Background Patients undergoing ileal pouch-anal anastomosis commonly wish to have their ileostomy reversed as quickly as possible. The safety of ileostomy reversal (DLI-R) within 8 weeks of surgery has not been established. Our hypothesis is early closure before 8 weeks is associated with negative outcomes. Methods Patients who underwent primary IPAA with DLI from 2000 – 2021 from our Pouch Registry were retrospectively reviewed and stratified into groups based on timing of ileostomy closure: very early, routine (< 8 weeks, 56–116 days, respectively). Reasons for early closure were reported. Our primary outcome was overall complication rates according to timing of closure. Univariate analysis was used to compare categorical variables between groups. Results 2,000 patients underwent DLI-R following IPAA at a very early or routine timepoint: 3-stage 62%, 2-stage 38%; median age 39.2. DLI-R was performed very early in 92 patients and early routine in 1,908. Median time to closure in the very early group is 49 days and in the early routine group was 93 days. There were no differences between the two groups in age or BMI, but the very early group had a higher proportion of females (62% vs 41.5% p<0.001) and a higher proportion of patients with ASA 1–2 (65.2% vs 51.9% p<0.02). Reasons for DLI-R in the very early group were stoma related problems in 39 patients (43.3%) with scheduled closure in 51 patients (56.7%). Complications following DLI-R occurred in 11.3% of patients overall. The complication rate in the very early group was 17.4% compared to 11% in the routine group (p=0.09) and are shown in Table 1. When the patients in the very early group were stratified according to reason for DLI-R those reversed early for stoma related problems had a complication rate of 25.6% compared to 11% in the early routine group (p=0.03). Patients undergoing scheduled DLI-R in the very early group did not have higher complication rates than the routine group (11.8% vs 11% respectively, p=1.0). Conclusion DLI-R at <8 weeks following IPAA does not appear to be associated with a statistically higher rate of complications compared to closure in a standard time frame. However, when patients were reversed early due to complications associated with their stoma they had worse outcomes.
Background Ileal pouch-anal anastomosis (IPAA) is a technically demanding procedure. Intraoperatively, great care must be taken to assure a straight superior mesenteric axis. Rarely, twisted pouches are inadvertently constructed, resulting in deviations of expected pouch function. Herein we describe our quaternary pouch referral center experience with twisted pouch syndrome (TPS). Methods We performed a retrospective review of our prospectively maintained pouch registry from 1995 – 2020. Patients were identified using free-text search of redo IPAA operative reports for variations of the term “twist”. We defined twisted pouch syndrome as intraoperative findings of twisting of the pouch around its mesenteric axis which could not be reduced without disconnection from the anus. Data represent frequency (proportion) or median (range). Results Over 25-years, we identified 31 patients with confirmed TPS who underwent a redo pouch procedure by 11 surgeons: 67% were female, median BMI 21.2 (16.9 – 29.5) kg/m2. The duration from the index IPAA to redo procedure was 5 (0.5 – 21) years; all (100%) were referral cases constructed elsewhere. Original diagnoses included: ulcerative colitis 28 (90%), FAP 2 (6.5%). All patients presented with symptoms of pouch dysfunction including erratic bowel habits 28 (93%) with urgency and frequency, abdominal/pelvic/rectal pain 26 (87%), and obstructive symptoms 28 (93%) i.e. obstructed defecation and incomplete evacuation. Most had (75%) been treated for chronic pouchitis with medical therapy, and 48% had undergone previous surgery. Prior to redo IPAA procedure patients underwent a thorough workup: 100% pouchoscopy, 94% pouchogram, 87% underwent EUA, 87% MRI/CT, 71% manometry, and 39% defecography. TPS was diagnosed in 16% by pouchoscopy, in 13% by imaging, and in 71% was diagnosed intra-operatively at re-diversion (20%) or revision/redo IPAA (51%). In terms of surgical intervention, 81% were initially re-diverted. A total of 18 (60%) underwent pouch revision, and 12 (40%) required neo-IPAA. Short-term outcomes: LOS 8 (3 – 32) days, any complication 48%, readmission 11%, reoperation 3.4%, zero mortalities. After a median follow-up 52.5 (1 – 206) months, there were 4 failures: 2 never had loop ileostomy closure, 1 pouch excision, 1 Kock pouch, yielding an overall pouch survival rate of 87%. Conclusion Twisted pouch syndrome presents with pouch dysfunction manifest by the triad of erratic bowel habits, unexplained pain, and obstructive (defecation) symptoms. This syndrome may also mimic chronic pouchitis. Despite a thorough workup suggesting a mechanical problem, many patient are not diagnosed until time of redo pouch surgery. Redo surgery for twisted pouch syndrome results in long-term pouch survival for the majority.
During air travel, increasing hypoxia with altitude ascent is a potentially serious problem for patients with hypoxemic chronic airway obstruction (CAO). Travel by air is the most popular way of transport nowadays & estimated that each year worldwide, more than 3 billion passengers travel by air & 736 million in the United States alone. For most passengers, even those with respiratory disease, air travel is safe and comfortable. Some patients with COPD &other Chronic Lung diseases may be at risk but, with screening, these patients can be identified and most of them can travel safely with supplemental oxygen. Some patients with chronic lung disease may have mild hypoxemia at sea level but during air travel in a hypobaric hypoxic environment, compensatory pulmonary mechanisms may be inadequate despite normal sea-level oxygen requirements. In addition, compensatory cardiovascular mechanisms may be less effective in some patients who are unable to increase cardiac output. Air travel also presents an increased risk of venous thromboembolism. It's estimated that, almost 1 medical emergency for every 600 flights. Respiratory symptoms accounted for 12% of all these in-air emergencies. Pulse Volume 12-14 2020-2022 p.16-21
Background Patients undergoing colorectal surgery for inflammatory bowel disease (IBD) are recognized to have an increased risk of venous thromboembolism (VTE). The aim of this study was to determine the perioperative risk factors for VTE and to create a predictive scoring system for VTE in the IBD cohort. Methods The NSQIP-IBD registry from 2017–2020 was used to identify patients for the study. Demographics, operative and outcomes data of IBD patients undergoing colectomies for IBD were analyzed. Student t and χ 2 tests were used for univariate analysis. A logistic multivariate regression model was performed using all significant variables to develop a predictive scoring system of VTE. Results 5003 patients (51.9% male, mean age 42.7, 57.3% Crohn’s / 42.7% ulcerative colitis) were included in the study. 125 (2.49%) developed VTE. The univariate analysis is presented in Table 1. On multivariate analysis ASA grade, ulcerative colitis, sepsis, serum sodium <139 mmol/L, an open abdomen and preoperative inter hospital transfer were associated with greater risk of VTE. An open abdomen postoperatively was associated with the highest odds of developing a VTE [2.69 (1.20 – 5.39, p=.009)]. Using these 6 significant factors, a risk model was created. The risk of VTE with one risk factor was 0.7% and 1.8% with two risk factors. The risk of VTE increased to 3.6% and 4.5% with three and four risk factors respectively. With five and six risk factors, the risk of VTE increased exponentially to 10.9%, 25% respectively (Figure 1). Conclusion This study affirms that multiple perioperative and operative factors increase the risk of VTE after surgery for IBD. We present a novel model which demonstrates a cumulative risk increasing exponentially when more than five risk factors are present.
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