Diane Mege

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 Crohns 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].

Restorative Proctocolectomy in Elderly IBD Patients: A Multicentre Comparative Study on Safety and Efficacy

Background and Aims Restorative proctocolectomy in elderly inflammatory bowel disease [ IBD] patients is controversial and limited data are available on the outcomes of surgery. The aim of this study was to evaluate the safety, efficacy, and long-term results of ileal-pouch-anal anastomosis in elderly patients, in a multicentre survey from European referral centres. Methods The International Pouch Database [IPD] combined 101 variables. Patients aged ≥ 65 years were matched on the basis of open versus laparoscopic surgery with a control group of consecutive younger unselected patients with a ratio of 1:2. Statistical analysis was performed using two-tailed t test, chi square and Fishers exact tests, Kaplan-Meier function, and log-rank tests where appropriate. Results In the IPD, 77 patients aged ≥ 65 years [Group A] and 154 control patients [Group B] were identified. Elderly patients had more comorbidities [p = 0.0001], longer disease duration [p = 0.001], less extensive disease [p = 0.006], more previous abdominal operations [p = 0.0006], surgery for cancer or dysplasia more frequently [p = 0.0001], fewer single-stage procedures [p = 0.03], more diversions after ileal pouch-anal anastomosis [IPAA] [p = 0.05], and a higher laparoscopic conversion rate [p = 0.04]. Postoperative complications and pouch failure were similar between the groups, but Group A had more Clavien-Dindo IV-V complications [p = 0.04], and longer length of stay [p = 0.007]. Laparoscopy was associated with a shorter duration of surgery [p = 0.0001], and length of stay [p = 0.0001], and the same complication rate as open surgery. Conclusions Restorative proctocolectomy can be performed in selected elderly patients, but there is a higher risk of postoperative complications and longer length of stay in this group. Laparoscopy is associated with shorter operating time and length of stay.

Anterior rectal duplication treated with transanal endoscopic microsurgery

A 20-year-old female, without any medical or surgical history, was referred in our surgical department for chronic pelvic pain associated with episodes of bloody diarrhea and rectal tenesmus evolving since 2 years. Abdominal examination was unremarkable, whereas digital rectal examination found an anterior flexible lesion, measuring 4 cm and located 5 cm from the anal verge. A flexible rectosigmoidoscopy showed an anterior lesion without involvement of the rectal mucosa. On pelvic magnetic resonance imaging (MRI), this anterior rectal lesion was developed in the rectal wall without invasion of the fascia recti or rectovaginal septum. It resulted in low signal intensity on T1-weighted images and high signal intensity in T2-weighted images, with enhanced wall, suggesting a cystic lesion (Fig. 1a). No locoregional lymph nodes were observed. Endorectal ultrasound (ERUS) revealed that the cystic lesion had developed in the rectal wall and had its own wall with a submucosa and a muscularis. These ultrasound features were in favor of a rectal duplication (Fig. 1b). The lesion was resected using transanal endoscopic microsurgery (TEM), with the patient placed in the lithotomy position. The procedure was performed using the TEO platform (Karl Storz, Tuttlingen, Germany). Operative time was 45 min. This approach allowed an en bloc full-thickness excision of the lesion, without vaginal injury. The pathological examination confirmed the diagnosis of nondegenerated cystic rectal duplication, due to the presence of digestive mucosa in the cysts and muscularis between the cysts (Fig. 2). Postoperative outcomes were uneventful, and the patient was discharged on postoperative day 3. She had no complaint in the outpatient clinic at 1 month. Enteric duplications are rare developmental abnormalities that can occur anywhere along the gastrointestinal tract, from the mouth to the anus. Aetiology is still unknown, despite being first described in 1733. The most prevalent theory is notochordodysraphy (or split notochord syndrome), which corresponds to a developmental abnormality occurring during the gastrulating stage with abnormal adhesion between the notochord and the endoblast [1]. Enteric duplications are defined by three features (Ladd’s criteria): 1. The lesion should be close to or in continuity with the gastrointestinal tract; 2. The lesion should have a smooth muscle cover; 3. The lesion should be covered by mucosa found in the gastrointestinal tract [2]. Furthermore, enteric duplications are most frequently single, tubular or cystic, and usually located on the mesenteric side of the native digestive tract. Jejunoileal duplications are the most frequent enteric duplications (50%). Rectal duplications are the rarest, accounting for less than 5% of cases. These congenital malformations are usually diagnosed during childhood and can be associated with other digestive, urogenital or spinal malformations [3]. Rectal duplications are more frequently posterior and cystic. Presentation in adults is extremely rare. The most frequent symptoms are pelvic or back pain, rectal bleeding, infection, perianal fistulation or mass effect & Yves Panis yves.panis@aphp.fr

Ileal pouch-anal anastomosis for dysplasia or cancer complicating inflammatory bowel disease: Is total mesorectal excision always mandatory? an analysis of 36 consecutive patients.

