Total Abdominal Colectomy Research Articles

Parastomal Evisceration: Rare Complication after Total Abdominal Colectomy

Parastomal Evisceration: Rare Complication after Total Abdominal Colectomy

Staged retroperitoneal mesenteric revascularisation and aortobifemoral bypass after endovascular rescue for acute mesenteric ischaemia

Visceral artery revascularisation through a retroperitoneal approach provides an infrequent yet viable, alternative means of managing mesenteric ischaemia in patients with previous abdominal operations. We present a unique case implementing...

Association of Preoperative Anti–Tumor Necrosis Factor Therapy With Adverse Postoperative Outcomes in Patients Undergoing Abdominal Surgery for Ulcerative Colitis

Despite the increasing use of anti-tumor necrosis factor (TNF) therapy in ulcerative colitis, its effects on postoperative outcomes remain unclear, with many patients requiring surgical intervention despite optimal medical management. To assess the association of preoperative use of anti-TNF agents with adverse postoperative outcomes. This analysis used insurance claims data from a large national database to identify patients 18 years or older with ulcerative colitis. These insured patients had inpatient and/or outpatient claims between January 1, 2005, and December 31, 2013, with Current Procedural Terminology codes for a subtotal colectomy or total abdominal colectomy, a total proctocolectomy with end ileostomy, or a combined total proctocolectomy and ileal pouch-anal anastomosis. Only data regarding the first or index surgical admission within the time frame were abstracted. Use of anti-TNF agents, corticosteroids, and immunomodulators within 90 days of surgery was identified using Healthcare Common Procedure Coding System codes. Inclusion in the study required the patient to have an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code for ulcerative colitis. Exclusion occurred if the patient had a secondary ICD-9-CM diagnosis code for Crohn disease or if the patient was not continuously enrolled in an insurance plan for at least 180 days before and after the index surgery. Data were collected and analyzed from February 1, 2015, to June 2, 2016. Outcomes included 90-day complications, emergency department visits, and readmissions. Multivariable logistic regression was used to model covariates, including anti-TNF agent use, on the occurrence of outcomes. Of the 2476 patients identified, 1379 (55.7%) were men, and the mean (SD) age was 42.1 (12.9) years. Among these, 950 (38.4%) underwent subtotal colectomy or total abdominal colectomy, 354 (14.3%) underwent total proctocolectomy with end ileostomy, and 1172 (47.3%) received ileal pouch-anal anastomoses. In univariate analyses, increased postoperative complications were observed among patients in the ileal pouch cohort who received anti-TNF agents preoperatively vs those who did not (137 [45.2%] vs 327 [37.6%]; P = .02) but not among those in the colectomy or proctocolectomy cohorts. An increase in complications was also observed on multivariable analyses among patients in the ileal pouch cohort (odds ratio, 1.38; 95% CI, 1.05-1.82). Unlike preoperative anti-TNF agent use among patients who underwent colectomy or total proctocolectomy and experienced no significant increase in postoperative complications, anti-TNF agent use within 90 days of surgery among patients who underwent ileal pouch-anal anastomosis was associated with higher 90-day postoperative complication rates.

Total abdominal colectomy vs. restorative total proctocolectomy as the initial approach to medically refractory ulcerative colitis.

There is scant data assessing the consequences of staging restorative proctocolectomy for ulcerative colitis. The aim of the study is to compare outcomes of initial vs. staged restorative proctocolectomy. Patients completing restorative proctocolectomy, including ileostomy reversal, during 2006-2012 were identified from an IRB-approved database. Demographics, treatment variables, and perioperative outcomes were assessed. Out of 521 patients, 322 (62%) underwent initial total abdominal colectomy before restorative proctectomy. This group was associated with more common preoperative anemia, leukocytosis, hypoalbuminemia, severe colitis, steroids and biologics use, decreased proximal ileostomy rate at the time of completion restorative proctectomy (92.5 vs 97.5%, p=0.023), shorter hospital stay (6.6 vs 7.8, p<0.001), and marginally decreased pelvic sepsis rate (6.2 vs 11.1%, p=0.05) compared with patients having initial restorative proctocolectomy. However, they also required longer combined postoperative hospital stays (17 vs 12days, p<0.001) and treatment span (10.4 vs 5.7months, p<0.001) to complete all surgical stages and they were associated with increased overall postoperative surgical site infection, hemorrhage, and small bowel obstruction rates. Pouch function and QOL were comparable between the groups, except for increased nightly bowel movements in the initial abdominal colectomy group (2.5±2.2 vs 2.1±1.8, p=0.012). Patients undergoing initial total abdominal colectomy require longer treatment time and experience increased overall morbidity, but ultimately experience comparable ileal pouch outcomes when compared to patients undergoing initial restorative proctocolectomy.

