Colectomy For Colitis Research Articles

Incidence of rectal cancer after colectomy for inflammatory bowel disease: nationwide study.

Inflammatory bowel disease increases the risk of colorectal neoplasia. A particular problem arises in patients who have undergone subtotal colectomy leaving a rectal remnant. The risk of future rectal cancer must be accurately estimated and weighed against the risks of further surgery or surveillance. The aim of this study was to estimate the 10-year cumulative incidence of rectal cancer in such patients. A nationwide study using England's hospital administrative data was performed. A cohort of patients undergoing subtotal colectomy between April 2002 and March 2014 was identified. A competing risks survival analysis was performed to calculate the cumulative incidence of rectal cancer. The effect of the COVID-19 pandemic on endoscopic surveillance was investigated using time-trend analysis. A total of 8120 patients were included and 61 patients (0.8%) were diagnosed with cancer. The cumulative incidence of rectal cancer was 0.26% (95% c.i. 0.17% to 0.39%), 0.49% (95% c.i. 0.36% to 0.68%), and 0.77% (95% c.i. 0.57% to 1.02%) at 5, 10, and 15 years respectively. A previous diagnosis of colonic dysplasia (HR 3.34, 95% c.i. 1.01 to 10.97; P = 0.047), primary sclerosing cholangitis (HR 5.42, 95% c.i. 1.34 to 21.85; P = 0.018), and elective colectomy (HR 1.83, 95% c.i. 1.11 to 3.02; P = 0.018) was associated with an increased incidence of rectal cancer. Regarding endoscopic surveillance, there was a 43% decline in endoscopic procedures performed in 2020 (333 procedures) compared with 2019 (585 procedures). The incidence of rectal cancer after subtotal colectomy is low. Asymptomatic patients without evidence of rectal dysplasia should be carefully counselled on the possible benefits and risks of prophylactic proctectomy.

What is the rate of definitive stoma after subtotal colectomy for inflammatory bowel disease? A nationwide study of 1860 patients.

Some patients with inflammatory bowel disease (IBD) require subtotal colectomy (STC) with ileostomy. The recent literature reports a significant number of patients who do not undergo subsequent surgery and are resigned to living with a definitive stoma. The aim of this work was to analyse the rate of definitive stoma and the cumulative incidence of secondary reconstructive surgery after STC for IBD in a large national cohort study. A national retrospective study (2013-2021) was conducted on prospectively collected data from the French Medical Information System Database (PMSI). All patients undergoing STC in France were included. The association between definitive stoma and potential risk factors was studied using univariate and multivariate analyses. A total of 1860 patients were included (age 45 ± 9 years; median follow-up 30 months). Of these, 77% (n = 1442) presented with ulcerative colitis. Mortality and morbidity at 90 days after STC were 5% (n = 100) and 47% (n = 868), respectively. Reconstructive surgery was identified in 1255 patients (67%) at a mean interval of 7 months from STC. Seveny-four per cent (n = 932) underwent a completion proctectomy with ileal pouch anal anastomosis and 26% (n = 323) an ileorectal anastomosis. Six hundred and five (33%) patients with a definitive stoma had an abdominoperineal resection (n = 114; 19%) or did not have any further surgical procedure (n = 491; 81%). Independent risk factors for definitive stoma identified in multivariate analysis were older age, Crohn's disease, colorectal neoplasia, postoperative complication after STC, laparotomy and a low-volume hospital. We found that 33% of patients undergoing STC with ileostomy for IBD had definitive stoma. Modifiable risk factors for definitive stoma were laparotomy and a low-volume hospital.

A retrospective cohort study on renal morbidity related to stoma type in inflammatory bowel disease patients following colectomy and ileal pouch-anal anastomosis surgery.

