AimSurgical technique constantly evolves in response to the pressure of progress. Ileal pouch anal anastomosis (IPAA) is a good example. We analysed the effect of changes in practice on the technique of IPAA and its outcomes. MethodPatients undergoing primary IPAA at this institution were divided into three groups by date of the IPAA: those operated from 1983 to 1993, from 1994 to 2004 and from 2005 to 2015. Demographics, patient comorbidity, surgical techniques, postoperative outcomes, pouch function and quality of life were analysed. ResultsIn all, 4525 patients had a primary IPAA. With each decade, increasing numbers of surgeons were involved (decade I, 8; II, 16; III, 31), patients tended to be sicker (higher American Society of Anesthesiologists score) and three-staged pouches became more common. After an initial popularity of the S pouch, J pouches became dominant and a mucosectomy rate of 12% was standard. The laparoscopic technique blossomed in the last decade. 90-day postoperative morbidity by decade was 38.3% vs 50% vs 48% (P<0.0001), but late morbidity decreased from 74.2% through 67.1% to 30% (P<0.0001). Functional results improved, but quality of life scores did not. Pouch survival rate at 10years was maintained (94% vs 95.2% vs 95.2%; P=0.06). ConclusionIPAA is still evolving. Despite new generations of surgeons, a more accurate diagnosis, appropriate staging and the laparoscopic technique have made IPAA a safer, more effective and enduring operation.

The advent of circular stapling instruments and advanced surgical techniques has resulted in sphincter-saving rectal resections becoming common practice in the surgical management of both benign and malignant rectal pathology. Using abdominal approaches to rectal resection further improvements in the rates of anal sphincter preservation for distal rectal pathology are limited by anatomical considerations. A number of additional surgical techniques have been developed to be used in combination with an abdominal approach to effectively excise rectal pathology while preserving the anal sphincter complex. Historically, these include abdominoanal pull-through, parasacral and abdominotranssphincteric techniques. More recently, intersphincteric resection has been introduced. However, such techniques are often associated with significant morbidity and poor, even unacceptable functional outcome following inadvertent or intentional injury to the anal sphincter complex.

Aim Whether reoperation in the postoperative period adversely affects oncologic outcomes for colorectal cancer patients undergoing resection has not been well characterized. The aim of this study was to determine whether long-term oncological outcomes are affected for patients who undergo repeat surgery in the early postoperative period.Method From a prospective colorectal cancer database, patients who underwent resection for colorectal cancer between 1982 and 2008 and were reoperated within 30 days after surgery (group A) were matched for age (+/- 5 years), gender, year of surgery (+/- 2 years), American Society of Anesthesiology score, tumor site (colon or rectum), cancer stage and differentiation with patients who did not undergo reoperation (group B). The two groups were compared for overall survival (OS), diseasefree survival (DFS) and local recurrence (LR).Results In total, 89 reoperated patients (45 rectal, 44 colon cancer) were matched to an equal number of nonreoperated patients. Anterior resection (39.2%) and right hemicolectomy (19.1%) were predominant primary operations. Indications for reoperation were anastomotic leak / abscess (n = 40, 45%), massive bleeding (n = 15, 16.9%), bowel obstruction (n = 11, 12.4%), wound complications (n = 9, 10.1%) and other indications (n = 14, 15.6%). Group A had significantly greater overall morbidity (100% vs 27%, P = 0.001) and required more blood transfusions (20.2% vs 7.9%, P = 0. 045). Adjuvant therapy use, on the other hand, was more common in group B (23.6% vs 12.3%, P = 0.1). The 5-year OS and DFS were lower in the reoperated group (OS 55.3% vs 66.4%, P = 0.02; DFS 50.8% vs 60.8%, P = 0.06, respectively). Five-year LR was slightly lower in the reoperated group (2.9% vs 6.3%, P = 0.34).Conclusions Compared with non-reoperated patients matched for patient, tumour and operative characteristics, patients reoperated in the early postoperative period have worse long-term oncological outcomes. Adoption of strategies to reduce the risk of reoperation may be associated with the additional advantage of improved oncological outcomes in addition to the short-term advantages.