Clostridium difficile extraintestinal abscess: a rare complication

Extraintestinal Clostridium difficile is rare. A 74-year-old man with a history of ulcerative colitis presented after a fall. Trauma work-up showed liver cirrhosis. Two days later he developed abdominal pain,...

Variant Two-Stage Ileal Pouch-Anal Anastomosis: An Innovative and Effective Alternative to Standard Resection in Ulcerative Colitis

Ulcerative colitis patients have been historically treated with standard single, 2-, and 3-stage operative approaches. We perform a variant 2-stage procedure beginning with total abdominal colectomy and end ileostomy followed by completion proctectomy and ileal pouch-anal anastomosis (IPAA) without a diverting loop ileostomy. This study evaluates the effectiveness of this innovative alternative. Patients with ulcerative colitis, admitted to the University of North Carolina Hospital between 2003 and 2010 for IPAA, were eligible for inclusion. The 3-year cumulative incidence of pouch leaks among patients undergoing variant 2-stage were compared with those undergoing classic 2-stage, using inverse probability-of-treatment weighted Kaplan- Meier survival curves, and 95% CIs were estimated using nonparametric bootstrapping. There were 248 patients who underwent IPAA; 139 (56.1%) underwent classic 2-stage and 109 (43.9%) underwent variant 2-stage. After standardization, there was no significant difference in the 3-year cumulative incidence of pouch leaks between patients undergoing variant 2-stage, compared with the standard single- or 2-stage procedure (risk difference 0.01; 95% CI -0.08, 0.15). At the time of the first surgical procedure, patients undergoing a variant 2-stage were more likely to have lower BMIs (median 22.5 kg/m2 vs 26.7 kg/m2; p<0.0001), an urgent/emergent procedure (56.9% vs 0.0%; p < 0.0001), biologic use within 2 weeks of surgery (32.1% vs 17.5%; p= 0.003), and high dose steroid use (60.4% vs 16.7%; p ≤ 0.0001). Variant 2-stage IPAA is a safe and effective operative approach with comparable outcomes in a more acute population based on BMI, steroid use, and urgency of operation.

Early Experience with Single-Incision Laparoscopic Total Abdominal Colectomy in Children.

Single-incision laparoscopic surgery for pediatric colorectal disease has been shown to be feasible and safe; however, the literature is scarce regarding the outcomes of single-incision laparoscopic total abdominal colectomy (SIL-TAC) in the pediatric population. The purpose of this pilot study was to review our initial experience and outcomes with SIL-TAC. A retrospective review of patients who underwent SIL-TAC from 2013 to 2015 was performed. General demographic and outcome data were analyzed. Five patients were included. Indications included ulcerative colitis (n = 4) and colonic dysmotility (n = 1). The median age was 13.5 years (8.5-19.4 years) and the median body mass index (BMI) percentile was 77.4 (2.2-98). The median operative time was 182 minutes (163-244 minutes). One case was converted to an open procedure. The median postoperative self-reported pain score was 2.8 (1.2-4.5). The median time until initiation of a diet was 2 days (1-8 days). The median length of hospital stay was 5 days (3-11 days). There were no 30-day complications. SIL-TAC is feasible and safe in children and offers improved cosmesis.

