McKenna, Nicholas P

BACKGROUND: Surgical management of Crohn’s disease of the colon and rectum frequently requires total proctocolectomy with end ileostomy. There are limited data on the need for Crohn’s disease–directed therapy and the prevalence of recurrence after surgery. OBJECTIVE: To determine the risk of small-bowel Crohn’s disease recurrence and evaluate risk factors for postoperative recurrence after total proctocolectomy with end ileostomy. DESIGN: Retrospective cohort study. SETTINGS: Multistate tertiary health care system. PATIENTS: Adult patients with Crohn’s disease undergoing total proctocolectomy with end ileostomy between 2014 and 2023. MAIN OUTCOME MEASURES: The primary outcome was small-bowel Crohn’s disease recurrence. RESULTS: A total of 193 patients with a median age of 45 years (interquartile range, 34–61) were included. More than half of the patients (n = 102; 52.9%) had a history of small-bowel Crohn’s disease, and the majority (n = 134; 69.4%) received biologic therapy before surgery. The median follow-up time was 4.8 years (interquartile range, 2.0–7.6). Postoperatively, 30.6% of patients (n = 59) received biologic therapy. Thirty-five patients (18.1%) had small-bowel Crohn’s disease recurrence for an estimated 5-year recurrence-free rate of 80.2% (95% CI, 73.0–85.7). Seven patients (3.6%) developed small-bowel Crohn’s disease recurrence requiring surgery for an estimated 5-year surgical recurrence-free rate of 94.7% (95% CI, 89.0–97.5). On multivariable analysis, history of small-bowel Crohn’s disease (HR 2.17; 95% CI‚ 1.04–4.54) and diagnosis at age younger than 18 years (HR 2.31; 95% CI‚1.1–4.86) were associated with small-bowel Crohn’s disease recurrence. LIMITATIONS: Retrospective design and nonstandardized follow-up. CONCLUSIONS: Patients undergoing total proctocolectomy with end ileostomy for Crohn’s disease have approximately a 20% risk of small-bowel recurrence at 5 years but a low risk of requiring surgical intervention. Patients with a history of small-bowel Crohn’s disease and younger age at diagnosis have a higher risk of recurrence and may warrant consideration of more frequent surveillance and medical prophylaxis. See Video Abstract . FACTORES DE RIESGO DE RECURRENCIA DE LA ENFERMEDAD DE CROHN DEL INTESTINO DELGADO DESPUÉS DE UNA PROCTOCOLECTOMÍA TOTAL ANTECEDENTES: El tratamiento quirúrgico de la enfermedad de Crohn del colon y el recto frecuentemente requiere proctocolectomía total con ileostomía terminal. Existe información limitada sobre la necesidad de terapia dirigida a la enfermedad de Crohn y la prevalencia de recurrencia tras la cirugía. OBJETIVO: Determinar el riesgo de recurrencia de la enfermedad de Crohn del intestino delgado y evaluar los factores de riesgo de recurrencia posoperatoria tras proctocolectomía total con ileostomía terminal. DISEÑO: Estudio de cohorte retrospectivo. ÁMBITO: Sistema de atención médica terciaria multiestatal. PACIENTES: Pacientes adultos con enfermedad de Crohn sometidos a proctocolectomía total con ileostomía terminal entre 2014 y 2023. PRINCIPALES MEDIDAS DE RESULTADO: El resultado primario fue la recurrencia de la enfermedad de Crohn del intestino delgado. RESULTADOS: Se incluyeron un total de 193 pacientes con una mediana de edad de 45 años (RIC, 34-61). Más de la mitad de los pacientes (n = 102, 52,9 %) tenían antecedentes de enfermedad de Crohn del intestino delgado y la mayoría (n = 134, 69,4 %) recibieron terapia biológica antes de la cirugía. El tiempo medio de seguimiento fue de 4,8 años (RIC, 2,0-7,6). Después de la cirugía, el 30,6 % de los pacientes (n = 59) recibieron terapia biológica. Treinta y cinco pacientes (18,1 %) tuvieron recurrencia de la enfermedad de Crohn del intestino delgado para una tasa estimada libre de recurrencia a 5 años del 80,2 % (IC del 95 %, 73,0-85,7). Siete pacientes (3,6 %) desarrollaron recurrencia de la enfermedad de Crohn del intestino delgado que requirió cirugía para una tasa estimada libre de recurrencia quirúrgica a 5 años del 94,7 % (IC del 95 %, 89,0-97,5). En el análisis multivariable, los antecedentes de enfermedad de Crohn del intestino delgado (HR 2,17; IC del 95%: 1,04-4,54) y el diagnóstico antes de los 18 años (HR 2,31; IC del 95%: 1,1-4,86) se asociaron con la recurrencia de la enfermedad de Crohn del intestino delgado. LIMITACIONES: Diseño retrospectivo y seguimiento no estandarizado. CONCLUSIONES: Los pacientes sometidos a proctocolectomía total con ileostomía terminal por enfermedad de Crohn tienen aproximadamente un 20% de riesgo de recurrencia en el intestino delgado a los 5 años, pero un bajo riesgo de requerir intervención quirúrgica. Los pacientes con antecedentes de enfermedad de Crohn del intestino delgado y menor edad al diagnóstico tienen un mayor riesgo de recurrencia y podrían requerir una vigilancia más frecuente y profilaxis médica. (AI-generated translation )