Aim The aim of this study was to characterize formally the mesocolic anatomy during and following total mesocolic excision. Total mesocolic excision may improve survival in patients with colon cancer. Although this requires a detailed knowledge of normal and variant mesocolic anatomy, the latter is poorly characterized. No studies have prospectively characterized the anatomy of the entire mesocolon.Method Total mesocolic excision was performed in 109 patients undergoing total abdominal colectomy. The mesocolon was maintained intact thereby permitting a precise anatomical characterization from ileocaecal to mesorectal levels. Two-and three-dimensional schematic reconstructions were generated to illustrate in situ conformation.Results Several previously undocumented findings emerged, including: (i) the mesocolon was continuous from ileocaecal to rectosigmoid level; (ii) a mesenteric confluence occurred at the ileocaecal and rectosigmoid junction as well as at the hepatic and splenic flexures; (iii) each flexure (and ileocaecal junction) was a complex of peritoneal and omental attachments to the colon centred on a mesenteric confluence; (iv) the proximal rectum originated at the confluence of the mesorectum and mesosigmoid; and (v) a plane occupied by Toldt's fascia separated the entire apposed mesocolon from the retroperitoneum.Conclusion When themesocolon is fullymobilized during a total mesocolic excision of the colon, several anatomical findings that have not been previously documented emerge. These findings provide a rationalization of the surgical, embryological and anatomical approaches to the mesocolon. This has implications for all related sciences.

526 Background: High tumor grade is included in practice guidelines as a marker of higher recurrence risk in stage II colon cancer. Multiple systems for tumor grading exist, without a standardized approach. We characterize agreement of 2 methods for tumor grading and association with recurrence in the context of clinical, pathologic, and genomic tumor features including mismatch repair (MMR) and the 12-gene recurrence score (RS). Methods: Colon tumors were graded independently by 2 academic GI pathologists (P1, P2). Grade was defined by % tumor with gland-like structures: well (> 95%), moderately (50-95%) and poorly (< 50%) differentiated. P1 used this 3-tier system while P2 used 2-tier scheme with well and moderately differentiated tumors defined as low grade and poorly differentiated as high grade. All mucinous tumors were high-grade by P2 but not P1. Relationship to recurrence-free interval (RFI) was assessed by Cox regression. Results: Primary tumors from 504 stage II colon cancer treated with surgery alone were included. 18% (P1) and 31% (P2) were high grade. High grade tumors were more likely right-sided (≥ 60%) and MMR deficient (≥ 35%) for P1 and P2 (all p < 0.001). Proportion of mucinous tumors was similar for high and low grade by P1 (25% vs. 21%, p = 0.39). P2 high grade trended to lower recurrence (HR = 0.63, p = 0.10) while P1 grade was not associated w/ RFI (p = 0.46). In multivariate analyses including grade and RS, P2 high grade was associated with lower recurrence (p = 0.007) but P1 grade was not associated w/ RFI (p = 0.30). Neither grade was associated w/ RFI (p > 0.30) after controlling for RS, MMR, tumor location and mucinous histology. Using the two-tier scheme, agreement b/w the 2 pathologists was low (kappa = 0.30, 95% CI 0.21-0.39) in all pts and moderate if mucinous tumors were excluded (kappa = 0.52, 95% CI 0.40-0.64). Conclusions: High tumor grade was not found to be a marker of higher recurrence risk in stage II colon cancer. Other markers validated in stage II colon cancer, such as MMR and RS, should be considered. Interpathologist agreement on colon tumor grade is modest, even with central expert review. [Table: see text]

