Matteo Rottoli

Prepouch Ileitis After Ileal Pouch-anal Anastomosis: Patterns of Presentation and Risk Factors for Failure of Treatment

Background and AimsnThere is a lack in the literature about prepouch ileitis [PI], in particular regarding risk factors associated with failure of the medical treatment. Aim of the study is to analyse the characteristics of PI patients and to compare those who required surgery with those who were successfully treated with conservative therapy.nnnMethodsnAll cases presenting a diagnosis of PI were included and analysed. Patients eventually requiring surgery were compared with those who were managed conservatively, for symptoms of presentation, endoscopic characteristics, and rate of response to medical treatment. A sub-analysis of outcomes based on the final histology was performed.nnnResultsnThe overall incidence of PI among 1286 patients was 4.4% [57], after a median of 6.8 years from pouch surgery. Symptoms included increased frequency [26.4%], outlet obstruction [21%], and bleeding [15.8%]. Afferent limb stenosis affected 49.1% of patients. The comparison showed that patients requiring surgery had a higher rate of Crohns disease and indeterminate colitis [42.1 vs 0% and 15.8 vs 2.6%, p < 0.0001], outlet obstruction as main symptom [47.4 vs 7.9%, p = 0.0023], and afferent limb stenosis [73.7 vs 36.8%, p = 0.008] at endoscopy. Rate of failure of medical treatment at 5 years was 8.2% in patients with ulcerative colitis and 75% in the presence of both indeterminate colitis and Crohns disease [p < 0.0001].nnnConclusionsnCrohns disease, indeterminate colitis, and stenosis with outlet obstruction are risk factors for failure of treatment after diagnosis of PI. Early aggressive therapy and surgery should be considered in these cases.

Endoluminal vacuum-assisted therapy as treatment for anastomotic leak after ileal pouch–anal anastomosis: a pilot study

AbstractBackgroundAnastomotic leak after ileal pouch–anal anastomosis (IPAA) could lead to poor functional results and failure of the pouch. The aim of the present study was to analyze the outcomes of the vacuum-assisted closure therapy as the unique treatment for anastomotic leaks following IPAA without any additional surgical operations.nMethodsConsecutive patients with anastomotic leak after IPAA treated at our institution between March 2016 and March 2017 were prospectively enrolled. After diagnosis, the Endosponge® device was positioned in the gap and replaced until the cavity was reduced in size and covered by granulating tissue. A pouchoscopy was performed every week for the first month and monthly subsequently. No additional procedures were performed.ResultsEight patients were included in the study. The leak was diagnosed at a median of 14 (6–35) days after surgery. At the time of diagnosis, seven patients had a defunctioning ileostomy performed as routine at the time of pouch formation, while one patient was diagnosed after ileostomy closure and underwent emergency diversion ileostomy. The Endosponge® treatment started after a median of 6.5 (1–158) days after the diagnosis of the leakage and was carried on for a median of 12 (3–42) days. The device was replaced a median of 3 (1–10) times. The median length of hospital stay after the first application of the treatment was 15.5 (6–48) days. The complete healing of the leak was documented in all patients, after a median of 60 (24–90) days from the first treatment. All patients but one had their ileostomy reversed at a median of 2.5 (1–6) months from the confirmation of the complete closure.ConclusionsEndosponge® is effective as the only treatment after IPAA leak. Based on the results of our prospective pilot study, application of Endosponge® should be the treatment of choice in selected pouch anastomotic leaks not requiring immediate surgery. These results will have to be confirmed by future prospective studies including a larger number of patients.

Transabdominal salvage surgery after pouch failure in a tertiary center: A case-matched study ☆

BACKGROUNDnSalvage surgery after failure of ileal pouch-anal anastomosis (IPAA) could be offered to selected patients. However, the results vary widely in different centers.nnnAIMSnTo assess the outcomes of salvage surgery by comparison with a control group matched for confounding variables.nnnMETHODSnFrom a prospective database of 1286 IPAA, patients undergoing transabdominal salvage surgery were compared for perioperative and functional outcomes and quality of life (QOL) to a 1:3 control group of primary IPAA cases.nnnRESULTSnSalvage surgery patients (30) had a higher rate of hand-sewn anastomoses (80 vs 20%, p <0.0001) and reoperations (10 vs 2.2%, p 0.02) than control group (90). A higher number of daytime and nighttime bowel movements (7.4 vs 4.1, p <0.0001, and 2.6 vs 1.8, p=0.002), a lower median CGQL score (0.7 vs 0.8, p=0.0001) and a higher rate of pouch fistulae (13.3 vs 1.1%, p=0.003) were reported after salvage surgery. Pouch failure rate after salvage surgery was 10.1%, 18.7% and 26.8% at 1, 5 and 10 years (vs 0%, 3.5% and 8.4% in control group, p=0.0085).nnnCONCLUSIONSnAlthough worse functional outcomes and decreased QOL have to be expected, salvage surgery after pouch failure is associated with acceptable outcomes when performed in a referral center.

