Pembérton, John H.

AbstractAimRestorative proctocolectomy with ileal‐pouch anal anastomosis is the procedure of choice for ulcerative colitis. Unfortunately, up to 10% of pouches will fail, requiring either reconstruction or excision. While several series have reported on the aetiology of pouch failure, no study to date has focused on the postoperative complications associated with pouch excision.MethodsPatients who had excision of ileoanal reservoir with ileostomy (CPT code 45136) were included. Data abstracted included preoperative, operative and postoperative variables. A Kaplan–Meier curve of pouch survival was performed.ResultsIn all, 147 patients met the inclusion criteria for the study. The median age of patients was 47 years (73 women), and 132 had a diagnosis of ulcerative colitis at the time of colectomy. The most common indications for pouch excision were sepsis (n = 46; 31%) and Crohn's disease (n = 37; 25%). 84 (57%) patients experienced short‐term (< 30 days) postoperative complications, the most common of which was a surgical site infection (n = 32; 21%); 55 (37%) patients had long‐term complications (> 30 days) postoperatively, the most common of which was a return to the operating room (n = 19; 13%) largely for perineal wounds. Thirty‐day mortality was zero. 4.8%, 47.6%, 65.3% and 84.4% of patients had undergone pouch excision by 1, 5, 10 and 20 years from the time of pouch construction, respectively.ConclusionsPouch excision has a high rate of both short‐ and long‐term postoperative complications. Patients should be appropriately counselled to set expectations accordingly. In view of these findings we suggest that this operation should ideally be performed at a high volume centre with the availability of a multidisciplinary surgical team.

535 Background: The most effective management of locally recurrent colorectal cancer (CRC) is resection. This is also true for hepatic metastases (HM). Data remains limited, however, regarding concomitant resection of recurrent CRC and HM. The aims of this study were to determine the feasibility, safety and outcomes in terms of disease-free survival (DFS) and overall survival (OS) in patients undergoing concomitant resection of recurrent CRC with HM. Methods: All patients who underwent resection of recurrent CRC from 1/1995 to 1/2007 at Mayo Clinic, Rochester were reviewed (n=406). The study group consisted of patients who underwentconcomitant resection of locally recurrent CRC and hepatic resection for metastatic CRC (n= 45). Kaplan-Meier Survival was used to estimate DFS and OS. Results: The study group consisted of 27 men and 18 women. The median age was 59 years. Surgical management involved pelvic dissection in 43 patients and ileotransverse colectomy in two. 17 patients required resection of contiguous organs. 24 patients received intra-operative radiation. 34 patients underwent multiple hepatic wedge resections, 6 patients segmentectomy, 3 left hepatectomy, and 2 right hepatectomy. There was no perioperative mortality. Morbidity was 37%, 2 patients required re-operation. The 1, 3, and 5 year DFS was 72.2, 42.3, and 18.5%, respectively. The 1, 3, and 5 year OS was 87.7, 47.6, and 36.2%, respectively. Conclusions: Synchronous resection of locally recurrent CRC and HM is safe and feasible; morbidity is reasonable and mortality zero. DFS and OS in this patient population appear comparable to that of patients undergoing separate, staged resections.