PURPOSE: This study was designed to investigate sexual and urinary dysfunction in women who underwent rectal cancer excision, and the influence of tumor and treatment variables on long-term outcomes.METHODS: Data were prospectively collected on 295 women who underwent rectal cancer excision at a tertiary referral colorectal center from 1998 to 2006. Sexual and urinary function was assessed preoperatively and at intervals up to five years after surgery. Functional outcomes were assessed by using univariate and multivariate regression analysis, chi-squared test for trend, or Kruskal-Wallis test.RESULTS: The mean age of the patients was 60.9 years. Anterior resection was performed in 222 patients (75.2 percent) and abdominoperineal resection in 73 patients (24.7 percent). Patients who underwent abdominoperineal resection were less sexually active (25 vs. 50 percent; P = 0.02) and had a lower frequency of intercourse than anterior resection patients at one year after surgery (anterior resection, 3 (0-5) (median interquartile range); abdominoperineal resection 0 (0-4); P = 0.029). The frequency of intercourse improved over time for abdominoperineal resection (4 months, 0 (0-0) median interquartile range; 5 years, 3 (0.25-4) median interquartile range; P = 0.028). Abdominoperineal resection was associated with increased dyspareunia (odds ratio, 5.75; 95 percent confidence interval (CI), 1.87-17.6; P = 0.002), urinary urgency (odds ratio, 8.52; 95 percent CI, 2.81-25.8; P < 0.001), incontinence (odds ratio, 2.41; 95 percent CI, 1.11-5.26; P = 0.026), poor stream (odds ratio, 5.64, 95 percent CI, 2.55-12.5; P <= 0.001), and urinary retention (odds ratio, 11.7; 95 percent CI, 4.15-32.9; P < 0.001). Women who underwent radiotherapy had a 4.68-fold increase in dyspareunia (95 percent CI, 1.84-11.9; P = 0.001). Intra-abdominal sepsis was associated with decreased ability to achieve arousal (odds ratio, 0.085; 95 percent CI, 0.008-0.958; P = 0.046).CONCLUSIONS: Abdominoperineal resection, radiotherapy, intra-abdominal sepsis, and age 65 years or older are associated with significant impairments in female urinary and sexual outcomes after rectal cancer excision. Sexual and urinary outcomes should be considered when planning treatment for patients with rectal cancer.

OBJECTIVES: Autoimmune disorders (ADs) frequently coexist with inflammatory bowel disease. The aim of the study was to determine whether coexisting AD in patients with ileal pouches increases the risk for chronic antibiotic-refractory pouchitis (CARP) and other inflammatory conditions of the pouch. METHODS: A total of 622 patients seen in our Pouchitis Clinic were enrolled. We compared the prevalence of adverse outcomes of the pouch (including CARP, Crohn's disease of the pouch, and pouch failure) in patients with or without concurrent AD and assessed the factors for these adverse outcomes. RESULTS: There were seven pouch disease categories: normal (N=60), irritable pouch syndrome (N=112), active pouchitis (N=131), CARP (N=67), Crohn's disease (N=131), cuffitis (N=83), surgical complications (N=36), and anismus (N=2). The prevalence of AD in these pouch disease categories was 4.5%, 12.5%, 9.2%, 13.4%, 10.7%, 3.8%, 1.5%, and 0%, respectively. The presence of at least one AD at time of pouch surgery was shown to be associated with a twofold increase in the risk for CARP (hazard ratio=2.29; 95% CI: 1.52, 3.46;P<0.001) and for pouchassociated hospitalization (hazard ratio=2.39; 95% CI: 1.59, 3.58;P<0.001). The presence of AD was not associated with increased risk for irritable pouch syndrome, active pouchitis, Crohn's disease, cuffitis, surgical complications, or pouch failure. Patients with Crohn's disease of the pouch had a 2.42 times higher risk for pouch failure (P=0.042) than these without. Active smoking or a history of smoking was shown to be associated with an increased risk for pouchassociated hospitalization and pouch failure. CONCLUSIONS: AD appears to be associated with an increased risk for CARP, and the presence of the association between these AD and pouch disorders may stimulate further research on the link of these organ systems on an immunological basis.

PURPOSE:Controversy exists regarding the safety for omission of diverting ileostomy in restorative proctocolectomy because of fears of increased septic complications. This study was designed to evaluate the outcomes of restorative proctocolectomy in a consecutive series of patients by comparing postoperative complications, functional results, and quality of life in patients with and without diverting ileostomy. METHODS:Data regarding demographics, length of stay, surgical characteristics, and complications were reviewed and recorded according to the presence (n= 1,725) or absence (n = 277) of a diverting ileostomy at the time of pelvic pouch surgery. Criteria for omission of ileostomy included: stapled anastomosis, tension-free anastomosis, intact tissue rings, good hemostasis, absence of airleaks, malnutrition, toxicity, anemia, and prolonged consumption of steroids. Functional outcome and quality of life indicators were prospectively recorded and compared. RESULTS:Patients in the ileostomy group had greater body surface area and older mean age at time of surgery, were taking greater doses of steroids preoperatively, and required more blood transfusions at the time of surgery compared with the one-stage (P < 0.05). There were no differences between the two groups in septic complications (P > 0.05). Early postoperative ileus was more common in the one-stage group (P < 0.001). There were no differences between the groups in quality of life and functional outcomes. CONCLUSIONS:For carefully selected patients undergoing restorative proctocolectomy with ileal pouch-anal anastomosis, omission of diverting ileostomy is a safe procedure that does not lead to an increase in septic complications or mortality. Quality of life and functional results are similar to those who undergo ileal pouch-anal anastomosis with diversion, provided that certain selection factors are considered.

