[Restorative proctocolectomy with an ileoanal pouch. Postoperative course and long-term functional results]

INTRODUCTION

Over the last 25 years restorative proctocolectomy with an ileoanal pouch has been the gold standard in the surgical treatment of ulcerative colitis and in selected patients with familial adenomatous polyposis. We present a study of the course, complications and long-term functional results.

MATERIALS AND METHODS

A prospective cohort analysis and a questionnaire in 178 consecutive patients operated since 1987 in Hvidovre Hospital.

RESULTS

Postoperative complications were seen in 38 patients (21%), but only few were serious: anastomotic leakage in 2 (1%), pelvic abscess in 4 (2%) and complications after ileostomy closure in 2 (1%). The late complications comprised reoperation for intestinal bowel obstruction in 10 (6%), pouch fistula in 6 (3%), pouchitis in 22 (12%), and anastomotic stricture in 8 (5%). Three patients (2%) had the pouch removed. After a median observation period of 7 years (range 1-19) the patients had a median of 7 bowel movements per 24 hours (range 3-15), and 2/3 were totally continent day and night. 88% were satisfied with the results.

CONCLUSION

Our results are similar to those in the literature, probably because the preoperative evaluation, operation, postoperative course and long-term follow-up were managed by few specialists in ileoanal pouch surgery. In our opinion restorative proctocolectomy with an ileoanal pouch is still the gold standard for patients with ulcerative colitis and for selected patients with familial adenomatous polyposis.

[Ileal pouch-anal anastomosis for ulcerative colitis: complications and long term functional results]

BACKGROUND

The ileo anal-pouch-anastomosis (IPAA) is the treatment of choice for patients with ulcerative colitis (UC).

AIM

To analyze the surgical outcomes, long term evolution and functional results of IPAA.

MATERIAL AND METHODS

All patients subjected to an IPAA, from 1984 to 2006 were identified from a prospectively constructed inflammatory bowel disease database. Surgical variables, postoperative complications and functional evaluation, using Oresland score were analyzed. Chi square, Fischer exact test, T Student, Mann Whitney and binary logistic regression were included in the statistical analysis.

RESULTS

In the study period 107 patients, aged 14 to 62 years (61 females), subjected to an IPAA, were identified in this period. All patients, except 4, had a J pouch. All were protected with a loop ileostomy. Thirteen patients (12.1%) had specific postoperative complications: pelvic collections in five (4.6%), wound infection in four (3.7%), fistula of the anastomosis in two (1.8%), hemoperitoneum and pouch necrosis in one each. Three (2.7%) patients were reoperated. There was no post-operative (30 days) mortality. A complete follow-up was obtained in 106 of 107 patients: four evolved as Crohn disease; four lost their pouch and two died for other causes. One patient required an ileostomy due to a vaginal fistula. Seventy two patients were followed more than 36 months after ileostomy closure and 92% have a satisfactory intestinal function. In the univariate analysis, poorest intestinal function was related to age of diagnosis of UC and presence of chronic pouchitis. In the multivariate analyses age of diagnosis was associated with poor function.

CONCLUSIONS

IPAA has a low rate of complications. The long term intestinal function is satisfactory in most patients. A poorer intestinal function was observed in older patients and those with chronic pouchitis).

Effect of anastomosis level on continence performance and quality of life after colonic J-pouch reconstruction

Total mesorectal excision (TME) has become the recommended method for treatment of cancer in the middle or lower third of the rectum. Thus very low anastomoses are necessary to preserve continence, and pouch reconstruction is favored. It is unclear whether the level of anastomosis is important for continence and quality of life in colonic J-pouch reconstruction. In this investigation all patients were included who underwent curative elective anterior continuity resection with colorectal or coloanal J-pouch reconstruction for primary rectal cancer between January 2001 and December 2004. Exclusion criteria were distant metastases and any signs of recurrence at the time of investigation. Evaluation of continence performance by Wexner and Holschneider questionnaire and quality of life using the QLQ-C30 and QLQ-CR38 (EORTC) questionnaires was done 220 +/- 38 days after closure of the protective Ileostomy, which was performed 106 +/- 48 days after primary intervention. Fifty-two patients (79%) were analyzed. Colopouch rectal anastomosis was performed in eighteen cases and colopouch anal anastomosis in thirty-four cases. Fifty percent of the patients in both groups were continent for solid stool. Patients with a colopouch anal anastomosis had a significantly higher rate of incontinence for liquid stool, however. They took stool-regulating medicine more frequently and complained of fecal soiling and a restricted quality of life. Patients with a colopouch anal anastomosis had a significantly lower score on the most important points of the QLQ-C30 (emotional functioning, social functioning, pain, and quality of life). The same applied to the QLQ-CR38 for body image and problems with defecation. The quality of life of patients with a colopouch anal anastomosis was still considered acceptable compared with reference data for the normal healthy population, however. Both continence and quality of life are substantially affected by the level of the anastomosis after colonic pouch reconstruction. This suggests preservation of a small part of the rectum when oncologically feasible and performing a colopouch rectal anastomosis.

Pouchitis

While restorative proctocolectomy with ileal pouch-anal anastomosis has significantly improved the quality of life in patients with underlying ulcerative colitis who require surgery, complications can occur. Pouchitis as the most common long-term complication represents a spectrum of disease processes ranging from acute, antibiotic-responsive type to chronic antibiotic-refractory entity. Accurate diagnosis using a combined assessment of symptoms, endoscopy and histology and the stratification of clinical phenotypes is important for treatment and prognosis the disease. The majority of patients respond favorably to antibiotic therapy. However, management of chronic antibiotic-refractory pouchitis remains a challenge.

Does infliximab influence surgical morbidity of ileal pouch-anal anastomosis in patients with ulcerative colitis?

PURPOSE

Since infliximab has been approved for treatment of patients with refractory ulcerative colitis, surgeons will be increasingly faced with operating on patients who have failed therapy with this potent immunosuppressant. This study was designed to compare short-term complications in patients with ulcerative colitis who were treated with and without infliximab before colectomy.

METHODS

The charts of patients undergoing ileal pouch-anal anastomosis or subtotal colectomy for refractory ulcerative colitis during the five-year period ending October 2005 were reviewed. Postoperative medical and surgical complications were assessed.

RESULTS

Seventeen patients had failed infliximab treatment and 134 patients were never treated with infliximab. Ileal pouch-anal anastomosis was performed in 112 patients (74 percent) and subtotal colectomy in 39 patients (36 percent). There were no deaths. Postoperative complications were observed in 43 patients (28 percent), with no significant difference observed between infliximab-treated (37 percent) and infliximab-untreated patients (27 percent). Of 61 patients (40 percent) treated with preoperative cyclosporine A, 5 patients also had been treated with infliximab. The infliximab and cyclosporine A-treated patient group had an 80 percent complication rate, significantly higher than the 29 percent complication rate noted in the cyclosporine A only-treated group (P = 0.04).

CONCLUSIONS

Although preoperative treatment with infliximab alone does not significantly increase the incidence of postoperative complications, using both inflixiamb and cyclosporine A before colectomy in refractory ulcerative colitis is associated with high surgical morbidity.

A randomized multicenter trial to compare long-term functional outcome, quality of life, and complications of surgical procedures for low rectal cancers

INTRODUCTION

Colonic pouches have been used for 20 years to provide reservoir function after reconstructive proctectomy for rectal cancer. More recently coloplasty has been advocated as an alternative to a colonic pouch. However there have been no long-term randomized, controlled trials to compare functional outcomes of coloplasty, colonic J-Pouch (JP), or a straight anastomosis (SA) after the treatment of low rectal cancer.

