Hasan T. Kirat

Single-port laparoscopy in colorectal surgery

Purpose  Laparoscopy is the approach of choice for the majority of colorectal disorders that require a minimally invasive abdominal operation. As the emphasis on minimizing the technique continues, natural orifice surgery is quickly evolving. The authors utilized an embryologic natural orifice, the umbilicus, as sole access to the abdomen to perform a colorectal procedure. Herein, we present our initial experience of single‐port laparoscopic colorectal surgery using a Uni‐X™ Single‐Port Access Laparoscopic System (Pnavel Systems, Morganville, New Jersey, USA) with a multi‐channel cannula and specially designed curved laparoscopic instrumentation.

Ileal pouch anal anastomosis: analysis of outcome and quality of life in 3707 patients.

Background:Ileal pouch anal anastomosis (IPAA) is the treatment of choice for chronic, medically refractory mucosal ulcerative colitis, indeterminate colitis, familial adenomatous polyposis (FAP), and a select group of patients with Crohns disease. Aim:We report outcomes, complications, and quality of life (QOL) in a cohort of 3707 patients treated at our institution from January 1984 to March 2010. Methods:Data were collected from a prospectively maintained database and chart review of 3707 consecutive primary IPAA cases. Patient demographics, postoperative complications, functional outcomes, and QOL data were available. Follow-up consisted of clinical examination with assessment of pouch function and QOL. Results:A total of 3707 patients underwent primary pouch and 328 underwent redo pouch surgery. Postoperative histopathological diagnoses were mucosal ulcerative colitis (n = 2953, 79.7%), indeterminate colitis (n = 63, 1.7%), FAP (n = 223, 6%), Crohns disease (n = 150, 4%), cancer/dysplasia (n = 97, 2.6%), and others (n = 221, 6.0%). Early perioperative complications were encountered in 33.5% of patients with a mortality rate of 0.1%. Excluding pouchitis, late complications were experienced by 29.1% of patients. Of those patients who had IPAA at our institution, pouch failure occurred in 197 patients (5.3%). During a median follow-up of 84 months, 119 patients (3.2%) required excision of the pouch, 32 (0.8%) had a nonfunctioning pouch, and 46 patients (1.2%) had redo IPAA. Functional outcomes and QOL were good or excellent in 95% of patients and similar in each histopathological subgroup. Conclusions:IPAA is an excellent option for patients with MUC, IC, FAP, and select patients with Crohns disease.

Comparison of outcomes after hand-sewn versus stapled ileal pouch-anal anastomosis in 3,109 patients

BACKGROUND The aim of this study was to compare outcomes after primary hand-sewn versus stapled ileal pouch-anal anastomosis (IPAA). METHODS Patients undergoing a primary IPAA (1983-2007) were identified from a prospective pelvic pouch database. Differences between group A (hand-sewn) and group B (stapled) for pre-operative and peri-operative factors, complications, functional outcomes, and quality of life (QOL) were investigated. RESULTS Of 3,382 patients with a primary IPAA, 3,109 were included. Median follow-up was 7.1 years (0.1-24). Mean age was 37.9 +/- 13.2 years. Overall, 1,741 patients (56%) were male. Group A (n = 474) and group B (n = 2635) had similar age (P = .28), sex (P = .8), albumin level (P = .74), prior colectomy (P = .98), and use of steroids (P = .1). Group A had a greater use of ileostomy (P = .001) and a longer duration of stay (P < .001). Group B had a greater body mass index (P < .001) and J-pouch (P < or = .001). Wound infection (P = .42) and pouchitis (P = .59) were similar. Anastomotic stricture (P = .002), septic complications (P = .019), bowel obstruction (P = .027), and pouch failure (P < .001) were greater in group A. At most recent follow-up, bowel frequency (P = .74) and rate of urgency were similar (P = .71). A greater proportion of patients in group A described incontinence (P < .001), seepage (P < .001), pad usage (P < .001), dietary (P < .001), social (P < .001), and work restrictions (P = .025). The Cleveland Global QOL score (P = .018) was greater in group B. CONCLUSION Patients undergoing a stapled IPAA had better outcomes and QOL than those undergoing a hand-sewn IPAA.

Repeat pouch surgery by the abdominal approach safely salvages failed ileal pelvic pouch.

PURPOSE: This study evaluated outcomes of patients with abdominal salvage operations for failed ileal pouch-anal anastomosis. METHODS: Patients undergoing laparotomy for ileoanal pouch salvage were reviewed from a prospectively maintained pouch database and records. RESULTS: From 1983 to 2007, 241 abdominal reconstructions were performed. The median follow-up was 5 years (range, 0.04-20.8). Diagnoses before primary ileal pouch-anal anastomosis were ulcerative colitis in 187, familial adenomatous polyposis in 22, indeterminate colitis in 20, Crohns disease in 9, and other in 3. The most common indications for salvage were fistula (n = 67), leak (n = 65), stricture (n = 42) pouch dysfunction (n = 40), pelvic abscess (n = 25). Seventy-one cases had a new pouch constructed. One hundred and seventy cases had the original pouch salvaged. Twenty-nine cases had either pouch excision or ileostomy without pouch excision the result of failure after reconstruction. To assess functional results and quality of life, patients with reconstruction were matched to those with a primary ileal pouch-anal anastomosis. Significantly higher proportions of patients with reconstruction reported seepage during daytime (P = 0.002), at night (P = 0.015), and daytime pad usage (P = 0.02). Other parameters and quality of life were similar between groups. CONCLUSIONS: Repeat abdominal surgery was a good alternative for pouch failure. Functional and quality of life outcomes were encouraging.

