Ileocolonic Anastomosis Research Articles

OP013 Disease management and outcomes of patients with Crohn's disease at high risk of recurrence. Results from PRACTICROHN study

Background: Surgery in Crohn disease (CD) is associated with poor prognosis and higher rate of clinical and surgical recurrence. The aim of our study was to compare the characteristics and management of CD patients that have undergo one surgery with patients that have undergo more than one surgery. Methods: PRACTICROHN was an observational study that included patients aged ≥18 years-old from 26 spanish hospitals who underwent CD-related resection with ileocolonic or ileorectal anastomosis between January 2007 and December 2010. Patient data were retrospectively collected from medical records. Categorical variables were compared with the χ2 test or Fisher's exact test. Kaplan-Meier method was used to assess time to clinical recurrence and a log-rank test to obtain statistical significance. Results: 314 patients were analyzed, 262 (83%)were included in the first surgery (50% males) and 52 (16%) referred previous surgeries (36% males). Mean age at diagnosis was similar in the first surgery group (FSG) (33±14 years) vs second surgery group (SSG). Age at index surgery was 39±13 years in FSG vs 43±12 in SSG, p=0.021. Smoking habit was higher in FSG vs SSG (41% vs 34%, p=0.47). Montreal classification in the two groups were similar except for behavior, with higher proportion of patients with B1 in FSG vs SSG (124 (48%) vs 13 (28%)) and higher proportion of B2 and B3 in SSG (74 (29%) B2 in FSG vs 21 (46%) in SSG and 57 (22%) B3 in FSG vs 12 (26%) in SSG), p=0.027. Regarding treatment, 33 (13%) patients in the FSG received steroids previous to surgery vs 13 (27%) patients in the SSG. p=0.029. No difference in IMM and biological treatment previous to surgery was found between the two groups. After surgery, a higher proportion of patients received prophylactic treatment with IMM in the SSG compared with FSG p=0.012. No difference in the rate of colonoscopies performed during first year after surgery was found between the two groups as well as in the findings at the colonoscopies. Hospitalizations and postoperative complications were also similar. There was no diference in clinical recurrence in SSG in patients receiving or not prophylaxis (p=0.5) whereas in FSG clinical recurrence-free survival was greater in patients with prophylactic treatment (p=0.03) (Fig. 1). Figure 1. Time to disease recurrence in FSG vs SSG. Conclusions: In our sample, although patients in SSG were less smokers and received more prophylaxis with IMM and similar post surgery follow-up, they presented more clinical recurrence. This confirms that undergoing a second surgery is a main factor of poor prognosis.

P214 What is the diagnostic accuracy of faecal calprotectin regarding endoscopic relapse in Crohn's disease patients following ileocecal resection? A tertiary single center experience

Background: There is still some discrepancy about the accuracy of faecal calprotectin (FC) in Crohn's disease (CD) patients after ileocecal resection and data from real daily practise on this topic is still scarce. Methods: For this purpose we prospectively gathered the simultaneous FC results of CD patients who were referred to the endoscopy unit in the postoperative (postop) setting. Patients with upper GI involvement were excluded. Demographic data like age, sex, disease duration, Rutgeerts score, FC, CRP results were all noted. All patients gave a stool sample 24 hours before colonoscopy and FC was determined via ELISA (Quantum Blue Calprotectin, Bühlmann Lab. AG, Switzerland). Results: Seventy-four CD patients [38 female (51%)] with an ileoceal resection were enrolled into the study protocol. Their mean age was 38.56±12 yr. with a mean disease duration of 123.52±84.88 mo. Fourty-four of 74 (60%) patients were in endoscopic remission whereas 30 (40%) had endoscopic relapse [i0- 31 patients (42%); i1- 13 patients (18%), i2- 11 patients (15%), i3- 14 patients (19%), i4- 5 patients (6%)]. Nonparametric Spearman correlation test only revealed that FC using a cut off of 30 μg/g weakly correlated with endoscopic relapse (r=0.329, p=0.004). Diagnostic accuracies of FC using different cut offs is shown in Table 1. Table 1 Diagnostic performance of FC regarding endoscopic relapse using different cut offs Conclusions: According to our results from our daily routine practise, the very low specificity of FC for each cut off in CD patients with an ileocecal resection lets us question the diagnostic utility of this non-invasive marker as an alternative tool to colonoscopy in the postop setting. A speculative explanation for this could either be the presence of unidentified lesions proximal to the ileocolonic anastomosis or ischemic anastomotic ulcers which might have been the reason behind the confusion of the endoscopist and let us judge the value of Rutgeerts score.

