Stocchi, Luca

Abstract Background Colorectal surgery in patients with inflammatory bowel disease (IBD) and cirrhosis has increased morbidity, which may preclude surgery. Preoperative transjugular intrahepatic portosystemic shunt (TIPS) is postulated to reduce surgical risk. In this retrospective single-center study, we characterized perioperative outcomes in patients with IBD and cirrhosis who underwent preoperative TIPS. Methods We identified patients with IBD and cirrhosis who had undergone preoperative TIPS for portal decompression between 2010 and 2023. All other indications for TIPS led to patient exclusion. Demographic and medical data were collected, including portal pressure measurements. Primary outcome of interest was perioperative outcomes. Results Ten patients met the inclusion criteria. The most common surgical indications were dysplasia (50%) and refractory IBD (50%). TIPS was performed at a median of 47 days (IQR 34–80) before surgery, with reduction in portal pressures (22.5 vs. 18.5 mmHg, P < .01) and portosystemic gradient (12.5 vs. 5.5 mmHg, P < .01). Perioperative complications occurred in 80% of patients, including surgical site bleeding (30%), wound dehiscence (10%), systemic infection (30%), liver function elevation (50%), and coagulopathy (50%). No patients required re-operation, with median length of stay being 7 days (IQR 5.5–9.3). The 30-day readmission rate was 40%, most commonly for infection (75%), with 2 patients having intra-abdominal abscesses and 1 patient with concern for bowel ischemia. Ninety-day and one-year survival was 100% and 90%, respectively. Patients with primary sclerosing cholangitis (PSC)-cirrhosis were noted to have higher perioperative morbidity and a 30-day readmission rate. Conclusions In patients with IBD and cirrhosis, preoperative TIPS facilitated successful surgical intervention despite heightened risk. Nevertheless, significant complications were noted, in particular for patients with PSC-cirrhosis.

Objective: This study aims to assess the costs of a same-day discharge (SDD) enhanced recovery pathway for diverting loop ileostomy (DLI) closure compared with a standard institutional enhanced recovery protocol. Background: Every year, 50,155 patients in the United States undergo temporary stoma reversal. While ambulatory stoma closure has shown promise, widespread adoption remains slow. This study builds on previous research, focusing on the costs of a novel SDD protocol introduced in 2020. Methods: A retrospective case-control study was conducted at Mayo Clinic, Rochester, Minnesota, and Mayo Clinic, Jacksonville, Florida, comparing patients undergoing SDD DLI closure from August 2020 to February 2023 to those in a matched cohort receiving standard inpatient enhanced recovery protocol. Patients were matched based on age, sex, american society of anesthesiologists score, surgery period, and hospital. Primary outcomes included direct hospitalization and additional costs in the 30 days postdischarge. Results: The SDD group (n = 118) demonstrated a significant reduction in median index episode hospitalization and 30-day postoperative costs compared with the inpatient group (n = 236), with savings of $4827 per patient. Complication rates were similar, and so were readmission and reoperation rates. Conclusions: Implementation of the SDD for DLI closure is associated with substantial cost savings without compromising patient outcomes. The study advocates for a shift towards SDD protocols, offering economic benefits and potential improvements in health care resource utilization.

Abstract Background Colorectal surgery in patients with inflammatory bowel disease (IBD) and cirrhosis is associated with high morbidity related to portal hypertension. Thought to reduce surgical risk, transjugular intrahepatic portosystemic shunt (TIPS) may be used to decrease portal pressures. In this study, we aimed to characterize surgical outcomes of patients with IBD and cirrhosis who underwent preoperative TIPS at a large tertiary care center. Methods We retrospectively identified patients with IBD and cirrhosis who had undergone TIPS between 2010-2023 for portal decompression prior to colorectal surgery. All other indications for TIPS led to patient exclusion. Demographic and medical data was collected, including surgical indication and portal pressure measurement. Data on surgical outcomes were compiled through chart review. Results We identified 10 patients (60% male) with IBD and history of decompensated cirrhosis who underwent preoperative TIPS for portal decompression (Table 1). Surgical indications were colonic dysplasia (50%), refractory IBD (50%), and stenosis or stricture (30%). All patients were deemed nonsurgical candidates due to significant surgical risk from portal hypertension. Following multidisciplinary coordination, patients underwent TIPS for portal decompression at a median of 47 days (IQR 34-80) prior to colorectal surgery. TIPS was associated with significant reduction in portal pressure (22.5 vs 18.5mmHg, p<0.01) and portosystemic gradient (12.5 vs 5.5mmHg, p<0.01) in all patients. Of 10 patients, 30% had TIPS-related complications (transient fluid overload and encephalopathy). In terms of surgical complications, 40% of patients required intraoperative blood transfusion (range: 1-4 units). Postoperatively, 30% of patients had surgical site bleeding and 10% had wound dehiscence, although none required reoperation. Systemic complications occurred in 30% of patients, with systemic signs of infection being the most common. Transaminitis (50%) and coagulopathy (40%) were also common. Median hospital stay was 7 days (IQR 5.5-9.3), with 40% of patients being readmitted within 30 days. Most common cause of readmission was systemic infection (75%), abdominal abscess (50%), or electrolyte abnormality (50%), with one patient requiring reoperation for wound dehiscence. Ninety-day and 1-year survival was 100% and 90% respectively. Conclusion In our series of patients with IBD and cirrhosis requiring surgery but deemed nonsurgical candidates, preoperative TIPS lead to portal decompression and facilitated successful surgical intervention despite heightened risk. Nevertheless, significant operative and postoperative complications were noted. Future studies are needed to determine optimal surgical timing following TIPS placement.