Defunctioning loop ileostomy (DLI) is frequently used to decrease the consequences of anastomotic leak after ileal pouch-anal anastomosis (IPAA) surgery but is controversial because of stoma-associated morbidity. The aim of this study was to describe stoma-associated morbidity in IPAA-DLI patients compared with terminal ileostomy patients. Patients treated with colectomy for inflammatory bowel disease at Skåne University Hospital, Sweden, between 2005 and 2021 were eligible for inclusion. Terminal stoma-related morbidity was measured until 12 months after colectomy, IPAA surgery, or conversion to ileorectal anastomosis, whichever occurred first. DLI-related morbidity was measured until 12 months after IPAA surgery or stoma closure, whichever occurred first. Laboratory data were reviewed up to 18 months after surgery since patients without complications were rarely subjected to blood sampling. Data on patient characteristics, renal function, surgical complications, and readmissions were collected retrospectively. Primary outcomes were DLI- and terminal ileostomy-related renal morbidity, whereas secondary outcomes focused on stoma-related complications. The study cohort consisted of 165 patients with terminal ileostomy after colectomy (median (interquartile range (IQR)): stoma time 30 (15-74) months) and 42 patients with IPAA-DLI (median (IQR): stoma time 4 (3-5) months). One case of anastomotic IPAA leakage was observed. IPAA-DLI patients more often required hospital care due to high-volume stoma output immediately after surgery (0-30 days, 29%) compared with terminal ileostomy patients (4%, p < 0.001). There were no significant differences in acute renal injury (p = 0.073) or chronic renal failure (p = 0.936) incidences between the groups. DLI closure was achieved in 95% of IPAA-DLI patients, with 5% suffering Clavien-Dindo complications > 2. IPAA-DLI patients exhibited higher incidence of short-term high-volume stoma output without higher rates of acute renal injury or chronic renal failure compared with terminal ileostomy patients in this small single-center retrospective study suggesting that the risk of renal morbidity in IPAA-DLI patients may have been overestimated.

SP10.3 Colectomy for Inflammatory Bowel Disease (IBD) – use of the National Consultant Information Programme (NCIP) to highlight colorectal surgical practice in England

Abstract Introduction The NCIP tool uses HES data from Trusts to understand the spread and variation of a range of surgical procedures. There are two forms of IBD; Crohn’s and Ulcerative Colitis (UC). This work uses NCIP to contextualise data and understand Covid-19’s impact and the current practice of colectomy for IBD in England. Method Pseudonymised data was extracted from NCIP dashboards by NHS England Improvement data analysts. Various metrics were analysed including surgical approach, frequency of cases, length of stay (LOS), incidence of stoma maturation and readmission, and mortality. Results 3907 Crohn’s and 1942 UC cases performed from April 2019-March 2022. Decrease observed in frequency during Covid-19. Crohn’s: 47.76% laparoscopic cases. 17.42% of total providers did &amp;lt;10 cases in 4-year period. Average LOS was 9.01 days ± 0.16 with 95% CI [8.70, 9.32], p&amp;lt;0.001. Mean stoma rate was 31.73% in units performing ≥20 cases. 30-day readmission was 17.33%. 90-day mortality was 0.23%. UC: 56.54% laparoscopic cases. 47.29% of total providers did &amp;lt;10 cases in the 4-year period. Average LOS was 10.39 days ± 0.29 with 95% CI [9.82,10.96], p&amp;lt;0.001. Mean stoma rate was 87.09% in units performing ≥20 cases. 30-day readmission was 21.94%. 90-day mortality was 0.82%. Conclusion Covid-19 decreased current practice for IBD colectomies, possibly due to RCS guidance recommending temporary suspension of non-cancer surgery during the pandemic. Lower laparoscopy rates than expected. Significant centre variation and variation in stoma rate observed. Data suggests stoma creation within episode is a contributor to higher average LOS and readmission rate (p&amp;lt;0.05).

Short-term outcomes following total colectomy for inflammatory bowel disease in Denmark after implementation of laparoscopy: a nationwide population-based study.