ABSTRACT Background The use of pressurized intraperitoneal aerosol chemotherapy (PIPAC) is becoming more frequent for patients with unresectable peritoneal metastases. This systematic review explores the indications, protocols, feasibility, safety, oncological outcomes, patient reported outcomes and quality of life outcomes for patients being treated with PIPAC. Methods A review of PubMed, Embase and the Cochrane Library was undertaken to identify studies pertaining to patients undergoing treatment with PIPAC. Clinicopathological characteristics, treatment protocols, safety data, treatment response data and outcome data were extracted from relevant studies and included in the analysis. Results Data from 1980 patients undergoing 4454 PIPAC procedures for peritoneal metastases from a range of primary cancers was extracted. The treatment protocols identified were relatively homogenous across all studies. Grade 3/4 complications, grade 3/4 toxicity and procedure related mortality occurred infrequently. At least partial histological response was seen in 61.8% of patients. Overall survival for studies presenting data for mixed primary tumors ranged from 8 to 25 months. Quality of life and function were relatively stable throughout treatment. Conclusions PIPAC is a safe and feasible treatment option for patients with peritoneal metastases. Ongoing studies are required to evaluate how it compares to best option standard of care chemotherapy.

BACKGROUND: Hemorrhoidal disease and immunosuppression are prevalent. Management of hemorrhoidal disease in this patient population is challenging. Most societies recommend conservative management due to the presumed risks of morbid complications, including sepsis and impaired healing. Data on the risks of office-based and operative procedures in immunocompromised patients are scant. OBJECTIVE: To evaluate postoperative outcomes after both office-based procedures and operative intervention for hemorrhoidal disease in immunocompromised patients. DESIGN: Retrospective medical record review. SETTINGS: Single-center, tertiary referral center. PATIENTS: Adult patients were included who had hemorrhoidal disease and primarily medication-induced immunosuppression and were undergoing an office-based procedure or operative intervention for hemorrhoidal disease while on immunosuppression at Mayo Clinic in Rochester between 2010 and 2023. MAIN OUTCOME MEASURES: The primary outcome was the development of infectious complications or wound complications. RESULTS: Fifty-five immunocompromised patients, with a median age of 60 years, underwent a total of 68 hemorrhoidal procedures during the study time frame. All patients had immunosuppression induced by medication, except for 1 patient with bone marrow failure syndrome. The most common reason for immunosuppression was rheumatoid arthritis, followed by prior kidney transplant. The most common medications were chronic corticosteroids and methotrexate in more than one-third of patients each. Of 68 total interventions, hemorrhoidectomy (32%) and excision of a thrombosed hemorrhoid (26%) were the 2 most common operations performed. Sixteen adverse events were reported in 14 patients (25%). Three cases of postoperative cellulitis were documented after thrombosed external hemorrhoid excision, hemorrhoidopexy, and Whitehead hemorrhoidectomy. No postoperative intravenous antibiotics were administered. No cases of pelvic sepsis were documented. LIMITATIONS: The retrospective nature of the study and the heterogeneity of the study population. CONCLUSIONS: These data suggest that office-based and surgical procedures