Background and Aims The extent of lymph node harvesting during surgery for colorectal neoplasm [dysplasia and/or cancer] complicating inflammatory bowel disease [IBD] is a matter of debate. This study aimed to assess the risk of invasive rectal cancer in patients undergoing ileal pouch-anal anastomosis [IPAA] for colonic neoplasm complicating IBD, and thus to clarify whether a systematic total mesorectal excision [TME] should be systematically performed, or not, in those patients. Methods From 1998 to 2015, all patients who underwent IPAA for colorectal neoplasm complicating IBD were included. Patients with preoperatively known rectal cancer were excluded. Pathological results were compared with preoperative endoscopic results. Results A totalof 36 patients [mean age 49 ± 14 years], comprising 10 women [31%] and 26 men [69%], underwent IPAA for colorectal neoplasm complicating IBD, with [n = 8; 22%] or without [n = 28; 78%] TME. Rectal cancer rate in pathological specimens was 0% [0/20] in patients with preoperatively known neoplasm only limited to the colon, 0% [0/8] among patients with preoperative rectal low-grade dysplasia, and 62% [5/8] among patients with preoperatively rectal high-grade dysplasia. Conclusions These results do not support systematic TME during IPAA for colonic neoplasm complicating IBD. Considering its association with postoperative sexual disorder, TME should be discussed only on a case-by-case basis.

Is abdominal CT useful for the management of patients with severe acute colitis complicating inflammatory bowel disease? A study in 54 consecutive patients

To evaluate the contribution of CT for the management of patients with severe acute exacerbation of colitis (SAC) complicating inflammatory bowel disease (IBD); in particular, its contribution to surgical decision making.

Is biological mesh interposition a valid option for complex or recurrent rectovaginal fistula

Many surgical techniques are available for the treatment of rectovaginal fistula (RVF). There is hitherto little information on its treatment by biological mesh interposition. The aim of the present study was to analyse our results of RVF treatment using biological mesh interposition.

Risk factors for small bowel obstruction after laparoscopic ileal pouch-anal anastomosis for inflammatory bowel disease. A multivariate analysis in 4 expert centres in Europe.

BACKGROUND AND AIMS Although laparoscopy is associated with a reduction in adhesions, no data are available about the risk factors for small bowel obstruction [SBO] after laparoscopic ileal pouch-anal anastomosis [IPAA]. Our aims here were to identify the risk factors for SBO after laparoscopic IPAA for inflammatory bowel disease [IBD]. METHODS All consecutive patients undergoing laparoscopic IPAA for IBD in four European expert centres were included and divided into Groups A [SBO during follow-up] and B [no SBO]. RESULTS From 2005 to 2015, SBO occurred in 41/521 patients [Group A; 8%]. Two-stage IPAA was more frequently complicated by SBO than 3- and modified 2-stage IPAA [12% vs 7% and 4%, p = 0.04]. After multivariate analysis, postoperative morbidity (odds ratio [OR] = 3, 95% confidence interval [CI] = 1.5-7, p = 0.002), stoma-related complications [OR = 3, 95% CI = 1-6, p = 0.03] and long-term incisional hernia [OR = 6, 95% CI = 2-18, p = 0.003] were predictive factors for SBO, while subtotal colectomy as first surgery was an independent protective factor [OR = 0.4, 95% CI = 0.2-0.8, p = 0.002]. In the subgroup of patients receiving restorative proctocolectomy as first operation, stoma-related or other surgical complications and long-term incisional hernia were predictive of SBO. In the patient subgroup of subtotal colectomy as first operation, postoperative morbidity and long-term incisional hernia were predictive of SBO, whereas ulcerative colitis and a laparoscopic approach during the second surgical stage were protective factors. CONCLUSIONS We found that SBO occurred in less than 10% of patients after laparoscopic IPAA. The study also suggested that modified 2-stage IPAA could potentially be safer than procedures with temporary ileostomy [2- and 3-stage IPAA] in terms of SBO occurrence.

Is trans-anal total mesorectal excision really safe and better than laparoscopic total mesorectal excision with a perineal approach first in patients with low rectal cancer? A learning curve with case-matched study in 68 patients

To compare the learning curve for trans‐anal total mesorectal excision (TATME) with laparoscopic TME started by a perineal approach (LTME).

Changing trends in surgery for abdominal Crohn's disease

The introduction of biological agents and laparoscopy are, arguably, the most important developments for the treatment of Crohns disease (CD) in the last two decades. Due to the efficacy of biological agents in treating mild disease, it is likely that the percentage of surgery for complex cases may have increased. The objective of this study was to analyse the changing characteristics and results of the surgical treatment of patients with CD over the past 13 years.

P476 Sigmoidostomy or Hartman's procedure during laparoscopic subtotal colectomy for acute colitis complicating inflammatory bowel disease? A comparative study in 129 consecutive patients

Background: Today, there is no consensus about the best management of the remaining rectum following subtotal colectomy for acute colitis complicating inflammatory bowel disease. There are three options: intra-peritoneal rectal stump closure (Hartmanns pouch with closed stapled rectal stump), creat