BACKGROUND: Clinical trials demonstrate that postresection chemotherapy conveys survival benefit to patients with stage III colon cancer. It is unclear whether this benefit can be extrapolated to the elderly, who are underenrolled in clinical trials. OBJECTIVE: The purpose of this study was to determine outcomes of selected octogenarians with stage III colon cancer with/without postresection adjuvant therapy. DESIGN: This was a retrospective cohort study (2006–2011) using unadjusted Kaplan–Meier and adjusted Cox proportional hazards analyses of overall survival. SETTING: The study was conducted with the National Cancer Database. PATIENTS: We included patients 80 to 89 years of age who were undergoing curative-intent surgery for stage III colon cancer and excluded patients who received neoadjuvant therapy, died within 6 weeks of surgery, or had high comorbidity. MAIN OUTCOME MEASURES: Overall survival was the main measure. RESULTS: A total of 8141 octogenarians were included; 3483 (42.8%) received postresection chemotherapy, and 4658 (57.2%) underwent surgery alone. Patients receiving chemotherapy were younger (82.0 vs 84.0 years; p < 0.001), healthier (73.1% vs 70.4% with no comorbidities; p = 0.009), and more likely to have N2 disease (40.4% vs 32.8%; p < 0.001). Overall survival was improved in patients receiving adjuvant chemotherapy (median = 61.7 vs 35.0 months; p < 0.001). Subgroup analysis of patients offered chemotherapy but refusing (n = 1315) demonstrated overall survival worse than those receiving adjuvant chemotherapy (median = 42.7 vs 61.7 months; p < 0.001). Multivariable analysis adjusting for potential confounders showed therapy with surgery alone to be independently associated with increased mortality hazard (HR = 1.83; p < 0.001), and the mortality hazard remained elevated in patients who voluntarily refused adjuvant therapy (HR = 1.45; p < 0.001). LIMITATIONS: The study was limited by its retrospective, nonrandomized design. CONCLUSIONS: In selected octogenarians with stage III colon cancer, postresection adjuvant chemotherapy was associated with superior overall survival. However, less than half of the octogenarians with stage III colon cancer in the National Cancer Database received it. The remaining majority, who were all fit and survived ≥6 weeks postsurgery, could have derived benefit from adjuvant chemotherapy. This represents a substantial opportunity for quality improvement in treating octogenarians with stage III colon cancer.

BACKGROUND Hidradenitis suppurativa (HS) is a progressive, recurrent inflammatory disorder. OBJECTIVE To assess long-term satisfaction and postoperative perceptions among patients who underwent surgical management of HS. MATERIALS AND METHODS A questionnaire was mailed to 499 HS surgical patients to assess surgical outcome, satisfaction, and quality of life. RESULTS Of the 499 questionnaires mailed, 113 were returned (22.6% response rate) and 2 were excluded for redundancy. Of the 111 respondents, 65 (58.6%) were female, 91 (82.0%) had Hurley Stage III disease, 88 (79.3%) were treated with excision and 23 (20.7%) with unroofing, 45 (40.5%) had perianal or perineal disease, and 41 (36.9%) had axillary disease. Most patients were satisfied or very satisfied with their surgical results (84.7%; 94 of 111), were glad they underwent surgery (96.3%; 105 of 109), and would recommend surgery to a friend or relative (82.6%; 90 of 109). Most patients were satisfied or very satisfied with the appearance of their healed wound (62.4%; 68 of 109). Retrospective mean quality of life increased significantly from 5 preoperatively to 8.4 postoperatively (p < .001). CONCLUSION Hidradenitis suppurativa surgical management was well regarded by patients and should be considered by future patients to limit the morbidity of HS.

AbstractAimSurgery aims to prevent cancer‐related morbidity for patients with ulcerative colitis (UC) associated dysplasia. The literature varies widely regarding the likelihood of dysplastic progression to higher grades of dysplasia or cancer. The aim of this study was to characterize the likelihood of the development of colorectal cancer (CRC) of patients with UC‐associated dysplasia who chose to defer surgery.MethodA retrospective review was carried out of patients undergoing surgery for UC at the Mayo Clinic, who were diagnosed to have dysplasia between August 1993 and July 2012. The relationships between grade of dysplasia, time to surgery and the detection of unsuspected carcinoma were investigated.ResultsIn all, 175 patients underwent surgery at a median of 4.9 (interquartile range 2.5–8.9) months after a diagnosis of dysplasia. Their median age was 52 (interquartile range 43−59) years. An initial diagnosis of indeterminate dysplasia was not associated with CRC [0/23; 17.7 (8.1−29.6) months]. Thirty‐six patients who had an initial diagnosis of dysplasia progressed from indeterminate to low‐grade dysplasia [24.2 (11.0−30.4) months]. Low‐grade dysplasia was associated with a 2% (1/56; T2N0M0) risk of CRC when present in random surveillance biopsies and a 3% (2/61; T1N0M0, T4N0M0) risk if detected in endoscopically visible lesions [7.4 (5.2−33.3) months]. Eighteen patients progressed from indeterminate to high‐grade dysplasia [19.1 (9.2−133.9) months]. Seventeen patients progressed from low to high‐grade dysplasia [11.0 (5.8−30.1) months]. None of the patients with high‐grade dysplasia (0/35) progressed to CRC [4.5 (1.7−9.9) months].ConclusionDysplasia was associated with a low incidence of node negative CRC if surgery was deferred for up to 5 years. These findings may help inform the decision‐making process for asymptomatic patients who are having to decide between intensive surveillance or surgery for UC‐associated dysplasia.