Diagnosis and management of afferent limb syndrome in patients with ileal pouch‐anal anastomosis

Background: Distal small bowel obstruction following ileal pouch‐anal anastomosis (IPAA) can occur secondary to acute angulation or prolapse of the afferent limb at the pouch inlet, namely, afferent limb syndrome (ALS). The aim of this study is to report our experience in diagnosis and management of ALS in patients with IPAA. Methods: All patients with ALS after IPAA were identified from prospectively maintained databases. Demographic, clinical, endoscopic, and radiographic features together with its management and outcome were studied. Results: Eighteen patients (12 female) were included. The mean age was 35.6 ± 14.3 years. Most patients presented with intermittent obstructive symptoms. Fifteen patients were diagnosed by pouch endoscopy with features of angulation of the pouch inlet and difficulty in intubating the afferent limb; 12 patients had kinking or narrowing of the pouch inlet identified with abdominal imaging. The median follow‐up was 1.3 (range, 0.14‐16.1) years. Nine patients underwent empiric balloon dilatation of the afferent limb/pouch inlet. Of nine, four needed repeat dilatations. One patient with repeat dilatation ultimately had pouch excision; another has been scheduled for surgery after failed repeat dilatations. Eight patients underwent surgery, resection of angulated bowel (n = 3), pouchopexy (n = 2), pouch mobilization with small bowel fixation (n = 1), and pouch excision (n = 2). One patient without symptoms did not receive any therapy despite the finding of ALS on pouchoscopy. Conclusions: ALS was characterized by clinical presentation of partial small bowel obstruction, which can be diagnosed by careful pouchoscopy and/or abdominal imaging. Endoscopic or surgical intervention is often needed and surgical therapy appears to be more definitive. (Inflamm Bowel Dis 2011;)

The predictive value of preoperative carcinoembryonic antigen level in the prognosis of colon cancer

BACKGROUND We evaluated factors associated with an increased preoperative carcinoembryonic antigen (CEA) level for colon cancer patients undergoing elective curative surgery and assessed whether this was associated with prognosis when accounting for other potential confounders. METHODS Prospectively accrued data of patients with stage I, II, and III colon cancer undergoing surgery (1980-2008) were retrieved retrospectively. Patients with a preoperative CEA level greater than 5 ng/mL (group B) were compared with those with a CEA level of 5 ng/mL or less (group A). RESULTS There were 651 patients (379 men) with a median age of 67 years (range, 21-94 y) and a median follow-up period of 5.9 years. Groups A (n = 451) and B (n = 200) had similar ages and tumor locations. Group B had larger tumors; more patients with T3 and N1/N2; and more patients with stage II/III tumors, and hence greater use of chemotherapy (P = .04). On multivariate analysis, patient age, tumor stage, and differentiation were associated with oncologic outcomes. A CEA level greater than 5 ng/mL was not associated independently with recurrence, recurrence-free survival (P = .47), or overall survival (P = .3). CONCLUSIONS An increased preoperative CEA level is a marker for a more advanced tumor stage. For adequately staged patients, a high preoperative CEA level is not associated independently with oncologic outcomes.

Technical Aspects of Ileoanal Pouch Surgery in Patients with Ulcerative Colitis

Restorative proctocolectomy with ileal pouch-anal anastomosis is the procedure of choice for patients with ulcerative colitis requiring surgery. A J-pouch with a stapled anastomosis has been the preferred technique because it is quicker, safer, and associated with good functional outcomes. A diverting loop ileostomy is usually created at the time of ileal pouch-anal anastomosis. In patients with severe fulminant colitis or toxic megacolon, restorative proctocolectomy with ileal pouch-anal anastomosis is performed in multistages. The technical aspects of ileal pouch-anal anastomosis in patients with ulcerative colitis are reviewed in this article.

Outcome of salvage surgery for ileal pouches referred with a diagnosis of Crohn's disease