AIM

: To compare the complications, long-term functional outcome, and quality of life (QOL) of patients undergoing a coloplasty, JP, or an SA in reconstruction of the lower gastrointestinal tract after proctectomy for low rectal cancer.

METHODS

A multicenter study enrolled patients with low rectal cancer, who were randomized intraoperatively to coloplasty (CP-1) or SA if JP was not feasible, or JP or coloplasty (CP-2) if a JP was feasible. Patients were followed for 24 months with SF-36 surveys to evaluate the QOL. Bowel function was measured quantitatively and using Fecal Incontinence Severity Index (FISI). Urinary function and sexual function were also assessed.

RESULTS

Three hundred sixty-four patients were randomized. All patients were evaluated for complications and recurrence. Mean age was 60 +/-12 years, 71% were male. Twenty-three (7.4%) died within 24 months of surgery. No significant difference was observed in the complications among the 4 groups. Two hundred ninety-seven of 364 were evaluated for functional outcome at 24 months. There was no difference in bowel function between the CP-1 and SA groups. JP patients had fewer bowel movements, less clustering, used fewer pads and had a lower FISI than the CP-2 group. Other parameters were not statistically different. QOL scores at 24 months were similar for each of the 4 groups.

CONCLUSIONS

In patients undergoing a restorative resection for low rectal cancer, a colonic JP offers significant advantages in function over an SA or a coloplasty. In patients who cannot have a pouch, coloplasty seems not to improve the bowel function of patients over that with an SA.

[Long term functional outcomes after ileoanal pouch in patients with and without postoperative complications]

BACKGROUND

the proctocolectomy with ilealpouch (IP) has become the gold standard for surgical treatment for ulcerative colitis (UC). The postoperative complications are frequent but the definitive outcome is acceptable.

AIM

our aim was to evaluate the long term functional outcome in a series of consecutive patients with IP and to establish its relation with postoperative complications.

PATIENTS AND METHODS

we included 144 patients categorized in two groups: I--patients without postoperative complications (n: 71); II--patients with postoperative complications (n: 73). Patients were followed for a median time of 3.8 years (range 1-15). We evaluated: stool frequency, anal discrimination between gas and stool, voluntary evacuation inhibition, requirement of antidiarrheal medications and presence of incontinence.

RESULTS

the functional outcome was similar between the two groups in terms of stool fequency medication use, anal discrimination and the voluntary inhibition of evacuation for more than 5 hours. A trend to present seepage was seen in patients with complications (34%) more than in those without them (20%; p<0.08 NS). Compared with group II, seepage in group I was significantly related with dietary lapses (p<0.01). The most frequent complication in incontinent patients was pelvic sepsis (56%).

CONCLUSIONS

our study showed that most of long-term functional parameters are not influenced by the presence of postoperative complications. However, a trend for incontinence seems to be related to postoperative complications, more frequently with pelvic sepsis.

Functional results after radiochemotherapy and total mesorectal excision for rectal cancer

BACKGROUND AND PURPOSE

The aim of this study was to prospectively define and measure evacuation and continence disorders after preoperative radiochemotherapy and total mesorectal excision (TME) for rectal cancer 1 year after surgery.

MATERIALS AND METHODS

We submitted 100 patients, who underwent neoadjuvant treatment and anterior resection with TME from 1996 to 2003, to a questionnaire on postoperative continence and evacuation. Anal sphincter function was further assessed by the Memorial Sloan-Kettering score. Factors influencing anorectal function were examined in univariate and multivariate analysis.

RESULTS

Median evacuation score was 16.12 +/- 5.12 (range 0-28). Sensation of incomplete evacuation was reported in 58% of cases, necessity to return to the bathroom <15 min in 37% and inability to evacuate completely <15 min in 35%. Median continence score was 13.7 +/- 4.79 (range 0-20). Incontinence to flatus was reported in 46% of cases. Colonic J-pouch allows better evacuation and continence. Continence was also better in absence of postoperative complications. Sphincter function resulted excellent or good in 75% of patients according to the Memorial Sloan-Kettering score.

CONCLUSIONS

The most frequent symptoms in our series are the sensation of incomplete evacuation, the incontinence to flatus, and the necessity to return to the bathroom <15 min. Colonic J-pouch warrants a better function. Postoperative complications compromise good functional results.

The impact of preoperative immunomodulation on pouch-related septic complications after ileal pouch-anal anastomosis

PURPOSE

We studied preoperative and perioperative factors with particular attention to the role of immunomodulatory medication, which may impact the incidence of pouch-related septic complications.

METHODS

A retrospective review of data from patients who underwent ileal pouch surgery during a 20-year period from 1985 to 2005 was performed. Preoperative use of immunomodulatory medication along with perioperative clinical, surgical, and disease variables were recorded. Patients were monitored for pouch-related sepsis in the early (within 30 days of surgery) and late (after 30 days of surgery) postoperative periods. Univariate and multivariate logistic regression analysis was performed.

RESULTS

There were 445 patients (206 females; 46.4 percent). Median age was 36 (interquartile range, 27-46) years. Median follow-up period was 52 (interquartile range, 26-86) months. Complete data were available for 335 patients. Early sepsis was seen in 58 patients (17.3 percent). Another 22 patients (6.5 percent) developed late sepsis. On multivariate analysis, only steroid use remained predictive of higher rates of early sepsis (odds ratio, 1.81; 95 percent confidence interval, 1.02-3.45; P=0.002). Likewise on multivariate analysis, both male gender (odds ratio, 0.24; 95 percent confidence interval, 0.09-0.71; P=0.007) and 5-aminosalicylic-acid use (odds ratio, 0.22; 95 percent confidence interval, 0.08-0.76; P=0.023) remained predictive of lower rates of sepsis.

CONCLUSIONS

Preoperative steroid use is associated with higher rates of early but not late pouch-related septic complications. We recommend that patients be weaned of steroids before ileal pouch surgery or be warned of the higher risk of postoperative sepsis.

Should ileal pouch-anal anastomosis include mucosectomy?

OBJECTIVE

Debate exists as to the benefits of performing mucosectomy as part of pouch surgery for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). Whilst mucosectomy results in a more complete removal of diseased mucosa, this benefit may be at the price of poorer function. We examined these issues.

METHOD

Using Medline, Embase, Ovid and Cochrane database searches papers were identified relating to the outcome following pouch surgery with and without mucosectomy. Potential reasons for functional problems were investigated, as were rates of 'cuffitis', dysplasia, polyposis and cancer in the ileal pouch and anal canal.

RESULTS

The available evidence suggests that performing a mucosectomy leads to a worse functional outcome. Meta-analysis suggested that nighttime seepage of stool and resting and squeeze pressure were worse after mucosectomy. The most likely reason for functional impairment following pouch surgery was the degree of anal manipulation. Mucosectomy does seem to confer benefit in terms of disease control but this benefit does not reach statistical significance.

CONCLUSION

Stapled anastomosis avoiding mucosectomy is the approach of choice for ileal pouch anal anastomosis because this leads to superior functional outcome. Performing mucosectomy results in some clinical benefits in terms of lower rates of inflammation and dysplasia in the retained mucosa in UC patients and lower rates of cuff polyposis in FAP patients. However, on the basis of available evidence mucosectomy is only indicated in those cases where the patient is at a high risk of disease in the retained rectal cuff.

