P310 Is ileoanal pouch excision a destination therapy for Inflammatory Bowel Disease? Data from a quaternary pouch referral center

Background Although ileal pouch-anal anastomosis (IPAA) is the surgical procedure of choice of many patients with ulcerative colitis and other conditions, some patients may require pouch excision (PEx). We aimed to describe our experience with pouch excisions and associated outcomes with an emphasis on late medical, endoscopic, and surgical interventions for inflammatory bowel disease (IBD). Methods We performed a retrospective review of a prospective colorectal surgery database. All pouch excisions performed at our quaternary pouch center from 2006 – 2019 were included; pelvic exenteration, PEx with neo-IPAA or Kock-pouch were excluded. Early complications occurred <30 days, late complications >30 days. Medications taken prior to PEx were included if taken within 12 weeks of pouch excision. Data are reported in frequency (proportion) or median (interquartile range). Results A total of 197 cases met inclusion criteria, and were performed by 23 surgeons, median 6 excision (IQR 2 - 14) cases over a 14-year period: of these, 105 had their index pouch created at our quaternary pouch referral center (overall PE rate 2.7%). Indications for PEx are shown in Table 1. Median time to PEx was 7 years and 94 (48%) patients had re-diversion prior to PEx. Medications prior to PEx: 34 (17%) steroids, 27 (14%) biologics, and 22 (11%) immune-modulators. The median duration of surgery was 4 hours (3.2-5). The median estimated blood loss was 263 ml (150-500) with 24 patients (12%) requiring at least one unit of packed red blood cells intra-operatively. Most pouch excisions were done through laparotomy; 2 cases (1%) were started robotically and 11 cases (10%) laparoscopically with a 26% conversion rate. Intersphincteric dissection was used in 172 cases (87%) while 26 cases (13%) required abdomino-perineal resection, of which 58% had a neoplastic indication. Intra-operative, early and late complications are shown in Table 2; 40 patients (20%) had perineal wound complications in less than 30 days, while 26 patients (13%) had long-term perineal wound complications, of which 15 patients required return to the operating room. After PEx, 23 patients out of 167 patients (14%) required continuation of IBD medications, 6 patients (3.6%) required surgery, and 4 patients (2.4%) required endoscopic intervention for their IBD. Conclusion In this large series of ileoanal pouch excisions, we found that perineal wound complications are common, but infrequently require operative intervention. For most IBD patients in this series, pouch excision did appear to be a destination therapy for IBD with a small minority requiring ongoing medical therapy for IBD.

IS ILEOANAL POUCH EXCISION A DESTINATION THERAPY FOR INFLAMMATORY BOWEL DISEASE? DATA FROM A QUATERNARY POUCH REFERRAL CENTER

Background Although ileal pouch-anal anastomosis (IPAA) is the surgical procedure of choice of many patients with ulcerative colitis and other conditions, some patients may require pouch excision (PE). We aimed to describe our experience with pouch excisions and associated outcomes with an emphasis on late medical, endoscopic, and surgical interventions for IBD. Methods We performed a retrospective review of a prospective colorectal surgery database. All PEs performed at our quaternary pouch center from 2006 – 2019 were included; pelvic exenteration, PE with neo-IPAA or Kock-pouch were excluded. Early complications occurred <30 days, late complications >30 days. Medications taken prior to PE were included if taken within 12 weeks of pouch excision. Data are reported in frequency (proportion) or median (interquartile range). Results A total of 197 cases met inclusion criteria, and were performed by 23 surgeons, median 6 excision (IQR 2 - 14) cases over a 14-year period: of these, 105 had their index pouch created at our quaternary pouch referral center (overall PE rate 2.7%). Indications for PE are shown in Table 1. Median time to PE was 7 years and 94 (48%) patients had re-diversion prior to PE. Medications prior to PE: 34 (17%) steroids, 27 (14%) biologics, and 22 (11%) immune-modulators. The median duration of surgery was 4 hours (3.2–5). The median estimated blood loss was 263 ml (150–500) with 24 patients (12%) requiring at least one unit of packed red blood cells intra-operatively. Most pouch excisions were done through laparotomy; 2 cases (1%) were started robotically and 11 cases (10%) laparoscopically with a 26% conversion rate. Intersphincteric dissection was used in 172 cases (87%) while 26 cases (13%) required abdomino-perineal resection, of which 58% had a neoplastic indication. Intra-operative, early and late complications are shown in Table 2; 40 patients (20%) had perineal wound complications in less than 30 days, while 26 patients (13%) had long-term perineal wound complications, of which 15 patients required return to the operating room. After PE, 23 patients (12%) required continuation of IBD medications, 6 patients (3.1%) required surgery, and 4 patients (2%) required endoscopic intervention for their IBD. Conclusions In this large series of ileoanal pouch excisions, we found that perineal wound complications are common, but infrequently require operative intervention. For most IBD patients in this series, pouch excision did appear to be a destination therapy for IBD with a small minority requiring ongoing medical therapy for IBD.