Crohn's disease with ankylosing spondylitis in an adolescent patient who had undergone long ileo-colonic anastomosis for Hirschsprung's disease as an infant.

Crohn's disease (CD) is a chronic, idiopathic, inflammatory disorder of the gastrointestinal tract. In rare cases, CD has been associated with Hirschsprung's disease (HD); however, the underlying pathophysiology of this and other comorbidities is not yet fully understood. In this report, we describe the case of a 17-year-old patient who was diagnosed with both CD and ankylosing spondylitis (AS), having undergone a long ileo-colonic anastomosis to treat HD at 12 months of age. To our knowledge, this is the first documented case of CD combined with AS in a patient with HD.

Current status of endoscopic balloon dilation for Crohn's disease.

The therapeutic target in Crohn's disease (CD) has been raised to the achievement of mucosal healing. Although effective treatments that target cytokines and other molecules has been widely used for CD, intestinal strictures are still a major cause of surgery. Endoscopic balloon dilation (EBD) is known to be an effective and safe intervention for intestinal strictures in CD. Since frequent intestinal resection often results in short bowel syndrome and can decrease the quality of life, EBD can help avoid surgery. EBD with a conventional colonoscope for Crohn's strictures of the colon and ileo-colonic anastomosis has established efficacy and safety. In addition, EBD using balloon-assisted enteroscopy has recently been applied for small bowel Crohn's strictures. Although the evidence is not strong, EBD may become an alternative to surgery in small bowel strictures in CD. EBD and other new methods such as self-expanding stent implantation for Crohn's strictures may be useful and safe; however, it is important to address several issues regarding these interventions and to establish a protocol for combined therapies.

Treatment of Postsurgery Crohn Disease

Sponsoring Organization: American Gastroenterological Association (AGA) Target Audience: Gastroenterologists, gastrointestinal surgeons Target Population: Patients with Crohn disease with an ileocolonic anastomosis who have no symptoms or macroscopic evidence of Crohn disease after surgical resection Background and Objective These graded evidence-based treatment guidelines are based on data from an accompanying systematic review on the treatment of Crohn disease after surgically induced remission. What's …

Management of Ileocolonic Anastomotic Strictures in Crohn Disease

Distal ileal or ileocolonic Crohn disease (CD) often requires resection with an ileocolonic anastomosis (ICA). Unfortunately, anastomotic strictures

Small Bowel Obstruction Caused by Epstein-Barr Virus Positive Extranodal Hodgkinʼs Lymphoma in a Patient with Crohnʼs Disease: A Case Report

Literature in the IBD population has reported increased risks for malignancy including lymphoproliferative disorders associated with biologic and thiopurine medications. A 55 year old male with a history of Crohn's disease presented with multiple symptoms of mid-abdominal pain, nausea, vomiting, constipation, and lack of flatus for three days. He had previous intestinal resections and intermittent therapy including systemic steroids, infliximab, azathioprine, and 5-ASA. The patient was found to have a small bowel obstruction which required surgical intervention and a nonpatent segment of an ileocolonic anastomosis was resected. Histological analysis of the resected anastomotic segment revealed positivity for PAX5, CD30, BCL-2, OCT-2, MUM1 for large cells. Neoplastic cells showed altered B-cell phenotype and decreased expression of PAX5, CD20, CD79a and BOB.1 consistent with Reed Sternberg cells. In-situ hybridization was positive for EBER confirming Epstein-Barr virus. The patient was diagnosed with ileocolonic anastomosis EBV positive classical Hodgkin lymphoma in Crohn's disease.Figure 1Figure 2Figure 3

ReFUSE to Give Up; A Case of Recurrent GI Bleeding Solved with Full Spectrum Endoscopy