Hand-Assisted Laparoscopic Colectomy Improves Perioperative Outcomes Without Increasing Operative Time Compared to the Open Approach: a National Analysis of 8791 Patients

IntroductionHand-assisted laparoscopic surgery (HALS) is often used in procedures too complex for completely minimally invasive approaches. However, there are concerns for whether this hybrid approach abrogates perioperative benefits of the completely minimally invasive technique. MethodsWe queried the 2012–2013 National Surgery Quality Improvement Program for adults undergoing elective HALS or open colectomy (OC). After propensity matching, short-term outcomes were compared. Subset analysis was performed for segmental resections. Multivariate analysis was used to determine predictors of utilizing either approach. ResultsThis query included 8791 patients (OC 2707, HALS 6084). Predictors of HALS included male sex (OR 1.17, p = 0.006), increasing BMI (OR 1.01, p = 0.02), benign indication (OR 1.48, p < 0.001), and total abdominal colectomy (OR 10.39, p < 0.001). Younger age, black race, ASA class ≥3, inflammatory bowel disease, and low pelvic anastomosis were predictive of OC (all p < 0.05). HALS demonstrated reduced overall complications (p < 0.001), wound complications (p < 0.001), anastomotic leak (p = 0.014), transfusion (p < 0.001), postoperative ileus (p < 0.001), length of stay (p < 0.001), and readmission (p < 0.001) without increased operative time. For segmental resection, HALS demonstrated reduced overall complications, wound complications, respiratory complications, postoperative ileus, anastomotic leak, transfusion, length of stay, and readmissions (all p < 0.05). ConclusionsCompared to OC, HALS demonstrates improved perioperative outcomes without increased operative time.

Giant megacolon: An unusual surgical emergency

Giant megacolon (GMC), an advanced form of chronic megacolon, is an uncommon diagnosis that may evolve into a surgical emergency. Here, we demonstrate a case of an elderly male who presented to our hospital with complaints of acute abdominal distention and diffuse abdominal pain. He was emergently taken to the operating room where necrotic cecum was found. The patient underwent total abdominal colectomy with end ileostomy. Radiographic and operative images of GMC are presented. The authors also discuss the pathophysiology and clinical management of this surgical condition. The following core competencies are addressed in this article: Medical knowledge, Patient care.

Long-term Outcomes of Sphincter-Saving Procedures for Diffuse Crohn's Disease of the Large Bowel.

Total abdominal colectomy with ileorectal anastomosis for Crohn's colitis is acceptable in the presence of a suitable rectum. Intentional IPAA has been proposed for diffuse Crohn's proctocolitis without enteric or anoperineal disease. The aim of this study was to evaluate the long-term outcomes of sphincter-saving procedures for large-bowel Crohn's disease. Patients with preoperative Crohn's disease diagnosis undergoing intentional IPAA and ileorectal anastomosis were included. The study was conducted at a tertiary care research center. Ileorectal anastomosis was performed in 75 patients with Crohn's disease, whereas 32 patients underwent intentional IPAA. Long-term functional results and permanent stoma requirement of sphincter-saving operations were assessed. Quality of life and postoperative medication use were also compared with a control group of patients undergoing total proctocolectomy and end ileostomy. Patients undergoing ileorectal anastomosis were older and had longer disease duration, higher prevalence of perianal and penetrating disease, and history of small-bowel resection than those receiving IPAA. Indications for surgery, preoperative use of immunomodulators, and postoperative use of biologics were also significantly different. Although functional defecatory outcomes were comparable, reported quality of life 3 years after surgery was significantly better in patients who underwent IPAA than in patients with ileorectal anastomosis. Patients with IPAA were associated with significantly lower cumulative rates of surgical recurrence (HR = 0.28 (95% CI, 0.09-0.84); p = 0.017), indefinite stoma diversion (HR = 0.35 (95% CI, 0.13-0.99); p = 0.039), and proctectomy with end ileostomy (HR = 0.27 (95% CI, 0.07-0.96); p = 0.030) than those with ileorectal anastomosis. The study was limited by its retrospective nature and small sample size. Contemporary patients selected to have intentional IPAA for Crohn's colitis have disease characteristics very different from those selected to have ileorectal anastomosis. Long-term follow-up confirms intentional IPAA as an acceptable option in selected patients with Crohn's colitis.