A laparoscopic approach to total colectomy (TC) for inflammatory bowel disease (IBD) is being increasingly used, but data on its comparative benefits over open TC are conflicting. The aim of this study was to examine 90-day outcomes following laparoscopic and open TC for IBD in a nationwide cohort after the introduction of laparoscopy. IBD patients undergoing TC in Denmark from 2005 to 2017 were identified from the Danish National Patient Registry. We used Kaplan-Meier methodology to estimate mortality and Cox regression analysis to estimate adjusted mortality rate ratios (aMRRs) and adjusted hazard ratios (aHRs) of reoperation, readmission and intensive care unit (ICU) transfer, comparing patients undergoing laparoscopic versus open TC. We identified 1095 patients undergoing laparoscopic TC and 1523 patients undergoing open TC. Following emergency TC, 90-day mortality was 2.8% (1.6%-4.9%) after laparoscopic TC and 9.1% (7.0%-11.8%) after open TC. Ninety-day mortality was 0.9% (0.3%-2.5%) after laparoscopic TC and 2.6% (1.5%-4.3%) after open elective TC. The aMRRs associated with laparoscopic TC were 0.45 (95% CI 0.25-0.80) in emergency cases and 0.29 (95% CI 0.10-0.86) in elective cases. Risks of readmission were comparable following laparoscopic versus open TC, both in emergency [aHR = 0.93 (95% CI 0.76-1.15)] and elective [aHR = 0.83 (95% CI 0.68-1.02)] cases, while risks of ICU transfer and reoperation were lower following laparoscopic TC, both in emergency cases [aHR = 0.53 (95% CI 0.35-0.82) and aHR = 0.26 (95% CI 0.15-0.47)] and elective [aHR = 0.58 (95% CI 0.35-0.95) and aHR = 0.37 (95% CI 0.21-0.66)] cases. The introduction of laparoscopic TC for IBD in Denmark was not associated with increased mortality or morbidity. In fact, laparoscopic TC for IBD may be associated with lower short-term mortality and morbidity compared with open TC.

Female and Male Fertility after Colectomy and Reconstructive Surgery in Inflammatory Bowel Diesase: A National Cohort Study from Sweden.

Colectomy and reconstruction in patients with inflammatory bowel disease [IBD] may adversely affect fertility, but few population-based studies on this subject are available. Fertility was assessed in 2989 women and 3771 men with IBD and prior colectomy during 1964-2014, identified from the Swedish National Patient Register, and in 35 092 matched individuals. Reconstruction with ileoanal pouch anastomosis [IPAA] was as common as ileorectal anastomosis [IRA] in ulcerative colitis [UC] and IBD-unclassified [IBD-U] but rare in Crohn's disease [CD]. Compared with the matched reference cohort, women with IBD had lower fertility overall after colectomy (hazard ratio [HR] 0.65, confidence interval [CI] 0.61-0.69), with least impact with leaving the rectum intact [HR 0.79, CI 0.70-0.90]. Compared with colectomy only, fertility in female patients remained unaffected after IRA [HR 0.86, CI 0.63-1.17 for UC, 0.86, CI 0.68-1.08 for IBD-U and 1.07, CI 0.70-1.63 for CD], but was impaired after IPAA, especially in UC [HR 0.67, CI 0.50-0.88], and after completion proctectomy [HR 0.65, CI 0.49-0.85 for UC, 0.68, CI 0.55-0.85 for IBD-U and 0.61, CI 0.38-0.96 for CD]. In men, fertility was marginally reduced following colectomy [HR 0.89, CI 0.85-0.94], regardless of reconstruction. Fertility was reduced in women after colectomy for IBD. The least impact was seen when a deviated rectum was left intact. IRA was associated with no further reduction in fertility, whereas proctectomy and IPAA were associated with the strongest impairment. IRA therefore seems to be the preferred reconstruction to preserve fertility in selected female patients. Fertility in men was only moderately reduced after colectomy.

P180 Ileorectal anastomosis preserves female fertility after colectomy in Ulcerative Colitis

Abstract Background Colectomy and reconstruction in patients with inflammatory bowel disease (IBD) may adversely affect fertility, but few population-based studies are available. Methods Fertility was assessed in 2,989 women and 3,771 men with IBD and prior colectomy 1964-2014, identified from the Swedish National Patient Register, and 35,092 matched population-based individuals. Results Reconstruction with ileoanal pouch anastomosis (IPAA) was as common as ileorectal anastomosis (IRA) in ulcerative colitis (UC) and IBD-unclassified (IBD-U) while rare in Crohn’s disease (CD). Compared with the matched non-IBD cohort, women with IBD had lower fertility overall post colectomy (HR 0.65, CI 0.61-0.69). The impact was least in patients with colectomy only with the rectum left intact (HR 0.79, CI 0.70–0.90) and more pronounced after reconstructive surgery. Comparing the surgical options within the cohort of women with colectomy for IBD using colectomy only as reference, fertility in female patients remained unaffected after IRA (HR 0.86, CI 0.63-1.17 for UC, 0.86, CI 0.68-1.08 for IBD-U and 1.07, CI 0.70-1.63 for CD), but was impaired after IPAA, especially in UC (HR 0.67 CI 0.50-0.88), and after completion proctectomy (HR 0.65, CI 0.49-0.85 for UC, 0.68, CI 0.55-0.85 for IBD-U and 0.61, CI 0.38-0.96 for CD). In men, fertility was marginally reduced in the entire cohort post colectomy (HR 0.89, CI 0.85-0.94), regardless of reconstruction. Conclusion Fertility was reduced in women after colectomy for IBD. The least impact was seen with a deviated rectum left in situ. IRA was associated with no further reduction in fertility, whereas proctectomy with or without IPAA were associated with the strongest impairment. IRA therefore seems to be the preferred reconstruction to preserve fertility in selected female patients. Fertility in men was only moderately reduced after colectomy and reconstructive choice.