Objectives: The objectives of this study were to evaluate the effect of radiotherapy (RT) on sexual function in patients undergoing oncologic resection for rectal cancer, and to develop a mathematical model for quantifying the risk of sexual dysfunction through time for this group of patients.Methods: Data were prospectively collected on patients undergoing proctosigmoidectomy (group 1: n = 101) or adjuvant radiotherapy (40-50 Gy) and resection (group 2: n = 100) for rectal cancer at a tertiary referral center between December 1998 and July 2004. Study end points were recorded at 7 time intervals (preoperatively, 4 months, 8 months, 1 year, 2 years, 3 years, and 4 years after surgery) and included: 1) ability to have an erection, 2) maintain an erection, 3) attain orgasm, 4) dry orgasm, and 5) whether they were sexually active. Multilevel logistic regression analysis for repeated measures was used to identify factors associated with the sexual dysfunction. A predictive model was developed and internally validated by comparing observed and model-predicted outcomes.Results: Radiotherapy had an adverse effect on the ability to get an erection, maintain an erection, attain orgasm, and being sexually active in comparison with patients undergoing surgery alone (7.4%, 12.6%, 16.2%, and 13.7% reduction 8 months after surgery respectively; P < 0.05). The effect of sexual dysfunction deteriorated with age (odds ratio for erectile function, 0.40 per 10-year increase in age; 95% confidence interval, 0.29-0.49; P < 0.001). A significant variability in sexual function was present among the 7 time points with a maximal deterioration occurring at 8 months after surgery with subsequent slow but not complete recovery (P < 0.001). The predictive model showed adequate discrimination on 4 of the 5 domains of sexual dysfunction (area under the receiver operating characteristic curve > 0.70).Conclusions: Radiotherapy has an adverse effect on sexual function, the effect being maximal at 8 months after surgery. The risk of sexual dysfunction can be quantified preoperatively using the proposed index and can assist patients in making better informed choices on the type of treatment they receive.

Transanal excision is an appealing treatment for low rectal cancers because of its low morbidity, mortality, and better functional results than transabdominal procedures. However, controversy exists about whether it compromises the potential for cure. Several, recent reports of high recurrence rates after local excision prompted us to review our results of transanal excision alone in patients with T1 rectal cancers.

PURPOSE: Ileal pouch-anal anastomosis has come to represent the procedure of choice for patients requiring surgery for mucosal ulcerative colitis. In contrast, a proven diagnosis of Crohn's disease is generally held to preclude ileal pouch-anal anastomosis. However, patients with ileal pouch-anal anastomosis for apparent mucosal ulcerative colitis who are subsequently found to have Crohn's disease have a variable course. We reviewed our experience in this scenario to determine whether selected patients with Crohn's disease may be candidates for ileal pouch-anal anastomosis. METHODS: A retrospective review of the prospectively maintained ileal pouch-anal anastomosis database was undertaken to identify patients with a diagnosis of Crohn's disease after ileal pouch-anal anastomosis. Clinical outcome and quality-of-life data were obtained from the database and chart review. End points were the development of recrudescent Crohn's disease, pouch failure, and quality of life and functional outcome at the time of data collection. Differences between groups were calculated using the chi-squared test. Cumulative incidence of recrudescent Crohn's disease and pouch loss were calculated by the Kaplan-Meier method. Factors predictive of development of recrudescent Crohn's disease and pouch loss were examined by univariate analysis. RESULTS: Sixty patients (32 females; median age, 33 (range, 15-74) years) who underwent ileal pouch-anal anastomosis for mucosal ulcerative colitis subsequently had that diagnosis revised to Crohn's disease. Median follow-up of all patients was 46 (range, 4-158) months at time of data collection by which time 21 patients (35 percent) had developed recrudescent Crohn's disease. No pre-ileal pouch-anal anastomosis factors examined were predictors of the development of recrudescent Crohn's disease on univariate analysis. Median follow-up of the latter group was 63 (range, 0-132) months from time of diagnosis, by which time six patients underwent pouch excision and another patient was permanently defunctioned. The overall pouch loss rate for the entire cohort was 12 percent and 33 percent for those with recrudescent Crohn's disease. Median daily bowel movements in those with ileal pouch-anal anastomosisin situat the time of data collection was 7 (range, 3-20), with 50 percent of patients rarely or never experiencing urgency and 59 percent reporting perfect or near perfect continence. Median quality of life, health, and happiness scores were 9.9 and 10 of 10. CONCLUSIONS: The secondary diagnosis of Crohn's disease after ileal pouch-anal anastomosis is associated with protracted freedom from clinically evident Crohn's disease, low pouch loss rate, and good functional outcome. Such results only can be improved by the continued development of medical strategies for the long-term suppression of Crohn's disease. These data support a prospective evaluation of ileal pouch-anal anastomosis in selected patients with Crohn's disease.