An institutional comparison of total abdominal colectomy and diverting loop ileostomy and colonic lavage in the treatment of severe, complicated Clostridium difficile infections

BackgroundTotal abdominal colectomy (TAC) is the standard surgical treatment of Clostridium difficile infection (CDI). An alternative therapy, loop ileostomy and colonic lavage (IL), was described in 2011, but the results have never been validated. MethodsPatients treated surgically for CDI between April 2011 and June 2015 were included. Bivariable analysis was used to compare 30-day mortality, 1-year mortality, CDI recurrence, colon preservation and ileostomy reversal. ResultsTen IL patients and thirteen TAC patients were identified. 30-day mortality (30% vs 23%, p = 1.0) and 1-year mortality (40% vs 46%, p = 1.0) were similar. Four IL and three TAC patients (57% vs 30%, p = 0.35) experienced recurrent CDI. All six surviving IL patients had successful colon preservation; five underwent ileostomy reversal compared to three in the TAC group (83% vs 43%, p = 0.27). ConclusionsAlthough IL allowed colon preservation and return of intestinal continuity in most patients, IL did not decrease mortality or recurrent CDI when compared to TAC.

Comparing Fecal Microbiota Transplantation to Total Abdominal Colectomy and Loop Ileostomy in Severe and Complicated Clostridium difficile Infections

Comparing Fecal Microbiota Transplantation to Total Abdominal Colectomy and Loop Ileostomy in Severe and Complicated Clostridium difficile Infections

Clostridium Difficile Extra-intestinal Abscess: A Rare Complication of Clostridium Difficile Infection

Clostridium difficile infection (CDI) occurs due to disruption of the normal colonic flora and overgrowth of toxigenic clostridium difficile (CD) causes a spectrum of manifestations, ranging from an asymptomatic carrier state to fulminant disease with toxic megacolon. CDI very rarely presents outside the colon. A 70 year old male with history of ulcerative colitis (UC), previously on sulfasalazine and antibiotics presented to the hospital with hip fracture after sustaining a fall. Trauma work up included a computed tomography (CT) of the abdomen, which showed an incidental finding of liver cirrhosis. Over the next 2 days, the patient developed severe abdominal pain, distension, diarrhea and leukocytosis. He tested positive for CDI, confirmed by PCR from the stool sample. A repeat CT abdomen showed pancolitis with dilated colon, suggestive of toxic megacolon. For the severe, complicated CDI a total abdominal colectomy and ileostomy with a rectal stump was done. He was discharged to a rehabilitation facility 10 days later. A week after discharge the patient represented to the hospital with chills, nausea, vomiting, mucus like discharge from the rectum. CT scan of the abdomen without contrast showed ileal loops with severe inflammatory changes and a 10.4 x 7.6 cm fluid collection in the pelvis above the urinary bladder. Repeat testing for CD was negative. A CT guided drainage of the abscess with catheter placement was done by Interventional radiology. The fluid aspirate culture grew CD. A barium enema performed did not reveal any leakage or communication from the rectal stump to the abscess. He was treated with intravenous metronidazole for 1 week with resolution of symptoms and was eventually discharged on oral metronidazole. The development of extra-intestinal CD abscess is very rare. Although no absolute causal link can be established in our case, it is likely due to a combination of factors such as gastrointestinal surgery causing possible leakage, severe and complicated CDI with toxic megacolon which might have led to microperforations, helping in setting up an extra-intestinal focus of infection. Immunosuppressed states such as UC and liver cirrhosis might have had a role in the development of this abscess as reported in the literature. In such cases, we recommend drainage of the abscess along with concomitant treatment with metronidazole and or vancomycin. We also recommend reimaging the abscess prior to cessation of antibiotics.

