Colonic adenocarcinoma and stones in an Indiana pouch

We report on a 63-year-old woman with adenocarcinoma and stones in an Indiana pouch. Adenocarcinoma of an Indiana pouch is extremely rare. To our knowledge, only four cases with adenocarcinoma in an Indiana pouch have been reported.

Serologic responses in indeterminate colitis patients before ileal pouch-anal anastomosis may determine those at risk for continuous pouch inflammation

PURPOSE

Although acute pouchitis after ileal pouch-anal anastomosis is common and easily treated, continuous pouch inflammation seen clinically as chronic, antibiotic-dependent pouchitis, and/or Crohn's disease remains a difficult management problem. Compared with ulcerative colitis, indeterminate colitis patients undergoing ileal pouch-anal anastomosis have a higher incidence of continuous pouch inflammation, which may represent persistent immune reactivity to microbial antigens. Antibody responses to three microbial antigens (oligomannan anti-Saccharomyces cerevisiae, outer membrane porin C of Escherichia coli, and an antigen (I2) from Pseudomonas flourescens) are more commonly seen in Crohn's disease, whereas antibodies to a cross-reactive antigen (perinuclear antineutrophil cytoplasmic antibodies) is more suggestive of ulcerative colitis. We examined whether preoperative serologic responses to these antigens were associated with Crohn's disease in indeterminate colitis patients after ileal pouch-anal anastomosis.

METHODS

Twenty-eight indeterminate colitis patients undergoing ileal pouch-anal anastomosis were prospectively assessed for the development of pouchitis or Crohn's disease. Serologic responses were determined by enzyme-linked immunosorbent assay and immunofluorescence. Patients were classified based on four predominant profiles of antibody expression. Antibody profiles were determined before knowledge of clinical outcome.

RESULTS

Median follow-up was 38 (range, 3-75) months. Of 16 patients (61 percent) who developed pouch inflammation, 4 (25 percent) had acute pouchitis and 12 (75 percent) had continuous pouch inflammation (9 had chronic pouchitis, 3 had Crohn's disease). No preoperative clinical factor predicted the development of these pouch complications. Overall, 16 patients (57 percent) had a positive antibody reactivity profile. Serologic expression of any marker alone did not predict the development of continuous pouch inflammation. However, continuous pouch inflammation developed in 10 of 16 patients (63 percent) who had a positive antibody reactivity profile compared with only 2 of 12 patients (17 percent) who had a negative antibody reactivity profile (P = 0.015).

CONCLUSIONS

Indeterminate colitis patients who have a positive antibody reactivity profile before ileal pouch-anal anastomosis have a significantly higher incidence of continuous pouch inflammation after surgery than those with a negative profile.

Pouch-vaginal fistula after ileal pouch-anal anastomosis: treatment and outcomes

PURPOSE

Pouch-vaginal fistula is an uncommon but serious complication after ileal pouch anal anastomosis. The management of pouch-vaginal fistulas is challenging and a number of treatment options exist. The purpose of this study was to examine the outcomes after various procedures for pouch-vaginal fistula performed at our institution.

METHODS

Patients who were treated for pouch-vaginal fistula at Mount Sinai Hospital were identified from a prospectively maintained database. Demographic, disease history, treatment, and outcomes data were obtained. Treatment success was defined as no recurrence of the fistula with a functioning pouch and no ileostomy.

RESULTS

Since November 1982, 24 of 619 (3.9 percent) women who had primary ileal pouch-anal anastomosis performed at Mount Sinai Hospital developed a pouch-vaginal fistula. Five women had ileal pouch-anal anastomosis performed at another institution and were referred for management of their pouch-vaginal fistula. Local and/or combined abdominoperineal repairs were performed in 22 of 29 patients. Combined abdominoperineal repairs were associated with a higher success rate than that of local perineal repairs (52.9 vs. 7.9 percent, respectively, at 10 years after repair; p = 0.035). Overall, 50 percent (11/22) of patients who underwent surgical repair of a pouch-vaginal fistula had a successful result with a functioning pouch and no recurrence of the fistula, and 21 percent (6/29) of patients required pouch excision.

CONCLUSIONS

The management of pouch-vaginal fistula after ileal pouch-anal anastomosis is associated with a high recurrence rate. Combined abdominoperineal repair appears to offer better results than those of local procedures.