Ileoanale Pouch-Operation

Restorative proctocolectomy with an ileal pouch-anal anastomosis is the treatment of choice in patients with ulcerative colitis (UC) and familial adenomatous polyposis requiring surgical therapy. Pouchitis is the most frequent complication, occurring in up to 50% of patients with underlying UC. Clinical symptoms of the disease are non-specific. Moreover, surgical complications must be differentiated from idiopathic pouchitis using pouchoscopy, endoscopic ultrasound or MRI of the pelvis in certain cases. The therapy for idiopathic pouchitis, its etiology and pathophysiology being unclear, is based on antibiotic treatment, usually with metronidazole or ciprofloxacin. Probiotics such as VSL#3 can be used to prevent relapse. In summary, the clinical and functional outcomes are excellent and stable for 20 years after surgery.

The downside of ileocystoplasty for persons with cervical spinal cord injury and an indwelling urinary catheter

PURPOSE

To explore the lived experience of persons with cervical spinal cord injury with a urinary catheter in situ, managing mucus in urine following ileocystoplasty

METHOD

Descriptive qualitative methodology was employed. Semi-structured, one-to-one, audiotaped interviews with men (n=6) and a woman (n=1) with cervical-level spinal cord injuries (C4-C6). Analyses of transcribed verbatim transcripts was undertaken using thematic analysis.

FINDINGS

There was a mean of 3.6 years since ileocystoplasty. Six major themes emerged from the data. All participants perceived the surgery had adversely affected their life, in part because regular intervention was needed to manage the significant problem of mucus. There was also an increase in autonomic dysreflexia episodes experienced due to mucus blocking bladder drainage.

CONCLUSION

Consequences of mucus production have impacted negatively upon participants' health and their ability to participate in life situations, as well as increasing their dependence on others.

Female fertility and childbirth after ileal pouch-anal anastomosis for ulcerative colitis

BACKGROUND

The aim of this study was to calculate the probability of becoming pregnant after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis, and to evaluate complications during pregnancy and childbirth.

METHODS

A questionnaire was posted to 160 women with an IPAA and to 160 controls. The probability of becoming pregnant after IPAA was calculated by the Kaplan-Meier method.

RESULTS

Of 54 women who had undergone IPAA surgery, 36 (67 per cent) succeeded in becoming pregnant naturally, compared with 49 (82 per cent) of 60 controls. The probability of pregnancy after 2 years of trying was 56 per cent in the IPAA group and 91 per cent in the control group (P < 0.001). Women in the IPAA group needed infertility investigations more often (24 versus 10 per cent; P = 0.044). In all, 39 (72 per cent) women in the IPAA group and 53 (88 per cent) in the control group bore a child. Twenty-one of 39 women in the IPAA group and 13 of 53 in the control group had a caesarean section (P = 0.005). Anal incontinence after delivery occurred more often in the control group.

CONCLUSION

Women with an IPAA mostly suffer a reduction in the probability of conception rather than complete infertility. Because complications during pregnancy and delivery were rare, caesarean section should be based mainly on obstetric indications.

[Gangrenous pyoderma and enterocutaneous fistulas after ileal pouch-anal anastomosis]

We describe the medical-surgical management of a patient with a complex inflammatory bowel disease who developed 2 acute episodes of pyoderma gangrenosum and enterocutaneous fistulas after ileal pouch-anal anastomosis for ulcerative colitis. The rarity of this postsurgical complication is emphasized. A good response to topical tacrolimus was achieved in cutaneous wounds. A less favorable response to infliximab was achieved in the abdominal fistulas, requiring surgical excision of the pouch.

Age-related analysis of functional outcome and quality of life after restorative proctocolectomy and ileal pouch-anal anastomosis for familial adenomatous polyposis

BACKGROUND

The aim of the present study was to evaluate the influence of a younger age at the time of ileal pouch-anal anastomosis (IPAA) on functional outcome and quality of life in patients with familial adenomatous polyposis (FAP).

METHOD

A total of 105 patients with FAP who had undergone IPAA were retrieved from a dedicated Institutional Review Board (IRB)-approved IPAA database. Fifty-three patients who had complete follow-up data at 1, 3 and 5 years were included in the study. Patients were categorized into three groups according to their ages at the time of surgery. Group 1, patients < or =20 years of age (n = 9); group 2, patients >20 and < or = 40 years of age (n = 23); and group 3, patients >40 years of age (n = 21). Perioperative characteristics, postoperative complications, quality of life scores and functional outcome at 1, 3 and 5 years of postoperative follow-up were assessed.

RESULTS

At any time point, there were no significant differences among the groups in terms of perioperative characteristics, quality of life scores or level of satisfaction with the procedure. However, younger patients had significantly lower nocturnal bowel movements at the first and third years of follow-up and tended to have less bowel movements per day at all stages of follow-up.

CONCLUSION

These findings indicate that younger patients with FAP are inclined to have better functional outcome after IPAA in the early postoperative period. This finding may be encouraging for colorectal surgeons who will operate on young patients with FAP.

A systematic review of the function and complications of colonic pouches

PURPOSE

This is a meta-analysis of randomized, controlled trials to compare the function and complications of a straight coloanal anastomosis to a colonic J-pouch after rectal excision at 1 year postoperatively.

MATERIALS AND METHODS

A search for articles from 1980 to 2005 was conducted on Medline, PubMed, and the Cochrane Controlled Trials Register using the keywords "colonic pouches, J-pouch, straight and coloanal anastomosis, rectal cancer, function and complications," either singularly or in combination. Reference lists from short-listed articles were also manually searched for relevant articles, journals, and conference proceedings. Randomized controlled trials (RCTs) in English publications comparing colonic J-pouches to straight coloanal anastomosis were selected. Trials with similar patient characteristics, duration of follow-up, and outcome measures were pooled for analysis. Stool frequency and fecal continence at 1 year postoperatively were used as measures of functional outcome. Complication rates in terms of anastomotic leak and stricture formation were analysed.

RESULTS

Ten RCTs with satisfactory methodology were identified. One trial reported the results at 2 years, while another reported results at 5 years only and were excluded from the meta-analysis, leaving only eight studies for further analysis. Overall, a colonic J-pouch appeared more favorable in terms of stool frequency (weighted mean difference of -1.21, 95% CI: -1.92 to -0.49) and continence (Odds ratio 0.23, 95% CI: 0.08-0.69), with a slightly lower risk of anastomotic dehiscence compared to a straight coloanal anastomosis (relative risk, RR 0.36; 95% CI: 0.12-1.08). Anastomotic stricture was reported in only two trials. They seemed more likely to occur after a pouch-anal anastomosis (RR 2.45, 95% CI: 0.79-7.57). However, the small numbers available for pooled analysis cannot allow these conclusions to be drawn with confidence.

CONCLUSIONS

A straight coloanal anastomosis resulted in poorer function due to loss of a rectal reservoir, while colonic J-pouches have improved frequency and continence up to a year. Although retrospective reports seem to favor the use of a pouch, there are limited longer term randomized trial data to suggest that the function and complications of a coloanal J-pouch is better than a straight coloanal anastomosis. Larger randomized studies are required to further verify the longer-term benefits of a coloanal pouch.

Systematic review of dysplasia after restorative proctocolectomy for ulcerative colitis

Background

The aim of this systematic review was to assess the prevalence and site of dysplasia after restorative proctocolectomy (RPC) for ulcerative colitis (UC), and to identify risk factors that could be used in a surveillance programme.