Familial Adenomatous Polyposis (FAP): A Rare Presentation of Severe Anemia with Pancytopenia

While anemia is present in nearly one quarter of patients at the time of primary diagnosis of FAP and varies in severity and incidence depending on anatomic site of carcinoma, the full range or degree of anemia and coexistent cytopenias are not well described. A 26-year-old Caucasian-American male without notable medical history presented with dyspnea, fatigue and night sweats for three days associated with a ten-pound weight loss over the past month. The patient was febrile, tachycardic, and pale on examination. Initial evaluation revealed pancytopenia with a significant iron deficient anemia (Hb 3.7 g/dL, MCV 52.4 fL, iron 12 ug/dL, ferritin 7 ng/mL, percent iron saturation 3.8), neutropenia (1100/uL WBC, ANC 675/uL), and thrombocytopenia (96,000/uL PLT). The patient was initially managed for neutropenic fever with suspicion of infection or hematological malignancy. Fecal occult blood returned positive. Infective evaluation was negative. CT demonstrated splenomegaly with non-enlarged scattered lymph nodes. Bone marrow biopsy revealed absent iron stores without evidence of malignancy. After resolution of neutropenia, colonoscopy revealed innumerable pedunculated and semi-pedunculated polyps from rectum to cecum. Pathology returned with multiple fragments of tubular adenomas, negative for high-grade dysplasia or malignancy. Genetic evaluation diagnosed FAP with a heterozygous mutation in the APC gene. Laparoscopic total abdominal colectomy with ileorectal anastamosis confirmed two synchronous invasive moderately differentiated colonic adenocarcinomas arising from separate tubular adenomas, polyposis coli, and metastatic disease involving 1 of 43 mesenteric lymph nodes, defining a stage IIIA pT2M1aM0 colon cancer. The patient now continues with his second cycle of modified FOLFOX chemotherapy. The case above fits the general description of presentation for FAP based on studies to date with fecal occult blood positivity (59% overall) and microscopic bleeding detected in 72% of patients between 20 and 40 years old. Nearly a quarter of patients suffer from anemia overall, ranging by age group (21% age 20-40, 17% age over 40) and location of carcinoma (35% rectal, 44% colonic, 43% small bowel). To the author's knowledge, there are no consistent reports regarding degree of anemia or other cytopenias, which evidently range from mild to severe, even without a history of visible colonic bleeding.

Giant Inflammatory Pseudopolyposis Mimicking Colonic Tumor in an Ulcerative Colitis Patient

Introduction: We report a case of giant inflammatory pseudopolyposis in an ulcerative colitis patient who had been refractory to medical management and eventually had a total colectomy. Case Report: A 21-year-old man presented with fatigue, unintentional weight loss, and intermittent abdominal pain. He developed significant anemia, and his hemoglobin levels were 7.1 g/dL. He was diagnosed as having pan-ulcerative colitis after a colonoscopy that demonstrated moderately severe colitis extending from the rectum to hepatic flexure. Additionally, colonic biopsies showed that he had chronic active colitis with cryptitis and crypt abscesses with glandular tissue distortion consistent with chronic inflammatory bowel disease. The patient was treated with budesonide-MMX and mesalamine, but his response was minimal, so his treatment was changed to anti-tumor necrosis factors - first adalizumab and then golizumab. A follow-up colonoscopy one year later showed a near-obstructing mass at the level of hepatic flexure and ascending colon, and it prohibited the movement of the colonoscope to the traverse colon (Figure 1). A computerized tomography scan of the abdomen demonstrated a solid appearing mass measuring 8 cm in size that was suspicious for a colonic neoplastic lesion (Figure 2). The patient then underwent a laparoscopic total abdominal colectomy and the resulting surgical pathology showed chronic, active ulcerative colitis with a diffuse infiltration of mixed inflammatory cells and large inflammatory pseudopolyposis but no evidence of dysplasia or malignancy. Discussion: Giant inflammatory pseudopolyps, defined as polyps larger than 1.5 cm in size, were first described in 1965 and tend to occur during the early and active disease course of young inflammatory bowel disease patients. The pathological features typically are a benign inflammatory process. Only one case has been reported with occult variable degrees of dysplasia. There are reported cases of regression of giant pseudopolyps after initiation of IBD therapy. When these pseudopolyps become refractory to medical treatment or cause obstructive symptoms, surgery is indicated.Figure 1Figure 2

