Prevalence of ‘pouch failure’ of the ileoanal pouch in ulcerative colitis: a systematic review and meta-analysis

Background and aims The ileoanal pouch (IPAA) provides patients with ulcerative colitis (UC) that have not responded to medical therapy an option to retain bowel continuity and defecate without the need for a long-term stoma. Despite good functional outcomes, some pouches fail, requiring permanent diversion, pouchectomy, or a redo pouch. The incidence of pouch failure ranges between 2 and 15% in the literature. We conducted a systematic review and meta-analysis aiming to define the prevalence of pouch failure in patients with UC who have undergone IPAA using population-based studies. Methods We searched Embase, Embase classic and PubMed from 1978 to 31st of May 2021 to identify cross-sectional studies that reported the prevalence of pouch failure in adults (≥ 18 years of age) who underwent IPAA for UC. Results Twenty-six studies comprising 23,389 patients were analysed. With < 5 years of follow-up, the prevalence of pouch failure was 5% (95%CI 3–10%). With ≥ 5 but < 10 years of follow-up, the prevalence was 5% (95%CI 4–7%). This increased to 9% (95%CI 7–16%) with ≥ 10 years of follow-up. The overall prevalence of pouch failure was 6% (95%CI 5–8%). Conclusions The overall prevalence of pouch failure in patients over the age of 18 who have undergone restorative proctocolectomy in UC is 6%. These data are important for counselling patients considering this operation. Importantly, for those patients with UC being considered for a pouch, their disease course has often resulted in both physical and psychological morbidity and hence providing accurate expectations for these patients is vital.

Diagnosis and Management of Chronic Anastomotic Leak

Chronic anastomotic leaks present a daunting challenge to colorectal surgeons. Unfortunately, anastomotic leaks are common, and a significant number of leaks are diagnosed in a delayed fashion. The clinical presentation of these chronic leaks can be silent or have low grade, indolent symptoms. Operative options can be quite formidable and highly complex. Leaks are typically diagnosed by radiographic and endoscopic imaging during the preoperative assessment prior to defunctioning stoma reversal. The operative strategy depends on the location of the anastomosis and the specific features of the anastomotic dehiscence. Low colorectal anastomosis (i.e. following low anterior resection) may require a transanal approach, transabdominal approach, or a combination of the two. While restoration of bowel continuity is encouraged, it is not infrequent for a permanent ostomy to be required to maximize patient quality of life.

Management of the injured bowel: preserving bowel continuity as a gold standard

Background Management of bowel traumatic injuries is a challenge. Although anastomotic or suture leak remains a feared complication, preserving bowel continuity is increasingly the preferred strategy. The aim of this study was to evaluate the outcomes of such a strategy. Methods All included patients underwent surgery for bowel traumatic injuries at a high volume trauma center between 2007 and 2017. Postoperative course was analyzed for abdominal complications, morbidity and mortality. Results Among 133 patients, 78% had small bowel injuries and 47% had colon injuries. 87% of small bowel injuries and 81% of colon injuries were treated with primary repair or anastomosis, with no difference in treatment according to injury site (p = 0.381). Mortality was 8%. Severe overall morbidity was 32%, and abdominal complications occurred in 32% of patients. Risk factors for severe overall morbidity were stoma creation (p = 0.036), heavy vascular expansion (p = 0.005) and a long delay before surgery (p = 0.023). Fistula rate was 2.2%; all leaks occurred after repairing small bowel wounds. Conclusion Primary repair of bowel injuries should be the preferred option in trauma patient, regardless of the site—small bowel or colon—of the injury. Stoma creation is an important factor for postoperative morbidity, which should be weighed against the risk of an intestinal suture or anastomosis.

Robotic Reversal of Hartmann's Procedure

The Hartmann's procedure first described in 1920 is a gold standard for a variety of emergent procedures of the sigmoid colon. A standardized approach to a robotic reversal of a Hartmann's procedure is described to reestablish bowel continuity.