INTRODUCTION: Predictive models play a pivotal role in the provision of risk-adjusted, operative mortality rates. The purpose of the study was to describe the development of a dedicated prognostic index for quantifying operative risk in colorectal cancer surgery. METHODS: Data were collected from 5,034 consecutive patients undergoing major surgery in a single center from October 1976 to July 2002. Primary end point was 30-day operative mortality. A multilevel Bayesian logistic regression model was developed to adjust for case-mix and accommodate the variability of outcomes between surgeons. The model was internally validated (split-sample) and tested using measures of discrimination, calibration, and subgroup analysis. RESULTS: The patients' median age was 66 (range, 18-98) years. Operative mortality was 2.3 percent with no significant variability between surgeons or through time. Multivariate analysis identified the following independent risk factors: age (odds ratio = 1.5 per 10-year increase), American Society of Anesthesiologists grade (odds ratio for ASA II, III, IV-Vvs. I = 2.6, 4.3, 6.8), TNM staging (odds ratio for Stage IVvs. I-III = 2.6), mode of surgery (odds ratio for urgentvs. nonurgent = 2.1) no-cancer resectionvs. cancer resection (odds ratio = 4.5), and hematocrit level. The model offered adequate discrimination (area under receiver operator characteristic curve = 0.801) and excellent agreement between observed and model-predicted outcomes over ten major colorectal procedures (P= 0.191). CONCLUSIONS: The colorectal cancer model provided an accurate means of estimating risk for individual patients in the preoperative setting. It has important implications in everyday practice, because it may be used as an adjunct in the process of informed consent and for monitoring surgical performance through time.

PURPOSE: Stapling of the ileal pouch-anal anastomosis with preservation of the anal transitional zone remains controversial because of concerns about the potential risk of dysplasia and cancer. The natural history and optimal treatment of anal transitional zone dysplasia ten or more years after surgery are unknown. This study establishes the risk of dysplasia in the anal transitional zone and the outcome of a conservative management policy for anal transitional zone dysplasia, with a minimum of ten years’ follow-up after ileal pouch-anal anastomosis. METHODS: A total of 289 patients undergoing anal transitional zone–sparing stapled ileal pouch-anal anastomosis for inflammatory bowel disease between 1986 and 1990 were studied. Patients undergoing anal transitional zone–sparing ileal pouch-anal anastomosis who were studied with serial anal transitional zone biopsies for at least ten years postoperatively were included (n = 178). Median follow-up was 130 (range, 120–157) months. RESULTS: Anal transitional zone dysplasia developed in 8 patients 4 to 123 (median, 9) months after surgery. There was no association with gender, age, preoperative disease duration, or extent of colitis, but the risk of anal transitional zone dysplasia was significantly associated with cancer or dysplasia as a preoperative diagnosis or in the proctocolectomy specimen. Dysplasia was high grade in two patients and low grade in six. Two patients with low-grade dysplasia on two or more occasions after detection of low-grade dysplasia underwent completion mucosectomy and perineal pouch advancement with neo–ileal pouch-anal anastomosis. One patient with high-grade dysplasia on two occasions was to undergo completion mucosectomy, but this was not technically feasible. Partial mucosectomy with vigorous anal transitional zone biopsy was performed with close postoperative surveillance. Biopsies were negative for dysplasia. The second recently diagnosed patient with high-grade dysplasia underwent examination under anesthesia with negative anal transitional zone biopsies and will be kept under close surveillance. No cancer in the anal transitional zone was found during the study period. The 4 other patients with low-grade dysplasia on 1 or 2 occasions were treated expectantly and have been dysplasia free for a median of 119 (range, 103–133) months. CONCLUSIONS: Anal transitional zone dysplasia after stapled ileal pouch-anal anastomosis is infrequent and is usually self-limiting. Anal transitional zone preservation did not lead to the development of cancer in the anal transitional zone with a minimum of ten years of follow-up. Long-term surveillance is recommended to monitor dysplasia. If repeat biopsy confirms persistent dysplasia, mucosectomy with perineal pouch advancement and neo–ileal pouch-anal anastomosis is recommended.