Full-spectrum endoscopy (FUSE®) is a novel technology developed to enhance detection of adenomatous polyps during colonoscopy. While research has shown FUSE® to be superior to standard forward-viewing colonoscopy for adenomatous polyp detection, it has not been studied in the setting of gastrointestinal (GI) bleeding. We present a case of recurrent GI bleeding solved utilizing FUSE®. A 75 year old female with a history of hepatitis c, hypertension, and right hemicolectomy presented in June of 2015 with recurrent melena for one year. Prior to her presentation, she underwent a workup at another institution which included upper endoscopy, push enteroscopy, colonoscopy and video capsule endoscopy (VCE) without identifying a source of bleeding. Upon her initial presentation to our institution, exam was notable for melena on rectal exam and laboratory workup for hemoglobin 7.0 g/dL, hematocrit 21.5%, platelet count 136 K/UL, and an MCV 79.3FL. Over the next six months, the patient required three hospitalizations for overt, obscure GI bleeding during which she underwent three colonoscopies, two endoscopies, two single balloon enteroscopies, and three VCEs. Initial colonoscopy revealed blood 40cm into the terminal ileum without a source. Subsequently, VCE revealed red blood starting at the distal-jejunum. A follow up small bowel enteroscopy was unremarkable. The bleeding resolved and the patient was discharged home. The patient presented one month later and underwent colonoscopy, enteroscopy and capsule endoscopy without a source. The distal and proximal extents reached within the small bowel were tattooed. Once again, the bleeding resolved. During the third hospitalization, a discussion to perform surgical assisted enteroscopy occurred but a final VCE was performed and demonstrated a possible lesion at the ileocolonic anastomosis (Figure 1). The decision was made to perform a final colonoscopy using FUSE®, which demonstrated a large, non-bleeding angiodysplastic lesion distal to the ileocolonic anastomosis on the right sided camera (Figure 2) between two folds. Argon plasma coagulation was performed and three hemostatic clips were placed. Since the procedure one year ago, the patient has not experienced further bleeding. In conclusion, FUSE® has been studied for adenoma detection in colon cancer prevention; however this case highlights a possible additional use of FUSE® in diagnosing the etiology of overt, obscure GI bleeding.Figure 1Figure 2

A Rare Cause of Diarrhea in a Crohnʼs Patient: Pancreatic Insufficiency Due to Portal Vein Thrombosis

Inflammatory bowel disease (IBD) is an inflammatory state with an increased risk of venous thromboembolism (VTE). Patients with IBD have a three-fold higher risk of VTE compared to patients without IBD. This may occur due to disequilibrium between procoagulant and anticoagulant factors, bacterial translocation leading to portal pylephlebitis, or post-operative state. Herein, we present a case of Crohn's disease with portal vein thrombosis (PVT) causing exocrine pancreatic insufficiency (EPI). A 44 year-old man with fistulizing and fibrostenosing Crohn's Disease since age 12 presented with more than 10 bowel movements daily for 1 month. He was previously treated with adalimumab for 4 years without improvement in subjective symptoms, thus the patient self-discontinued medication at age 40. One year prior to presentation, the patient had severe abdominal pain and was found to have a peri-anal fistula and mid-transverse colonic stricture. He underwent an elective resection of 14.5 cm of his transverse colon with ileo-colonic anastomosis. On post-operative imaging, he was found to have PVT and completed 3 months of lovenox. Three months post-operative, he developed frequent non-bloody post-prandial diarrhea with early satiety and vague abdominal discomfort. He was tried on cholestyramine with minimal improvement. An EGD and colonoscopy to evaluate the diarrhea were non-diagnostic. He was sent for a CT scan to rule out small bowel to colonic fistula and was found to have extension of his portal vein thrombus from the left hepatic vein to the splenic vein. In addition, the CT scan showed atrophy of hepatic segments 6 and 7, but no evidence of pancreatitis. CBC and serum tryptase were unremarkable. He had an elevated AST, ALT, and alkaline phosphatase. He was started on pancrelipase and long-term anticoagulation with rivaroxaban with rapid improvement in symptoms consistent with EPI due to extension of the PVT into venous drainage of the pancreas. Active IBD is a risk factor for VTE. Here we describe a rare case of persistent diarrhea in a patient with Crohn's disease due to EPI associated with PVT. This has rarely been described in the literature, but the pathophysiology is thought to be due to PVT leading to obstruction of pancreatic venous drainage, causing pancreatic duct atrophy and exocrine insufficiency. Thus, in IBD patients with a history of PVT and persistent diarrhea it is important to consider EPI as an etiology.

