Ravi P. Kiran

BACKGROUND: Ileal pouch anal anastomosis (IPAA) is the treatment of choice for chronic, medically refractory mucosal ulcerative colitis, indeterminate colitis, familial adenomatous polyposis (FAP), and a select group of patients with Crohn's disease. AIM: : We report outcomes, complications, and quality of life (QOL) in a cohort of 3707 patients treated at our institution from January 1984 to March 2010. METHODS: Data were collected from a prospectively maintained database and chart review of 3707 consecutive primary IPAA cases. Patient demographics, postoperative complications, functional outcomes, and QOL data were available. Follow-up consisted of clinical examination with assessment of pouch function and QOL. RESULTS: A total of 3707 patients underwent primary pouch and 328 underwent redo pouch surgery. Postoperative histopathological diagnoses were mucosal ulcerative colitis (n = 2953, 79.7%), indeterminate colitis (n = 63, 1.7%), FAP (n = 223, 6%), Crohn's disease (n = 150, 4%), cancer/dysplasia (n = 97, 2.6%), and others (n = 221, 6.0%). Early perioperative complications were encountered in 33.5% of patients with a mortality rate of 0.1%. Excluding pouchitis, late complications were experienced by 29.1% of patients. Of those patients who had IPAA at our institution, pouch failure occurred in 197 patients (5.3%). During a median follow-up of 84 months, 119 patients (3.2%) required excision of the pouch, 32 (0.8%) had a nonfunctioning pouch, and 46 patients (1.2%) had redo IPAA. Functional outcomes and QOL were good or excellent in 95% of patients and similar in each histopathological subgroup. CONCLUSIONS: IPAA is an excellent option for patients with MUC, IC, FAP, and select patients with Crohn's disease.

In Brief Objectives: To clarify whether bowel preparation use or its individual components [mechanical bowel preparation (MBP)/oral antibiotics] impact specific outcomes after colorectal surgery. Methods: National Surgical Quality Improvement Program–targeted colectomy data initiated in 2012 capture information on the use/type of bowel preparation and colorectal-specific complications. For patients undergoing elective colorectal resection, the impact of preoperative MBP and antibiotics (MBP+/ABX+), MBP alone (MBP+/ABX−), and no bowel preparation (no-prep) on outcomes, particularly anastomotic leak, surgical site infection (SSI), and ileus, were evaluated using unadjusted/adjusted logistic regression analysis. Results: Of 8442 patients, 2296 (27.2%) had no-prep, 3822 (45.3%) MBP+/ABX−, and 2324 (27.5%) MBP+/ABX+. Baseline characteristics were similar; however, there were marginally more patients with prior sepsis, ascites, steroid use, bleeding disorders, and disseminated cancer in no-prep. MBP with or without antibiotics was associated with reduced ileus [MBP+/ABX+: odds ratio (OR) = 0.57, 95% confidence interval (CI): 0.48–0.68; MBP+/ABX−: OR = 0.78, 95% CI: 0.68–0.91] and SSI [MBP+/ABX+: OR = 0.39, 95% CI: 0.32–0.48; MBP+/ABX−: OR = 0.80, 95% CI: 0.69–0.93] versus no-prep. MBP+/ABX+ was also associated with lower anastomotic leak rate than no-prep [OR = 0.45 (95% CI: 0.32–0.64)]. On multivariable analysis, MBP with antibiotics, but not without, was independently associated with reduced anastomotic leak (OR = 0.57, 95% CI: 0.35–0.94), SSI (OR = 0.40, 95% CI: 0.31–0.53), and postoperative ileus (OR = 0.71, 95% CI: 0.56–0.90). Conclusions: These data clarify the near 50-year debate whether bowel preparation improves outcomes after colorectal resection. MBP with oral antibiotics reduces by nearly half, SSI, anastomotic leak, and ileus, the most common and troublesome complications after colorectal surgery. National Surgical Quality Improvement Program–targeted colectomy data initiated in 2012 were queried for all patients undergoing elective colorectal resection. Results show that mechanical bowel preparation with oral antibiotics independently reduces the odds of postoperative colorectal-specific adverse outcomes including surgical site infection, anastomotic leak, and ileus, the most common and troublesome complications after colorectal surgery.

In Brief Objective Comparison of outcome and costs after laparoscopic and open colectomy. Summary Background Data Previous studies comparing laparoscopic and open colectomy report conflicting results with regard to clinical outcome and costs. Methods Laparoscopic colectomy patients from a prospective database were matched for age, gender, and disease-related grouping to patients who underwent the same operation by the open approach over the same period (2000 to 2001). Data for the latter group was gathered by retrospective analysis and the 2 groups were compared for outcome and direct costs. Results Laparoscopic colectomy patients (n = 150) were compared with the same number of open colectomy patients. American Society of Anesthesiologists classification (P = 0.09), body mass index (P = 0.17), diagnosis (P = 0.12), complications (P = 0.14), and rate of readmission within 30 days (P = 0.44) were similar for both groups. Operating room costs were significantly higher after laparoscopic colectomy (P < 0.0001), but length of hospital stay was significantly lower (P < 0.0001). This resulted in significantly lower total costs (P = 0.0007) owing to lower pharmacy (P < 0.0001), laboratory (P <0.0001), and ward nursing costs (P = 0.0004). Conclusions Laparoscopic colectomy results in significantly lower direct costs compared with open colectomy for carefully matched patients. In carefully matched patients, length of hospital stay after laparoscopic colectomy is shorter than open surgery. Higher operating room costs for laparoscopic surgery are offset by lower costs for hospitalization due to less utilization of pharmacy, laboratory and nursing services. Clinical outcome is comparable.