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Background: In patients with inflammatory bowel disease (IBD) who need intestinal resection, prior data suggest that earlier surgical intervention may be associated with improved outcomes. However, surgery is often deferred for additional trials of advanced therapies, which potentially shifts patients from a fit to a frail preoperative state. Objectives: This study aimed to evaluate clinical changes that occur in the year prior to intestinal resection in patients with IBD. Design: Retrospective cohort study. Methods: This was a multi-hospital retrospective study of patients ⩾18 years old who underwent initial IBD-related intestinal resection between January 1, 2018 and May 31, 2023. Clinical characteristics and radiographical skeletal muscle mass were compared using the Wilcoxon Signed-Rank test for continuous variables and McNemar’s test for categorical variables. Results: A total of 170 patients were included (120 with Crohn’s disease, 40 with ulcerative colitis, and 10 with indeterminate colitis), with a median disease duration of 7.4 years (interquartile range (IQR) 3.3–13.8). Median age at surgery was 32.6 years (IQR 25.9–44.9), and 51% were female. In the month prior to surgery as compared to the 6–12 months prior, individuals were more likely to have an IBD-related hospitalization (31% vs 5%, p < 0.01), malnutrition (30% vs 18%, p < 0.01), or an infection (74% vs 28%, p < 0.01). Though not statistically significant, there was an increase in the proportion of individuals who developed a venous thromboembolism in the month prior to surgery, and a decrease in skeletal muscle mass among those with two computerized tomography scans in the year prior to surgery (n = 6, 126 vs 111 cm2; p = 0.06). Conclusion: In the 6–12 months prior to an IBD-related intestinal resection, as compared to the month prior, individuals were less likely to be malnourished, have an infection, or need hospitalization for IBD. This suggests that minimizing delays to surgery may lead to improved outcomes. Plain language summary An assessment of changes that occur in the year prior to surgery among patients with inflammatory bowel disease (IBD) Why was the study done? Surgery may be delayed among patients with inflammatory bowel disease for repeated trials of medications. In order to assess the impact that these delays in surgery may have, we evaluated the clinical changes that occur in the year prior to surgery. What did the researchers find? Among the 170 patients with IBD who underwent their first intestinal surgery, there were significantly higher rates of malnutrition, IBD-related hospitalization, and infection in the month prior to surgery, as compared to the 6–12 months prior. There was also a decline in muscle mass in the year prior to surgery. What do the findings mean? Earlier surgical resection in patients with IBD may result in more favorable preoperative characteristics, thereby leading to improved clinical outcomes.

In patients with failing ileo-anal pouches there is often diagnostic uncertainty. In this setting, we may offer revisional pouch surgery with biologic \"coverage\" for presumed Crohn's disease (CD) which enables an alternative to pouch excision and end ileostomy to highly motivated patients. The aim of this study is to assess postoperative outcomes in patients who underwent revisional/redo ileal pouch anal anastomosis (IPAA) for failing pouches with biologic coverage for possible CD. This is a retrospective cross-sectional study based on data from a tertiary inflammatory bowel disease center. Patients who underwent revisional/redo IPAA surgery between September 2016 and December 2022 were included. The primary outcome measure was the rate of functioning pouch. Of the 213 patients who underwent revisional/redo IPAA surgery, 17 underwent redo IPAA surgery with biologic coverage due to concern for CD. An additional seven patients were started on biologics between the two operative stages of redo IPAA surgery. At a median follow-up of 17 months, the functioning pouch rate was 75%. Revisional IPAA surgery for suspected CD-related complications leading to pouch failure, in conjunction with concurrent medical therapy, provides a stoma-free alternative to patients otherwise facing pouch excision and end ileostomy. Despite the limited number of patients and varying follow-up times, this approach shows promise for maintaining pouch function in a challenging patient population.