Preoperative Biologics Exposure Predisposes Ulcerative Colitis Patients to a Distinct Delayed Postoperative Ileus Syndrome After Colectomy.

BACKGROUND Postoperative ileus (POI) remains the most common complication after colectomy for inflammatory bowel disease (IBD). Delayed POI (DPOI) can develop late (>14 days) after colectomy in clinical settings, with unknown etiology. The aim of this study was to address a novel entity of POI after colectomy for ulcerative colitis (UC). MATERIAL AND METHODS The data of 263 UC patients who underwent colectomy from Jan 1, 2013 to May 31, 2021 were collected. DPOI was defined as POI occurring on or after postoperative day (POD) 14 with apparent resolution from obligatory POI. Univariate and multivariate analysis were conducted to identify the risk factors for DPOI. RESULTS The rate of canonical prolonged POI and DPOI were 11.7% (31/263) and 9.9% (26/263), respectively. The pathophysiological process of DPOI demonstrated an ileus-dysbiosis-recovery triad. Two DPOI cases were diagnosed with UC-related severe enteritis and underwent re-laparotomy. Multivariate analysis showed preoperative biologics exposure was an independent risk factor for DPOI (OR 3.100 95% CI 1.261-7.619, P=0.018) and the number of biologics session/course moderately predicted the occurrence of DPOI (AUC=0.639, 95% CI=0.578-0.697, P=0.0129). CONCLUSIONS A distinct pattern of ileus was identified in a tertiary IBD center. Clarification of this syndrome complemented the spectrum of post-IPAA complications and offered experience to treat this condition.

Minimally Invasive Surgery for Persistent Uterine Incarceration in a Patient with a History of Prior Colectomy

<h3>Study Objective</h3> 1. Review the diagnosis, risk factors and management options for the incarcerated gravid uterus. 2. Present a case of an incarcerated uterus at 18 weeks gestation which resulted in acute urinary retention and was able to be resolved with minimally invasive surgery after initial noninvasive methods failed. 3. Discuss the management of the incarcerated uterus including the role of minimally invasive surgery and specific suggestions which may be helpful. <h3>Design</h3> Case presentation. <h3>Setting</h3> Operating room at a tertiary academic medical center. <h3>Patients or Participants</h3> A 25-year-old gravida 2 para 0 at 18 weeks gestation with symptomatic and persistent uterine incarceration causing urinary retention. This patient also had a history of prior laparoscopic colectomy for inflammatory bowel disease. <h3>Interventions</h3> Laparoscopic and vaginal approach to reducing uterine incarceration under general anesthesia. <h3>Measurements and Main Results</h3> Resolution of uterine incarceration and urinary retention as well as favorable pregnancy outcome. <h3>Conclusion</h3> The incarcerated gravid uterus is an uncommon but potentially severe complication of pregnancy with risks to the mother and fetus. It can be confirmed on imaging and a stepwise approach to reduction can be employed to minimize invasive interventions. We present a combined laparoscopic and vaginal approach which successfully reduced a case of persistent incarcerated uterus at 18 weeks gestation and resolved urinary retention. Additionally, we suggest history of prior total colectomy as an additional risk factor for this condition as the absence of a mobile rectum in the pelvis may contribute to incarceration of the uterus.

Does an Ileoanal Anastomosis Decrease the Rate of Successful Pregnancy Compared With an Ileorectal Anastomosis? A National Study of 1491 Patients.

