Marco Zoccali

Does Morbid Obesity Change Outcomes after Laparoscopic Surgery for Inflammatory Bowel Disease? Review of 626 Consecutive Cases

BACKGROUNDnLittle is known about the impact of obesity on morbidity in patients with inflammatory bowel disease (IBD) who are undergoing laparoscopic resections. The aim of this study was to evaluate outcomes in a consecutive series of normal weight (NW), overweight (OW), and obese (OB) patients undergoing elective laparoscopic colorectal surgery for IBD.nnnSTUDY DESIGNnThis study is a retrospective analysis of a prospectively collected, Institutional Review Board-approved IBD database.nnnRESULTSnLaparoscopic colorectal resection was performed in 626 patients (335 NW, 206 OW, and 85 OB) between August 2002 and December 2011. Operative time and blood loss were significantly higher in the OW and OB groups compared with the NW group (p = 0.001 and p < 0.001). No differences were observed in terms of intraoperative blood transfusions (p = 0.738) or complications (p = 0.196). The OW and OB groups had a significantly higher conversion rate (p = 0.049 and p = 0.037) and a longer incision compared with the NW group (p = 0.002 and p < 0.001). Obesity was an independent predictor of conversion to open surgery. No significant differences between groups were observed in terms of overall 30-day postoperative morbidity (p = 0.294) and mortality (p = 0.796). Long-term complications occurred in 6.3% NW, 7.3% OW, and 4.7% OB patients (p = 0.676). Incisional hernias were more common in the OB group compared with the NW group (p = 0.020). On multivariate analysis, obesity was not an independent risk factor for either early or late postoperative complications.nnnCONCLUSIONSnObesity increases the complexity of laparoscopic resections in IBD with higher blood loss, operative time, and conversion rates, without worsening outcomes.

Gastroesophageal Reflux Disease and Antireflux Surgery-What Is the Proper Preoperative Work-up?

BackgroundMany surgeons feel comfortable performing antireflux surgery (ARS) on the basis of symptomatic evaluation, endoscopy, and barium esophagography. While esophageal manometry is often obtained to assess esophageal peristalsis, pH monitoring is rarely considered necessary to confirm the diagnosis of gastroesophageal reflux disease (GERD).AimsThe aim of this study was to analyze the sensitivity and specificity of symptoms, endoscopy, barium esophagography, and manometry as compared to pH monitoring in the preoperative evaluation of patients for ARS.Patients and MethodsOne hundred and thirty-eight patients were referred for ARS with a diagnosis of GERD based on symptoms, endoscopy, and/or barium esophagography. Barium esophagography, esophageal manometry, and ambulatory 24-h pH monitoring were performed preoperatively in every patient.ResultsFour patients were found to have achalasia and were excluded from the analysis. Based on the presence or absence of gastroesophageal reflux on pH monitoring, the remaining 134 patients were divided into two groups: GERD+ (nu2009=u200978, 58xa0%) and GERD− (nu2009=u200956, 42xa0%). The groups were compared with respect to the incidence of symptoms, presence of reflux and hiatal hernia on esophagogram, endoscopic findings, and esophageal motility. There was no difference in the incidence of symptoms between the two groups. Within the GERD+ group, 37 patients (47xa0%) had reflux at the esophagogram and 41 (53xa0%) had no reflux. Among the GERD− patients, 17 (30xa0%) had reflux and 39 (70xa0%) had no reflux. A hiatal hernia was present in 40 and 32xa0% of patients, respectively. Esophagitis was found at endoscopy in 16xa0% of GERD+ patients and in 20xa0% of GERD− patients. Esophageal manometry showed no difference in the pressure of the lower esophageal sphincter or quality of peristalsis between the two groups.ConclusionsThe results of this study showed that (a) symptoms were unreliable in diagnosing GERD, (b) the presence of reflux or hiatal hernia on esophagogram did not correlate with reflux on pH monitoring, (c) esophagitis on endoscopy had low sensitivity and specificity, and (d) manometry was mostly useful for positioning the pH probe and rule out achalasia. Ambulatory 24-h pH monitoring should be routinely performed in the preoperative work-up of patients suspected of having GERD in order to avoid unnecessary ARS.

Preoperative infliximab therapy does not increase morbidity and mortality after laparoscopic resection for inflammatory bowel disease.

