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Ileal pouch anal anastomosis is the preferred operation for restoration of intestinal continuity in patients with ulcerative colitis due to favorable functional outcomes and quality of life. However, up to 30% can develop postoperative complications, of which pelvic sepsis is the most dreaded due to impaired pouch function and increased rates of pouch failure. Several modifiable risk factors are associated with postoperative pelvic sepsis including obesity, poor nutritional status, anemia, and immunosuppressive therapy. While the evidence regarding the effect of immunosuppressive therapy on adverse postoperative outcomes is controversial, there is mounting data to suggest the operation performed at the time of immunosuppression exposure is critical for subsequent pouch outcomes. This has resulted in an increased number of pouches being performed as a modified 2-stage or 3-stage approach, a conservative yet safe approach to avoid potential deleterious effects of immunosuppression at the critical step of pouch formation.

Crohn׳s disease (CD) is a chronic inflammatory disease of the intestinal tract characterized by transmural inflammation, which can progress to intestinal perforation, intra-abdominal abscesses, intestinal strictures, and fistula development. Surgery is frequently required to correct these disease-related complications. Unfortunately, there is no medical or surgical cure for the disease, and the etiology remains undefined. Thus, many patients will undergo multiple operations over their lifetime when the disease process becomes medically refractory and complications ensue. The index operation in CD can be challenging due to the active disease and any associated inflammation in non-diseased bowel. However, reoperative CD surgery even more complex due to the underlying disease process, adhesive disease, altered anatomy from the prior surgery or surgeries and the imperative to preserve small bowel. Several steps can be taken in the preoperative phase to optimize outcomes, and there are many technical aspects should be considered during the reoperation to assist in the performance of a safe operation and attempt to minimize intestinal resection. Herein, we review some of the important principles of operative and reoperative Crohn׳s surgery that can assist the operating surgeon when approaching this challenging patient population.

Screening practices for anal dysplasia with the use of anal cytology and high-resolution anoscopy (HRA) has become a topic of increased interest to colon and rectal surgeons. However, screening continues to be practiced by a minority of clinicians. One major hurdle is how to incorporate anal cytology screening programs into busy colorectal surgical practices. In this article, I highlight my early experience treating anal dysplasia and review my current approach and practice pattern for treating anal dysplasia. I also suggest a few paradigms for implementing screening into various clinical settings, and offer surveillance algorithms for individual patients with anal dysplasia based on risk factors.

Perianal disease is a particularly morbid phenotype of Crohn's disease with significantly diminished quality of life, affecting up to a third of patients. Medical therapies achieve long term durable remission in only a third of patients. Thus, most undergo operative intervention, at the expense of a risk of incontinence. Mesenchymal stem cell therapy is an emerging therapy without risk of incontinence and improved efficacy as compared to conventional therapy. Additional manifestations of perianal Crohn's disease including hemorrhoids and skin tags are possible to manage operatively, only in the absence of proctitis and anal canal disease.

Several events have cascaded into the current climate of quality initiatives to improve the quality and safety of medical care. This has resulted in an explosion of public reporting of hospital and physician outcomes. While the intent is to provide useful and accurate information, there are several limitations to making direct comparisons across hospitals and physicians that care for a variety of patients in varying systemic environments. It is important to understand the limitations of public reporting before the widespread adoption of their use for reimbursement and referral patterns.

Effective anesthesia and postoperative pain management are key elements for both optimal perioperative patient care and satisfaction and an accelerated recovery after ambulatory or inpatient colorectal surgery. A major concern for patients undergoing surgery continues to be pain control both during and after the operation. Although recent advances have been made in the development of new analgesics, treatment strategies, and delivery systems, providing effective pain control can still be a challenge. This is especially true in the setting of accelerated recovery programs that aim for early ambulation, earlier hospital discharge, and a more rapid return to the activities of daily living. We review the common methods of anesthesia and pain management for both ambulatory and major abdominal surgery and describe how, when properly chosen and implemented, the result is better patient care and expedited operative recovery.