are safe and feasible in patients with immunosuppression. See Video Abstract . SEGURIDAD DE LOS PROCEDIMIENTOS PARA EL TRATAMIENTO DE HEMORROIDES EN PACIENTES INMUNODEPRIMIDOS: LA EXPERIENCIA DE LA CLÍNICA MAYO ANTECEDENTES: La enfermedad hemorroidal y la inmunosupresión son prevalentes. El tratamiento de la enfermedad hemorroidal en esta población de pacientes es difícil. La mayoría de las sociedades recomiendan un tratamiento conservador debido a los riesgos presuntos de complicaciones mórbidas, como sepsis y alteración de la cicatrización. Los datos sobre los riesgos de los procedimientos ambulatorios y quirúrgicos en pacientes inmunodeprimidos son escasos. OBJETIVO: Evaluar los resultados posoperatorios tras procedimientos ambulatorios y cirugía para la enfermedad hemorroidal en pacientes inmunodeprimidos. DISEÑO: Revisión retrospectiva de historias clínicas. ENTORNO: Centro terciario de referencia único. PACIENTES: Pacientes adultos con enfermedad hemorroidal e inmunosupresión inducida principalmente por medicamentos que se sometieron a un procedimiento ambulatorio o a una intervención quirúrgica para la enfermedad hemorroidal mientras estaban en tratamiento inmunosupresor en la Clínica Mayo de Rochester entre 2010 y 2023. PPRINCIPALES MEDIDAS DE RESULTADO: El resultado principal fue la aparición de complicaciones infecciosas o complicaciones de la herida. RESULTADOS: Cincuenta y cinco pacientes inmunodeprimidos, con una mediana de edad de 60 años, se sometieron a un total de 68 procedimientos hemorroidales durante el periodo de estudio. Todos los pacientes presentaban inmunosupresión inducida por medicación, excepto uno con síndrome de insuficiencia medular. La causa más frecuente de inmunosupresión fue la artritis reumatoide, seguida de un trasplante renal previo. Los medicamentos más frecuentes fueron los corticosteroides crónicos y el metotrexato, en más de un tercio de los pacientes. De las 68 intervenciones totales, la hemorroidectomía (32 %) y la extirpación de una hemorroide trombosada (26 %) fueron las dos operaciones más comunes realizadas. Se notificaron 16 eventos adversos en 14 (25 %) pacientes. Se documentaron tres casos de celulitis posoperatoria tras la extirpación de una hemorroide externa trombosada, una hemorroidopexia y una hemorroidectomía de Whitehead. No se administraron antibióticos intravenosos postoperatorios. No se documentaron casos de sepsis pélvica. LIMITACIONES: El carácter retrospectivo del estudio y la heterogeneidad de la población estudiada. CONCLUSIONES: Estos datos sugieren que los procedimientos ambulatorios y quirúrgicos son seguros y viables en pacientes con inmunosupresión. (AI-generated translation )

The aim was to determine whether on-call case volumes differ amongst colorectal surgeons, and what cases are performed on-call in an academic colorectal surgery practice. The on-call schedule for the year 2021 of a colorectal surgery practice was analyzed. Details of the case origin and operative details were collected. Average cases performed per call per surgeon were compared. Ten surgeons were included, and average cases per call ranged from .5 to 1.4 with 1.0 the overall average ( P = .007). Analyzing individual pairs, differences existed between the 2 busiest and the least busy on-call surgeon (both P < .05). Most patients operated on-call were admitted via the emergency department (59%), and the most common operations were exams under anesthesia (39%) and bowel resections (33%). On average, 1 on-call case was performed per day. Surgeon on-call volume was similar aside from the busiest and least busy on-call surgeons.