Adenocarcinoma after ileoanal anastomosis for familial adenomatous polyposis: review of risk factors and current surveillance apropos of a case

Restorative proctocolectomy has become the most common surgical option for familial adenomatous polyposis (FAP) patients, based on the premise that it provides good functional results and reduces colorectal cancer risk. But several adenomas may develop in the pouch mucosa over the years, and even cancer at the anastomosis or in the pouch mucosa has been reported rarely. This article aims to describe a case of pouch cancer after restorative proctocolectomy for FAP, reviewing the possible causes of this unfortunate outcome. A 40-year-old man started presenting with fecal blood loss 12 years after restorative proctocolectomy with mucosectomy and hand-sewn anastomosis for FAP. Proctologic examination revealed an elevated mass 3 cm from the anal margin, which biopsy determined to be a mucinous adenocarcinoma. The patient underwent pouch excision and terminal ileostomy. Histologic analysis showed a 2.2 cm mucinous adenocarcinoma between the ileal and anal mucosa (T2N0Mx) and multiple tubular microadenomas in the ileal pouch. The present case and the data presented here suggest that restorative proctocolectomy is not a "cancer-free" alternative to ileorectal anastomosis, because it does not remove the risk of metachronous intestinal neoplasia. Although the long-term risk of malignancy is not known, lifelong follow-up seems to be necessary after restorative proctocolectomy. Current recommendations for pouch surveillance are presented.

Squamous-cell carcinoma developing after an ileoanal pouch procedure: report of a case

PURPOSE

This study was designed to report a new variant of a rare but serious complication of restorative proctocolectomy.

METHODS

We present a 47-year-old female who underwent restorative proctocolectomy after 16 years of disease. Twenty-five years after her pouch procedure, she underwent pouchoscopy for fever and poor pouch function. A suspicious mass was biopsied and pathology indicated squamous metaplasia. On referral, a mass could be palpated above the anorectal ring. Biopsy of the mass was read as invasive squamous carcinoma in the background of normal intestinal mucosa. This represents the twelfth reported case of carcinoma arising in a pouch, but the first report of a squamous carcinoma, as all previous reports had been of adenocarcinoma.

RESULTS

The patient has undergone chemoradiation. Response to therapy, functional status, and biopsy after treatment will determine whether the patient will be able to salvage the pouch.

CONCLUSIONS

Diligence and vigilance with regard to active follow-up, and a high index of suspicion, are required to prevent this from becoming a more frequently seen problem.

Results and complications after ileal pouch anal anastomosis: a meta-analysis of 43 observational studies comprising 9,317 patients

OBJECTIVE

To analyze the literature of ileal pouch anal anastomosis (IPAA) regarding complications and functional outcome, to provide audit data for individual surgeons and units to assess their own performance against and also to serve as reference standard for the assessment of novel alternatives.

BACKGROUND

IPAA is the standard restorative procedure for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). This operation is, however, associated with distinct rates of failure, complications and fecal incontinence.

METHODS

A meta-analysis on pooled incidences of complications of IPAA was conducted. Medline search and cross-reference search identified studies on IPAA (n > or = 50). Two authors independently performed the data extraction on study characteristics, diagnosis, type of operation, pouch-related complications, pouch failure and functional results. In case of disagreement consensus was reached by joint review of the study. Estimates of pouch-related complications, pouch failure and functional results are described as pooled percentages with 95% confidence interval.

RESULTS

The initial search based on 1,206 abstracts yielded 43 studies eligible for further analysis. Indications for IPAA were UC in 87.5%, FAP in 8.9% and other diagnoses in 3.6%. The median follow-up was 36.7 months. Pouch failure was 6.8%, increasing to 8.5% in case of follow-up of more than 60 months. Pelvic sepsis occurred in 9.5%. Severe, mild and urge fecal incontinence were reported in 3.7, 17, and 7.3%, respectively. No effect of experience, duration of follow-up and type of surgical technique on the incidence of pouch failure and pelvic sepsis was demonstrable.

CONCLUSIONS

Current techniques for restorative surgery after proctocolectomy are associated with non-negligible complication rates and leave room for improvement and continuation of development of alternative procedures.