Outcomes of Endoscopic Therapy of Luminal Strictures in Crohnʼs Disease

Introduction: Crohn's disease (CD)-related strictures may benefit from endoscopic therapy. We sought to describe the outcomes of endoscopic therapy of luminal strictures in CD patients (pts) at a large tertiary referral center. Methods: All pts with endoscopic dilation of CD strictures were identified between 1/1/1990 and 11/30/2013. Demographics, disease characteristics including medication use and history of surgeries, details of endoscopic procedures, and long-term outcomes including complications and need for surgery were analyzed. Successful endoscopic stricture dilation was defined as ability of the endoscope to pass through the stricture after dilation or effacement of the dilating balloon. Kaplan-Meier and Cox proportional hazards analysis were used. Results: A total of 603 procedures were performed in 274 pts. Median age was 45.9 yrs (range, 14.9-92.2) and 53.6% were female. Median duration of CD was 16.9 yrs (1.1-67.9). Most pts (94.8%) were symptomatic at the time of their procedure. Most common procedures were colonoscopy/flexible sigmoidoscopy (72.5%), esophagogastroduodenoscopy (EGD) (11.9%), and pouchoscopy (6.5%). Conscious sedation was used for 442 procedures (73.8%), and fluoroscopy was used in 80 procedures (13.5%). Most common stricture locations were ileocolonic anastomosis (41.1%) and colon (13.2%). Balloon dilation was used in 548 strictures (90.9%), Savary dilation in 19 strictures (3.2%), and Hegar dilators in 33 strictures (5.1%). Mean inner diameter of all index strictures was 8.2 mm (1.0-18.0). Steroid injection into the stricture was performed in 89 cases (14.9%). Seventy-three patients (25.4%) had a medication change after the initial procedure (addition of immunomodulators or biologics). One hundred fifteen pts had a second dilation. Cumulative probability of need for a second dilation following the index procedure was 32.5% (25.8%-38.6%) at 1 year, 53.6% (45.6%-60.8%) at 3 years, and 60.7% (51.9%-68.0%) at 5 years. See Table for factors associated with second dilation. Six complications occurred after the first procedure: 4 perforations, 1 pt with bleeding, and 1 pt with abdominal pain. Conclusion: In the largest cohort of its type, endoscopic stricture dilation in Crohn's disease was safe and effective. About 30% of pts required a second dilation at 1 year after the initial dilation; younger age and smaller inner diameter of the index stricture predicted need for a second dilation.Table 1: Predictors of a Second Dilation Based on Univariate Cox Analysis

Use of a lumen-apposing metal stent to treat GI strictures (with videos)

Benign GI strictures occur typically in the esophagus and pyloric channel but can occur anywhere in the GI tract and at anastomotic sites. Such strictures can be treated with dilation, incisional therapy, steroid injection, and stents. Our aim was to describe the use of a lumen-apposing metal stent (LAMS) to treat short, benign GI strictures. Consecutive patients who underwent LAMS placement for various benign strictures at 2 tertiary care centers from August 2014 to November 2015 were reviewed retrospectively. The main outcome measures were technical success, clinical success, stent migration, and adverse events. Twenty-five patients (7 males, 18 females) with a median age of 54 years (33-85 years) underwent 28 LAMS placements to treat various benign strictures. The location of the strictures included esophagogastric anastomoses (n=4), gastrojejunal anastomoses (n=13), pylorus (n=6), vertical banded gastroplasty (n=1), and ileocolonic anastomosis (n=1). Twenty patients had been previously treated with dilation alone (9 patients with≥3 dilations), 11 patients with dilation and steroid injection, 2 patients with additional needle-knife therapy, and 1 patient with placement of a traditional fully covered self-expandable metal stent. A 15-mm internal diameter LAMS was placed in all patients; 3 patients had been treated previously with a 10-mm LAMS. Technical success was achieved in all patients, whereas clinical success was achieved in 15 of 25 patients (60%) who completed a minimum of 6 months of follow-up after placement. Median stent dwell time was 92 days (range, 3-273 days). Stent migration was seen in 2 of 28 stent placements (7%). Four of 25 patients (16%) developed 5 moderate adverse events (pain requiring removal, 2; new stricture formation, 2; bleeding, 1). Median follow-up was 301 days after stent placement. Study limitations include the small, select group of patients, the retrospective study design, and short follow-up. LAMS placement for benign GI strictures is technically easy and safe with low migration rates and may be an option to treat selected patients with short-length strictures.