188 Right Hemicolectomy with End-To-Side Circular Stapled Ileo-Colic Anastomosis: Evaluation of Outcomes in A Series Of 55 Consecutive Patients

Background Stapled ileo-colic anastomosis is a well-established alternative to hand-sewn anastomosis after right hemicolectomy. A side-to-side configuration (SSA) is the option commonly practiced. This study describes our experience using a less well described technique, using an end-to-side circular stapled ileo-colic anastomosis (ESSA). Method Consecutive adult patients undergoing a right or extended- right hemicolectomy with ESSA for colonic cancer between July 2013 and March 2020 were included. Perioperative outcomes including anastomotic leak and anastomotic bleeding were extracted from a prospectively maintained institutional database. The Clavien-Dindo classification was used to stratify post-operative complications. Data are presented in medians and IQR. Results Right hemicolectomy with circular stapled ESSA ileo-colic anastomosis was performed in 55 consecutive patients (M:F 26:29) by a single surgeon at a tertiary referral centre. Over half of patients (54.5%, 30/55) were in the 8th and 9th decades of age with a median BMI of 26.5 (IQR:24-30.7). Median postoperative length of stay was 6 days (IQR:4-8) and the overall morbidity rate was 34.5% (19/55). Anastomotic leak and anastomotic bleeding were seen in 5.45% (3/55) and 3.64% (2/55), respectively. None of the patients with leak or bleeding needed a re-operation. Conclusions In comparison to the widely used SSA type of ileo-colic anastomosis, the ESSA configuration using a circular stapling device is a viable option for restoring bowel continuity after right colonic resections with comparable results. Potential advantages of this approach include avoidance of cross stapling and improved ileo-colic anatomical fidelity.

Fecal Diversion for Perianal Crohn Disease in the Era of Biologic Therapies: A Multicenter Study

Background The natural history of perianal Crohn disease (PCD) after fecal diversion in the era of biologics is poorly understood. We assessed clinical and surgical outcomes after fecal diversion for medically refractory PCD and determined the impact of biologics. Methods We performed a retrospective, multicenter study from 1999 to 2020. Patients who underwent fecal diversion for refractory PCD were stratified by diversion type (ostomy with or without proctectomy). Times to clinical and surgical outcomes were estimated using Kaplan-Meier methods, and the association with biologics was assessed using multivariable Cox proportional hazards models. Results Eighty-two patients, from 3 academic institutions, underwent a total of 97 fecal diversions: 68 diversions without proctectomy and 29 diversions with proctectomy. Perianal healing occurred more commonly after diversion with proctectomy than after diversion without proctectomy (83% vs 53%; P = 0.021). Among the patients who had 68 diversions without proctectomy, with a median follow-up of 4.9 years post-diversion (interquartile range, 1.66-10.19), 37% had sustained healing, 31% underwent surgery to restore bowel continuity, and 22% underwent proctectomy. Ostomy-free survival occurred in 21% of patients. Biologics were independently associated with avoidance of proctectomy (hazard ratio, 0.32; 95% confidence interval, 0.11-0.98) and surgery to restore bowel continuity (hazard ratio, 3.10; 95% confidence interval, 1.02-9.37), but not fistula healing. Conclusions In this multicenter study, biologics were associated with bowel restoration and avoidance of proctectomy after fecal diversion without proctectomy for PCD; however, a minority of patients achieved sustained fistula healing after initial fecal diversion or after bowel restoration. These results highlight the refractory nature of PCD.

Laparoscopic Lavage in the Management of Hinchey III/IV Diverticulitis

Diverticulitis manifestations may cover a spectrum of mild local inflammation to diffuse feculent peritonitis. Up to 35% of patients presenting with diverticulitis will have purulent (Hinchey grade III) or feculent (Hinchey grade IV) contamination of the abdomen, with a high-associated morbidity and mortality. Surgical management may involve segmental resection with or without restoration of bowel continuity. However, emergency resection for diverticulitis can be associated with high mortality rates, as well as low stoma reversal rates at 1 year. Therefore, laparoscopic peritoneal lavage has been proposed for use in selected patients with purulent peritonitis. The topic of laparoscopic peritoneal lavage for the treatment of perforated diverticulitis in the literature has been controversial. Our review of the recent data show that laparoscopic lavage may be safe and feasible in select patients with similar rates of mortality and major morbidity. There is, however, a concern regarding an associated higher rate of postoperative abscess and early reintervention risk.