Quality of life, functional outcome, and complications of coloplasty pouch after low anterior resection

PURPOSE

The colonic J-pouch has been used to improve bowel function in patients undergoing low colorectal or coloanal anastomosis. However, a narrow pelvis, difficulties in reach, a long anal canal with prominent sphincters, or a fatty mesentery may turn this technique into a technically challenging procedure in certain patients. In these circumstances, "coloplasty" offers an alternative to a straight anastomosis. The purpose of this study was to compare the quality of life, functional outcome, and complications between patients undergoing coloplasty, colonic J-pouch, or straight anastomosis.

METHODS

Altogether, 162 patients who underwent coloanal or low colorectal anastomosis between 1998 and 2001 were studied. Data collected included demographics, length of follow-up, technique and type of anastomosis, complications, quality of life, and functional outcome. Results were analyzed according to use of a coloplasty (n = 69), colonic J-pouch (n = 43), or straight anastomosis (n = 50). The choice of the technique was based on the surgeon's preference. Usually coloplasty or straight anastomosis was favored in male patients with a narrow pelvis or when a handsewn anastomosis was used.

RESULTS

Quality of life assessment with the short form-36 questionnaire revealed better scores in coloplasty and colonic J-pouch groups. The coloplasty (1.0 +/- 1.7) and colonic J-pouch (1.0 +/- 1.2) groups had fewer night bowel movements than the straight anastomosis group (1.5 +/- 2.0) (P < 0.05). The coloplasty group also had fewer bowel movements per day than the straight anastomosis group (3.8 +/- 2.9 vs. 4.8 +/- 3.6; P < 0.05); also, less clustering and less antidiarrheal medication use were observed than in the straight anastomosis group. Colonic J-pouch patients with handsewn anastomosis had a higher anastomotic leak rate (44 percent) than the patients in the coloplasty with handsewn anastomosis group (3.6 percent).

CONCLUSIONS

Coloplasty seems to be a safe, effective technique for improving the outcome of low colorectal or coloanal anastomosis. It is especially applicable when a colonic J-pouch anastomosis is technically difficult.

High-magnification chromoscopic pouchoscopy: a novel in vivo technique for surveillance of the anal transition zone and columnar cuff following ileal pouch-anal anastomosis

BACKGROUND

Persistence of underlying disease in the residual rectal mucosa and anal transition zone (ATZ) following ileal pouch-anal anastomosis (IPAA) for ulcerative colitis and familial adenomatous polyposis provides a site for potential malignancy. For this reason endoscopic surveillance is performed, although conventional assessment may be unreliable. We hypothesized that the novel technique of high-magnification chromoscopic pouchoscopy (HMCP) may permit accurate anatomical localization of this high risk zone in vivo and permit improved biopsy accuracy.

PATIENTS AND METHODS

We studied 132 patients with IPAA using HMCP. Three distinct zones were defined using magnification endoscopy: ATZ, appearing as a linear cellular marix; columnar cuff, identifiable by a type I crypt pattern; and ileal pouch body, appearing as villous projections. Quadrantic biopsies of these zones were taken in addition to biopsies of any other lesions noted.

RESULTS

A total of 1586 biopsies were taken from zones 1-3 (median, 12; range, 5-16 per patient). Overall biopsy-targeting accuracies using magnification guidance as compared with histopathology were 82%, 73% and 91% for the ATZ, cuff and pouch body, respectively. No dysplasia was identified in the quadrantic surveillance biopsies. Histologically confirmed columnar metaplasia was visualized in vivo using magnification chromoscopy. Patients with IPAA >3 years' duration were more likely to have pouch reservoir columnar metaplasia as compared to those <3 years (p<0.01). Pouch reservoir metaplasia was associated with a pre-morbid diagnosis of high-grade dysplasia or carcinoma within the premorbid colectomy specimen (p<0.001).

CONCLUSIONS

This is the first study to evaluate this novel application of high magnification chromoscopy. Magnification pouchoscopy is a valid predictor of ATZ and cuff anatomy, permitting accurate biopsy targeting. Further randomized studies validating this technique with an emphasis on dysplasia detection in larger cohorts are required.