Submucosal Plexitis as a Predictive Factor for Postoperative Endoscopic Recurrence in Patients with Crohn's Disease Undergoing a Resection with Ileocolonic Anastomosis: Results from a Prospective Single-centre Study.

Ileocolonoscopy allows early detection of recurrence after surgical resection for Crohn's disease [CD]. Plexitis, defined as presence of inflammatory cells in or around enteric ganglia or nerve bundles, in the proximal surgical margin has been associated with an increased overall recurrence risk. We investigated prospectively whether plexitis can predict endoscopic recurrence [ER] in a consecutive cohort of CD patients undergoing ileocolonic resection. All CD patients undergoing ileocolonic resection in our institution between October 2009 and December 2012 were eligible for this study. Clinical data were obtained prospectively from the patients' files, and biopsies from the proximal surgical margins were analysed immunohistochemically for inflammation at the myenteric and submucosal plexus [lymphocytes, mast cells, eosinophils]. The degree of plexitis was correlated with the presence of ER at 6 months, defined as a modified Rutgeerts' score of ≥ i2b. Multivariate models were developed and tested to predict posterior probability of ER. A total of 74 patients were included. Six months after ileocolonic resection, 50% showed ER. Known risk factors such as penetrating disease, previous resections, and active smoking, showed no relation with ER. On the other hand, submucosal lymphocytic plexitis was associated with ER [p = 0.020]. The predictive value of lymphocytic cell count increased with more extensive biopsy sampling and with application of immunohistochemistry. Submucosal lymphocytic plexitis in the proximal surgical margin was significantly related with a higher risk for ER after ileocolonic resection. These data support development of a postoperative prevention trial with vedolizumab, which may block lymphocytic trafficking in the postoperative bowel.

Ileal or Anastomotic Location of Lesions Does Not Impact Rate of Postoperative Recurrence in Crohn's Disease Patients Classified i2 on the Rutgeerts Score.

The Rutgeerts score with 5 grades of severity (i0-i4) is a suitable endoscopic model to predict clinical recurrence following ileocolonic resection in Crohn's disease (CD). Definition of grade i2 includes lesions confined to the ileocolonic anastomosis (i2a) or moderate lesions on the neo-terminal ileum (i2b). The aim of the present study was to evaluate the probability of clinical recurrence in i2a and i2b patients. This multicenter retrospective study included all CD patients classified i2 at the first postoperative ileocolonoscopy. The primary outcome was to evaluate the probability of clinical recurrence in patients classified i2a and i2b. The secondary outcome was to compare the rate of global recurrence of CD. Fifty patients were included: 23 were classified i2a and 27 were classified i2b. The median duration of follow-up was 40 (18.0-80.4) months in the i2a group and 53.5 (25.0-69.0) months in the i2b group (p=0.9). The probability of clinical recurrence was not significantly different between patients classified i2a and i2b (p=0.64). Median time to clinical recurrence after the first ileocolonoscopy and probability of global CD recurrence were not different between the two groups (p≥0.19). The rate of clinical postoperative recurrence is not different in i2a and i2b patients. These results suggest that the same therapeutic strategy should be used in all patients classified i2 on the Rutgeerts score whatever the location of postoperative CD recurrence.