What are the consequences of enlarging the extraction site to exteriorize a large specimen during laparoscopic surgery for Crohn's enteritis?

The implications of extraction site enlargement for the removal of large specimens during laparoscopic surgery for Crohns disease have not been clearly described; such a description is the aim of this study.

Morbidity associated with closure of ileostomy after a three-stage ileal pouch-anal anastomosis

The aim of the study was to compare the perioperative outcomes of patients undergoing ileostomy closure after a three-stage ileal pouch-anal anastomosis to a control group of patients who had elective colorectal resections and stoma, and to analyse the differences based on the technique of closure. The cases were retrospectively compared for demographic characteristics and postoperative outcomes. Chi-square, Fisher’s exact and Wilcoxon rank sum tests were used as appropriate. Between 2011 and 2016, 338 patients having their stoma reversed after three-stage IPAA were compared to 158 patients in the control group. A younger age (43.2 vs 60.6xa0years, pu2009<u20090.0001), a lower body mass index (22 vs 24.4xa0kg/m2, pu2009<u20090.0001), a higher rate of hand-sewn anastomosis (84.3 vs 15.7%, pu2009<u20090.0001), a lower rate of intraoperative complications (0 vs 1.2%, pu2009=u20090.038), a shorter operative time (91.5 vs 99.4xa0min, pu2009=u20090.0046) and length of hospital stay (6.6 vs 7.6xa0days, pu2009=u20090.045) were seen in the IPAA group. The 30-day rate of wound infection, anastomotic leak (0.6 vs 0.6%), small bowel obstruction (SBO, 8 vs 11.4%) and reoperation (1.8 vs 1.3%) was similar. Among IPAA patients, the hand-sewn anastomosis was correlated with a higher chance of developing SBO (9.1 vs 1.9%, pu2009=u20090.03). Closure of ileostomy after three-stage IPAA is associated with low rate of serious complications, despite the higher number of previous abdominal surgeries. This supports the construction of routine ileostomy during IPAA to reduce the risk of pelvic sepsis.

Gracilis muscle transposition for the treatment of recurrent rectovaginal and pouch-vaginal fistula: is Crohn’s disease a risk factor for failure? A prospective cohort study

BackgroundThe surgical management of rectovaginal fistulae associated with Crohn’s disease is often frustrated by poor results regardless of the different techniques. The outcomes of the gracilis muscle transposition (GMT) for the treatment of recurrent Crohn’s-associated fistulae are still debated. The aim of the study is to determine whether the success rate of GMT is similar in Crohn’s disease patients and in a control group.Materials and methodsAll patients undergoing GMT for rectovaginal or pouch-vaginal fistula were collected from a prospectively maintained database (2005–2016). The primary study outcome was the comparison of the success rate of GMT in Crohn’s disease and control group patients.ResultsTwenty-one patients with a rectovaginal fistula due to Crohn’s disease (8, 38.1%) or other etiologies (13, 61.9%) were included. The groups had similar characteristics and postoperative outcomes. After a median follow-up time of 81 and 57xa0months (p 0.34), the success rate of GMT was 75% in patients with Crohn’s disease and 68.4% in control group (p 0.6). The median time to recurrence was 3.5xa0months (1–12). The success rate in patients who had more than two previous attempts of repair was lower regardless of the etiology (50 vs 79.4%, p 0.1).ConclusionGMT is associated with a high success rate, especially in Crohn’s disease-related rectovaginal fistula. In consideration of the low morbidity rate and the fact that an increasing number of previous local operations might be associated with failure, the procedure should be considered as a first line of treatment for recurrent rectovaginal fistulae.

Outcomes of pelvic exenteration for recurrent and primary locally advanced rectal cancer