BACKGROUND: The impact of infliximab on the postoperative course of patients with IBD is under debate. OBJECTIVE: The aim of this study was to evaluate the influence of infliximab on perioperative outcomes in patients undergoing elective laparoscopic resection for IBD. DESIGN: This study is a retrospective analysis of a prospectively collected, institutional review board-approved database. SETTING, PATIENTS, INTERVENTIONS: Patients undergoing laparoscopic resection on preoperative infliximab (infliximab group) were compared with patients who did not receive infliximab (noninfliximab group). MAIN OUTCOME MEASURES: The short-term and long-term morbidity and mortality rates were assessed. RESULTS: Elective laparoscopic resection for IBD was performed on 518 patients from January 2004 through June 2011; 142 patients were treated with infliximab preoperatively. Both groups had similar demographics, type and severity of IBD, comorbidities, and type of surgery. A significantly higher number of patients in the infliximab group had been on aggressive medical therapy to control symptoms of IBD during the month preceding surgery, including steroids (73.9 vs 58.8%, p = 0.002) and immunosuppressors (32.4 vs 20.5%, p = 0.006). Operative time and blood loss were similar (p = 0.50 and p = 0.34). Intraoperative complication rate was 2.1% in both groups. No significant differences were observed in terms of the conversion rate to laparotomy (6.3% vs 9.3%, p = 0.36), overall 30-day postoperative morbidity (p = 0.93), or mortality (p = 0.61). The rates of anastomotic leak (2.1% vs 1.3%, p = 0.81), infections (12% vs 11.2%, p = 0.92), and thrombotic complications (3.5% vs 5.6%, p = 0.46) were similar. Subgroup analyses confirmed similar rates of overall, infectious, and thrombotic complications regardless of whether patients had ulcerative colitis or Crohn’s disease. LIMITATIONS: This study is subject to the limitations of a retrospective design. CONCLUSIONS: Infliximab is not associated with increased rates of postoperative complications after laparoscopic resection.

Single Incision (“Scarless”) Laparoscopic Total Abdominal Colectomy with End Ileostomy for Ulcerative Colitis

IntroductionTotal abdominal colectomy with ileal pouch–anal anastomosis is the intervention of choice for patients with medically uncontrolled ulcerative colitis. A three-stage approach is preferred in particularly debilitated patients. In this setting, laparoscopic surgery has shown to be safe, offering several advantages over the open approach. Single incision laparoscopic surgery is a new minimally invasive approach which represents a true scarless procedure for the first step of the restorative proctocolectomy. In this article, we describe our technique in performing the single-incision total abdominal colectomy.MethodsThe single-access device is inserted through a circular incision made at the ileostomy site, which was marked preoperatively. The procedure is performed with conventional laparoscopic instruments through one 12-mm and three 5-mm trocars introduced in the single-access device gel platform. Good exposure of the operating field is obtained by changing the Trendelenburg position and the lateral tilting of the table. We start the operation by mobilizing the right colon, then proceeding clockwise to the rectosigmoid junction. The ileocolic pedicle is divided after the visualization of the right ureter and duodenum. The right colon is mobilized in the medial-to-lateral fashion. The hepatocolic ligament is taken down, and the transverse mesocolon and the greater omentum are divided to mobilize the transverse colon. Subsequently, the lateral attachments of descending colon are taken sharply, and the avascular line of Toldt is bluntly dissected. Under direct visualization of the left ureter, the inferior mesenteric vein and the branches of the sigmoid arteries are identified, dissected, and divided. After switching to a 5-mm laparoscope, the rectosigmoid junction is divided with an endoscopic stapler. The specimen is exteriorized, and the terminal ileum is divided extracorporeally. Finally, the ileostomy is matured in the standard Brooke fashion.ConclusionBetween May and November 2010, we performed ten single-incision total abdominal colectomies, all completed successfully without complications or need of conversion, with a mean operative time of 139±24 min and an estimated blood loss of 100±120 ml. The postoperative course was unremarkable in all cases, with prompt return of bowel activity and short postoperative stay. In our experience, single-incision total abdominal colectomy has shown to be a safe alternative to standard laparoscopy in selected patients and appears to be a promising technique with the potential to improve short-term outcomes.

Single-incision laparoscopic total abdominal colectomy for refractory ulcerative colitis.

