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The increased risk of colorectal cancer (CRC) in patients with inflammatory bowel disease (IBD) has been well documented in the literature. The present study aimed to assess the characteristics and outcomes of rectal cancer in patients with IBD. This study was a retrospective review of a prospectively maintained IRB-approved database at Cleveland Clinic Florida. Rectal cancer patients with or without IBD treated with curative surgery between 2016 and 2020 were compared for demographics, disease characteristics, and pathologic and oncologic outcomes. The primary outcomes were 3-year overall survival (OS) and disease-free survival (DFS). Secondary outcomes were clinicopathologic outcomes including disease stage, tumor histology and histologic features, and treatments received. 238 patients with rectal cancer were included, 15 (6.3%) of whom had IBD. IBD patients were significantly younger (52.9 vs 60.3 years, p = 0.033), presented more often with cT1-2 tumors (64.3% vs 30.4%, p = 0.008), and signet-ring cell pathology (14.3% vs 2%, p = 0.02). IBD patients received neoadjuvant chemoradiation less often (40% vs 72.6%, p = 0.029) and had shorter time between diagnosis and surgery (7.5 vs 25 weeks, p = 0.013) than did non-IBD patients. Both groups had similar OS (36 vs 34.7 months, p = 0.431) and DFS (36 vs 32.9 months, p = 0.121). IBD patients with rectal cancer tend to present at a younger age, with a less invasive disease, and signet-ring carcinomas, and receive neoadjuvant treatment less often than non-IBD patients. Based on low level of evidence, IBD and non-IBD rectal cancer patients might have similar survival., (© 2023. Italian Society of Surgery (SIC).)

Background: Restorative total proctocolectomy with IPAA may not be feasible in some patients because of technical intraoperative limitations., Objective: This study aimed to assess preoperative predictors for intraoperative IPAA and review management., Design: This is a retrospective review., Setting: This study was conducted at Cleveland Clinic between January 2010 and May 2018., Patients: Patients ≥18 years of age who underwent ileoanal pouch surgery were included. Patients with successful pouch creation as planned were grouped as "successful IPAA creation." Operative reports of patients who underwent alternative procedures were reviewed to identify cases when the pouch was preoperatively planned but intraoperatively abandoned (IPAA-abandoned group). Multivariate logistic regression models were developed to determine predictors of intraoperative pouch abandonment. We also reviewed the management of patients in whom the initial pouch creation failed., Main Outcome Measures: The primary outcomes measured were preoperative predictors for intraoperative ileoanal pouch abandonment., Results: A total of 1438 patients were offered an ileoanal pouch; 21 (1.5%) experienced pouch abandonment due to inadequate reach (n = 17) and other technical reasons (n = 4). These patients underwent alternative procedures such as end or loop ileostomy with/without proctectomy. Multivariate logistic regression analysis indicated male sex (OR, 6.021; 95% CI, 1.540-23.534), BMI (OR, 1.217; 95% CI, 1.114-1.329), and a 2-stage procedure (OR, 14.510; 95% CI, 4.123-51.064) as independent factors associated with intraoperative abandonment of pouch creation. Alternative procedures were total proctocolectomy with end ileostomy (n = 14) and total abdominal colectomy with end ileostomy without proctectomy (n = 7). Ultimately, pouch creation was achieved in 6 of 21 patients after a median interval of 8.8 (range, 4.1-34.8) months. All patients had intentional weight loss before a reattempt and total abdominal colectomy with end ileostomy without proctectomy as their initial procedure., Limitations: This study was limited by its retrospective nature., Conclusions: Ileoanal pouch abandonment is rare and can be mitigated by initial total abdominal colectomy and weight loss. Male, obese patients are at a higher risk of failure. Intraoperative assessment of ileoanal pouch feasibility should occur before rectal dissection. See Video Abstract at http://links.lww.com/DCR/B156. PREDICCIÓN MULTIVARIANTE DEL ABANDONO INTRAOPERATORIO DE LA ANASTOMOSIS ANAL CON BOLSA ILEAL: La proctocolectomía total restaurativa con anastomosis de bolsa ileoanal puede no ser posible en algunos pacientes debido a limitaciones técnicas intraoperatorias.Evaluar los predictores preoperatorios para el abandono intraoperatorio de la bolsa ileoanal y revisar el manejo.Revisión retrospectiva.Cleveland Clinic entre Enero de 2010 y mayo de 2018.Pacientes > 18 años que se sometieron a cirugía de bolsa ileoanal. Los pacientes con una creación exitosa de la bolsa según lo planeado se agruparon como "creación exitosa de anastomosis de bolsa ileoanal". Se revisaron los informes operativos de los pacientes que se sometieron a procedimientos alternativos para identificar los casos en que la bolsa se planificó preoperatoriamente pero se abandonó intraoperatoriamente (grupo de "anastomosis anal de bolsa ileoanal abandonada"). Se desarrollaron modelos de regresión logística multivariante para determinar los predictores del abandono intraoperatorio de la bolsa. También revisamos el manejo de pacientes que fallaron en la creación inicial de la bolsa.Predictores preoperatorios para el abandono intraoperatorio de la bolsa ileoanal.A un total de 1438 pacientes se les ofreció una bolsa ileoanal; 21 (1.5%) experimentaron abandono de la bolsa debido a un alcance inadecuado (n = 17) y otras razones técnicas (n = 4). Estos pacientes se sometieron a procedimientos alternativos como ileostomía final o de asa con / sin proctectomía. El análisis de regresión logística multivariante indicó género masculino (OR, 6.021; IC 95%, 1.540-23.534), índice de masa corporal (OR, 1.217; IC 95%, 1.114-1.329) y procedimiento en 2 etapas (OR, 14.510; IC 95%, 4.123-51.064) como factores independientes asociados con el abandono intraoperatorio de la creación de la bolsa. Los procedimientos alternativos fueron la proctocolectomía total con ileostomía final (n = 14) y la colectomía abdominal total con ileostomía final sin proctectomía (n = 7). Finalmente, la creación de la bolsa se logró en 6/21 pacientes después de un intervalo medio de 8.8 (rango, 4.1-34.8) meses. Todos los pacientes tuvieron pérdida de peso intencional antes de la reintenta y colectomía abdominal total con ileostomía final sin proctectomía como procedimiento inicial.Naturaleza retrospectiva.El abandono de la bolsa ileoanal es raro y puede mitigarse mediante la colectomía abdominal total inicial y la pérdida de peso. Los pacientes masculinos y obesos tienen un mayor riesgo de fracaso. La evaluación intraoperatoria de la viabilidad de la bolsa ileoanal debe ocurrir antes de la disección rectal. Consulte Video Resumen en http://links.lww.com/DCR/B156. (Traducción-Dr. Yesenia Rojas-Kahlil).