Methods

Medical databases were searched for potentially relevant publications between 1978 and 2006. Studies that dealt with RPC for UC and postoperative surveillance were included. Two researchers independently performed study selection, quality assessment, data extraction and analysis.

Results

Twenty-three observational studies and case series were included, with a total of 2040 patients. The pooled prevalence of confirmed dysplasia in the pouch, anal transitional zone or rectal cuff was 1·13 (range 0–18·75) per cent. The prevalence of high-grade dysplasia, low-grade dysplasia and indefinite for dysplasia was 0·15 (range 0–4·49), 0·98 (range 0–15·62) and 1·23 (range 0–25·28 per cent) respectively. Dysplasia was equally frequent in the pouch and rectal cuff or anal transitional zone. Dysplasia and cancer identified before or at operation seemed to be significant predictors of the development of dysplasia. Pouchitis and duration of follow-up were not of predictive value.

Conclusion

Although based on low-level evidence from uncontrolled studies, the prevalence of dysplasia observed after RPC was remarkable. A surveillance programme that takes into account the risk factors found is therefore advocated.

Dysbiosis in pouchitis: evidence of unique microfloral patterns in pouch inflammation

BACKGROUND & AIMS

Pouch inflammation after surgery for ulcerative colitis can significantly alter quality of life and thus ideally should be prevented. Dysbiosis or altered microflora is suspected to be the key pathogenic factor for pouchitis. However, dysbiosis in pouchitis has not been characterized carefully because of a lack of available sensitive microbiological technology suitable for in vivo studies in human beings. Thus, the aims of our study were as follows: (1) to show the use of the length heterogeneity polymerase chain reaction (LH-PCR) technique for studying microflora in human beings, and (2) to use the technique to characterize the microfloral patterns in the ileal pouch of patients with pouchitis.

METHODS

Microfloral patterns initially were assessed using a 16S ribosomal RNA technique (LH-PCR) to determine the qualitative changes in the luminal and mucosal intestinal flora. We subsequently cloned and sequenced the LH-PCR amplification products from the community 16S ribosomal RNA found in patients with pouchitis and in control pouch to identify the microbial species involved in pouchitis.

RESULTS

We have shown unique microfloral patterns in pouchitis. Through cloning and sequencing of the LH-PCR amplicons, we have shown the persistence of Fusobacter and Enteric species associated with the disease state and the absence of specific bacteria such as Streptococcus species in the inflamed pouch.

CONCLUSIONS

We have shown that the LH-PCR technique is suitable for studying microflora in human beings. By using this technique and the clone sequences, we have shown dysbiosis in the microbial biofilm adherent to the mucosa in pouchitis. Our data provide direct evidence of the role of bacteria in the pathogenesis of pouchitis.

The fate of the rectal stump after subtotal colectomy for ulcerative colitis

OBJECTIVE

To review the outcome of patients who had undergone subtotal colectomy for ulcerative colitis with formation of a rectal stump. To specifically look at the fate of the rectal stump, whether patients underwent emergency colectomy as opposed to urgent or elective resection.

PATIENTS AND METHODS

Between January 1990 and August 2000, a total of 31 patients underwent subtotal colectomy for ulcerative colitis. Patients were identified using the computerized coding system for the years 1995 to 2000, supplemented by pathology records, discharge letters, and operation notes. Postal and telephone surveys were undertaken using a standard questionnaire assessing social, physical, sexual, and bowel activities of patients.

RESULTS

In 28 out of 31 patients, the follow-up was complete. Twenty-four of 28 patients (86%) underwent excision of rectal stump. Four patients (14%) preferred to undergo excision of rectum only, resulting in a permanent ileostomy; 20/28 (71%) had attempted ileal pouch-anal anastomosis, with success in 85%. In four patients (14%), the rectal stump remained in situ and was associated with a decrease in the quality of life. There were no perioperative deaths and morbidity was low for all procedures.

CONCLUSION

These data show that after subtotal colectomy, the majority of our ulcerative colitis patients undergo ileal pouch-anal anastomosis. Patients' satisfaction is high with reasonable social and excellent sexual function on quality of life assessment. During its retention, the rectal stump causes considerable symptoms. When left in situ, it is associated with a decrease in the quality of life.

Iron-deficiency anemia as presentation of pouchitis

GOALS

This study sought to describe the percentage and cause of anemia in patients who underwent ileal pouch with anal anastomosis (IPAA) for ulcerative colitis (UC), and to compare the distribution of complications in patients with and without anemia, especially pouchitis, after IPAA.

BACKGROUND

IPAA is the surgical procedure of choice for UC. Complications include pouchitis (40%), strictures (30%), small bowel obstruction (10%), pelvic sepsis (<5%), and urinary and sexual dysfunctions (<5%). Few studies have described the prevalence of anemia after IPAA, but no conclusive findings have been reported.

STUDY

Patients who had undergone IPAA for UC were recruited from the UPR Inflammatory Bowel Disease Clinic and the Gastroenterology Research Unit. Demographic and medical data were obtained. Anemia was diagnosed using standard hematologic criteria. Serum iron, ferritin, transferrin, folate, vitamin B12, erythropoietin, total iron-binding capacity, reticulocyte count, peripheral smear, and bone marrow aspirate were evaluated in patients with anemia. Data analysis was performed with EPI Info version 6.4d.

RESULTS

Iron-deficiency anemia was identified in 55.5% (10/18) of patients and pouchitis was found in 77% (14/18). All 10 patients with anemia had pouchitis, whereas only 4 of the 8 without anemia had pouchitis. In half of the anemic patients, pouchitis was asymptomatic.

CONCLUSIONS

Iron-deficiency anemia may be a clinical presenting sign of pouchitis. Hemoglobin levels may be considered as surveillance tools for pouchitis in patients with IPAA.

Risk factors for clinical phenotypes of Crohn's disease of the ileal pouch

BACKGROUND

Crohn's disease (CD) of the pouch can occur in patients with colectomy and ileal pouch-anal anastomosis (IPAA) originally performed for a preoperative diagnosis of ulcerative colitis. The clinical presentations of CD of the pouch are inflammatory, fibrostenotic, and fistulizing. Risk factors for clinical phenotypes of CD of the pouch have not been characterized.

METHODS

A total of 78 eligible patients with CD of the pouch together with 294 nonselected non-CD patients with IPAA seen in the Pouchitis Clinic were enrolled, including 28 with inflammatory CD, 18 with fibrostenotic CD, and 32 with fistulizing CD. The clinical phenotypes of CD were diagnosed based on a combined assessment of clinical, endoscopic, radiographic, and histologic features. Three separate analyses were performed, and for each analysis, the outcome of interest was having one of the phenotypes versus not having it. A stepwise selection multivariable logistic regression analysis was used.

RESULTS

In the multivariable analysis, the risk factor for inflammatory CD was higher afferent-limb endoscopy scores (hazard ratio [HR] 1.87 95% confidence interval [CI] 1.54-2.27); the risk factors for fibrostenotic CD were higher afferent-limb (95% CI 1.81-3.48, HR 2.51) and higher cuff (95% CI 1.01-1.84, HR 1.36) endoscopy scores; and for fistulizing CD the risk factors were younger age (95% CI 0.93-0.99, HR 0.96), female gender (95% CI 1.35-6.97, HR 3.07), a preoperative diagnosis of indeterminate colitis (95% CI 1.72-9.34, HR 4.00), and no use of nonsteroidal antiinflammatory drugs (95% CI 1.31-8.25, HR 3.28).