Background The aim of this study was to evaluate the clinical implications of pathologic complete response (pCR) (i.e., T0N0M0) after neoadjuvant chemoradiation and radical surgery in patients with locally advanced rectal cancer. Materials and Methods A single-center, prospectively maintained colorectal cancer database was queried for patients with primary cII and cIII rectal cancer staged by CT and ERUS/MRI undergoing long-course neoadjuvant chemoradiation followed by proctectomy with curative intent between 1997 and 2007. Patients were stratified into pCR and no-pCR groups and compared with respect to demographics, tumor and treatment characteristics, and oncologic outcomes. Outcomes evaluated were 5-year overall survival, disease-free survival, disease-specific mortality, local recurrence, and distant recurrence. Results The query returned 238 patients (73% male), with a median age of 57 years and median follow-up of 54 months. Of these, 58 patients achieved pCR. Patients with pCR vs no-pCR were statistically comparable with respect to demographics, chemoradiation regimens, tumor distance from anal verge, clinical stage, surgical procedures performed, and follow-up time. No patient with pCR had local recurrence. Overall survival and distant recurrence were also significantly improved for patients achieving pCR. Conclusions Achievement of pCR after neoadjuvant chemoradiation is associated with greatly improved cancer outcomes in locally advanced rectal cancer. Future studies should evaluate the relationship between increases in pCR rates and improvements in cancer outcomes in this population.

Purpose The aim of this study was to determine the effect of a longer interval between neoadjuvant chemoradiation and surgery on perioperative morbidity and oncologic outcomes. Methods A colorectal cancer database was queried for clinical stage II and III rectal cancer patients undergoing neoadjuvant chemoradiation followed by proctectomy between 1997 and 2007. The neoadjuvant regimen consisted of long course external beam radiation and 5-fluorouracil chemotherapy. Patients with inflammatory bowel disease, hereditary cancer, extracolonic malignancy, urgent surgery, or non-validated treatment dates were excluded. Patients were divided into two groups according to the interval between chemoradiation and surgery (<8 and ≥8 weeks). Perioperative complications and oncologic outcomes were compared. Results One hundred seventy-seven patients were included. Groups were comparable with respect to demographics, tumor, and treatment characteristics. Perioperative complications were not affected by the interval between chemoradiation and surgery. Patients undergoing surgery ≥8 weeks after chemoradiation experienced a significant improvement in pathologic complete response rate (30.8% vs. 16.5%, p  = 0.03) and had decreased 3-year local recurrence rate (1.2% vs. 10.5%, p  = 0.04). A Cox regression analysis was performed to assess the compounding effect of a complete pathologic response on oncologic outcome. A longer interval correlated with less local recurrence, although statistical significance was not reached ( p  = 0.07). Conclusion An interval between chemoradiation and surgery ≥8 weeks is safe and is associated with a higher rate of pathologic complete response and decreased local recurrence.

Abstract Background Sarcopenia has been associated with adverse postoperative outcomes in older age cohorts, but has not been assessed in older adults with inflammatory bowel disease (IBD). Further, current assessments of sarcopenia among all aged individuals with IBD have used various measures of muscle mass as well as cutoffs to define its presence, leading to heterogeneous findings. Methods In this single-institution, multihospital retrospective study, we identified all patients aged 60 years and older with IBD who underwent disease-related intestinal resection between 2012 and 2022. Skeletal Muscle Index (SMI) and Total Psoas Index (TPI) were measured at the superior L3 endplate on preoperative computed tomography scans and compared through receiver operating characteristic curve. We then performed multivariable logistic regression to assess risk factors associated with an adverse 30-day postoperative outcome. Our primary outcome included a 30-day composite of postoperative mortality and complications, including infection, bleeding, cardiac event, cerebrovascular accident, acute kidney injury, venous thromboembolism, reoperation, all-cause rehospitalization, and need for intensive care unit-level care. Results A total of 120 individuals were included. Overall, 52% were female, 40% had ulcerative colitis, 60% had Crohn’s disease, and median age at time of surgery was 70 years (interquartile range: 65-75). Forty percent of older adults had an adverse 30-day postoperative outcome, including infection (23%), readmission (17%), acute kidney injury (13%), bleeding (13%), intensive care unit admission (10%), cardiac event (8%), venous thromboembolism (7%), reoperation (6%), mortality (5%), and cerebrovascular accident (2%). When evaluating the predictive performance of SMI vs TPI for an adverse 30-day postoperative event, SMI had a significantly higher area under the curve of 0.66 (95% CI, 0.56-0.76) as compared to 0.58 (95% CI, 0.48-0.69) for TPI (P = .02). On multivariable logistic regression, prior IBD-related surgery (adjusted odds ratio [adjOR] 6.46, 95% CI, 1.85-22.51) and preoperative sepsis (adjOR 5.74, 95% CI, 1.36-24.17) significantly increased the odds of adverse postoperative outcomes, whereas increasing SMI was associated with a decreased risk of an adverse postoperative outcome (adjOR 0.88, 95% CI, 0.82-0.94). Conclusions Sarcopenia, as measured by SMI, is associated with an increased risk of postoperative complications among older adults with IBD. Measurement of SMI from preoperative imaging can help risk stratify older adults with IBD undergoing intestinal resection. Lay Summary Sarcopenia has been associated with adverse postoperative outcomes in older adult populations but data among older adults with inflammatory bowel disease are limited. In our study, sarcopenia was significantly associated with adverse postoperative outcomes in older adults undergoing disease-related intestinal resection.

