Stefan D. Holubar

BACKGROUND: Anastomotic leaks, pelvic sepsis, and related complications are established predictors of pouch failure after ileal pouch-anal anastomosis (IPAA). However, the effect of the timing of index pouch failure on outcomes after redo pouch surgery remains poorly understood. OBJECTIVE: To evaluate whether the timing of index pouch failure predicts redo pouch survival. DESIGN: Retrospective cohort study. SETTING: Single quaternary referral center. PATIENTS: Patients with prior IPAA who underwent redo pouch surgery between 2000 and 2024. MAIN OUTCOME MEASURES: The primary outcome was redo pouch failure, defined as a composite of pouch excision, permanent rediversion after redo pouch creation, or failure to achieve ileostomy closure. The primary exposure was the timing of index pouch failure, categorized as early failure (rediversion ≤ 6 months after index IPAA) or late failure (rediversion > 6 months). RESULTS: A total of 320 patients met inclusion criteria, including 57 with early index pouch failure and 263 with late failure. Index pouch leak (50.9% vs. 33.5%; p =0.01) and pelvic abscess (36.8% vs. 14.1%; pp =0.07). On multivariable Cox proportional hazards regression, late index failure (HR 3.09; 95% CI 1.07-8.87; p =0.04) and inflammatory indications for redo (HR 2.40; 95% CI 1.15-5.0; p=0.02) were independent predictors of redo pouch failure. Secondary pouch failure occurred in 10.7% of the early group vs. 22.8% of the late group ( p =0.04). Sensitivity analyses using bootstrap internal validation confirmed the model's reliability, with an optimism-corrected C-index of 0.64; the low model optimism (3.9%) suggests the findings are robust and likely to generalize to other patient populations. LIMITATIONS: Retrospective design and single-center setting may limit generalizability. CONCLUSIONS: Late failure after index IPAA was associated with increased risk of subsequent pouch failure after redo IPAA. See Video

Background: Redo ileocolic resection (ICR) for Crohn's disease is technically challenging, and surgeons often debate whether a laparoscopic approach should be attempted given the risk of conversion. We evaluated predictors of conversion and postoperative outcomes following conversion to inform operative decision‐making. Methods: Patients undergoing redo ileocolic resection for Crohn's disease from 2009 to 2021 at a quaternary referral centre were identified from a prospectively maintained database. Cases were categorized as completed laparoscopically, converted or planned open. Predictors of conversion and perioperative outcomes were analysed. Results: Among 436 redo ileocolic resections, 100 were attempted laparoscopically, with a 10% conversion rate. Penetrating disease was significantly associated with conversion. Postoperative outcomes after conversion were comparable to planned open surgery, including overall complications, readmission and reoperation. Length of stay was shorter after completed laparoscopy. Conclusions: Conversion during laparoscopic redo ileocolic resection is uncommon and primarily driven by penetrating disease. Importantly, outcomes after conversion approximate those of planned open surgery, supporting an initial laparoscopic approach in appropriately selected patients.

Aim: Literature comparing total proctocolectomy with permanent end ileostomy (TPC‐EI) and IPAA in patients with UC is sparse. We aimed to (a) elucidate reasons for non‐restorative surgery in ulcerative colitis (UC), (b) describe the incidence of perineal wound complications and (c) assess differences in short‐term outcomes between groups. We hypothesized that non‐restorative surgery was associated with a higher overall complication rate than ileoanal pouch (IPAA). Methods: We identified a sample of patients with UC who underwent proctectomy (2005–2023) at our institution. The primary endpoint was the overall 30‐day complication rate. Odds ratios (ORs) and 95% confidence intervals are presented. Results: A total of 821 patients were included: 689 (83.9%) IPAA and 132 (16.1%) TPC‐EI (80% and 52% staged proctectomy, respectively). The most common reasons for TPC‐EI over IPAA were patient preference (53%), neoplasia (10.6%), incontinence (9.1%) and obesity (7.6%). Compared with IPAA patients, TPC‐EI patients were older, had more comorbidities, and more were receiving biologics. Postoperatively, 18.2% of TPC‐EI patients developed perineal wound complications, whereas 4.5% of IPAA patients experienced leaks. The overall 30‐day complication rate was higher after TPC‐EI (37.1% vs. 19.2%, p < 0.0001); however, after excluding these procedure‐specific complications, rates were equivalent (22.7% vs. 17.9%, p = 0.23). In multivariable analysis after propensity score matching, TPC‐EI remained a significant predictor of any complication (OR 2.84, 95% CI 1.37–6.08, p = 0.006). Conclusions: Patient preference was the most common reason for permanent ileostomy in UC. Although short‐term complication rates were similar overall, perineal complications occurred in 18% after TPC‐EI. These data may inform preoperative counselling when discussing surgical options for UC.

This is the second of two articles presenting the European Crohn’s and Colitis Organisation [ECCO] evidence‑based consensus guidelines on the management of adult patients with ulcerative colitis [UC]. The first article covers the medical management of UC, including acute severe colitis. The present article addresses the surgical management of medically refractory UC, including the general surgical approach and perioperative optimisation, surgical strategies and techniques, and recommended levels of centre expertise and surgical specialisation. Together, these two articles aim to inform shared decision‑making and to guide clinicians and healthcare professionals involved in the care of patients with UC, drawing on the best available evidence.