CONCLUSIONS

Each of the three phenotypes of CD of the pouch was associated with certain risk factors, suggesting that each of these diseases has a different etiology and disease process. The identification and management of some of the modifiable risk factors may reduce CD-related morbidity.

Factors associated with failure in managing pelvic sepsis after ileal pouch-anal anastomosis (IPAA)--a multivariate analysis

BACKGROUND

Pelvic sepsis is known to cause a detrimental outcome after ileal pouch-anal anastomosis (IPAA). The aim of this study was to examine potential factors associated with failure in managing pelvic sepsis after IPAA.

METHODS

We performed univariate and multivariate logistic regression analysis on 2518 IPAA patients between 1983 and 2005. Failure was defined as pouch failure, the need for a permanent ileostomy, or mortality as a result of sepsis. There were 157 patients (6.2%) with pelvic sepsis after IPAA. These involved anastomotic leak 34% (54/157) and fistula 25% (40/157). There were 5 mortalities related to sepsis. Mean age at surgery was 38.1 +/- 14.4 years and mean follow-up was 5.5 +/- 4.7 years.

RESULTS

Pouches were saved in 75.8% patients. Univariate analysis identified early sepsis (P = .040), preoperative steroid use (P = .007), and need for percutaneous drainage (P = .004) as significant factors associated with treatment success. Factors associated with failure were hypertension (P = .026), hand-sewn anastomosis (P = .038), associated fistula (P = .0003), need for transanal drainage (P = .0002), need for laparotomy to control septic complications (P < .0001), delayed ileostomy closure (P = .0003), and need for a new diverting ileostomy (P < .0001). By using multivariate analysis with selected covariates, significant factors associated with failure were associated fistula (P = .0013), need for transanal drainage (P = .003), delayed ileostomy closure (P = .022), need for a new ileostomy diversion (P = .004), and hypertension (P = .039). We developed a predictive scoring system for failure to use in management plans and decision-making for the treatment of septic complications of IPAA.

CONCLUSIONS

Pelvic sepsis after IPAA has a significant impact on pouch failure. This predictive model for failure may play an important role in providing risk estimates for successful outcomes.

Threefold increased risk of infertility: a meta-analysis of infertility after ileal pouch anal anastomosis in ulcerative colitis

BACKGROUND

Increased infertility in women has been reported after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis but reported infertility rates vary substantially.

AIMS

(1) To perform a systematic review and meta-analysis of the relative risk of infertility post-IPAA compared with medical management; (2) to estimate the rate of infertility post-IPAA; and (3) to identify modifiable risk factors which contribute to infertility.

METHODS

Medline, EMBASE, Current Contents, meeting abstracts, and bibliographies were searched independently by two investigators. The titles and abstracts of 189 potentially relevant studies were reviewed; eight met the criteria and all data were extracted independently. Consensus was achieved on each data point, and fixed effects meta-analyses, a funnel plot, and sensitivity analyses were performed.

RESULTS

The initial meta-analysis of eight studies had significant heterogeneity (p = 0.004) due to one study with very high preoperative infertility (38%). When this study was omitted, the relative risk of infertility after IPAA was 3.17 (2.41-4.18), with non-significant heterogeneity. The weighted average infertility rate in medically treated ulcerative colitis was 15% for all seven studies, and the weighted average infertility rate was 48% after IPAA (50% if all eight studies are included). We were unable to identify any procedural factors that consistently affected the risk of infertility.

CONCLUSIONS

IPAA increases the risk of infertility in women with ulcerative colitis by approximately threefold. Infertility, defined as achieving pregnancy in 12 months of attempting conception, increased from 15% to 48% in women post-IPAA for ulcerative colitis. This provides a basis for counselling patients considering colectomy with IPAA. Further studies of modifiable risk factors are needed.

Creating the evidence base: the journey from practice to research

The ability to deliver accurate, evidence-based information when helping patients make decisions about their care is fundamental to the role of the clinical nurse specialist. For patients with ulcerative colitis who are considering surgery to form an ileo-anal pouch, it is essential to give them information about the psychosocial, as well as the physical, effects of such surgery. As many of these patients are of working age, understanding the likely consequences for paid employment is a priority. However, very little evidence is available on this subject. The authors therefore decided to develop a research study aimed at filling this gap. A proposal to conduct a phenomenological study into the subsequent employment experiences of patients who have undergone ileo-anal pouch formation has been developed. This article seeks to explore how the research idea and its methodology stemmed from practice and highlights the importance of seeing research and practice as complementary components of good nursing care.

Leukocyte removal therapy for ulcerative colitis does not affect postoperative complications

BACKGROUND

We investigated the incidence of postoperative complications in patients treated with or without preoperative leukocyte removal therapy (LRT).

METHODS

The case notes of 387 patients with ulcerative colitis (UC) who underwent surgical intervention were retrospectively reviewed. One hundred nine patients were treated with LRT within 8 weeks before surgery (LRT group), and 278 had not received LRT since at least 8 weeks before surgery (without LRT group). We reviewed the postoperative complications according to type of initial operation.

RESULTS

Of the patients who underwent an ileal J-pouch anal anastomosis (IPAA) without an ileostomy, 3 (6.5%) in the LRT group developed pouch-related complications (PRC), while 11 (7.5%) in the without LRT group developed PRC. The overall postoperative complication rates were 28.3% in the LRT group and 21.8% in the without LRT group. For patients who underwent an IPAA with an ileostomy, the overall rates of postoperative complications were 39.1% in the LRT group and 31.8% in the without LRT group. Among those undergoing a total colectomy, 33.3% in the LRT group and 18.2% in the without LRT group had postoperative complications. No statistically significant differences were demonstrated between the two groups with respect to postoperative complications.

CONCLUSIONS

Our results suggest that preoperative LRT does not influence the rate of postoperative complications in UC patients.

Sources and Severity of Self-Reported Food Intolerance after Ileal Pouch–Anal Anastomosis

Data on food intolerance after ileal pouch-anal anastomosis are scarce. The aim of this study was to identify foods causing intolerance and to determine the nature and severity of reported symptoms. Patients from the Dutch Crohn's and Ulcerative Colitis Association were mailed a survey on food intolerance; 105 (31% men) of 137 patients took part. They all reported intolerance to one or more foods. Common symptoms (scored from 0=absent to 10=severe), included diarrhea (mean score=5.8), fatigue (mean score=5.5), and thirst (mean score=4.6). Spicy foods, cabbage, and citrus fruits (or juice) were most likely to decrease stool consistency, increase stool frequency, or cause perianal irritation. Onions, cabbage, or leeks were reported by 28% of the patients to cause flatulence. The urge to defecate was stronger after a cooked meal (45% within (1/2) hour) than after sandwiches (15% within (1/2) hour). Foods reported to increase stool consistency were potato products, bread, and bananas. This study demonstrates that food intolerance is a common, albeit mild, problem after ileal pouch-anal anastomosis. Food and nutrition professionals should encourage patients to base their food choices on individual tolerance as long as no (patho-) physiological-based evidence to the contrary is available.

A comparison of hand-sewn versus stapled ileal pouch anal anastomosis (IPAA) following proctocolectomy: a meta-analysis of 4183 patients

OBJECTIVE

Using meta-analytical techniques, the study compared postoperative adverse events and functional outcomes of stapled versus hand-sewn ileal pouch-anal anastomosis (IPAA) following restorative proctocolectomy.