INTRODUCTION: Technical complications after ileal pouch-anal anastomosis may be mislabeled as Crohns disease. The purpose of our study is to evaluate the presentation, treatment, and outcomes of patients with a potential misdiagnosis of Crohns disease who have undergone redo ileal pouch-anal anastomosis. METHODS: We evaluated a historical cohort of patients, initially referred from outside institutions with a diagnosis of Crohns disease of the pouch, who subsequently had redo ileal pouch-anal anastomosis (redo pouch or pouch revision for pouch failure) at our institution. With the use of validated questionnaires, the functional outcomes and quality of life of this cohort were compared with a control group of patients who underwent primary ileal pouch-anal anastomosis to assess whether a change in the diagnosis from Crohns disease to technical complications was appropriate. RESULTS: Thirty-three patients underwent a redo pouch procedure for a previous diagnosis of Crohns disease of the pouch. Precolectomy diagnosis included ulcerative colitis (31 patients) and indeterminate colitis (2 patients). Findings on our further evaluation and subsequent indications for repeat pouch surgery included pouch fistula (20 patients), pelvic sepsis or anastomotic leak (17 patients), stricture (4 patients), refractory pouchitis (2 patients), long exit conduit (1 patient), and retained rectal stump (1 patient). All patients had medical treatment for Crohns disease before referral. Median time between primary and redo pouch was 2.1 years (interquartile range, 1.8–4.9). Median follow-up was 1.7 years (interquartile range, 1.0–3.5). Pouch retention rate was 84.8%. Five patients (15.2%) had pouch failure. Seven patients (21.2%) ultimately had pathology consistent with Crohns disease. Comparison of the redo pouch and control groups revealed that functional outcomes and quality of life were similar between groups. CONCLUSION: Patients identified as having Crohns disease need to be carefully reevaluated because some of these patients may actually have surgery-associated complications and can have a favorable long-term outcome after redo ileal pouch-anal anastomosis.

Permanent ostomy after ileoanal pouch failure: pouch in situ or pouch excision?

BACKGROUND: The risks and benefits of pouch excision and end ileostomy creation when compared to the alternative option of a permanent diversion with the pouch left in situ when restoration of intestinal continuity is not pursued for patients who develop pouch failure after IPAA have not been well characterized. OBJECTIVE: This study aimed to compare the early and long-term outcomes after permanent diversion with the pouch left in situ vs pouch excision with end ileostomy creation for pouch failure. DESIGN: This study is a retrospective review of prospectively gathered data. SETTINGS: This investigation was conducted at a tertiary center. PATIENTS: Patients with pouch failure who underwent a permanent ileostomy with the pouch left in situ and those who underwent pouch excision were included in the study. MAIN OUTCOME MEASURES: The primary outcomes measured were the perioperative outcomes and quality of life using the pouch and Short Form 12 questionnaires. RESULTS: One hundred thirty-six patients with pouch failure underwent either pouch left in situ (n = 31) or pouch excision (n = 105). Age (p = 0.72), sex (p = 0.72), ASA score (p = 0.22), BMI (p = 0.83), disease duration (p = 0.74), time to surgery for pouch failure (p = 0.053), diagnosis at pouch failure (p = 0.18), and follow-up (p = 0.76) were similar. The predominant reason for pouch failure was septic complications in 15 (48.4%) patients in the pouch left in situ group and 39 (37.1%) patients in the pouch excision group (p = 0.3). Thirty-day complications, including prolonged ileus (p = 0.59), pelvic abscess (p = 1.0), wound infection (p = 1.0), and bowel obstruction (p = 1.0), were similar. At the most recent follow-up (median, 9.9 y), quality of life (p = 0.005) and health (p = 0.008), current energy level (p = 0.026), Cleveland Global Quality of Life score (p = 0.005), and Short Form 12 mental (p = 0.004) and physical (p = 0.014) component scales were significantly higher after pouch excision than after pouch left in situ. Urinary and sexual function was similar between the groups. Anal pain (n = 4) and seepage with pad use (n = 8) were the predominant concerns of the pouch left in situ group on long-term follow-up. None of the 18 patients with pouch in situ, for whom information relating to long-term pouch surveillance was available, developed dysplasia or cancer. LIMITATIONS: This study was limited by its retrospective nature. CONCLUSIONS: Although technically more challenging, pouch excision, rather than pouch left in situ, is the preferable option for patients who develop pouch failure and are not candidates for restoration of intestinal continuity. Because pouch left in situ was not associated with neoplasia, this option is a reasonable intermediate or long-term alternative when pouch excision is not feasible or advisable.

Influence of stapler size used at ileal pouch-anal anastomosis on anastomotic leak, stricture, long-term functional outcomes, and quality of life.

BACKGROUND The aim of this study was to evaluate whether stapler size used at ileal pouch-anal anastomosis (IPAA) influences outcomes. METHODS Data of patients undergoing stapled IPAA (1983-2007) were obtained. Differences between groups A (stapler size 28-29 mm) and B (31-33 mm) for pre- and perioperative factors, stricture, leak, quality of life (QOL), and function were compared. Associations between stapler size and stricture or leak were assessed with a multivariable Cox model. RESULTS Groups A (n = 1,221) and B (n = 899) had comparable age, diagnosis, body mass index (BMI), and albumin level. Group B had more males (P < .001) but fewer patients with ileostomy (P < .001). There was no significant difference in rates of leak (4.5% vs 6.2%, P = .08) or stricture (1.9% vs 2.7%, P = .1) for groups A and B. On multivariate analysis, female gender was associated with stricture, while greater BMI and male gender were associated with leak. Group A had greater urgency at 1 year and nighttime pad use at 15 years. The other determinants of function and QOL were similar. CONCLUSIONS There was no significant association between the size of stapler used at IPAA and long-term complications.