Comprehensive evaluation of inflammatory and noninflammatory sequelae of ileal pouch-anal anastomoses

BACKGROUND AND AIMS

Ileal pouch-anal anastomosis (IPAA) improves quality of life (QOL) for ulcerative colitis patients who require surgery. Crohn's disease (CD) of the pouch, pouchitis, cuffitis, and irritable pouch syndrome (IPS) have an adverse impact on physical and psychological well-being, which can compromise the gain in QOL after the surgery. Their clinical, endoscopic, and histologic features have not been fully characterized. The aim of this study was to compare demographic, clinical, endoscopic, and histologic features between CD of the pouch, pouchitis, cuffitis, IPS, and normal pouches. METHODS We enrolled 124 patients: normal pouches (N = 26), CD of the pouch (N = 23), pouchitis (N = 22), cuffitis (N = 21), and IPS (N = 32). Symptomatology, endoscopy, histology, and the Cleveland Global QOL and the Irritable Bowel Syndrome-QOL scores were compared among the groups.

RESULTS

Univariate analysis of demographic and clinical data showed a possible association between NSAID use and pouchitis, extraintestinal manifestation and cuffitis, and antidepressant use and IPS. There were no differences in the Pouchitis Disease Activity Index symptom scores between the disease groups, with an exception of bleeding, which occurred almost exclusively in cuffitis. Endoscopy was useful in discriminating between CD of the pouch, pouchitis, cuffitis, and normal pouches or IPS. Patients with diseased IPAA had worse QOL scores.

CONCLUSIONS

Symptoms largely overlapped among the disease groups of IPAA. Endoscopy is valuable for diagnosis. Inflammatory or noninflammatory sequelae of IPAA adversely affected patients' QOL.

Restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis and familial adenomatous polyposis: twenty years follow-up in 174 patients

BACKGROUND

Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical procedure of choice for patients with ulcerative colitis and familial adenomatous polyposis.

OBJECTIVES

To evaluate the long-term functional outcome of patients who underwent this surgical procedure.

METHODS

We performed this observational study in 174 consecutive patients: 146 with UC and 28 with FAP. The patients, 91 males and 83 females with a mean age of 34.1+/-10.6 years (range 6-67 years), underwent the procedure between January 1984 and January 2004 (mean follow-up 64.8 months, range 1-240 months). The indications for surgery were intractable disease in 124 patients (71%), dysplasia in 36 (21%), severe bleeding in 8 (5%), and perforation in 6 (3%).

RESULTS

A protective ileostomy was performed in 140 patients (96%) with UC and 12 (43%) with FAP. An urgent three-stage procedure was necessary in 14 patients (8.4%). A mucosal proctectomy was performed in 94 (54%), and a double stapling technique in 80 (46%). Mean length of hospital stay was 9.4+/-6.6 days (range 5-34 days, median 8). Complications included pelvic sepsis in 7 patients (4.2%), anastomotic leakage in 8 (4.8%), bowel obstruction in 22 (13.2%), incisional hernia in 12 (7.2%), anastomotic stenosis that usually responded to manual dilatation in 46 (27.6%), pouchitis in 106 (61%), recto-vaginal fistula in 3 (1.8%), retrograde ejaculation in 3 (1.8%), and impotence in 2 (1.2%). There was no mortality in this group of patients. The median number of bowel movements per 24 hours was six in UC patients and five in FAP patients, with at least one bowel movement during the night. Complete daytime and night-time continence was documented in 124 patients (71%). Overall satisfaction was 95%.

CONCLUSIONS

Restorative proctocolectomy with ileal pouch-anal anastomosis confers a long-term good quality of life to both UC and FAP patients, and the majority of patients are fully continent with five to six bowel movements per day.

Fertility is reduced after restorative proctocolectomy with ileal pouch anal anastomosis: a study of 300 patients

BACKGROUND

Restorative proctocolectomy and ileal pouch anal anastomosis (RP/IPAA) has become the gold standard surgical therapy for the majority of patients with mucosal ulcerative colitis and familial adenomatous polyposis. The aims of this study were to evaluate the fertility rates before and after RP/IPAA, to compare them with the reproductive data of the general United States population, and to determine surgical parameters that might influence subsequent fertility.

METHODS

Three hundred women of reproductive age who underwent RP/IPAA between 1983 and 2001 completed a mailed questionnaire regarding their reproductive function before and after the procedure. Additional information was obtained from the pelvic pouch database. The reproductive information was compared to age-matched historical control subjects from the United States general population. The associations between changes in fertility and surgical parameters were also investigated.