Recommendations for Quality Colonoscopy Reporting for Patients with Inflammatory Bowel Disease

Consensus on what constitutes a quality colonoscopy report for patients with inflammatory bowel disease (IBD) is lacking. We developed a template for quality colonoscopy reporting that can be used broadly by endoscopists. After a literature review of topics relevant to colonoscopy reporting, members of the Building Research in Inflammatory Bowel Disease Globally (BRIDGe) group and 2 external experts proposed candidate reporting elements. The RAND/University of California, Los Angeles appropriateness method was applied to rate the importance and feasibility of elements for inclusion in colonoscopy reports for patients with IBD. Panelists used the modified Delphi method to anonymously rate the importance and feasibility of candidate elements on a 1-to-9 scale (1-3: not important/feasible, 4-6: moderately important/feasible, 7-9: very important/feasible). Disagreement was assessed using a validated index. The panelists then met in person for discussion followed by a second round of voting. Elements rated a median of 7 or higher on importance after rerating were retained. One hundred two reporting elements were proposed. A total of 48 elements were retained across the four themes of "disease background," "findings and interventions," "Crohn's disease with an ileocolonic anastomosis," and "pouchoscopy." A comprehensive list of recommended elements for quality IBD colonoscopy reporting stratified by clinical scenario has been described, using a rigorous and evidence-based approach. These elements can be incorporated into endoscopy reporting software platforms. Standardized endoscopy reporting may improve the quality of care in IBD.

Interobserver Variation Study of the Rutgeerts Score to Assess Endoscopic Recurrence after Surgery for Crohn's Disease.

After resection surgery for Crohn's disease, recurrence of endoscopic lesions at the site of the anastomosis or in the neoterminal ileum is graded according to the Rutgeerts score (RS). The goal of this study was to test the interobserver variability for RS. Thirteen trained endoscopists evaluated the RS on 39 videotapes of patients who had undergone resection for Crohn's disease with an ileocolonic anastomosis 6 months earlier. Videotapes were randomly assigned to endoscopists through a balanced incomplete block design. Each videotape was scored independently by four endoscopists, and each endoscopist evaluated 12 videotapes, making a total of 156 videotape assessments. Reproducibility levels of the RS were assessed through unweighted kappa estimates among multiple raters. The proportion of inappropriate therapeutic initiation was estimated by randomly selecting one endoscopist for each videorecording, assuming that the majority of endoscopists correctly classified endoscopic recurrence. The kappa estimates were 0.43 (95% confidence interval: 0.33-0.52) for the RS on a 5-grade scale, 0.47 (0.28-0.66) for RS < i2 vs. ≥ i2, and 0.64 (0.42-0.85) for RS ≤ i2 vs. > i2. The percentages of inappropriate therapeutic initiation were 12.8% (3.8-21.9) when initiation was triggered by a RS ≥ i2 and 8.3% (1.1-15.6) when initiation was triggered by a RS > i2 (p = 0.41). The reproducibility of the RS was moderate, especially when differentiating <i2 from ≥i2, which may lead to incorrect therapeutic decisions in >10% of patients.

Tu1953 Postoperative Clinical Recurrence Is Not Different in Crohn's Disease Patients Classified I2 on Rutgeerts Score With Lesions Confined to the Ileocolonic Anastomosis Compared to Patients With Lesions of the Neo-Terminal Ileum

Tu1953 Postoperative Clinical Recurrence Is Not Different in Crohn's Disease Patients Classified I2 on Rutgeerts Score With Lesions Confined to the Ileocolonic Anastomosis Compared to Patients With Lesions of the Neo-Terminal Ileum