BackgroundA three-stage restorative proctocolectomy with ileal pouch-anal anastomosis is the treatment of choice for the particularly debilitated patient with medically refractory ulcerative colitis (UC). Laparoscopic surgery has been shown to offer several advantages over the open approach in this setting. Single-incision laparoscopic surgery is an emerging minimally invasive strategy representing a truly scarless procedure for the first surgical step, namely, the total abdominal colectomy (TAC).MethodsNine consecutive patients with medically refractory UC underwent a single-incision laparoscopic TAC between May and October 2010. All patients were on aggressive medical therapy with corticosteroids or immunosuppressors and were selected for this approach on the basis of their body habitus and the absence of relevant comorbidities. The whole operation was performed through a single access to the abdominal cavity, placed at the ostomy site marked preoperatively.ResultsMean operating time was 142xa0±xa023xa0min, with an estimate blood loss of 108xa0±xa0125xa0ml. No intraoperative complications or conversions to conventional laparoscopy or open surgery occurred. In all cases the postoperative course was uneventful. The return of bowel function was observed on postoperative day 1.7xa0±xa00.7, and patients could tolerate a solid diet on postoperative day 3xa0±xa00.5. The mean postoperative length of stay was 5.2xa0±xa01.3xa0days.ConclusionsIn our experience, a single-incision laparoscopic approach to total abdominal colectomy for refractory ulcerative colitis has been shown to be safe and feasible. Initial results suggest that this technique can lead to improvements in short-term outcomes in selected patients.

Antimesenteric Functional End-to-End Handsewn (Kono-S) Anastomosis

IntroductionAnastomotic recurrence is a frequent event after bowel resection for Crohn’s disease. To date, no anastomotic technique has been proven to be superior in reducing surgical recurrence rates in this setting. In this article, we describe our technique in performing a new antimesenteric functional end-to-end handsewn (Kono-S) anastomosis.MethodsThe segment of bowel to be resected is identified and mobilized. The bowel is then divided transversely with a linear stapler–cutter device. The intervening mesentery is divided close to the bowel. The corners of the two stapled lines are sutured together, and the two stapled lines are approximated with interrupted sutures. An antimesenteric longitudinal enterotomy is performed on both sides, starting no more than 1xa0cm away from the staple line, to allow a transverse lumen of 7–8xa0cm. The openings are closed transversely in two layers.ResultsFrom May 1, 2010 to July 31, 2011 we performed 46 Kono-S anastomoses. One patient had a contained anastomotic leak successfully treated conservatively. Currently, 18 patients (43xa0%) have undergone follow-up endoscopic surveillance with an average Rutgeert’s score of 0.7 (0–3) at a mean of 6.8xa0months.ConclusionThe Kono-S anastomosis is a safe anastomotic technique. Long-term studies are needed to confirm its efficacy in preventing surgical recurrence.

Total Abdominal Colectomy for Refractory Ulcerative Colitis. Surgical Treatment in Evolution

IntroductionTotal abdominal colectomy is the procedure of choice for debilitated patients with acute, medical refractory ulcerative colitis in our practice. A laparoscopic approach has been previously shown to be safe and effective, and has become our preferred strategy. This study illustrates the laparoscopic evolution towards a truly minimally invasive approach comparing three phases of a single colorectal surgeon experience.Material and methodsIn May 2010 single incision laparoscopy was introduced in our practice and has become our preferred approach. Ten consecutive ulcerative colitis patients were case matched and compared with 10 previous laparoscopic-assisted (Feb 2003–Jan 2007) and 10 hand-assisted (Feb 2006–Apr 2010) total abdominal colectomies. Patient, disease and surgery-related factors were analyzed and short-term outcomes were compared.ResultsGiven the study design, there were no differences in demographics, smoking history, disease duration and severity, nutritional and inflammatory parameters, and indication for surgery between groups. Single incision patients were more likely to have received immunosuppressive therapy within 30xa0days of the surgery (pu2009=u20090.016). In the single incision group we noticed significantly shorter duration of surgery (pu2009<u20090.001) and faster resumption of solid diet (pu2009=u20090.019) compared to the other groups. Other short-term outcomes did not differ between groups.ConclusionSingle incision laparoscopy offers a safe alternative to other laparoscopic approaches. Despite the higher technical complexity, the duration of surgery is shorter with faster resumption of oral intake. Studies with larger sample size and longer follow-up will be required to confirm the benefits of this approach.

