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Postoperative bowel dysfunction following restorative proctectomy, commonly referred to as Low Anterior Resection Syndrome (LARS), is a common long term sequela of rectal cancer treatment. While many of the established risk factors for LARS are non-modifiable, others may be well within the surgeon’s control. Several pre-, intra-, and postoperative decisions may have a significant impact on postoperative bowel function. Some of these factors include the extent of surgical resection, surgical approach, choice of anastomotic reconstruction, and use of fecal diversion. This review article summarizes the available evidence regarding how surgical decision-making can affect postoperative bowel function.

Abstract Background Patients with inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC) frequently undergo restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for medically refractory disease or colonic dysplasia/neoplasia. Subtotal colectomy with ileosigmoid or ileorectal anastomosis may have improved outcomes but is not well studied. Due to increased risk for colorectal cancer in PSC-IBD, there is hesitancy to perform subtotal colectomy. We aim to describe the frequency of colorectal dysplasia/neoplasia following IPAA vs subtotal colectomy in PSC-IBD patients. Methods We completed a retrospective study from 1972 to 2022 of patients with PSC-IBD who had undergone total proctocolectomy with IPAA or subtotal colectomy. We abstracted demographics, disease characteristics, and endoscopic surveillance data from the EMR. Results Of 125 patients (99 IPAA; 26 subtotal), the indication for surgery was rectal sparing medically refractory disease (51% vs 42%), dysplasia (37% vs 30%) and neoplasia (11% vs 26%) in IPAA vs subtotal colectomy patients, respectively. On endoscopic surveillance of IPAA patients, 2 (2%) had low-grade dysplasia (LGD) in the ileal pouch and 2 (2%) had LGD in the rectal cuff after an average of 8.4 years and 12.3 years of follow-up, respectively. One (1%) IPAA patient developed neoplasia of the rectal cuff after 17.8 years of surgical continuity. No subtotal colectomy patients had dysplasia/neoplasia in the residual colon or rectum. Conclusions In patients with PSC-IBD, there was no dysplasia or neoplasia in those who underwent subtotal colectomy as opposed to the IPAA group. Subtotal colectomy may be considered a viable surgical option in patients with rectal sparing PSC-IBD if adequate endoscopic surveillance is implemented. Lay Summary We sought to evaluate the risk of developing dysplasia in patients with both inflammatory bowel disease and primary sclerosing cholangitis, following surgery with either total proctocolectomy with ileal pouch-anal anastomosis or subtotal/total colectomy with ileosigmoid or ileorectal anastomosis. Graphical Abstract Graphical Abstract

BackgroundThe rate of obesity is rapidly increasing in patients with inflammatory bowel disease (IBD), but whether bariatric surgery in patients with IBD is safe and effective is not well understood.MethodsA retrospective review of patients with IBD undergoing bariatric surgery across a multi-state health system was performed. Thirty-day postoperative outcomes, weight loss, and long-term complications were recorded.ResultsThirty-one patients (81% female) with IBD and a mean preoperative body mass index (BMI) of 42.4 kg/m2 underwent 32 bariatric operations (n = 14 Roux-en-Y gastric bypass, n = 14 sleeve gastrectomy, n = 4 gastric band). Short-term infectious complications included superficial surgical site infection (n = 2), infected intra-abdominal hematoma (n = 1), and a hepatic abscess (n = 1). Percent excess weight loss was 57.2% (n = 25) at 6 months, 62.9% (n = 22) at 12 months, and 57.4% (n = 11) at 24 months. No IBD flares requiring surgery were observed at a median follow-up of 2.7 years (interquartile range, 0.8–4.2 years).ConclusionIn carefully selected patients with IBD, bariatric surgery appears safe with respect to short-term infectious complications and results in sustained weight loss until at least 2 years postoperatively.

Abstract Background Restorative proctocolectomy and ileal pouch anal anastomosis (IPAA) has become the procedures of choice for restoration of intestinal continuity in ulcerative colitis or familial adenomatous polyposis. This systematic review aims to assess short-term postoperative and long-term functional outcomes in pediatric patients undergoing IPAA. Methods A literature search was performed for all publications of pediatric IPAA in which short- and long-term outcomes were reported. Papers were excluded based on title, abstract, and full-length review. Data collection included patient demographics, medication use preoperatively, operative approach, 30-day postoperative outcomes, long-term functional outcomes (to maximal date of follow-up), and pouch failure rate. Outcomes were compared in those patients with and without perioperative corticosteroid exposure. Study quality and risk of bias was assessed using the Newcastle-Ottawa Scale as all studies were cohort studies. Results Of 710 records reviewed, 42 full papers were included in the analysis. Rates of superficial surgical site infection, pelvic sepsis, ileus, and small bowel obstruction at <30 days were 10%, 11%, 10%, and 14%, respectively. Rates of pouchitis, stricture, chronic fistula tract, incontinence, and pouch failure were 30%, 17%, 12%, 20%, and 8%, respectively, at 37–109 months of follow-up; incontinence was significantly higher in those exposed to corticosteroids preoperatively (52% vs 20%; P < 0.001). The median daytime, nighttime, and 24-hour stool frequency were 5.3, 1.4, and 5 bowel movements, respectively. Conclusions IPAA is safe with good long-term functional outcomes in pediatric patients.