RESULTS

The median (25th, 75th percentile) age at surgery was 28 (24, 33) years. Out of 300 women, 206 attempted to conceive. Before operation, 48 (38%) of 127 patients were unsuccessful after 1 year of unprotected intercourse, whereas after operation, 76 (56%) of 135 patients were unsuccessful. This infertility rate was higher after operation than before (P <.001). For the subgroup of 56 women who tried to get pregnant both before and after operation, the infertility rate was higher after operation than before (69% vs 46%; P=.005). Also, a higher percentage of these patients who had an intraoperative transfusion were infertile after operation compared to patients who did not have an intraoperative transfusion (54% vs 21%; P=.023).

CONCLUSIONS

There was an increase in the infertility rate after RP/IPAA. Intraoperative blood transfusion had a negative impact on the fertility rate after operation in patients who tried to conceive both before and after RP/IPAA.

Management of pouch dysfunction or pouchitis with an ileoanal pouch

Pouchitis, a non-specific inflammation of the ileal reservoir, is the most frequent long-term complication after pouch surgery for ulcerative colitis. Incidence rates vary widely. The etiology is still unknown, but genetic susceptibility and fecal stasis with bacterial overgrowth seem to be important factors. A clinical diagnosis should be always confirmed by endoscopy and histology, and Pouchitis Disease Activity Index (PDAI), based on clinical symptoms, endoscopic appearance and histologic findings, represents an objective and reproducible scoring system for pouchitis. The treatment of pouchitis is largely empiric given the few controlled studies available. Antibiotics, especially metronidazole and ciprofloxacin, are the therapy of choice. Chronic pouchitis occurs in about 10-15% of patients; in these cases, further diagnostic tests should be performed to exclude alternative diagnoses. Highly concentrated probiotics (VSL#3) have been shown to be effective in preventing the onset and relapse of pouchitis.

Management of refractory fistulizing pouchitis with infliximab

This study provides the long-term follow-up data on the efficacy of infliximab in the treatment of chronic refractory pouchitis complicated by fistulae following ileo-pouch anal anastomosis (IPAA) for ulcerative colitis (UC).

METHODS

Seven patients (4 F, 3 M) with chronic refractory pouchitis complicated by fistulae were included in an open study. Pouchitis was diagnosed by clinical plus endoscopical and histological criteria. Fistulae were: pouch-bladder in 1, vaginal in 3, perianal in 2, both vaginal and perianal in 1 patient. Extraintestinal manifestations were present in 4 patients. All the patients were refractory to antibiotics (3 patients also to steroids). Crohn's disease was carefully excluded in all patients after re-evaluation of the history, re-examination of the original proctocolectomy specimen, examination of the proximal small bowel. Patients received Infliximab 5 mg/kg at 0, 2 and 6 weeks. Azathioprine (2.5 mg/kg) was also started for all patients as bridge therapy. Clinical response was classified as complete, partial, and no response. Fistulae closure was classified as complete, partial, and no closure. The pouchitis disease activity index (PDAI) and quality of life (QoL) were also used as outcome measures.

RESULTS

Clinically, all patients improved. At 10-week follow-up, 6 out of 7 patients had a complete clinical response, and 5 out of 7 patients had complete fistulae closure. At 10- week follow-up, median PDAI dropped from 12 (baseline) (range, 10-15) to 5 (range, 3-8); median QoL decreased from 37 (range, 33-40) to 14 points (range, 9-18), respectively. Extraintestinal manifestations (erythema nodosum and arthralgiae) completely remitted soon after the first infusion of infliximab. Clinical response and fistulae closure were maintained in the long-term follow-up.

CONCLUSIONS

These results seem indicate that infliximab plus azathioprine may be recommended for the treatment of refractory pouchitis complicated by fistulae following IPAA for UC.

Transurethral injection of bulking agents for stress urinary incontinence following orthotopic neobladder reconstruction in women

PURPOSE

The clinical efficacy of transurethral bulking agents for the treatment of new onset urinary incontinence following radical cystectomy and orthotopic lower urinary tract reconstruction in women was evaluated.

MATERIALS AND METHODS

Between 1990 and 2002, 101 female patients with primary transitional cell carcinoma of the bladder were treated with radical cystectomy and orthotopic ileal neobladder reconstruction. Of the 101 patients 12 (12%) underwent treatment for new onset urinary incontinence following exenterative surgery with transurethral injection of bulking agents, including collagen in 11 and nonabsorbable pyrolytic carbon coated beads in 1.