Report the rate of successful pregnancy in a national cohort of women with either an ileal pouch anal (IPAA) or ileorectal (IRA) anastomosis constructed after colectomy for inflammatory bowel disease (IBD) or polyposis. Fertility after IPAA is probably impaired. All available data are corroborated by only small sample size studies. It is not known whether construction of IPAA versus IRA influences the odds of subsequently achieving a successful pregnancy, especially with increased utilization of the laparoscopic approach. All women (age: 12-45y) undergoing IRA or IPAA in France for polyposis or IBD, between 2010-2020, were included. A control population was defined as women aged from 12 to 45 years undergoing laparoscopic appendicectomy during the same period. The odds of successful pregnancy were studied using an adjusted survival analysis. A total of 1491 women (IPAA=872, 58%; IRA=619, 42%) were included. A total of 220 deliveries (15%) occurred during the follow-up period of 71 months (39-100). After adjustment, the odds of successful pregnancy was not significantly associated with type of anastomosis (after IPAA: Hazard Ratio [HR]=0.79, 95% confidence interval=0.56-1.11, P =0.17). The laparoscopic approach increased the odds of achieving successful pregnancy (HR=1.79, 95% confidence interval=1.20-2.63, P =0.004). IRA and IPAA significantly impacted fertility when compared with the control population ( P <0.001). In this large cohort study, total colectomy for polyposis or IBD was associated with reduced fertility compared with the general population. No difference in odds of achieving successful pregnancy was found between IRA and IPAA after adjustment. This analysis suggests laparoscopic surgery may be associated with greater likelihood of pregnancy.

P253 Are we doing enough to prevent colectomy in Inflammatory Bowel Disease (IBD) patients? A 5-year review of colectomy rates in Shropshire and Mid-Wales UK (2015–2019)

Abstract Background Colectomy for IBD significantly impacts the psycho-social aspects &amp; quality of life. Methods Electronic records were retrospectively analysed for colectomy rates &amp; parameters of interest. Results 68 patients (Men 37:Women31), median age 30 years had colectomies. Annual colectomy rates remained constant;7 (2015), 20 (2016), 11 (2017) &amp; (2018) each and 19 (2019). 28% had colectomy within 1 year of diagnosis and only 63% received a biologic agent. Over half, (54%)had emergency surgeries &amp; 37% experienced infections, re-laparotomy and ileus (20% each). Conclusion There is an opportunity to risk-stratify patients at diagnosis based on the risk factors (men, younger age, severe/extensive disease) to a top-down therapy &amp; treat to target strategy to reduce colectomy rates.

Fecal Microbiota Transplantation Is Effective for Postcolectomy Recurrent Clostridioides difficile Infection

Background The outcomes from fecal microbiota transplantation (FMT) for recurrent Clostridioides difficile infection (rCDI) in patients after complete or partial colectomy are not well-defined. Objectives We sought to report our experience with FMT for rCDI in patients who have undergone colectomy. Methods Descriptive analyses of FMT outcomes from 2014 to 2020 were performed in patients who previously had undergone complete or partial colectomy. Results Twenty-nine patients with prior colectomy for inflammatory bowel disease, malignancy, slow-transit constipation refractory to medical therapy, or fulminant CDI underwent FMT for rCDI. Two patients (6.9%) had rCDI within 8 weeks post-FMT. Seven had CDI beyond 8 weeks (median 10 months) with 71% related to antibiotic exposure post-FMT, suggesting a 69% overall success. Conclusion FMT resolves rCDI in most patients after colectomy with subsequent antibiotic exposure predicting CDI after FMT.

Rectal Cancer Risk and Survival After Total Colectomy for IBD: A Population-Based Study.