V1-01 ROBOTIC INTRACORPOREAL INDIANA POUCH: REPLICATING OPEN SURGERY

You have accessJournal of UrologyRobotics-Bladder/Reconstruction1 Apr 2016V1-01 ROBOTIC INTRACORPOREAL INDIANA POUCH: REPLICATING OPEN SURGERY Andre Luis de Castro Abreu, Giuseppe Simone, Sameer Chopra, Mariaconsiglia Ferriero, Rocco Papalia, Nariman Ahmadi, Riccardo Mastroianni, Daniel Park, Andre Berger, Salvatore Guaglianone, Rene Sotelo, Michelle Gallucci, Monish Aron, Inderbir Gill, and Mihir Desai Andre Luis de Castro AbreuAndre Luis de Castro Abreu More articles by this author , Giuseppe SimoneGiuseppe Simone More articles by this author , Sameer ChopraSameer Chopra More articles by this author , Mariaconsiglia FerrieroMariaconsiglia Ferriero More articles by this author , Rocco PapaliaRocco Papalia More articles by this author , Nariman AhmadiNariman Ahmadi More articles by this author , Riccardo MastroianniRiccardo Mastroianni More articles by this author , Daniel ParkDaniel Park More articles by this author , Andre BergerAndre Berger More articles by this author , Salvatore GuaglianoneSalvatore Guaglianone More articles by this author , Rene SoteloRene Sotelo More articles by this author , Michelle GallucciMichelle Gallucci More articles by this author , Monish AronMonish Aron More articles by this author , Inderbir GillInderbir Gill More articles by this author , and Mihir DesaiMihir Desai More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2115AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Continent cutaneous diversion is an option for patients undergoing cystectomy. Herein we report our experience of 10 consecutive patients who underwent completely intracorporeal robotic Indiana Pouch construction following robotic cystectomy. METHODS Surgical steps: Robotic cystectomy and pelvic lymph node dissection (PLND) are performed with a 6-trocar access. Robot is undocked and specimen extracted from the left lateral port. Both left side ports are closed and three additional ports are placed. Table is rotated 45 degree to left and the robot is re-docked on right side. Replicating open techniques: 12 cm of distal ileum and 30cm of right colon are isolated; side to side stapled ileocolonic anastomosis is performed; colonic segment is detubularized along the antimesenteric tenia up to 3cm distal to the ileocecal valve and U folded. The medial aspect of the folded colon is sewn. Ureterocolonic anastomoses are performed on the posterior aspect of the pouch. Bilateral J stents are placed in ureters and secured to a 24-Fr hematuria catheter inserted via the appendiceal orifice. After closing the lateral aspect of the pouch, a Foley catheter is inserted via the umbilical port and through efferent ileal limb and placed into the colonic pouch. The efferent limb is tapered with a 60mm stapler on the antimesenteric aspect. The ileocecal valve and the efferent limb are plicated to increase the outflow resistance. The efferent limb is now extracted and the stoma created at the umbilical site. RESULTS There were no intraoperative complications and all procedures (n=10) were successfully completed robotically. Median operative times were 60 min for cystectomy, 65 min for PLND, 45 min for repositioning/re-docking and 210 min for pouch construction. The median overall operative time was 365 (295-540) min. No patients were transfused. Median hospital stay was 9 days. 30-day complication rate was 40%. There were no grade 3 or 4 complications. At 3-month follow-up urodynamics demonstrated a mean maximum capacity of 270mL without ureteral reflux and minimal urine residual; 9 patients (90%) reported full continence. No patient died. CONCLUSIONS Robotic Indiana pouch can be safely performed, completely intracorporeally. This technique provides a minimally-invasive, time efficient approach with acceptable complication rates. Patients undergoing radical cystectomy can now be offered all types of urinary diversions robotically. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e61 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Andre Luis de Castro Abreu More articles by this author Giuseppe Simone More articles by this author Sameer Chopra More articles by this author Mariaconsiglia Ferriero More articles by this author Rocco Papalia More articles by this author Nariman Ahmadi More articles by this author Riccardo Mastroianni More articles by this author Daniel Park More articles by this author Andre Berger More articles by this author Salvatore Guaglianone More articles by this author Rene Sotelo More articles by this author Michelle Gallucci More articles by this author Monish Aron More articles by this author Inderbir Gill More articles by this author Mihir Desai More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

DOP016. Postoperative clinical recurrence is not different in Crohn’s disease patients classified as i2 on the Rutgeerts score with lesions confined to the ileocolonic anastomosis than in those with lesions of the neoterminal ileum

DOP016. Postoperative clinical recurrence is not different in Crohn’s disease patients classified as i2 on the Rutgeerts score with lesions confined to the ileocolonic anastomosis than in those with lesions of the neoterminal ileum