Background: Perineal wound complications after ileoanal pouch excision remain a significant cause of morbidity., Objective: The purpose of this work was to describe the incidence, outcomes, and predictors of perineal wound complications after pouch excision., Design: This was a retrospective medical chart review., Settings: The study was conducted in a single clinical institution., Patients: Patients who underwent pouch excision at our institution from July 1992 through July 2012 were identified. Patient and perioperative variables were reviewed. Multivariate and univariate analyses were undertaken., Main Outcome Measures: Perineal wound (including perineal wound infection and persistent perineal sinus [nonhealing by 6 months]) and perineal hernia were measured., Results: A total of 47 patients (mean age, 46 years; 42.6% men) with familial adenomatous polyposis (10.6%), mucosal ulcerative colitis (61.7%), or Crohn's disease (27.7%) underwent pouch excision, including 36.2% for IPAA-related sepsis (presacral abscess; perineal-, sacral-, or pouch-vaginal fistula; and anastomotic defect), 44.7% for pouch dysfunction, 10.6% for refractory pouchitis, and 8.5% for neoplasia. Fourteen (29.8%) developed perineal wound complications, including 100% perineal wound infection, 28.6% persistent perineal sinus, and 7.1% perineal hernia. Perineal wound infection was associated with delayed healing (>6 weeks; 71.4% vs 24.2%; p = 0.002) and IPAA-related sepsis (28.6% vs 0%; p = 0.001). Patients with and without perineal wound complications were similar in age, diagnoses, fecal diversion, immunosuppression, comorbid conditions, nutrition, and surgical variables. Most patients underwent intersphincteric dissection (87.2%) with primary perineal closure (97.0%). Perineal wound complications were significantly associated with IPAA-related sepsis as an indication for pouch excision (57.1% vs 27.2%; p = 0.05), intraoperative pouch perforation (35.7% vs 9.1%, p =0.03), and smoking (21.4% vs 3.0%; p = 0.04). IPAA-related sepsis and a current smoking status (OR, 19.3 [95% CI, 1.8 -488.1]) are significant independent predictors on multivariate logistic regression (OR, 6.4 [95% CI, 1.4-30.2]) of perineal wound complications. All of the patients with persistent perineal sinus achieved successful healing at a median of 734 days (range, 363-2182 days), requiring a median of 1.5 procedures., Limitations: This was a single-center retrospective review with a small sample size., Conclusions: Preoperative IPAA-related sepsis and current smoking are significant risk factors for perineal wound complications after pouch excision.

Aim: Colonic epithelial dysplasia is deemed the precursor lesion of cancer arising in inflammatory bowel disease (IBD). It has been suggested that many dysplastic lesions could be endoscopically detected to obtain target biopsies, leading to better yield. However, the clinical impact of a diagnosis of dysplasia may be hampered by a significant degree of histological and endoscopic intra-observer and inter-observer variability. This study aimed to evaluate intra-observer and inter-observer variability in the microscopic diagnosis of dysplasia in IBD and correlate endoscopic and histological findings., Method: In total, 158 cases of ulcerative colitis and 14 of Crohn's disease with dysplasia were selected from a pathology database. Slides were blindly reviewed twice by two expert gastrointestinal pathologists. Results of endoscopic examinations were extracted from the reports. The degree of intra-observer and inter-observer variability was determined by kappa statistics., Results: Overall, there was an excellent degree of histopathological inter-observer agreement (κ = 0.786). The lowest level of agreement in the dysplasia group was for indefinite dysplasia (κ = 0.251). Negative and high grade dysplasia diagnosis reached the highest level of agreement with κ values of 0.822 [95% confidence interval (CI) 0.673-0.971] and 1.00 (95% CI 0.850-1.149), respectively. Intra-observer agreement was good and increased during the latter period of the study (κ = 0.734, 95% CI 0.642-0.826). Endoscopic-histological correlation was poor among the negative endoscopies, as up to 43% of cases were diagnosed with at least focal high grade dysplasia. The endoscopic-histological correlation improved when evaluating suspicious endoscopic lesions., Conclusion: Dysplasia is reliably diagnosed by expert gastrointestinal pathologists but has poor correlation with an endoscopic diagnosis of dysplasia., (Colorectal Disease © 2014 The Association of Coloproctology of Great Britain and Ireland.)