Patients undergoing total colectomy for IBD may develop cancer in the rectal remnant, but the association is poorly understood. This study aimed to examine the risk and prognosis of rectal cancer after total colectomy for IBD. This is a nationwide population-based study. Treatment of the patients took place in Denmark from 1977 to 2013. Patients with IBD undergoing total colectomy were included. We examined the incidence of rectal cancer among patients with IBD and total colectomy and compared cancer stage to that of other patients with rectal cancer in Denmark. We used Kaplan-Meier methodology to estimate survival and Cox regression to estimate adjusted mortality rate ratios following a rectal cancer diagnosis, comparing patients with and without IBD and a rectal remnant. We identified 4703 patients with IBD (1026 Crohn's disease; 3677 ulcerative colitis) who underwent total colectomy with a rectal remnant. During 29,725 years of follow-up, 30 rectal cancers were observed, compared with 8 rectal cancers expected (standardized incidence ratio = 3.6 (95% CI, 2.4-5.1)). Cancer stage distributions were similar. Risk of rectal cancer 35 years after total colectomy was 1.9% (95% CI, 1.1%-2.9%). Five years after rectal cancer diagnosis, survival was 28% (95% CI, 12%-47%) and 38% (95% CI, 37%-38%) for patients with and without IBD and a rectal remnant. The adjusted mortality rate ratio 1 to 5 years after a rectal cancer diagnosis was 2.5 (95% CI, 1.6-3.9). Median time from last recorded nondiagnostic proctoscopy to rectal cancer diagnosis for patients with IBD and total colectomy was 1.1 years. This study was limited by the few outcomes and the use of administrative and not clinical data. Long-term risk of rectal cancer following total colectomy for IBD was low. Survival following a diagnosis of rectal cancer was poorer for patients with IBD and total colectomy than for patients who had rectal cancer without IBD and total colectomy. Endoscopic surveillance, as it appeared to be practiced in this cohort, may be inadequate. See Video Abstract at http://links.lww.com/DCR/B497. RIESGO DE CÁNCER DE RECTO Y SUPERVIVENCIA DESPUÉS DE UNA COLECTOMÍA TOTAL POR ENFERMEDAD INFLAMATORIA INTESTINAL: UN ESTUDIO POBLACIONAL: Los pacientes sometidos a colectomía total por enfermedad inflamatoria intestinal (EII) pueden desarrollar cáncer en el remanente rectal, pero la asociación es poco conocida.Examinar el riesgo y el pronóstico del cáncer de recto después de una colectomía total para la EII.Estudio poblacional a nivel nacional.Dinamarca 1977-2013.Pacientes con EII sometidos a colectomía total.Examinamos la incidencia de cáncer de recto entre pacientes con EII y colectomía total y comparamos el estadio del cáncer con el de otros pacientes con cáncer de recto en Dinamarca. Utilizamos la metodología de Kaplan-Meier para estimar la supervivencia y la regresión de Cox para estimar las tasas de mortalidad ajustadas (aMRR) después de un diagnóstico de cáncer de recto, comparando pacientes con y sin EII y un remanente rectal.Identificamos 4.703 pacientes con EII (1.026 enfermedad de Crohn; 3.677 colitis ulcerosa) que se sometieron a colectomía total con remanente rectal. Durante 29,725 años de seguimiento, se observaron 30 cánceres de recto, en comparación con los 8 esperados [razón de incidencia estandarizada (SIR) = 3.6, (intervalo de confianza (IC) del 95%: 2.4-5.1)]. Las distribuciones de las etapas del cáncer fueron similares. El riesgo de cáncer de recto 35 años después de la colectomía total fue del 1,9% (IC del 95%: 1,1% -2,9%). Cinco años después del diagnóstico de cáncer de recto, la supervivencia fue del 28% (IC del 95%: 12% -47%) y del 38% (IC del 95%: 37% -38%) para los pacientes con y sin EII y un remanente rectal, respectivamente. La aMRR 1-5 años después de un diagnóstico de cáncer de recto fue de 2,5 (IC del 95%: 1,6-3,9). La mediana de tiempo desde la última proctoscopia no diagnóstica registrada hasta el diagnóstico de cáncer de recto en pacientes con EII y colectomía total fue de 1,1 años.Pocos resultados, uso de datos administrativos y no clínicos.El riesgo a largo plazo de cáncer de recto después de una colectomía total para la EII fue bajo. La supervivencia después de un diagnóstico de cáncer de recto fue más pobre para los pacientes con EII y colectomía total que para los pacientes con cáncer de recto sin EII y colectomía total. La vigilancia endoscópica, como parecía practicarse en esta cohorte, puede ser inadecuada. Consulte Video Resumen en http://links.lww.com/DCR/B497. (Traducción-Dr. Adrian Ortega).

Postoperative diagnostic revision for Crohn disease after subtotal colectomy for inflammatory bowel disease.