Purpose Anorectal melanoma (ARM) poses a significant challenge due to the lack of established guidelines and a 5-year overall survival rate of less than 20%. The only recognized death risk factors are positive lymph nodes and positive surgical margins. This study aimed to identify the risk factors for local/distant recurrences and death in a 22-year multi-institutional experience. Methods All patients who underwent curative surgical resection or were referred to after resection at the Mayo Clinic for non-metastatic ARM (2002–2024) were included. Risk factors for local/distant recurrences, and deaths were assessed through multivariable Cox regression. Results Eighty-eight patients were included in the study. Seventy-eight percent of patients had anal melanoma and 22% rectal melanoma. Nineteen percent had clinically positive lymph nodes. The surgical margins were positive in 62% of local surgeries, while they were positive in 13% of radical surgery cases. The first recurrence was often a local recurrence (67%), followed by distant metastasis (21%), with an overall comparable overall survival between the two. Radiotherapy administration, radical surgery, and negative margins were associated with less local recurrence. Clinically positive lymph nodes and local recurrences increased the risk of developing distant metastasis over time. Clinically negative lymph nodes, radiotherapy administration, radical surgery, and negative margins all contributed to a reduced death risk. Conclusion Local recurrences in ARM may influence distant metastasis and death more than what was previously believed. Positive surgical margins in local surgery were remarkably high, reaching 62%. Protective factors for local recurrence and death included radical surgery, negative surgical margins, and radiotherapy.

Surgical site infections (SSIs) are one of the most common complications following diverting loop ileostomy (DLI) closures. This study assesses SSIs after DLI closure and the temporal trends in skin closure technique. A retrospective review was conducted using the American College of Surgeons National Surgical Quality Improvement Program database for adult patients who underwent a DLI closure between 2012 and 2021 across a multistate health system. Skin closure technique was categorized as primary, primary ​+ ​drain, or purse-string closure. The primary outcome was SSI at the former DLI site. A SSI was diagnosed in 5.7% of patients; 6.9% for primary closure, 5.7% for primary closure ​+ ​drain, and 2.7% for purse-string closure (p ​= ​0.25). A diagnosis of Crohn's disease, diverticular disease, and increasing operative time were significant risk factors for SSIs. There was a positive trend in the use of purse-string closure over time (p ​< ​0.0001). This study identified a low SSI rate after DLI closure which did not vary significantly based on skin closure technique. Utilization of purse-string closure increased over time. [Display omitted] •There was a low surgical site infection rate after diverting loop ileostomy closure.•Surgical site infections did not vary significantly based on skin closure technique.•Crohn's, diverticulitis, and longer operative times were significant risk factors.•Utilization of the purse-string closure technique has increased over time.

A left-sided anastomotic leak risk score was previously developed and internally but not externally validated. Left-sided colectomy anastomotic leak risk scores were calculated for patients within the ACS NSQIP Colectomy Targeted PUF from 2017 to 2018 and institutional NSQIP databases at three hospitals from 2011 to 2019. The calibration and discrimination of the risk score was assessed. A total of 21,116 patients (ACS NSQIP) and 485 patients (institutional NSQIP) were identified. Anastomotic leak rate was 2.8% and 2.9% respectively. C-statistic in the ACS NSQIP cohort was 0.61 and 0.64 in the institutional cohort compared to 0.66 in the original development cohort. Strong visual correspondence existed between predicted and observed anastomotic leak rates in the ACS NSQIP cohort. The left-sided anastomotic leak risk score was validated in two new populations. Use of the score would aid in the decision of when to perform a diverting stoma. •A left-sided colectomy anastomotic leak risk score was externally valid.•Validation of risk calculators requires large data sets when using a rare event.•Use of temporary diversion varies widely when compared to anastomotic leak risk.•Anastomotic leak risk scores may help optimize decision making on use of diversion.

Surgical outcomes and pouch outcomes in the setting of vedolizumab remains poorly understood. We sought to determine the rate of 30-day postoperative surgical infectious complications and pouch-specific complications among patients with ulcerative colitis (UC) who received vedolizumab within 12 weeks of surgery.Methods:A retrospective chart review between 5/1/2014 and 12/31/2016 of all adult patients with UC who underwent an abdominal operation was performed. Patients with UC who received vedolizumab within 12 weeks of their abdominal operation were compared with patients with UC on anti-TNFα treatment.Results:Eighty-eight patients received vedolizumab and 62 received anti-TNFα within 12 weeks of surgery. More vedolizumab-treated patients had superficial surgical site infections (P = 0.047) and mucocutaneous separation at the ileostomy (P = 0.047), but there was no difference in the overall surgical infectious complication rate, deep space SSI, 30-day hospital readmission or return to the operating room. On univariate analysis of SSI among patients with UC, exposure to vedolizumab was not a significant predictor of SSI (P = 0.27), but steroids were predictive of SSI on univariate (P = 0.02) and multivariable analysis (P = 0.02). After ileal pouch anal anastomosis, there was a higher rate of intra-abdominal abscesses (31.3% versus 5.9%) and mucocutaneous separation (18.8% versus 0%) in the vedolizumab group compared with the anti-TNFα group, but statistical significance was not reached.Conclusions:Vedolizumab patients had significantly increased rates of superficial SSI, but not overall infectious complications. Among ileal pouch anal anastomosis patients, peripouch abscess rates were increased among vedolizumab-treated patients, but this did not reach statistical significance. Vedolizumab seems safe in the perioperative period for patients with UC.