Clostridium Difficile the Landmine of Medicine

Clostridium difficile infection (CDI) is a rising challenge to the US health system. Many intervention measures were designed and implemented in an attempt to control CDI including antibiotic stewardship, improved hand hygiene and contact isolation. We are presenting a case series of 2 patients with a unique infection source. A 69 years old Caucasian female (CF) scrub nurse (patient 1) who participated in an elective ileostomy reversal of a 77 years old CF (patient 2) with past medical history of sigmoidectomy and diverting ileostomy. Patient 1 had complaints of persistent diarrhea for 4 weeks before the operation (initial evaluation at that time was negative for C. diff). She came to the emergency department complaining of severe abdominal pain and watery diarrhea 12 days after the operation. Her stool PCR was positive for C. diff and she was treated with IV metronidazole and oral vancomycin with great response. She was discharged on oral Vancomycin. Patient 2 complained of abdominal pain, loose bowel movement with blood and white count of 19100 two days post-surgery. Her stool PCR was positive for C. diff. Oral vancomycin was started and then switched to IV metronidazole and tigecycline due to her nausea and vomiting. Unfortunately, in the next 3 days her condition deteriorated and as medical intervention failed she had an exploratory laparotomy leading to total abdominal colectomy. She improved and was discharged on oral vancomycin.Figure 1Figure 2Figure 3CDI is one of the major causes of healthcare associated infections. There has been a steady increase in the morbidity and mortality associated with C diff given the advent of more toxigenic/virulent strains. Studies have established asymptomatic carriage in up to two thirds of the patients with C diff colonization. Acquisition of C diff infection can be through feco-oral, surface or skin contamination with spores that are highly resistant to microbicides. Diagnosis is established using the clinical features, EIA of toxin or GDH and PCR in equivocal cases. Patient one complained of diarrhea initially and tested negative for C Diff by EIA (64% sensitive) and the diagnosis was missed. Being a healthcare worker (HCW) and at high risk of acquiring C. Diff/carrier state, is it prudent to treat empirically, do a PCR to screen for C. diff carrier state in HCW's ? With this case series we review the available literature, the accuracy of tests and raise questions on possible interventions and their overall cost effectiveness.

Severe complicated Clostridium difficile infection: Can the UPMC proposed scoring system predict the need for surgery?

Clostridium difficile infection (CDI) is one of the most common health care-associated infections, and it continues to have significant morbidity and mortality. The onset of fulminant colitis often requires total abdominal colectomy with ileostomy, which has a mortality rate of 35% to 57%. University of Pittsburgh Medical Center (UPMC) developed a scoring system for severity and recommended surgical consultation for severe complicated disease. The aim of this study was to evaluate if the UPMC-proposed scoring system for severe complicated CDI can predict the need for surgical intervention. This is a retrospective review of all patients who developed severe complicated CDI at Geisinger Medical Center between January 2007 and December 2012 as defined by the UPMC scoring system. Main outcomes were the need for surgical intervention and 30-day mortality. Eighty-eight patients had severe complicated CDI based on the UPMC scoring system. Fifty-nine patients (67%) required surgery and 29 did not. All patients had a diagnosis of CDI as shown by positive toxin assays. There was no difference between the groups with respect to age, sex, body mass index, or comorbidities. When comparing the surgical group to the nonsurgical cohort, the surgical cohort averaged 20 points on the scoring system compared to 9 in the nonoperative cohort. In patients with severe complicated CDI, 15 or more points predicted the need for surgery 75% of the time. Forty-two percent of the surgical cohort had respiratory failure requiring mechanical ventilation compared to 0% in the nonsurgical cohort (p < 0.0001). Forty-nine percent of the surgical cohort required vasopressors for septic shock before surgery compared to 0% in the nonsurgical cohort (p < 0.0001). Acute kidney injury was present in 92% of the surgical cohort versus 72% within the nonsurgical cohort (p = 0.026). Seventy-six percent of the surgical patients were admitted to the ICU before surgery. Within the nonsurgical cohort, only 24% of patients required ICU stay during admission. Overall, 30-day mortality in the surgical cohort was 30%, and there was no mortality in the nonsurgical cohort. The UPMC scoring system for severe complicated CDI can help us predict patients who need a surgical consult and the need for surgical intervention. In patients with severe complicated CDI, evidence of end-organ failure predicts surgical intervention. Prognostic study, level III; therapeutic study, level IV.