Abstract Background Approximately 15%–20% of patients with ulcerative colitis (UC) will require surgery during their lifetime. Ileal pouch–anal anastomosis (IPAA) is the preferred surgical option, which typically requires access to a specialist experienced in surgery for inflammatory bowel diseases (IBD). Methods The aims of this study are the assessment of the comparative use of IPAA for UC among different racial/ethnic groups and observe trends over the past decade in the United States as well as the comparative assessment of their respective postoperative outcomes. This was an observational retrospective study using the National Inpatient Sample (NIS) 2009–2018 dataset. All patients with ICD-9/10CM codes for UC were included. The primary outcome was comparative trends in IPAA construction across races/ethnicities in the past decade, which was compared to White patients as reference. Multivariate regression analyses were used to adjust for age, gender, Charlson comorbidity index, income in patient zip code, insurance status, hospital region, location, size, and teaching status. Results The number of patients discharged from US hospitals with an associated diagnosis of UC increased between 2009 and 2018, but the number of patients undergoing an IPAA decreased during that time period. Of 1 153 363 admissions related to UC, 60 688 required surgery for UC, of whom 16 601 underwent IPAA in the study period. Of all the patients undergoing surgery for UC, 2862 (4.7%) were Black, while 44 351 were White. This analysis indicated that Black patients were less likely to undergo IPAA both in 2009 and in 2018 compared to Whites. Hispanic patients were significantly less likely to receive IPAA in 2009 but were no longer less likely to receive IPAA in 2018 when compared to Whites. Conclusions The use of IPAA among Black patients requiring surgery for UC remains less common than amongst their White counterparts. Further research is needed to determine if racial disparity is a factor in decreased access to specialized care.