OBJECTIVE:To identify risk factors associated with ileal pouch failure and to develop a multifactorial model for quantifying the risk of failure in individual patients. SUMMARY BACKGROUND DATA Ileal pouch anal anastomosis (IPAA) has become the treatment choice for most patients with ulcerative colitis and familial adenomatous polyposis who require surgery. At present, there are no published studies that investigate collectively the interrelation of factors related to ileal pouch failure, nor are there any predictive indices for risk stratification of patients undergoing IPAA surgery. METHODS:Data from 23 preoperative, 7 intraoperative, and 10 postoperative risk factors were recorded from 1,965 patients undergoing restorative proctocolectomy in a single center between 1983 and 2001. Primary end point was ileal pouch failure during the follow-up period of up to 19 years. The "CCF ileal pouch failure" model was developed using a parametric survival analysis and a 70%:30% split-sample validation technique for model training and testing. RESULTS:The median patient follow-up was 4.1 year (range, 0-19 years). Five-year ileal pouch survival was 95.6% (95% CI, 94.4-96.7). The following risk factors were found to be independent predictors of pouch survival and were used in the final multivariate model: patient diagnosis, prior anal pathology, abnormal anal manometry, patient comorbidity, pouch-perineal or pouch-vaginal fistulae, pelvic sepsis, anastomotic stricture and separation. The model accurately predicted the risk of ileal pouch failure with adequate calibration statistics (Hosmer Lemeshow chi2 = 3.001; P = 0.557) and an area under the receiver operating characteristics curve of 82.0%. CONCLUSIONS:The CCF ileal pouch failure model is a simple and accurate way of predicting the risk of ileal pouch failure in clinical practice on a longitudinal basis. It may play an important role in providing risk estimates for patients wishing to make informed choices on the type of treatment offered to them.

OBJECTIVE To evaluate how age affects functional outcome and quality of life after ileal pouch anal anastomosis (IPAA). SUMMARY BACKGROUND DATA Because of the limited number of older patients undergoing IPAA, it has been difficult to assess functional outcome and quality of life stratified by age. METHODS IPAA was performed in 1895 patients. Patients were stratified by age into <45 (n = 1410), 46-55 (n = 289), 56-65 (n = 154), and more than 65 years (n = 42). Outcome was assessed prospectively. Results are presented at 1, 3, 5, and 10 years after surgery.RESULTS Patients were followed for 4.6 +/- 3.7 years (maximum, 17 years). Pouch failure occurred in 4.1% (pouch excision or permanent diversion). Incontinence and night time seepage were more common in older patients. There were minor differences in the quality of life, health, energy and happiness between age groups, with a slight benefit for those under 45 years. Fourteen percent or fewer patients experienced social, sexual or work restrictions. Overall, 96% of patients were happy to have undergone their surgery, and 98% recommended it to others. Although the respective figures were 89% and 96% in the over-65 age group, the difference was not significant. CONCLUSIONS These data provide a unique assessment of outcome after IPAA at multiple time points. Although functional outcome after IPAA is not as good in older patients, appropriate case selection confers acceptable function and quality of life to patients of all ages.