Early Post-Operative Perineal Wound Complications in Patients Undergoing Extra Levator Abdominoperineal Excision, A Retrospective Study at Department of Surgical Oncology

Objectives: Extra Levator Abdominoperineal Excision (ELAPE) is an emerging technique for the management of locally advanced distal rectal cancers. Current evidence suggests that this technique is associated with better oncological outcomes and hence survival. Extra levator abdominoperineal excision is associated with significant perineal complications both in short and long term. The objective of the current study is to emphasize on the early wound complications of the above-mentioned procedure. Study Design: It was a retrospective observational study with continent sampling. Place and Duration of Study: The study was conducted at department of Surgical Oncology Shaukat Khanum Memorial Cancer Hospital & Research Center Lahore, Pakistan. The study period was from 1st January 2014 to 31st December, 2019. Patients and Methods: A total of 84 patients were included in the study who underwent extra levator abdominoperineal excision (ELAPE). All patients undergoing extra levator abdominoperineal excision during the said period were included. Results: A total of 84 patients underwent Extra Levator Abdominoperineal Excision between January 2014 and December 2019. Wound infection was observed in 32 (38.09%) of the patients. Wound dehiscence was seen is five patients. Median day of detection of infection was day 10 (5-22). Median hospital stay was 7 (4-22) days. Conclusion: Extra Levator Abdominoperineal Excision is a procedure with significant perineal wound complication rate. The occurrence of perineal wound complications is multifactorial. Judicial use of the procedure is warranted

A one-stop perineal clinic: our eleven-year experience

Introduction and hypothesis The perineal clinic is a dedicated setting offering assessment for various childbirth-related presentations including obstetric anal sphincter injuries (OASIs), perineal wound complications, pelvic floor dysfunction and other conditions such as female genital mutilation(FGM). We describe the clinical presentation and outcomes of women from a tertiary perineal clinic based on data collected over an 11-year period. Methods This is a retrospective observational study. A one-stop outpatient service was offered to all women who sustained OASIs (postnatally and antenatally in a subsequent pregnancy), perineal complications (within 16 weeks postpartum), FGM and/or peripartum symptoms of urinary/anal incontinence or prolapse. Assessment included history with validated questionnaires, examination and anal manometry and endoanal ultrasound when appropriate. Outcomes were compared among different grades of OASIs. Management of each type of presentation was reported with outcomes. Results There were 3254 first attendance episodes between 2006 and 2016. The majority (58.1%) were for OASIs, followed by perineal wound complications. Compared to the lower grades, the higher grades of OASI were associated with poorer outcomes in terms of symptoms, investigations and complications. Women with OASIs had unrelated symptoms such as urinary incontinence, perineal pain and wound infections that needed further intervention. A high proportion(42%) of wound complications required further specialist management. Conclusion We describe a dedicated, one-stop perineal clinic model for antenatal and postnatal women for management of perineal and pelvic floor disorders. This comprehensive and novel data will enable clinicians to better counsel women regarding of outcomes after OASI and focus training to minimize risks of morbidities.

The results of use of myoplasty for closure of the pelvic floor defect after extralevator abdominoperineal excision of the rectum

Background. Extralevator abdominoperineal excision is associated with a high incidence of perineal wound complications. There is no uniform standard for choosing the method for pelvic floor reconstruction after extralevator abdominoperineal excision.The purpose of the study was to compare the results of extralevator abdominoperineal excisions of the rectum using various methods of perineal wound closure.Materials and Methods. Between 2014 and 2018, 120 patients underwent extralevator abdominoperineal excisions of the rectum using various options for closure of the pelvic floor. The patients were divided into 3 groups. Group I patients (n=64) underwent simple plasty of the peritoneal wound. Group II patients (n=43) underwent myoplasty using the gluteus maximus muscle. Group III patients (n=13) underwent myoplasty using the rectus abdominis muscle. The incidence of perineal wound complications in the early postoperative period was assessed.Results. The total number of perineal wound complications in Group I, II and III was 33 (51.5 %), 13 (30.2 %), and 6 (46.1 %), respectively. Grade IIIA-IIIB complications according to the Clavien-Dindo classification were observed in 25 % of Group I patients, in 18.6 % of Group II patients and in 7.7 % of Group II patients. Postoperative perineal wound complications occurred more often in Group I patients after simple plasty than in Group II and III patients after myoplasty (51.5 % versus 30.2 %). However, perineal wound complications were observed more often in Group III than in Group II (46.1 % versus 30.2 %, respectively). No significant differences in the frequency of complications between 3 groups were found.Conclusion. Using various options for closure of the pelvic floor after extralevator abdominoperineal excisions of the rectum, there was a tendency to reduction in the incidence of grade IIIA-IIIB perineal wound complications.