Contemporary management of anastomotic leak after colon surgery: assessing the need for reoperation

BackgroundWe sought to investigate contemporary management of anastomosis leakage (AL) after colonic anastomosis. MethodsThe American College of Surgeons National Surgical Quality Improvement Program database 2012 to 2013 was used to identify patients with AL. Multivariate regression analysis was performed to find predictors of the need for surgical intervention in management of AL. ResultsA total of 32,280 patients underwent colon resection surgery with 1,240 (3.8%) developing AL. Overall, 43.9% of patients with AL did not require reoperation. Colorectal anastomosis had significantly higher risk of AL compared with ileocolonic anastomosis (adjusted odds ratio [AOR], 1.20; P = .04). However, the rate of need for reoperation was higher for AL in colocolonic anastomosis compared with ileocolonic anastomosis (AOR, 1.48; P = .04). White blood cell count (AOR, 1.07; P < .01), the presence of intra-abdominal infection with leakage (AOR, 1.47; P = .01), and protective stoma (AOR, .43, P = .02) were associated with reoperation after AL. ConclusionsNonoperative treatment is possible in almost half of the patients with colonic AL. The anatomic location of the anastomosis impacts the risk of AL. Severity of leakage, the presence of a stoma, and general condition of patients determine the need for reoperation.

Small Intestinal Bacterial Overgrowth (SIBO) and Fungal Overgrowth (SIFO): A Frequent and Unrecognized Complication of Colectomy: ACG Category Award: Presidential Poster

Introduction: Following subtotal colectomy, approximately 40% of patients report abdominal pain and diarrhea, and this is associated with poor quality of life. Its cause is unknown and many are labeled as IBS. In a pilot study, we observed a high incidence of bacterial overgrowth in post-colectomy patients. Our aim was to determine the prevalence of SIBO/SIFO in patients with unexplained GI symptoms following colectomy (> 1 year). Methods: Patients seen between January 2012 to March 2015 with chronic GI complaints and a history of colectomy and negative GI evaluation (endoscopy, blood tests, CT scan) other than post-op changes were assessed and underwent testing for SIBO with either 75 g glucose breath test (GBT) and/or distal duodenal aspiration (DDA). The DDA was performed using aseptic technique with a sterile 6F Liguory nasobiliary catheter, and cultures were obtained for aerobic, anaerobic, and fungal organisms. Bacterial concentrations≥103 cfu/mL was defined as SIBO positive. Results: 50 patients (F/M =41/9; mean age 52.32 years) with prior colectomy were assessed. Of these, 48/50 patients underwent GBT alone, 33 underwent GBT and DDA, and 2 underwent DDA alone. We found that 31/50 patients(62%) had SIBO. 16 subjects with SIBO had aerobic flora (streptococcus and klebsiella spp.), and 11 had anaerobic flora (bacteroides veillonella, and peptostreptococcus spp). In this subgroup 12/31(39%) had concurrent SIFO and 2/50(4%) had SIFO alone—all grew candida. Abdominal pain, gas, bloating, diarrhea, and nausea are common and severe (table1). Patients with SIBO/SIFO had greater symptoms than those without. The indication for subtotal colectomy was constipation(36%), diverticular disease(8%), bowel obstruction(8%), colorectal carcinoma(8%), polyps(6%), other (26%), or not documented (8%). The prevalence of SIBO in patients with history of constipation was 10/18(56%) compared to 22/32(69%) in patients without constipation. Conclusion: Overall 62% of patients with previous colectomy and chronic GI symptoms had undiagnosed SIBO and 39% had concurrent SIFO. SIBO and SIFO are important, frequent, and unrecognized complications following colectomy that explain their persistent gas, bloating, and pain. This occurs either because of small intestinal colonization by colonic flora by translocation through a widely patent ileocolonic anastomosis and/or dysmotility. SIBO/SIFO should be identified and treated in patients with persistent GI symptoms after colectomy, and not mislabeled as IBS.Table 1: Symptom prevalence and severity in patients with SIBO, Mixed SIBO and SIFO, SIFO and no overgrowth