Abstract Background The epidemiology of inflammatory bowel disease (IBD) in developing countries may uncover etiopathogenic factors. We investigated IBD prevalence in Brazil by investigating its geographic, spatial, and temporal distribution, and attempted to identify factors associated with its recent increase. Methods A drug prescription database was queried longitudinally to identify patients and verify population distribution and density, race, urbanicity, sanitation, and Human Development Index. Prevalence was calculated using the number of IBD patients and the population estimated during the same decade. Data were matched to indices using linear regression analyses. Results We identified 162 894 IBD patients, 59% with ulcerative colitis (UC) and 41% with Crohn’s disease (CD). The overall prevalence of IBD was 80 per 100 000, with 46 per 100 000 for UC and 36 per 100 000 for CD. Estimated rates adjusted to total population showed that IBD more than triplicated from 2008 to 2017. The distribution of IBD demonstrated a South-to-North gradient that generally followed population apportionment. However, marked regional differences and disease clusters were identified that did not fit with conventionally accepted IBD epidemiological associations, revealing that the rise of IBD was variable. In some areas, loss of biodiversity was associated with high IBD prevalence. Conclusions When distribution is considered in the context of IBD prevalence, marked regional differences become evident. Despite a background of Westernization, hotspots of IBD are recognized that are not explained by population density, urbanicity, sanitation, or other indices but apparently are explained by biodiversity loss. Thus, the rise of IBD in developing countries is not uniform, but rather is one that varies depending on yet unexplored factors like geoecological conditions. Lay Summary The analysis of a large population of inflammatory bowel disease (IBD) patients in a developing country reveals that the rising prevalence of IBD is not uniform and is linked to factors not traditionally associated with IBD, such as geosocial features and loss of biodiversity.

Introduction Crohn’s disease can present with complex surgical pathologies, posing a significant risk of morbidity and mortality for patients. The implementation of a loop ileostomy for selected patients may help minimize associated risks. Methods In this retrospective cohort study, we investigated the utilization of temporary fecal diversion through the creation of a loop ileostomy in Crohn’s surgery. Closure of all ostomies involved a hand-sewn single-layer technique. We then conducted bivariate analysis on 30-day outcomes for closures, focusing on favorable recovery defined as the restoration of bowel continuity without the occurrence of two challenges in recovery: newly developed organ dysfunction or the necessity for reoperation. Results In total, 168 patients were included. The median age of the patients was 38 years (IQR 27–51). The most common indication for a loop ostomy was peritonitis (49%). After ileostomy closure, 163 patients (97%) achieved favorable recovery, while five encountered challenges; four (2.4%) underwent abdominal surgery, and one (0.6%) developed acute renal failure requiring dialysis. Two patients (1.2%) had a re-creation of ileostomy. Patients encountering challenges were older (56 [IQR 41–61] vs. 37 [IQR 27–50]; p 0.039) and more often required secondary intention wound healing (40% vs. 6.7%; p 0.049) and postoperative parenteral nutrition following their index surgery (83% vs. 26%; p 0.006). Conclusion Selectively staging the Crohn’s disease operations with a loop ileostomy is a reliable practice with low morbidity and high restoration rates of bowel continuity. Our hand-sewn single-layer technique proves effective in achieving successful surgical recovery.

