-sewn versus stapled pouch-anal anastomosis has been a subject of debate with no clear consensus as to which method provides better functional results and long-term outcomes. METHODS: Comparative studies published between 1988 and 2003, of hand-sewn versus stapled IPAA were included. Endpoints were classified into postoperative complications and functional and physiologic outcomes measured at least 3 months following closure of ileostomy or surgery if no proximal diversion was used, quality of life following surgery, and neoplastic transformation within the anal transition zone. RESULTS: Twenty-one studies, consisting of 4183 patients (2699 hand-sewn and 1484 stapled IPAA) were included. There was no significant difference in the incidence of postoperative complications between the 2 groups. The incidence of nocturnal seepage and pad usage favored the stapled IPAA (odds ratio [OR] = 2.78, P < 0.001 and OR = 4.12, P = 0.007, respectively). The frequency of defecation was not significantly different between the 2 groups (P = 0.562), nor was the use of antidiarrheal medication (OR = 1.27, P = 0.422). Anorectal physiologic measurements demonstrated a significant reduction in the resting and squeeze pressure in the hand-sewn IPAA group by 13.4 and 14.4 mm Hg, respectively (P < 0.018). The stapled IPAA group showed a higher incidence of dysplasia in the anal transition zone that did not reach statistical significance (OR = 0.42, P = 0.080). CONCLUSIONS: Both techniques had similar early postoperative outcomes; however, stapled IPAA offered improved nocturnal continence, which was reflected in higher anorectal physiologic measurements. A risk of increased incidence of dysplasia in the ATZ may exist in the stapled group that cannot be quantified by this study. We describe a decision algorithm for the choice of IPAA, based on the relative risk of long-term neoplastic transformation.