BACKGROUNDnPelvic exenteration is the only radical treatment for locally advanced (ARC) or recurrent (RRC) rectal cancers. The long-term results of the procedure are variably reported in the literature, with recent series suggesting similar survival between ARC and RRC. The study aimed to analyze and compare the long-term survival and perioperative outcomes of patients undergoing pelvic exenteration for ARC and RRC in a tertiary center.nnnMATERIALS AND METHODSnThis was a retrospective analysis of prospectively collected data. Comparison of variables was performed using Chi-square, Fishers exact or Wilcoxon rank sum test as appropriate. The Kaplan Meier method was used to analyze the disease-free survival (DFS) and the log-rank test to compare the two groups.nnnRESULTSnSince 2002, 46 patients underwent pelvic exenteration for ARC (28, 60.9%) and RRC (18, 39.1%). The groups had comparable characteristics, perioperative results, including postoperative complications, and rate of adjuvant chemotherapy. A R0 resection was obtained in 71.4% and 55.6% (p 0.41) and a T4 stage was diagnosed in 75% and 94.4% (p 0.22) of ARC and RRC patients, respectively. After a median follow-up time of 32.5 and 56.6 months (p 0.01), the 5-year DFS was significantly lower in the RRC group (23.6 vs 46.2%, p 0.006), even after exclusion of R1 cases (30 vs 54.5%, p 0.044).nnnCONCLUSIONnThe long-term disease free survival of patients undergoing pelvic exenteration is significantly worse when the procedure is performed for RRC, regardless of the tumor involvement of the resection margins.

Is transanal total mesorectal excision a reproducible and oncologically adequate technique? A pilot study in a single center

PurposeAn oncologically effective total mesorectal excision (TME) still represents a technical challenge, especially in the presence of a low rectal cancer and anatomical restraints such as obesity or narrow pelvis. Recently, few reports have shown that transanal TME was feasible and associated with good outcomes. Nevertheless, a widespread employment of the technique has yet to happen due to the doubts about the reproducibility of the results outside a tertiary specialized center.MethodsBetween February 2014 and June 2015, patients with low rectal cancer underwent a transanal TME with laparoscopic assistance. The end points included the oncologic adequacy of the mesorectal excision and the perioperative outcomes.ResultsEleven patients (9 male, median age 70.5xa0years) with proven low rectal cancer were enrolled in the study. The median distance of the tumor from the anal verge was 5xa0cm (2–7). Four patients (36.4xa0%) received preoperative chemoradiation. The median operative time was 360xa0min (275–445). Postoperative morbidity (36.4xa0%) included one (9.1xa0%) anastomotic leak requiring a reoperation. The median length of hospital stay was 8xa0days (3–28). The median distance from the circumferential and distal resection margins were, respectively, 5 (1–20) and 10 (5–20)u2009mm, and the mean number of harvested lymph nodes was 21.7 (11–50). All cases had a complete or nearly complete mesorectal plane of surgery.ConclusionsAlthough technically challenging, the initial results suggest that transanal TME could be a feasible, oncologically safe, and reproducible operation. However, more robust studies are required to assess the short- and long-term outcomes.

A Prolonged Operative Time Nullifies the Postoperative Advantages of Laparoscopic Rectal Resection (14th World Congress of Endoscopic Surgery and 22nd International Congress of the European Association for Endoscopic Surgery (EAES) Paris, France, 25–28 June 2014)

Background: Outcomes after surgery for diverticulitis across the United States are of continued interest to improve quality of care. Determining the variations in mortality, length of stay, and patient charges between the states are the aim of this study. Methods: A retrospective analysis of the Nationwide Inpatient Sample (NIS) database was performed. Patients with diverticulitis who underwent laparoscopic or open partial colectomy were identified by ICD-9 diagnosis codes and then subdivided by state. Patients younger than age of 18 years were excluded. Multivariate analyses examined mortality, length of stay (LOS), and total charges. Results were adjusted for age, race, gender, Charlson comorbidity index, and insurance status. Results: From 1998–2010, 148,348 patients had partial colon resection for diverticulitis. 90048 procedures were performed in hospitals with less than 5 % laparoscopic operations for diverticulitis. Using California as the comparison state, and after adjusting for other covariates, in-hospital mortality was significantly higher in the State of New York (adjusted OR 1.28; 1.10–1.51 95 % CI; P 0.05) and Mississippi (adjusted OR 2.75; 1.21–6.23 95 % CI, P 0.015). While California had a comparatively low mortality, Wisconsin even had a significant lower mortality rate (adjusted OR 0.72; 0.57–0.91 95 % CI, P 0.004). LOS was 1.2 days longer in New York and 0.54 days shorter in Wisconsin than in California (P 0.001). Patients with age [ 40 years and patients without private insurance had higher in-hospital mortality and longer length of stay. Average hospital charges differed dramatically between the different States in the observation period. Highest charging states were California, Nebraska, and Nevada while lowest charging states were Maryland and Utah. Conclusions: Patients who undergo surgical treatment for diverticulitis have high variation in mortality, LOS, and hospital charges when controlled for demographic and socioeconomic factors. Further analysis should be performed to identify the causes of outlier states in each category, with the goal of improving and standardizing best practices for all states. O002 Intestinal, Colorectal and Anal Disorders