Subtotal colectomy (STC) is performed for severe acute and refractory colitis. The diagnosis can be difficult even after the surgery when colectomy specimen has overlapping features of ulcerative colitis (UC) and Crohn's disease (CD). The aim of this study was to evaluate the rate of postoperative diagnostic revision to CD after surgery and determine predictor factors. Retrospective study of 110 patients who underwent STC (2005-2018). Preoperative diagnosis comprised UC = 80 (73%), CD = 11 (10%), and unclassified colitis (IBDU = 19, 17%). Initial diagnosis of IBDU and UC was modified to CD in 6 patients (6%) after STC. The final diagnosis after the follow-up of 10 ± 6years switched from CD for 8 patients (9%). The multivariate analysis showed that patients with a colitis evolving for less than 10years and initial diagnosis of IBDU were the two independent factors associated with an increased risk of diagnosis change to CD (p = 0.03; p = 0.016). At the end of the follow-up, 15 patients (14%) had a definitive stoma. In patients with IBD, attention must be paid to determine the right restorative strategy to patients with an evolution of the disease less than 10years or with IBDU who are more at risk to have a diagnosis change to CD after STC.

An audit of process and outcome for emergency colectomy in England and Wales.

The aim of this work was to describe process and outcome for patients undergoing emergency colectomy for colitis in England and Wales. The National Emergency Laparotomy Audit (NELA) is a national audit including patients undergoing emergency laparotomy and laparoscopic resectional procedures. Data from adult patients under 65years of age who underwent emergency subtotal colectomy or panproctocolectomy for colitis between 2013 and 2016 were analysed. In total 1204 patients were included. Although approximately a third of patients underwent a colectomy within 5days of admission [37% (440/1204)], 32% (383/1204) were admitted for more than 10days prior to surgery. Colorectal surgeons were present at operation in 72% (869/1204) of cases and consultant surgeons attended 94% (1137/1204) of procedures. Laparoscopy was attempted in 32% (390/1204) of operations with wide institutional variation in its use (0-100% of cases). The overall 30-day inpatient mortality was 2.9% (35/1204). On multivariable regression analysis, age>55years [OR 3.59 (1.05-12.21), P=0.041], female gender [OR 2.88 (1.27-6.52), P=0.011] and American Society of Anesthesiologists grade 5 [OR 37.43 (2.72-514.52), P=0.007] were associated with increased mortality. There is a consultant-driven service that is largely delivered by specialist colorectal surgeons. Laparoscopy rates were high although there was wide variation in use across institutions. Preoperative delays were evident, and further work is necessary to determine the underlying reasons for these.

Ketorolac after colectomy for ulcerative colitis in children: An analysis of opioid utilization and postoperative complications

IntroductionEnhanced recovery protocols include multimodal perioperative pain control and frequently include use of NSAIDs. There is conflicting evidence that ketorolac use in inflammatory bowel disease (IBD) may precipitate disease flares and postoperative complications. The outcomes of children who receive ketorolac in this setting are not well known. We sought to evaluate ketorolac utilization in children following colectomy for ulcerative colitis. MethodsAll patients undergoing colectomy for ulcerative colitis between 2007 and 2017 at a tertiary children's hospital were reviewed. We collected patient age, duration of symptoms, operative details, medication utilization, length of stay, and postoperative complications. We performed a cohort comparison of these variables across patients who did vs. did not receive postoperative ketorolac. ResultsSixty children were identified with median age at diagnosis of 12.6 years (IQR: 9.9–14.5). At colectomy, patients had a median PUCAI score of 60 (45–70), ESR 34 mm/h (15–50), hemoglobin 10.9 g/dL (9.3–12.9), and albumin 3.1 g/dL (2.4–3.8). Postoperatively, 45% (n = 27) received ketorolac. Patients in both cohorts had a similar length of stay, duration of opioid exposure, total morphine equivalents utilized, readmission rate, and unexpected return to the operating room. There were no documented cases of postoperative bleeding, acute kidney injury, or disease related flares among children receiving ketorolac. ConclusionsAdministration of ketorolac after colectomy in IBD was not associated with an increase in any postoperative complications, though the study was underpowered to detect these differences. However, ketorolac administration did not lead to a decreased utilization of opioid analgesia. Further prospective research is necessary to understand whether ketorolac in this population is safe and offers benefit. Type of studyRetrospective study. Level of evidenceIII

Extracolonic Cancer Risk After Total Colectomy for Inflammatory Bowel Disease: A Population-based Cohort Study.