BACKGROUND: Surgical management of splenic flexure carcinoma remains controversial. OBJECTIVE: This study aimed to establish an expert international consensus on splenic flexure carcinoma management. DESIGN: A 3-round online-based Delphi study was conducted between September 2020 and April 2021. SETTING: The first round included 18 experts from 12 different countries. For the second and third rounds, each expert in the first round was asked to invite 2 more colorectal surgeons (n = 47). Out of 47 invited experts, 89% (n = 42) participated in the second and third rounds of the consensus. INTERVENTIONS: A total of 35 questions were created and sent via the online questionnaire tool. MAIN OUTCOME MEASURES: Levels of recommendation based on voting concordance were graded as follows: more than 75% agreement was defined as strong, between 50% and 75% as moderate, and below 50% as weak. RESULTS: There was moderate consensus on the definition of splenic flexure (55%) as 10 cm from either side where the distal transverse colon turns into the proximal descending colon. Also, experts recommended an abdominopelvic CT scan plus intraoperative exploration (moderate consensus, 72%) for tumor localization and cancer registry. Segmental colectomy was the preferred technique for the management of splenic flexure carcinoma in the elective setting (72%). Moderate consensus was achieved on the technique of complete mesocolic excision and central vascular ligation principles for splenic flexure carcinoma (74%). Only strong consensus was achieved on the surgical approach for minimally invasive surgery (88%). LIMITATIONS: Subjective decisions are based on individual expert clinical experience and not evidence based. CONCLUSIONS: This is the first internationally conducted Delphi consensus study regarding splenic flexure carcinoma. The definition of splenic flexure remains ambiguous. To more effectively compare oncologic outcomes among different cancer registries, guidelines need to be developed to standardize each domain and avoid arbitrary definitions. See Video Abstract at http://links.lww.com/DCR/C143. ESTANDARIZACIÓN DE LA DEFINICIÓN Y MANEJO QUIRÚRGICO DEL CARCINOMA DE ÁNGULO ESPLÉNICO ESTABLECIDO POR UN CONSENSO INTERNACIONAL DE EXPERTOS UTILIZANDO LA TÉCNICA DELPHI: ¿ESPACIO PARA MEJORAR? ANTECEDENTES: El tratamiento quirúrgico del cáncer de ángulo esplénico sigue siendo controvertido. OBJETIVO: Establecer un consenso internacional de expertos sobre el manejo del cáncer del ángulo esplénico. DISEÑO: Se condujo un estudio Delphi en línea de 3 rondas entre septiembre de 2020 y febrero de 2021. ESCENARIO: La primera ronda incluyó a 18 expertos de 12 países distintos. Para la segunda y tercera rondas, a cada experto de la primera ronda se le pidió que invitara a 2 cirujanos colorrectales más de su región (n = 47). De los 47 expertos invitados, el 89% (n = 42) participó en la segunda y tercera ronda del consenso. INTERVENCIONES: Se crearon y enviaron un total de 35 preguntas a través de la herramienta de cuestionario en línea. PRINCIPALES MEDIDAS DE RESULTADO: Los niveles de recomendación basados en la concordancia de votos fueron jerarquizados de la siguiente manera: más del 75% de acuerdo se definió como fuerte, entre 50 y 75% como moderado y por debajo del 50% como débil. RESULTADOS: Hubo un consenso moderado sobre la definición de ángulo esplénico (55%) como 10 cm desde cualquier lado donde el colon transverso distal se convierte en el colon descendente proximal. Así también, los expertos recomendaron la tomografía computarizada abdominopélvica más la exploración intraoperatoria (consenso moderado, 72%) para la localización del tumor y el registro del ángulo esplénico. La colectomía segmentaria fue la técnica preferida para el tratamiento del cáncer de ángulo esplénico en el caso de ser electivo (72%). Se logró un consenso moderado sobre la técnica de escisión completa del mesocolon y los principios de ligadura vascular a nivel central para el cáncer de ángulo esplénico (74%). Solo se logró un fuerte consenso sobre el abordaje quirúrgico para la cirugía mínimamente invasiva (88%). LIMITACIONES: Decisiones subjetivas basadas en la experiencia clínica de expertos individuales y no basadas en evidencia. CONCLUSIONES: Este es el primer estudio internacional de consenso Delphi realizado sobre el cáncer de ángulo esplénico. Si bien encontramos un consenso moderado sobre las modalidades de diagnóstico preoperatorio y el manejo quirúrgico, la definición de ángulo esplénico sigue siendo ambigua. Para comparar de manera más efectiva los resultados oncológicos entre diferentes registros de cáncer, se deben desarrollar pautas para estandarizar cada dominio y evitar definiciones arbitrarias. Consulte Video Resumen en http://links.lww.com/DCR/C143. (Traducción—Dr. Osvaldo Gauto )

AbstractUlcerative colitis (UC) requires surgical management in 20 to 30% of patients. Indications for surgery include medically refractory disease, dysplasia, cancer, and other complications of UC. Appropriate patient selection for timing and staging of surgery is paramount for optimal outcomes. Restorative proctocolectomy is the preferred standard of care and can afford many patients with excellent quality of life. There have been significant shifts in the treatment of UC-associated dysplasia, with less patients requiring surgery and more entering surveillance programs. There is ongoing controversy surrounding the management of UC-associated colorectal cancer and the techniques that should be used. This article reviews the most recent literature on the indications for elective and emergent surgical intervention for UC and the considerations behind the surgical options.

AbstractMalnutrition is a very common and often underrecognized condition among patients with inflammatory bowel diseases (IBD). This is most commonly due to increased nutritional requirements and gastrointestinal losses, along with reduced oral intake. Screening for malnutrition is an essential component of managing both inpatients and outpatients with IBD. Although enteral nutrition is the preferred route of supplementation, parenteral nutrition (PN) remains an important strategy and should be considered in certain situations, such as cases with short-bowel syndrome, high-output intestinal fistula, prolonged ileus, or small-bowel obstruction. Appropriate use of PN is critical in order to prevent associated complications. This review addresses the common indications for use of PN, the composition of PN, and the possible complications encountered with PN use, as well as scenarios of inappropriate PN use among patients with IBD. A clinical management algorithm for utilizing PN among patients with IBD is proposed in this review.