Postoperative Portomesenteric Venous Thrombosis: Lessons Learned From 1,069 Consecutive Laparoscopic Colorectal Resections

AbstractBackgroundnPortomesenteric venous thrombosis (PVT) is a known complication after open and laparoscopic colorectal (LCR) surgery. Risk factors and the prognosis of PVT have been poorly described.MethodsThis study is a retrospective analysis of a prospectively collected database. Patients with new-onset postoperative abdominal pain were evaluated with a computed tomography scan of the abdomen. Patients found to have PVT were analyzed. A multivariate analysis was performed to identify predictors of PVT.ResultsA total of 1,069 patients undergoing LCR surgery for inflammatory bowel disease (IBD) or nonmetastatic cancer between June 2002 and June 2012 were included. Altogether, 37 (3.5xa0%) patients experienced symptomatic postoperative PVT. On univariate analysis, IBD (pxa0<xa00.001), ulcerative colitis (pxa0=xa00.016), preoperative therapy with steroids (pxa0=xa00.008), operative timexa0≥220xa0min (pxa0=xa00.004), total proctocolectomy (TPC) (pxa0<xa00.001), ileoanal pouch anastomosis (pxa0=xa00.006), and postoperative intraabdominal septic complications (pxa0<xa00.001) were found to be significant risk factors. By multivariate analysis, TPC (pxa0=xa00.026) and postoperative intraabdominal septic complications (pxa0<xa00.001) were independent predictors of PVT. In the PVT group, postoperative length of stay was longer (14.8 vs. 7.4xa0days, pxa0<xa00.001). Of the patients evaluated with a hematologic workup, 72.7xa0% were found to have a hypercoagulable condition. All patients were managed with oral anticoagulation for at least 6xa0months. No death or complications related to PVT occurred.ConclusionsPVT is a potentially serious complication that is more likely to occur after TPC and in the presence of postoperative intraabdominal septic complications, particularly in patients with a coagulation disorder. Prompt diagnosis and treatment with oral anticoagulation are recommended to avoid long-term sequelae.

Minimally invasive approaches for the treatment of inflammatory bowel disease.

Despite significant improvements in medical management of inflammatory bowel disease, many of these patients still require surgery at some point in the course of their disease. Their young age and poor general conditions, worsened by the aggressive medical treatments, make minimally invasive approaches particularly enticing to this patient population. However, the typical inflammatory changes that characterize these diseases have hindered wide diffusion of laparoscopy in this setting, currently mostly pursued in high-volume referral centers, despite accumulating evidences in the literature supporting the benefits of minimally invasive surgery. The largest body of evidence currently available for terminal ileal Crohns disease shows improved short term outcomes after laparoscopic surgery, with prolonged operative times. For Crohns colitis, high quality evidence supporting laparoscopic surgery is lacking. Encouraging preliminary results have been obtained with the adoption of laparoscopic restorative total proctocolectomy for the treatment of ulcerative colitis. A consensus about patients selection and the need for staging has not been reached yet. Despite the lack of conclusive evidence, a wave of enthusiasm is pushing towards less invasive strategies, to further minimize surgical trauma, with single incision laparoscopic surgery being the most realistic future development.

Totally laparoscopic total proctocolectomy: A safe alternative to open surgery in inflammatory bowel disease

Background: Inflammatory bowel disease (IBD) patients have a high incidence of wound and overall postoperative complications. A totally laparoscopic approach could potentially reduce these risks. We adopted totally laparoscopic total proctocolectomy (TL‐TPC) using the perineal wound for extraction as the procedure of choice in IBD patients who are not candidates for a restorative procedure. This study looks at the TL‐TPC results and compares them with our open cohort. Methods: Prospectively collected data from 52 consecutive patients undergoing TL‐TPC from 2002 to 2010 were compared to 31 contemporary patients undergoing open TPC. Results: Demographics and patient characteristics including body mass index were similar. Mean operative times were 340 ± 7 minutes for TL‐TPC and 337 ± 9 minutes for open TPC (P = 0.91). Intraoperative blood loss was 228 ± 2 mL for TL‐TPC and 484 ± 3 mL for open TPC (P < 0.001). Return of bowel function measured as an ileostomy output >100 mL per 8 hours occurred at 2.7 ± 2.8 days for TL‐TPC versus 3.3 ± 1.8 days for open TPC (P = 0.025). The length of stay was 8.4 ± 5.0 days for TL‐TPC versus 9.2 ± 3.2 days for open TPC (P = 0.05). The overall complication rate was 43% for TL‐TPC versus 65% for open TPC (P = 0.07). Postoperative abdominal wound infections and parastomal hernias occurred in 23% and 10% of open TPC patients, respectively, versus zero (P = 0.001) and 6% (P = 0.67) for TL‐TPC. Conclusions: TL‐TPC is therefore considered a safe alternative to open surgery for selected IBD patients not candidates for a restorative procedure. (Inflamm Bowel Dis 2011;)