Patients with inflammatory bowel disease are at increased risk of extracolonic cancers. Little is known regarding this risk following total colectomy [TC]. Patients who underwent TC for inflammatory bowel disease in Denmark during 1977-2013 were identified from the Danish National Patient Registry. Incidence rates of extracolonic cancers were determined through record linkage to the Danish Cancer Registry and compared with expected incidence rates in the general population. Standardized incidence ratios [SIRs] were calculated as the observed vs expected cancer incidence. In total, 4430 patients (3441 with ulcerative colitis [UC]; 989 with Crohn's disease [CD]) were followed for 54,183 person-years after TC. Following their surgery, 372 patients were diagnosed with extracolonic cancer compared to 331 expected [SIR = 1.1 (95% confidence interval {CI}: 1.0-1.2)]. The risk of extracolonic cancer overall was increased among patients with CD and TC (SIR = 1.5 [95% CI: 1.2-1.8]), but not among patients with UC and TC (SIR = 1.0 [95% CI: 0.9-1.2]). Patients with UC and TC had a higher risk of intestinal extracolonic cancer (SIR = 2.0 [95% CI: 1.4-2.7]). Patients with CD and TC had a higher risk of smoking-related cancers (SIR = 1.9 [95% CI: 1.2-2.9]), intestinal extracolonic cancer (SIR = 3.1 [95% CI: 1.6-5.5]) and immune-mediated cancers (SIR = 1.5 [95% CI: 1.0-2.1]). Patients with CD and TC had a higher risk of extracolonic cancer overall compared to the general population, while patients with UC and TC did not. Site-specific cancer risk varied according to inflammatory bowel disease type.

Sprue-Like Intestinal Disease Following Crohn’s Disease

A 48-yr old female was reviewed for ongoing symptoms of diarrhea and weight loss following a total colectomy for colitis. Pathological review of the surgical specimens revealed changes of Crohn’s colitis. Subsequent investigations after the colectomy revealed endoscopic evidence of duodenal mucosal scalloping, negative celiac serological studies and moderate to severe changes in villous architecture including crypt hyperplasia with complete villus atrophy and increased numbers of intra-epithelial lymphocytes. No changes were present in the distal small intestine. Over the course of almost a decade, measures directed towards symptom relief were effective. However, in spite of a strict gluten-free diet, repeated endoscopic biopsies of the proximal small bowel remained severely abnormal with persistent crypt hyperplastic villus atrophy. “Sprue-like” intestinal disease occurs in Crohn’s disease limited to the duodenum, mimicking biopsy changes of celiac disease and may represent a post-colectomy complication in Crohn’s disease.

Incidence of Deep Venous Thrombosis in Children after Colectomy for Inflammatory Bowel Disease: A Multicenter Study

Traynor, Michael D. MD; Polites, Stephanie F. MD; Bence, Christina MD; Muenks, Peter MA; Ha, Derrick BS; St Peter, Shawn D. MD, FACS; Landman, Matthew P. MD, MPH, FAAP, FACS; Densmore, John C. MD, FACS; Potter, D Dean MD Author Information

Single Port Laparoscopic Total and Subtotal Colectomies for Inflammatory Bowel Disease in a District General Hospital.

Background: Single incision laparoscopic surgery (SILS) is expanding, enhancing the advantages of multi-port laparoscopic surgery (MLS). Limited literature exists regarding SILS total/subtotal colectomies for inflammatory bowel disease (IBD). Aim of the study was to present the initial experience with this type of approach in a district general hospital and extrapolate its feasibility and safety in this specific context based on gold standard outcomes reported in literature. Materials and Methods: Preoperative parameters, operative details and surgical outcomes of consecutive patients who underwent colonic SILS for IBD in a 5-year period were reviewed retrospectively. Median length of follow-up was 26 months. Results: Fourteen patients underwent SILS subtotal/total colectomy. Median body mass index was 25 (18.1-35). Two patients had previous abdominal surgeries. Median operating time was 202.5 minutes. Two cases were converted to open. Median length of stay was 5 days. Three patients presented complications. Three patients developed parastomal hernias (21.4%). Five out of 12 patients with ulcerative colitis declined further surgery, 3 are awaiting laparoscopic/SILS pouch formation, 1 underwent SILS pouch formation, 1 SILS ileo-rectal anastomosis and 1 patient had SILS completion proctectomy. One patient was not followed up. Conclusions: Despite literature data heterogeneity, these results provide support to the feasibility and applicability of SILS in the subgroup of patients who undergo subtotal/total colectomies for IBD, offering the option for subsequent SILS completion or restorative procedures. Further studies are required to explore the benefit of SILS over MLS (including cosmesis and quality of life) and non-inferiority of SILS regarding the parastomal hernia issue and the operative duration.