Prenatally diagnosed congenital pyloric atresia in consecutive three siblings: a case report

Background Congenital pyloric atresia (CPA) is a rare gastrointestinal anomaly frequently associated with epidermolysis bullosa (EB). Although the complications of familial isolated CPA are minor, delays in diagnosis can increase the chances of morbidity. Case presentation Three female infants born to a Japanese mother presented with CPA at birth. There was no consanguinity between the parents, and the spacing between pregnancies was 2 years in each case. All 3 siblings had a prenatal diagnosis of CPA owing to polyhydramnios and a dilated stomach, without dilatation of the rest of the gastrointestinal tract. All patients underwent reconstructive surgeries for establishing bowel continuity (Case 1, pyloromyotomy; Case 2, gastroduodenostomy in a diamond fashion; and Case 3, gastroduodenostomy in a side-to-side fashion) soon after birth. Their postoperative courses were uneventful, and they grew up healthily, without any complications. Conclusion Fetal ultrasonography is useful for diagnosing CPA prenatally. Successful prenatal diagnosis can lead to timely intervention after birth.

Modified Oesophago-Gastric Dissociation (M-OGD) — a technical modification

Adhesions and fibrosis following failed primary surgery for severe gastro-oesophageal reflux (GOR) in neurologically impaired children (NI) can render mobilization of the lower oesophagus and oesophago-jejunal anastomosis a technically demanding exercise both at open surgery and laparoscopy. This paper presents the Modified Oesophago-Gastric Dissociation (M-OGD) as a less complex technical modification of the original Total Oesophago-Gastric Dissociation (TOGD). The stomach is detached from the oesophago-gastric junction with an articulated 5-mm stapler, leaving a 5-mm strip of stomach attached to the oesophagus. An end-to-side isoperistaltic oesophago-jejunostomy is created between the gastric stump and the isoperistaltic jejunal Roux loop. A jejuno-jejunal anastomosis restores bowel continuity. Between May 2018 and February 2020, M-OGD was performed on 3 NI patients with a weight of 9–27.3 kg (median = 14 kg). Median age at surgery was 60 months (18–180), median surgical time 170 min (146–280), median re-feeding time was 3 days (2–5), and median length of stay was 20 days (11–25). All patients healed primarily and after a median follow-up of 3 months, there were no problems related to the oesophago-jejunal anastomosis. M-OGD reduces the difficulties of redo oesophageal surgery following failed anti-reflux procedures, with a safer oesophago-jejunal anastomosis and a good long-term outcome.

Computed tomography findings at 6th month related to chronic anastomotic complications after rectal surgeryShort running headline: CT findings related to chronic complication

Objective: This study aimed to assess a radiologic test and clinical findings as risk factors of chronic complications after anastomotic leakage (CCAL) in rectal surgery.Summary of Background Data: Anastomotic leakage (AL) is the most important complication that is related to chronic complications like unhealed chronic sinuses, strictures, and infections.Methods: This retrospective study included patients who developed anastomotic leakage (AL) after undergoing extraperitoneal anastomosis. Patients with the following characteristics were excluded: (1) patients with no anastomoses, (2) patients undergoing multiple resections due to synchronous colorectal lesions, (3) patients with no curative resections of the primary lesions, and (4) patients experiencing immediate postoperative mortality. Finally, 72 patients were analyzed in this study. The patients were divided into the no chronic complication (NCC) group and the chronic complication (CC) group.Results: Of the 72 included patients, 17 (23.6%) had CCAL. The patients in the CC group more frequently had radiotherapy and lower tumor compared to the patients in the NCC group. A total of 52 (52/55 [94.5%]) and 4 patients (4/17 [23.5%]) in the NCC group and the CC group achieved bowel continuity 3 years after the primary surgery, respectively (p &lt; 0.0001). According to the multivariate analysis, CT findings at the 6th postoperative month and tumor height were associated with CCAL (p &lt; 0.0001 and p = 0.046, respectively).Conclusion: This study showed that CT findings at the 6th postoperative month and tumor height were possibly associated with CCAL.