Abstract Background There is controversy regarding the postoperative outcomes in Crohn’s disease [CD] patients exposed to vedolizumab [VDZ] or ustekinumab [UST]. We aimed to describe our surgical outcomes in patients who underwent minimally invasive ileocolonic resection [MIS-ICR] for CD who had preoperative biologic therapy. Methods All consecutive adult patients who had MIS-ICR for CD between 2014 and 2021 at our institution were included. Patients were divided into four groups: VDZ, UST, anti-tumour necrosis factor [anti-TNF], and no biologic group. Timing between the last dose of biologics and surgery was per surgeon’s discretion. The primary outcome was intra-abdominal septic complications. Secondary outcomes included all 30-day complications. Results A total of 274 patients were identified. Of these, 113 [41.2%] patients had received anti-TNF, 52 [19%] had received UST, and 19 [7%] had received VDZ. There was no difference between the four groups regarding baseline risk factors. There was no difference between the four groups regarding intra-abdominal septic complications [4.4% for no biologic, 5.3% for anti-TNF, 5.8% for UST, and 5.3% for VDZ; p = 0.987], surgical site infection rate, overall 30-day morbidity, overall 30-day readmission, overall surgical and medical complications, urinary tract infection, pulmonary infections, or length of stay. Those results were consistent after a subgroup analysis based on complexity of the disease. Conclusions This retrospective analysis demonstrates an equivalent postoperative safety profile for patients treated with preoperative anti-TNF, VDZ, or UST versus no biologic therapy within 3 months of MIS-ICR for Crohn’s disease. Preoperative biologic therapy may not increase complications after minimally invasive ileocolonic resection in Crohn’s disease. Further studies with larger sample sizes are needed to confirm results.

Abstract Aim The aim of this study was to describe the surgical management, outcomes and risk of malignancy of presacral tailgut cysts. Method A retrospective analysis of all patients who underwent resection of tailgut cyst at Mayo Clinic in Arizona, Florida and Minnesota between 2008 and 2020 was performed. Demographics, presentation, evaluation, surgical approach, postoperative complications, pathology and recurrence rates were reviewed. Results Seventy‐three patients were identified (81% female) with a mean age of 45 years. Thirty‐nine patients (53%) were symptomatic, most commonly with pelvic pain (26 patients). Digital rectal examination identified a palpable mass in 68%. Mean tumour size was 6 cm. Resection was primarily performed through a posterior approach (77%, n = 56), followed by a transabdominal approach (18%, n = 13) and a combined approach (5%, n = 4). Six patients underwent a minimally invasive resection (laparoscopic/robotic). Coccygectomy or distal sacrectomy was performed in 41 patients (56%). Complete resection was achieved in 94% of patients. Thirty‐day morbidity occurred in 18% and was most commonly wound related; there was no mortality. Malignancy was identified in six patients (8%). For the 30 patients with follow‐up greater than 1 year, the median follow‐up was 39 months (range 1.0–11.1 years). Local recurrence was identified in three patients and distant metastatic disease in one patient. Conclusion The rate of malignancy in presacral tailgut cysts based on this current review was 8%. Overall recurrence was 5% at a median of 24 months.

AbstractAimThe existing literature was updated, assessing the use of surgery in patients with ulcerative colitis in more recent years.MethodsThis was a retrospective observational study identifying all patients with ulcerative colitis within the National Inpatient Sample, years 2009–2018. All patients with International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification diagnostic codes for ulcerative colitis were included. The primary outcome was the trend in total number of total abdominal colectomy, proctocolectomy and simultaneous versus delayed pouch construction.ResultsA total of 1 184 711 ulcerative‐colitis‐related admissions were identified. An increase of 18.6% in the number of patients was observed, while the number of surgeries decreased. A total of 40 499 patients underwent total colectomy, annually decreasing from 5241 to 3185. The number of proctocolectomies without pouch decreased from 1191 to 530, while the number of patients undergoing pouch construction decreased from 2225 to 1284. The proportion of patients undergoing initial pouch at time of proctocolectomy decreased from 995 (45%) to 265 (21%), while the proportion of patients undergoing delayed pouch construction in 2018 was 79% (n = 1120).ConclusionSurgery use in ulcerative colitis has decreased in the last decade despite increasing numbers of hospital admissions in patients with this condition. While the overall proportion of patients undergoing pouch construction remained stable, the majority of patients were initially treated with total colectomy and their ileal pouches werre constructed in a delayed fashion.