Abstract Background Patients with inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC) frequently undergo restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for medically refractory disease or colonic dysplasia/neoplasia. Subtotal colectomy with ileosigmoid or ileorectal anastomosis may have improved outcomes but is not well studied. Due to increased risk for colorectal cancer in PSC-IBD, there is hesitancy to perform subtotal colectomy. We aim to describe the frequency of colorectal dysplasia/neoplasia following IPAA vs subtotal colectomy in PSC-IBD patients. Methods We completed a retrospective study from 1972 to 2022 of patients with PSC-IBD who had undergone total proctocolectomy with IPAA or subtotal colectomy. We abstracted demographics, disease characteristics, and endoscopic surveillance data from the EMR. Results Of 125 patients (99 IPAA; 26 subtotal), the indication for surgery was rectal sparing medically refractory disease (51% vs 42%), dysplasia (37% vs 30%) and neoplasia (11% vs 26%) in IPAA vs subtotal colectomy patients, respectively. On endoscopic surveillance of IPAA patients, 2 (2%) had low-grade dysplasia (LGD) in the ileal pouch and 2 (2%) had LGD in the rectal cuff after an average of 8.4 years and 12.3 years of follow-up, respectively. One (1%) IPAA patient developed neoplasia of the rectal cuff after 17.8 years of surgical continuity. No subtotal colectomy patients had dysplasia/neoplasia in the residual colon or rectum. Conclusions In patients with PSC-IBD, there was no dysplasia or neoplasia in those who underwent subtotal colectomy as opposed to the IPAA group. Subtotal colectomy may be considered a viable surgical option in patients with rectal sparing PSC-IBD if adequate endoscopic surveillance is implemented.

BACKGROUND: Existing venous thromboembolism (VTE) risk scores help identify patients at increased risk of postoperative VTE who warrant extended prophylaxis in the first 30 days. However, these methods do not address factors unique to colorectal surgery, wherein the tumor location and operation performed vary widely. VTE risk may extend past 30 days. Therefore, we aimed to determine the roles of tumor location and operation in VTE development and evaluate VTE incidence through 90 days postoperatively. STUDY DESIGN: Adult patients undergoing surgery for colorectal cancer between January 1, 2005, and December 31, 2021, at a single institution were identified. Patients were then stratified by cancer location and by operative extent. VTEs were identified using diagnosis codes in the electronic medical record and consisted of extremity deep venous thromboses, portomesenteric venous thromboses, and pulmonary emboli. RESULTS: A total of 6,844 operations were identified (72% segmental colectomy, 22% proctectomy, 6% total (procto)colectomy), and tumor location was most commonly in the ascending colon (32%), followed by the rectum (31%), with other locations less common (sigmoid 16%, rectosigmoid junction 9%, transverse colon 7%, descending colon 5%). The cumulative incidence of any VTE was 3.1% at 90 days with a relatively steady increase across the entire 90-day interval. Extremity deep venous thromboses were the most common VTE type, accounting for 37% of events, and pulmonary emboli and portomesenteric venous thromboses made up 33% and 30% of events, respectively. More distal tumor locations and more anatomically extensive operations had higher VTE rates. CONCLUSIONS: When considering extended VTE prophylaxis after colorectal surgery, clinicians should account for the operation performed and the location of the tumor. Further study is necessary to determine the optimal length of VTE prophylaxis in high-risk individuals.

Lay SummaryEnterovesical fistula in Crohn’s disease that require surgery may be managed safely laparoscopically with similar morbidity to open repair and a shorter length of stay. Preoperative biologic exposure does not affect surgical morbidity.

BACKGROUND: The development of major low anterior resection syndrome (LARS) after low anterior resection is severely detrimental to quality of life, yet awareness of it by clinicians and patients and the frequency of treatment of LARS is unclear. STUDY DESIGN: Patients who underwent low anterior resection for sigmoid or rectal cancer at a tertiary center between 2007 and 2017 (n = 798) were surveyed in 2019 to assess LARS symptoms and report medications or treatment received for LARS. LARS scores were calculated (score range 0–42) and normalized to published data on LARS prevalence in the general population in Europe, stratified by age (<50 or ≥50) and sex. RESULTS: Of the 594 patients (74%) who returned the survey, 255 (43%) were identified as having major LARS (LARS score ≥30). This prevalence was significantly higher than published normative data from Denmark and Amsterdam when stratified by age greater than or less than 50 and sex. Patients with major LARS infrequently reported current use of first-line therapies (antidiarrheal medications 32%, fiber supplements 16%, and both 13%). Only 3% reported receiving second-line therapy of transanal irrigations and/or pelvic floor rehabilitation, and only 1% had undergone third-line therapy of sacral nerve stimulator implantation. CONCLUSION: Major LARS is common yet seemingly underrecognized by clinicians because less than half of patients are on first-line therapy and practically none are on second- and third-line therapies. Long-term follow-up of patients after low anterior resection, improved preoperative and postoperative education, and continued symptom assessment is necessary to improve treatment of major LARS.