Risk factors associated with portomesenteric venous thrombosis in patients undergoing restorative proctocolectomy for medically refractory ulcerative colitis.

Data on risk factors for portomesenteric venous thrombosis (PMVT) following abdominal surgery for ulcerative colitis (UC) are limited. The aim of this study was to investigate factors associated with PMVT after surgical treatment for UC. Patients who underwent restorative proctocolectomy (RPC) and ileal pouch-anal anastomosis (IPAA) including diverting ileostomy closure for medically refractory UC were identified from a prospectively maintained database. Patient-related, disease-related and treatment-related variables were collected. Univariable and multivariable analyses were performed to assess factors associated with PMVT. Of the 521 patients completing surgical treatment for UC between 2006 and 2012, symptomatic PMVT occurred in 36 (7%), which resulted in a significantly increased hospital stay (P < 0.001). Patients developing PMVT were younger (P = 0.014), had a lower preoperative albumin level (P = 0.037) and were more likely to have been taking steroids within 1 month before surgery (P = 0.006). The combined incidence of PMVT was comparable between patients having a three-stage and two-stage management (6% vs. 8%, P = 0.43), but the relative incidence of PMVT after RPC + IPAA was 8%, significantly higher than the 4% after total abdominal colectomy (TAC) (P = 0.005) and the 2% after subsequent completion proctectomy (CP) + IPAA (P = 0.038). Multivariate analysis confirmed that RPC + IPAA was associated with a significantly greater risk of PMVT than CP + IPAA (OR = 4.9, P = 0.003) or TAC (OR = 3.5, P = 0.011). Preoperative steroid use was an independent factor for PMVT (OR = 5.8, P = 0.006). Steroid use 1 month before surgery is associated with an increased risk of PMVT. A staged restorative proctocolectomy does not increase the overall incidence of PMVT.

Da Vinci Total Abdominal Colectomy for Ulcerative Colitis

Da Vinci Total Abdominal Colectomy for Ulcerative Colitis

Rates and burden of surgical site infections associated with pediatric colorectal surgery: insight from the National Surgery Quality Improvement Program

PurposeThe purpose of this study was to characterize the rates of surgical site infections (SSI) associated with colorectal procedures in children and the relative burden of these events within the scope of pediatric surgical practice. MethodsThe NSQIP-Pediatric Public Use File was queried for all pediatric surgery procedures captured from 50 hospitals during 2012—2013. Rates of incisional and deep organ/space SSIs (ISSI and OSI, respectively) were calculated for all procedures, and the relative burden of SSIs from the entire dataset attributable to colorectal procedures was determined. ResultsColorectal procedures accounted for 2.5% (2872/114,395) of the NSQIP-P caseload and contributed 7.1% of the SSI burden. The SSI rate for all colorectal procedures was 5.9% (ISSI:3.2%; OSI:2.7%), and the highest rates were associated with total abdominal colectomy (11.4%) partial colectomy (8.3%), and colostomy closure (5.0%). Inflammatory bowel disease contributed the greatest relative burden of SSIs among colorectal diagnoses (24.9%; ISSI:22%; OSI:28.6%), followed by Hirschsprung's Disease (14.2%; ISSI:15.4%; OSI:12.8%) and anorectal malformations (12.4%; ISSI:17.6%; OSI:6.4%). ConclusionColorectal procedures are responsible for a disproportionate burden of SSIs within pediatric surgery. The rate and relative burden of SSIs are particularly high for colostomy closure, partial colectomy, and procedures for inflammatory bowel disease. Efforts to reduce SSI burden may be best focused on this cohort of children.