BACKGROUND

The choice of mucosectomy and hand-sewn versus stapled pouch-anal anastomosis has been a subject of debate with no clear consensus as to which method provides better functional results and long-term outcomes.

METHODS

Comparative studies published between 1988 and 2003, of hand-sewn versus stapled IPAA were included. Endpoints were classified into postoperative complications and functional and physiologic outcomes measured at least 3 months following closure of ileostomy or surgery if no proximal diversion was used, quality of life following surgery, and neoplastic transformation within the anal transition zone.

RESULTS

Twenty-one studies, consisting of 4183 patients (2699 hand-sewn and 1484 stapled IPAA) were included. There was no significant difference in the incidence of postoperative complications between the 2 groups. The incidence of nocturnal seepage and pad usage favored the stapled IPAA (odds ratio [OR] = 2.78, P < 0.001 and OR = 4.12, P = 0.007, respectively). The frequency of defecation was not significantly different between the 2 groups (P = 0.562), nor was the use of antidiarrheal medication (OR = 1.27, P = 0.422). Anorectal physiologic measurements demonstrated a significant reduction in the resting and squeeze pressure in the hand-sewn IPAA group by 13.4 and 14.4 mm Hg, respectively (P < 0.018). The stapled IPAA group showed a higher incidence of dysplasia in the anal transition zone that did not reach statistical significance (OR = 0.42, P = 0.080).

CONCLUSIONS

Both techniques had similar early postoperative outcomes; however, stapled IPAA offered improved nocturnal continence, which was reflected in higher anorectal physiologic measurements. A risk of increased incidence of dysplasia in the ATZ may exist in the stapled group that cannot be quantified by this study. We describe a decision algorithm for the choice of IPAA, based on the relative risk of long-term neoplastic transformation.

Increased experience and surgical technique lead to improved outcome after ileal pouch-anal anastomosis: a population-based study

PURPOSE

This study was designed to determine whether changes in length of stay and 30-day readmission, reoperation, and excision rates for the ileal pouch-anal anastomosis occurred over time and with changes in surgical technique and hospital volume.

METHODS

Using three population-based administrative databases, data on all ileal pouch-anal anastomoses performed in the province of Ontario between January 1992 and June 1998 were obtained. The effect of age, gender, stage of the procedure, year of surgery, and hospital volume were examined for their effect on length of stay and readmission, reoperation, and excision rates.

RESULTS

There were 1,285 ileal pouch-anal anastomoses performed in 58 hospitals. There was a significant decrease in length of stay and reoperation and excision rates but a concommitant increase in readmission rate during the study period. Patients younger than aged 40 years had a significantly lower length of stay and excision rate. Patients who had a two-stage procedure had a shorter length of stay, readmission, and reoperative rate compared with those having a three-stage procedure. Hospital volume was a significant predictor of need for reoperation and excision with both low-volume and medium-volume hospitals having significantly higher rates than high-volume hospitals.

CONCLUSIONS

Outcome after ileal pouch-anal anastomosis has improved. It is significantly better in patients younger than aged 40 years, having a two-stage procedure, and where surgery is performed at high-volume hospitals. It is likely that both modifications in surgical technique and surgical experience have led to improvements in clinical outcome after ileal pouch-anal anastomosis.

Sacral osteomyelitis after ileal pouch-anal anastomosis: report of four cases

PURPOSE

This study describes an institutional experience with sacral osteomyelitis after proctocolectomy and ileal pouch-anal anastomosis.

METHODS

A total of 2,375 patients underwent ileal pouch-anal anastomosis at the Mayo Clinic between January 1981 and January 2002. In addition, we have served as a tertiary referral base for patients with complications after ileal pouch-anal anastomosis performed at other institutions. Review of our ileal pouch-anal anastomosis prospective database and directed search of the central pathology, microbiology, radiology, and surgical records at the Mayo Clinic was performed using these keywords: osteomyelitis, ileal pouch-anal anastomosis, inflammatory bowel disease, chronic ulcerative colitis, and Crohn's disease.

RESULTS

Two of 2,375 patients (0.08 percent) with ileal pouch-anal anastomosis performed at our institution have had sacral osteomyelitis. In addition, two patients have been referred for continuing care after construction of an ileal pouch-anal anastomosis and diagnosis of sacral osteomyelitis at another institution. Two of the four patients maintained normal pouch function after sacral debridement and a period of fecal stream diversion. One patient remains diverted with resolved sacral osteomyelitis after debridement. The last patient died from squamous-cell cancer involving the sacrum.

CONCLUSIONS

Sacral osteomyelitis is a rare and heretofore unreported complication of ileal pouch-anal anastomosis. Conservative measures using antibiotics alone proved unsuccessful, and delaying definitive management may have contributed to the degeneration of a chronic sacral abscess into squamous-cell cancer. With more aggressive treatment comprising sacral debridement, long-term antibiotics, and fecal diversion, pouch function can potentially be preserved.

Timing of restorative proctectomy following subtotal colectomy in patients with inflammatory bowel disease

BACKGROUND

There is no general consensus regarding the timing of restorative proctocolectomy (RPC) in patients who have undergone subtotal colectomy with end ileostomy (STC). The aim of this study was to determine the impact of timing of RPC in patients who have undergone subtotal colectomy and end ileostomy for inflammatory bowel disease (IBD).

METHODS

A retrospective medical record review of patients who had undergone RPC after STC was undertaken. Patients were divided into 3 groups according to timing of the completion proctectomy: <or= 3 months, 4-7 months and > 7 months.

RESULTS

From 1990 to 2000, 91 patients had undergone RPC after STC for IBD. There were no statistically significant differences among the three groups relative to mean age, gender, final diagnosis, duration of disease, body mass index, comorbidity, extraintestinal manifestations, use of immunuosuppressives, or operative time. The number of intra-operative complications were significantly higher in the <or= 3 month group compared to the other groups. There was no significant difference in the overall incidence of postoperative complications among the 3 groups. Postoperative fistulas were significantly more common after RPC in Groups 1 and 2 as compared to Group 3.

CONCLUSION

Restorative proctocolectomy performed within 3 months after the initial subtotal colectomy was associated with a significant increase in the incidence of intra-operative complications. Although this increase was not statistically significant, there was a significantly higher incidence of fistula formation when RPC was undertaken at up to 7 months after the subtotal colectomy for IBD. Thus, if possible, early RPC after subtotal colectomy should be discouraged.

Surgical management of pouch-vaginal fistula after restorative proctocolectomy

BACKGROUND

Pouch-vaginal fistula (PVF) is a devastating complication after restorative proctocolectomy with ileal pouch anal anastomosis (IPAA). The aim of this study was to evaluate the surgical management of PVF.

METHODS

After Institutional Review Board approval, all patients treated for PVF between 1988 and 2003 were retrospectively reviewed. Success of treatment was defined as the complete absence of symptoms or no radiologic evidence of fistula.

RESULTS

The study included 23 female patients; indications for IPAA were mucosal ulcerative colitis in 20 (87%), indeterminate colitis in 1 (4.3%), and familial adenomatous polyposis in 2 (8.7%) patients. Seven patients with mucosal ulcerative colitis were postoperatively diagnosed with Crohn's disease. Mean time interval from initial IPAA to development of symptomatic fistula was 17.2 months. Mean number of surgical treatments was 2.2. Overall, success was achieved in 17 (73.9%) patients at a mean followup of 52.3 months. Fistulas in patients with Crohn's disease occurred relatively late after IPAA (p = 0.015) and required a median of three (p = 0.001) surgical procedures, compared with patients without Crohn's disease. Pelvic sepsis after original IPAA occurred in eight (35.8%) patients, four (50%) of whom ultimately required pouch excision.