Background and AimsCrohn’s disease (CD) can lead to work disability with social and economic impacts worldwide. In Brazil, where its prevalence is increasing, we assessed the indirect costs, prevalence, and risk factors for work disability in the state of Rio de Janeiro and in a tertiary care referral center of the state.MethodsData were retrieved from the database of the Single System of Social Security Benefits Information, with a cross-check for aid pension and disability retirement. A subanalysis was performed with CD patients followed up at the tertiary care referral center using a prospective CD database, including clinical variables assessed as possible risk factors for work disability.ResultsFrom 2010 to 2018, the estimated prevalence of CD was 26.05 per 100,000 inhabitants, while the associated work disability was 16.6%, with indirect costs of US$ 8,562,195.86. Permanent disability occurred more frequently in those aged 40 to 49 years. In the referral center, the prevalence of work disability was 16.7%, with a mean interval of 3 years between diagnosis and the first benefit. Risk factors for absence from work were predominantly abdominal surgery, anovaginal fistulas, disease duration, and the A2 profile of the Montreal classification.ConclusionsIn Rio de Janeiro, work disability affects one-sixth of CD patients, and risk factors are associated with disease duration and complications. In the context of increasing prevalence, as this disability compromises young patients after a relatively short period of disease, the socioeconomic burden of CD is expected to increase in the future.

Introduction The field of laparoscopic rectal cancer surgery is expanding. We compare short-term and early oncological outcomes after laparoscopic versus open resection in carefully matched rectal cancer patients. Methods All consecutive patients undergoing elective laparoscopic resection for rectal cancer were reviewed. Laparoscopic resections were matched 1:1 to open resections by age, gender, American Society of Anesthesiologists class, body mass index, neoadjuvant chemoradiation, and type of surgery. Data were analyzed using Fisher’s exact, chi-square, Wilcoxon rank-sum tests, and Kaplan–Meier estimates. P -value <0.05 was considered statistically significant. Results Ninety-one rectal cancer patients with laparoscopic resection were included, 59% were male, and median age was 62 years. Conversion rate was 18.7%. Laparoscopic and open surgery had similar 30-day morbidity and mortality except wound infection, which was lower for the laparoscopic group ( p  = 0.02). Laparoscopic surgery had similar 30-day readmissions but shorter total length of hospital stay (5 versus 7 days, p < 0.01), time to first flatus (3 versus 4.5 days, p = 0.001), and time to first bowel movement (4 versus 5 days, p = 0.05) when compared with open surgery. The 3-year disease-free survival, local recurrence, and distant recurrence rates were also similar between the two groups. Conclusion Laparoscopic surgery can be safely performed for rectal cancer, with better postoperative recovery and acceptable early oncological outcomes. Results from large ongoing randomized trials with longer follow-up time are pending to better define oncologic outcomes.

Background Conceivably, the benefits of earlier recovery associated with a minimally invasive technique used in laparoscopic colectomy (LC) may be amplified for patients with comorbid disease. The dearth of evidence supporting the safety of laparoscopy for these patients led to a comparison of outcomes between LC and open colectomy (OC) for patients with American Society of Anesthesiology (ASA) classifications 3 and 4. Methods Data for all ASA 3 and 4 patients who underwent elective LC were reviewed from a prospectively maintained laparoscopic database. The patients who underwent LC were matched with OC patients by age, gender, diagnosis, year, and type of surgery. Estimated blood loss, operation time, time to return of bowel function, length of hospital stay, readmission rate, and 30-day complication and mortality rates were compared using chi-square, Fisher’s exact, and Wilcoxon tests as appropriate. A p value <0.05 was considered statistically significant. Results In this study, 231 LCs were matched with 231 OCs. The median age of the patients was 68 years, and 234 (51%) of the patients were male. There were 44 (19%) conversions from LC to OC. More patients in the OC group had undergone previous major laparotomy (5 vs. 15%; p  < 0.001). Estimated blood loss, return of bowel function, length of hospital stay, and total direct costs were decreased in the LC group. Wound infection was significantly greater with OC ( p  = 0.02). When patients with previous major laparotomy were excluded, the two groups had similar overall morbidity. The other benefits of LC, however, persisted. Conclusion The findings show that LC is a safe option for patients with a high ASA classification. The LC approach is associated with faster postoperative recovery, lower morbidity rates, and lower hospital costs than the OC approach.