Non-healing perineal wounds (NHPWs), including persistent presacral sinuses, remain a common and morbid complication after elective intersphincteric proctectomy (ISP) for fistulizing perianal Crohn’s disease (pCD), with reported healing rates of approximately 70% at 1 year. These complications significantly impair quality of life and increase healthcare utilization, highlighting the importance of prevention. This narrative review summarizes contemporary evidence and expert practice to present ten pragmatic strategies to reduce perineal wound dehiscence after ISP for pCD. Prevention begins with comprehensive preoperative optimization, including correction of malnutrition and anemia, minimization of corticosteroid exposure, smoking and nicotine cessation, and optimization of relevant medical comorbidities. Careful assessment and control of Crohn’s disease activity are emphasized through current disease staging, proactive therapeutic drug monitoring, and aggressive surgical control of perianal sepsis. These measures often involve repeated examinations under anesthesia, drainage of abscesses and fistula tracts, fecal diversion when indicated, and selective use of hyperbaric oxygen therapy to improve local conditions before definitive surgery. Operative strategies focus on technical decisions that minimize perineal wound burden and promote healing. Key elements include performing proctectomy in the intersphincteric plane with total mesorectal excision when feasible, meticulous debridement and management of fistula tracts, and robust multilayered perineal closure. Adjunctive techniques such as horizontal mattress suturing of the levators to enhance tissue apposition, use of pedicled omental flaps with fluorescence angiography to confirm perfusion, and prophylactic incisional negative pressure wound therapy are highlighted. Collectively, these strategies provide a practical framework to reduce perineal wound complications after ISP for pCD.

Background: Fistulotomy is highly effective (> 90%) for cryptoglandular fistula-on-ano, but fistulotomy in perianal Crohn’s disease (pCD) is limited due to increased risk of recurrent fistulae, diarrhea, and fecal incontinence. We hypothesized that superficial fistulotomy resulted in wound healing in most patients. Method: We conducted a single-center retrospective review of adult patients with pCD who underwent fistulotomy from 1999 to 2022. Baseline characteristics, pCD characteristics, and short- and long-term surgical and functional outcomes were reported. Matched-pair Wilcoxon signed-rank test was used to compare continuous data. Results: A total of 43 adult patients with pCD underwent fistulotomy and were included: 29 (67.4%) were male, with an age of 34 (28–42) years and a follow-up time of 4.3 years. Prior interventions included draining setons (48.8%) and partial fistulotomy (17.4%); 25.6% had no prior surgery. Fistulotomies were subcutaneous (65.1%), low transsphincteric (16.3%), intersphincteric (4.7%), and unspecified (14%). Short-term complications included pain (20.9%), bleeding (4.7%), and seepage (2.3% each), and 58.1% of the patients had no complications. Long-term complications included bleeding, keyhole deformity, nonhealing wounds, and anal stricture (2.3% each), and 60.5% did not experience long-term complications. At the last follow-up, 41 (95.3%) patients had complete healing of the fistulotomy site. Conclusions: Fistulotomy was safe in select patients with fistulizing pCD and superficial fistulas with little or no sphincter involvement. We observed that fistulotomy was associated with wound healing, decreased drainage, and social restrictions in most patients, suggesting that this is a viable and safe option for this at-risk group.

Background: Perianal Crohn’s disease (pCD) is a severe phenotype frequently complicated by fistulas and recurrent abscesses. Although perianal sepsis is well described, genital involvement is rare, with scrotal abscesses previously reported only in case reports. Consequently, their presentation, management, and outcomes remain poorly understood. Methods: We conducted a retrospective cohort study of male patients with Crohn’s who developed scrotal abscesses between January 1, 2009, and October 31, 2024, at our quaternary referral center. Clinical records were reviewed for demographics, disease phenotype, abscess characteristics, diagnostic modality, management, microbiology, and clinical outcomes. Results: A total of 40 patients were identified. Median age at abscess presentation was 42 years (IQR 34.5–50), and median BMI was 24.7 kg/m ² (IQR 22.3–31.4). Most patients had colonic disease (57.5%) and long-standing Crohn’s disease. Prior Crohn’s-related abscesses occurred in 82.5%, and 37.5% had a history of perianal seton placement. Abscesses were most commonly right-sided (57.5%), and 35% of patients had a scrotal fistula. Diagnosis was most frequently established using computed tomography (32.5%). All patients received antibiotics; 30% underwent bedside incision and drainage, and 37.5% underwent operative drainage. Hospital admission was required in 60%, recurrence within 12 months occurred in 40%, and escalation of advanced therapy in 20%. During follow-up, 35% required fecal diversion (72% or 25% overall), and 20% underwent proctectomy. Conclusion: Scrotal abscesses are an uncommon but clinically significant complication of pCD, occurring in patients with severe perianal disease and are associated with substantial morbidity. Early recognition and multidisciplinary management are essential for successful outcomes.