CONCLUSIONS

Fecal diversion and local procedures are effective in the majority of patients with PVF after IPAA. Patients with Crohn's disease tend to have a delayed onset of fistula occurrence and require more extensive surgical management. Pelvic sepsis can be a predictive factor of poor outcomes.

Combined carriership of TLR9-1237C and CD14-260T alleles enhances the risk of developing chronic relapsing pouchitis

AIM

To investigate the single nucleotide polymorphisms (SNPs) in genes involved in bacterial recognition and the susceptibility to pouchitis or pouchitis severity.

METHODS

Analyses of CD14 -260C>T, CARD15/NOD2 3020insC, Toll-like receptor (TLR)4 +896A>G, TLR9 -1237T>C, TLR9+2848G>A, and IRAKM + 22148G>A SNPs were performed in 157 ileal-pouch anal anastomosis (IPAA) patients (79 patients who did not develop pouchitis, 43 infrequent pouchitis patients, 35 chronic relapsing pouchitis patients) and 224 Italian Caucasian healthy controls.

RESULTS

No significant differences were found in SNP frequencies between controls and IPAA patients. However, a significant difference in carriership frequency of the TLR9-1237C allele was found between the infrequent pouchitis and chronic relapsing pouchitis groups [P = 0.028, oddos ratio (OR) = 3.2, 95%CI = 1.2-8.6]. This allele uniquely represented a 4-locus TLR9 haplotype comprising both studied TLR9 SNPs in Caucasians. Carrier trait analysis revealed an enhanced combined carriership of the alleles TLR9 -1237C and CD14 -260T in the chronic relapsing pouchitis and infrequent pouchitis group (P = 0.018, OR = 4.1, 95%CI = 1.4 -12.3).

CONCLUSION

There is no evidence that the SNPs predispose to the need for IPAA surgery. The significant increase of the combined carriership of the CD14 -260T and TLR9 -1237C alleles in the chronic relapsing pouchitis group suggests that these markers identify a subgroup of IPAA patients with a risk of developing chronic or refractory pouchitis.

Secondary pouchitis in a post-operative patient with ulcerative colitis, successfully treated by salvage surgery

We report a case of secondary pouchitis, defined as a mucosal inflammatory lesion in the ileal reservoir provoked by pouch-related complication following total colectomy and pouch anal anastomosis, which was successfully treated by salvage surgery. A 20-year-old woman with ulcerative colitis developed acute severe bloody diarrhea following proctocolectomy, ileal pouch-anal anastomosis and diverting ileostomy. She was diagnosed as having a secondary pouchitis mainly caused by a peripouch abscess and partly concerned with the abnormal pouch formation. The remnant rectum and ileal pouch were excised and ileal pouch-anal anastomosis and diverting ileostomy were constructed. The postoperative course was uneventful with no sign of pouchitis. Salvage surgery may be indicated to treat secondary pouchitis when caused by surgery-related complications.

Effects of Mosapride Citrate on Patients after Vagal Nerve Preserving Distal Gastrectomy Reconstructed by Interposition of a Jejunal J Pouch with a Jejunal Conduit for Early Gastric Cancer

BACKGROUND

Vagal nerve-preserving distal gastrectomy reconstructed by interposition of a jejunal J pouch with a jejunal conduit (hereinafter called DGP) is a function-preserving operation for early gastric cancer. However, some patients after DGP have suffered from postprandial stasis in the substitute stomach, and postprandial stasis leads to abdominal symptoms. To clarify the significance of mosapride citrate (MS) for prevention of food stasis in the substitute stomach for patients after DGP, we studied the effects of MS before and after administration of MS.

MATERIALS AND METHODS

In a total of 18 patients (10 men, 8 women; aged 34 to 70 years, average 63.1 years) during 5 years after DGP for early gastric cancer (Billroth I, D1+alpha lymph node dissection, curability A), the relationship between their postoperative quality of life (QOL) and emptying function of the substitute stomach (EFS) was compared using a radioisotope method before MS therapy and after MS therapy at an oral dose of 15 mg/day for 3 months.

RESULTS

(1) Interview. After MS therapy patients evidently had more appetite and ate more, with a slightly increase in body weight (0.5 approximately 2 kg) compared with patients before MS therapy. Before and after MS therapy no patients had early dumping symptoms, and after MS therapy all patients clearly had fewer symptoms such as reflux esophagitis, nausea, and abdominal pain compared with before MS therapy. After MS therapy they also had significantly decreased abdominal fullness compared with before MS therapy (P=0.0026). Endoscopically, we found reflux esophagitis in 2 patients from the before MS therapy group but in no patients from the after MS therapy group. All patients in the before MS therapy group showed residual contents in the substitute stomach, and seven patients in the after MS therapy group showed residual contents in the substitute stomach (P<0.0001). There was a significant difference between before and after MS therapy (P<0.0001). (2) EFS; The time to 50% residual rate of the before MS therapy group (80.5+/-16.2 min) was significantly slower than that of the after MS therapy patients (65.6+/-9.4 min) (P=0.0091). After MS therapy (28.4%+/-5.2%), the residual rates at 120 minutes were significantly decreased compared with patients before MS therapy (38.2%+/-5.7%) (P=0.0372).

CONCLUSIONS

Patients from the after MS therapy group clearly had improved gastric stasis compared with the before MS therapy group. These results showed more satisfactory QOL in patients after MS therapy. It is possible that MS therapy improves abdominal fullness due to the postprandial stasis in the substitute stomach, contributing to the improvement of QOL of patients after DGP.

Clinical approach to diseases of ileal pouch-anal anastomosis

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for ulcerative colitis (UC) patients with medically refractory disease or dysplasia. IPAA significantly improves quality of life in UC patients who require surgery. However, certain inflammatory and noninflammatory diseases can develop after the surgery, including pouchitis, Crohn's disease of the pouch, cuffitis, and irritable pouch syndrome. The etiology and pathogenesis of these disease conditions of IPAA are largely unknown. Accurate diagnosis and classification are important for appropriate management. Endoscopic evaluation is the most important tool for the diagnosis and differential diagnosis.

The ileoanal pouch procedure in the long–term perspective: a critical review

An ileo-pouch anal anastomosis (IPAA) has become the gold standard procedure for ulcerative colitis and familial adenomatous polyposis. Clinical results on the pelvic pouch procedure have often been encouraging; when confronted with the different surgical options, the majority of patients select IPAA as the best operation. However, even if IPAA is a great innovation, it is by no means the first choice for all patients. For patients old enough to join in a responsible discussion, the pros and cons of the various operations must be carefully described; the choice of surgical procedure must meet the patient's wishes and appear soundly based to the surgeon. The young age of most patients has to be considered and a long follow-up time is required to establish whether and, if so, to what extent the operation may adversely impact the patient's continence, sex life, fertility, and quality of life. The risk of cancer transformation in the residual rectal mucosa in the muscular or columnar cuff is another important factor that may influence the eventual decision. This article critically reviews our experience and the literature.

