Lightner, Amy L.

AbstractAimShort‐term morbidity and long‐term functional outcome of patients with an ileal pouch‐anal anastomosis (IPAA) exposed to pelvic external beam radiation therapy (EBRT) remains unknown. We report the largest series to date regarding the effects of pelvic EBRT on: (i) 30‐day postoperative outcomes; and (ii) long‐term functional outcome following IPAA.MethodA retrospective chart review was conducted of patients who received EBRT before or after IPAA between 1980 and 2017 across three international inflammatory bowel disease referral centres.ResultsNineteen patients were included. Indications for EBRT were rectal adenocarcinoma (n = 13), prostate adenocarcinoma (n = 4) or anal squamous cell carcinoma (ASCC) (n = 2). EBRT was given prior to IPAA in 12 (63%) patients and after IPAA in seven (37%). In EBRT before IPAA, patients had a median of 5 (range: 4–8) daytime bowel movements, 1 (range: 0–5) night‐time bowel movement, no daytime incontinence, and only one patient used pads at a median follow up of 25 (range: 11–163) months; one patient underwent pouch excision 15 months after IPAA. In EBRT after IPAA, patients reported a median of 8 (range: 5–10) daytime and 2 (range: 0–5) night‐time bowel movements, 80% had either daytime or night‐time incontinence and 80% used pads at a median follow up of 90 (range: 25–315) months.ConclusionPelvic EBRT administered prior to IPAA is associated with acceptable long‐term function outcome. However, when pelvic EBRT is given to an IPAA in situ, most patients experience poor long‐term pouch function without pouch failure.

BACKGROUND: Intra-abdominal sepsis complicates <10% of ileocolic resections for Crohn’s disease, but the impact of combination immunosuppression and repeat resection on its development remains unknown. OBJECTIVE: The purpose of this study was to determine risk factors for intra-abdominal sepsis after ileocolic resection, specifically examining the role of combination immunosuppression and repeat intestinal resection. DESIGN: This was a retrospective review of patient records from 2007 to 2017. SETTINGS: The study was conducted at a single-institution IBD tertiary referral center. PATIENTS: Patients with a diagnosis of Crohn’s disease who were undergoing ileocolic resection with primary anastomosis were included. Diverted patients were excluded. MAIN OUTCOME MEASURES: Preoperative and intraoperative variables, including preoperative immunosuppressive regimens and previous intestinal resection, were evaluated as potential risk factors for intra-abdominal sepsis. RESULTS: A total of 621 patients (55% women) underwent ileocolic resection for Crohn’s disease; 393 (63%) were first-time resections. The rate of 30-day intra-abdominal sepsis was 8% (n = 50). On univariate analysis, triple immunosuppression (combination of a corticosteroid, immunomodulator, and biological) and previous intestinal resection were significantly associated with intra-abdominal sepsis. Both risk factors remained significant on multivariable analysis (OR for triple immunosuppression (vs none) = 3.53 (95% CI, 1.27–9.84); previous intestinal resection OR = 2.27 (95% CI, 1.25–4.13)). A significant trend was seen between an increasing number of these risk factors (triple immunosuppression and previous intestinal resection) and rate of intra-abdominal sepsis (5%, 12%, and 22% for 0, 1, and 2 risk factors; p < 0.01). A trend was observed between increasing number of previous intestinal resections and the rate of intra-abdominal sepsis (p < 0.01). LIMITATIONS: This study is limited by its single-institution tertiary referral center scope. CONCLUSIONS: Combination immunosuppression and previous intestinal resection were both associated with the development of intra-abdominal sepsis. In light of these results, surgeons should consider the effects of combination immunosuppression and a history of previous intestinal resection, in addition to other risk factors, when deciding which patients warrant temporary intestinal diversion. See Video Abstract at http://links.lww.com/DCR/A664.

Objective: To determine the relative or combined effects of Crohn disease (CD) and ulcerative colitis (UC) and the operation performed on postoperative venous thromboembolism (VTE) to better guide recommendations on extended VTE prophylaxis. Summary Background Data: There is growing evidence to suggest patients with inflammatory bowel disease have an increased risk of postoperative VTE, but prior studies have not accounted for the operation performed nor acknowledged differences between CD and UC. Methods: The American College of Surgeons National Surgical Quality Improvement Project database from 2005 to 2016 was queried for patients with a diagnosis of CD, UC, malignancy, or benign disease (diverticular disease, Clostridium difficile) undergoing major abdominal surgery. Operations with a VTE rate >3% were designated high risk. Operation-specific univariate and multivariable logistic regression analyses were conducted. Results: A total of 231,718 operations were analyzed with 4426 patients experiencing a VTE (1.9%). The overall rate of VTE ranged widely based on the operation performed from 0.7% for enterostomy closure to 5.3% for open subtotal colectomy. Seven operations met our threshold of 3% to be considered high risk. For each operation, postoperative VTE rates were similar regardless of diagnostic indication when performed in the elective setting. However, when performed emergently, the same operations had significantly higher VTE rates. Compared with the malignancy and benign disease groups, neither CD nor UC was associated with increased odds of VTE after any operation. Conclusions: Postoperative VTE risk varies widely by the operation performed, and a diagnostic indication of CD or UC does not play a role. Extended duration VTE prophylaxis should be considered in all patients undergoing high-risk operations, regardless of their underlying diagnosis.

Linked ContentThis article is linked to Tse et al and Ma and Kotze paper. To view these articles visit https://doi.org/10.1111/apt.14829 and https://doi.org/10.1111/apt.14858.

Surgery remains the cornerstone of rectal cancer treatment. However, there is significant morbidity and mortality associated with pelvic surgery, and the past decade has illustrated that a cohort of rectal cancer patients sustain a remission of local disease with chemoradiation alone. Thus, questions remain regarding the optimal management for rectal cancer; namely, accurately identifying patients who have a complete pathologic response and determining the oncologic safety of the observational approach for this patient group. This review aims to summarize the current evidence to provide an overview to the ‘watch and wait’ approach in rectal cancer patients with a complete response to neoadjuvant chemoradiation therapy.