SummaryBackgroundTemporary faecal diversion is sometimes used for management of refractory perianal Crohn's disease (CD) with variable success.AimsTo perform a systematic review with meta‐analysis to evaluate the effectiveness, long‐term outcomes and factors associated with success of temporary faecal diversion for perianal CD.MethodsThrough a systematic literature review through 15 July 2015, we identified 16 cohort studies (556 patients) reporting outcomes after temporary faecal diversion. We estimated pooled rates [with 95% confidence interval (CI)] of early clinical response, attempted and successful restoration of bowel continuity after temporary faecal diversion (without symptomatic relapse), and rates of re‐diversion (in patients with attempted restoration) and proctectomy (with or without colectomy and end‐ileostomy). We identified factors associated with successful restoration of bowel continuity.ResultsOn meta‐analysis, 63.8% (95% CI: 54.1–72.5) of patients had early clinical response after faecal diversion for refractory perianal CD. Restoration of bowel continuity was attempted in 34.5% (95% CI: 27.0–42.8) of patients, and was successful in only 16.6% (95% CI: 11.8–22.9). Of those in whom restoration was attempted, 26.5% (95% CI: 14.1–44.2) required re‐diversion because of severe relapse. Overall, 41.6% (95% CI: 32.6–51.2) of patients required proctectomy after failure of temporary faecal diversion. There was no difference in the successful restoration of bowel continuity after temporary faecal diversion in the pre‐biological or biological era (13.7% vs. 17.6%, P = 0.60), in part due to selection bias. Absence of rectal involvement was the most consistent factor associated with restoration of bowel continuity.ConclusionsTemporary faecal diversion may improve symptoms in approximately two‐thirds of patients with refractory perianal Crohn's disease, but bowel restoration is successful in only 17% of patients.

AbstractBackgroundThe aim of the study was to assess which aspects of an enhanced recovery programme are associated with better outcomes following laparoscopic colorectal surgery.MethodsA database of laparoscopic colorectal procedures performed in 2011 was reviewed. Elements of the enhanced recovery programme and compliance were evaluated for short-term (30-day) outcomes. Individual elements included gabapentin, celecoxib, intrathecal analgesia, diet, postoperative fluids, and paracetamol/non-steroidal anti-inflammatory drug pain management.ResultsFive hundred and forty-one consecutive procedures were included. Compliance with the enhanced recovery programme elements ranged from 82·4 to 99·3 per cent. Median length of hospital stay was 3 (i.q.r. 2–5) days, with 25·9 per cent of patients discharged within 48 h. Patients without complications had a median length of stay of 3 (i.q.r. 2–4) days if compliant and 3 (3–5) days if not (P &lt; 0·001). Low oral opiate intake (oral morphine equivalent of less than 30 mg) (odds ratio (OR) 1·97, 95 per cent confidence interval 1·29 to 3·03; P = 0·002), full compliance (OR 2·36, 1·42 to 3·90; P &lt; 0·001) and high surgeon volume (more than 100 cases per year) (OR 1·50, 1·19 to 1·89; P &lt; 0·001) were associated with discharge within 48 h. Compliance with the elements of oral intake and fluid management in the first 48 h was associated with a reduced rate of complications (8·1 versus 19·6 per cent; P = 0·001). Median oral opiate intake was 37·5 (i.q.r. 0–105) mg in 48 h, with 26·2 per cent of patients receiving no opiates.ConclusionCompliance with an enhanced recovery pathway was associated with less opiate use, fewer complications and a shorter hospital stay.