Ileal pouch-anal anastomosis (IPAA): functional outcome after postoperative pelvic sepsis. A prospective study of 100 patients

INTRODUCTION

The ileal pouch-anal anastomosis (IPAA) has become a standard procedure for patients with ulcerative colitis requiring surgical intervention. The technique has greatly improved and, since 1990, all patients at Huddinge University Hospital have been operated on with the double stapled technique. Pelvic sepsis is one of the most serious complications postoperatively, and, according to previous reports, leads to impaired function of the pouch and, in some cases, extirpation of the pouch.

AIM

The purpose of this study was to find out if pelvic sepsis postoperatively after IPAA leads to impaired functional outcome at long-term follow-up.

PATIENTS AND METHODS

One hundred consecutive patients with ulcerative colitis operated on between 1990 and 1997 with double stapled J-shaped pouches were followed prospectively with a standardised questionnaire, clinical follow-up and endoscopy of the pouch. The function of the pouch has been evaluated at a minimum of 2 years after surgery to compare the functional outcome between patients with and without pelvic sepsis postoperatively.

RESULTS

Twelve patients developed pelvic sepsis postoperatively. No significant differences were found in pouch evacuation frequency, incontinence, deferral time, usage of protecting pads, skin irritation, evacuation problems, diet, usage of medication or social handicap. There was one failure in the control group.

CONCLUSION

In this study, no evidence was found that suggested pelvic sepsis postoperatively impairs functional outcome after IPAA at long-term follow-up.

Ileal pouch-anal anastomosis-vaginal fistula: a review

BACKGROUND

Fistula between an ileal pouch and the vagina is an uncommon complication of ileal pouch-anal anastomosis. Its optimal management has not been determined because of its low incidence.

METHODS

The literature describing such fistulas was reviewed to determine the incidence, cause, and appropriate investigation and repair of these lesions. A literature search was performed with the PubMed, MEDLINE, and EMBASE databases. Through this search we located English-language articles from 1970 to 2003 on pouch-vaginal fistulas following ileal pouch-anal anastomosis. References from these articles were searched manually for further references.

RESULTS AND CONCLUSION

Pouch-vaginal fistula occurs in 6.3 (range, 3.3-15.8) percent of female patients with an ileal pouch-anal anastomosis. Sepsis and technical factors are the most common contributors. It is the cause of considerable morbidity. Management depends on the level of the fistula, the amount of pelvic scar tissue, and previous treatments. An algorithm for surgical treatment is suggested.

Crohn's disease and indeterminate colitis and the ileal pouch-anal anastomosis: outcomes and patterns of failure

PURPOSE

This study was designed to determine the outcome of patients with Crohn's disease and indeterminate colitis who have an ileal pouch-anal anastomosis.

METHODS

Between 1982 and 2001, 1,270 patients underwent a restorative proctocolectomy at the Mount Sinai Hospital: 1,135 had ulcerative colitis, 36 had Crohn's disease, 21 had indeterminate colitis, and 78 had another diagnosis. Perioperative data were collected prospectively. Functional outcomes were assessed with a 35-question survey mailed to all patients with a functioning pouch of at least six months duration.

RESULTS

Pouch complications were significantly more common in patients with Crohn's disease (64 percent) and indeterminate colitis (43 percent) compared with patients with ulcerative colitis (22 percent) (P < 0.05). Similarly, 56 percent of patients with Crohn's disease had their pouch excised or defunctioned, compared with 10 percent of patients with indeterminate colitis and 6 percent with ulcerative colitis (P < 0.01). In the subgroup of patients with a diagnosis of Crohn's disease, multivariate analysis revealed that the pathologist's initial designation of ulcerative colitis (based on the colectomy specimen) and an increasing number of pathologic, clinical, and endoscopic features of Crohn's disease were independently associated with pouch failure. The functional results in patients with Crohn's disease with a successful pouch were not significantly different from those with indeterminate colitis or ulcerative colitis.

CONCLUSIONS

Although complication rates may be higher in patients with indeterminate colitis compared with ulcerative colitis, the overall pouch failure rate is similar. On the other hand, more than one-half of patients with Crohn's disease will require pouch excision or diversion. Our data suggest that it is difficult to identify patients with Crohn's disease who are likely to have a successful outcome after restorative proctocolectomy. Thus, Crohn's disease should remain a relative contraindication to restorative proctocolectomy, whereas ileal pouch-anal anastomosis is an acceptable alternative for patients with indeterminate colitis.

Salvage reoperation for complications after ileal pouch-anal anastomosis

BACKGROUND

Surgical revision may be possible in patients with a poor outcome following ileal pouch-anal anastomosis (IPAA), using either a transanal approach or a combined abdominoperineal approach with pouch revision and reanastomosis.

METHODS

Sixty-four patients underwent revisional surgery. The indication for salvage was sepsis in 47 patients, mechanical dysfunction in ten, isolated complications of the residual glandular epithelial cuff in three and previous intraoperative difficulties in four patients.

RESULTS

A transanal approach was used in 19 patients and a combined abdominoperineal procedure in 45. Six of the latter had pouch enlargement and 25 received a new pouch. During a mean(s.d.) follow-up of 30(25) months, three patients required pouch excision because of Crohn's disease. Two patients had poor continence after abdominoperineal surgery. At last follow-up 60 (94 per cent) of 64 patients had a functional pouch. Half of the patients experienced some degree of daytime and night-time incontinence, but it was frequent in only 15 per cent. Of 58 patients analysed, 27 of 40 who had an abdominoperineal procedure and 13 of 18 who had transanal surgery rated their satisfaction with the outcome as good to excellent.

CONCLUSION

Surgical revision after failure of IPAA was possible in most patients, yielding an acceptable level of bowel function in two-thirds of patients.

Risk factors associated with ileal pouch-related fistula following restorative proctocolectomy

Introduction

Pouch-related fistula occurs in 5–10 per cent of patients after restorative proctocolectomy. The present study identified risk factors associated with the development of such fistulas.

Methods

Data on preoperative and postoperative risk factors were recorded from 1965 patients who underwent restorative proctocolectomy in a single tertiary centre between 1983 and 2001. Cox regression analysis was used to identify independent predictors of pouch–perineal, pouch–abdominal wall and pouch–vaginal fistula during follow-up.

Results

Median patient follow-up was 4·1 (range 0–19) years. By 15 years' follow-up, pouch–vaginal fistulas had occurred in 44 women (5·2 per cent). The prevalence of ileal pouch–perineal and pouch–abdominal wall fistula was 3·6 per cent (70 patients) and 1·5 per cent (30 patients) respectively. Independent predictors of pouch-related fistula identified by multivariate analysis were diagnosis of indeterminate colitis or Crohn's disease (hazard ratio (HR) 1·28 (95 per cent confidence interval (c.i.) 1·00 to 1·65) and 1·73 (95 per cent c.i. 1·07 to 3·48) respectively versus ulcerative colitis or familial adenomatous polyposis), previous anal pathology (HR 3·43 (95 per cent c.i. 2·43 to 4·84) and 4·02 (95 per cent c.i. 1·27 to 12·77) respectively for perineal abscess and fistula in ano versus no previous anal pathology), abnormal anal manometry (HR 4·29 (95 per cent c.i. 2·33 to 7·91)), patient sex (HR 0·74 (95 per cent c.i. 0·58 to 0·95) for men versus women) and pelvic sepsis (HR 3·79 (95 per cent c.i. 2·48 to 5·79)).

Conclusion

This study suggests that Crohn's disease and the clinical signs that favour the diagnosis of Crohn's disease may contribute to the development of pouch-related fistula.