RESULTS

A total of 25 injections were administered to 12 female patients with a mean age of 75.4 years following orthotopic neobladder reconstruction. Mean followup was 22.5 months (range 2 to 51). Two of the 12 patients (16.7%) reported complete continence and were considered cured, although subjective complaints of urinary frequency persisted. Four patients (33%) had decreased objective average daily pad use (6.75 to 2.25) and 6 (50%) showed no subjective or objective improvement in symptomatology.

CONCLUSIONS

Although injection of urethral bulking agents is a minimally invasive treatment for stress urinary incontinence following orthotopic neobladder reconstruction, long-term results in patients with severe disease show a less than optimal durable response.

Full-thickness pouch prolapse after restorative proctocolectomy: a potential future problem treated by the new technique of external pelvic neorectal suspension (the Express procedure)

Full thickness pouch prolapse following restroative proctocolectomy is an uncommon complication but likely to become more frequent as this population of patients grows older. Conventional procedures to correct the prolapse may be impossible or significantly risk permanent ileostomy formation. The Express technique which is relatively minimally invasive, is a perineal procedure which elevates and suspends the antero-lateral walls of the prolapsing pouch to the external surface of the pelvis, utilizing strips of long lasting collagen.

Treatment of rectal cuff inflammation (cuffitis) in patients with ulcerative colitis following restorative proctocolectomy and ileal pouch-anal anastomosis

BACKGROUND

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice in the majority of patients with ulcerative colitis (UC) who require surgery. To ease the construction of the IPAA and improve functional outcome by minimizing sphincter related stretch injury, a stapling technique is being commonly used in the pouch-anal anastomosis. Despite its advantages, the procedure normally leaves a 1-2 cm of anal transitional zone or rectal cuff, which is susceptible to recurrence of residual UC or cuffitis. Cuffitis can cause symptoms mimicking pouchitis.

AIM

To conduct an open-labeled trial of topical mesalamine in patients with cuffitis.

METHODS

We treated 14 consecutive patients with cuffitis by giving mesalamine suppositories 500 mg b.i.d. (mean 3.2 months, range 1-9 months). The Cuffitis Activity Index (adapted from the Pouchitis Disease Activity Index) scores and improvement in symptoms of bloody bowel movements and arthralgias were measured as primary and secondary outcomes.

RESULTS

All patients had surgery for medically refractory UC. There were significant reductions in the total Cuffitis Activity Index scores after the therapy (11.93 +/- 3.17 vs 6.21 +/- 3.19, p < 0.001). Symptom (3.24 +/- 1.28 vs 1.79 +/- 1.31), endoscopy (3.14 +/- 1.29 vs 1.00 +/- 1.52), and histology (4.93 +/- 1.77 vs 3.57 +/- 1.39) scores each were significantly reduced (p < 0.05). Ninety-two percent of patients with bloody bowel movements and 70% of patients with arthralgias improved after the therapy. No systemic or topical adverse effects were reported.

CONCLUSION

Topical mesalamine appears well tolerated and effective in treating patients with cuffitis, with improvement in symptom as well as endoscopic and histologic inflammation.

The failed pelvic pouch: conversion to a continent ileostomy

BACKGROUND

Excision of the ileal pouch-anal anastomosis (IPAA) with construction of a conventional ileostomy is in general the ultimate procedure after unsuccessful salvage surgery. Conversion of the IPAA to a continent ileostomy (CI) is an alternative.

METHODS

The clinical outcome of 13 patients operated with conversion of IPAA into CI was evaluated. Median follow-up was 6 years. One patient was lost to follow-up.

RESULTS

There were two failures with pouch excision. At follow-up, ten patients with intact CI were fully continent and none needed to use a stoma appliance. Revisional surgery had been required in 8 patients.

CONCLUSIONS

Conversion of a failed IPAA into CI is a feasible procedure that may be considered an alternative to Brooke's ileostomy in motivated patients. The operation should ideally be done in specialized units.

Large contractions in the colonic J-pouch as a possible cause of incomplete evacuation

BACKGROUND AND AIM

Restoration of neo-rectal capacity is of importance in obtaining better bowel function after low anterior resection for rectal carcinoma. However, evacuatory disorders, such as incomplete evacuation, have been reported in some patients undergoing colonic J-pouch reconstruction. Therefore, we conducted this study to explore the possible factor affecting incomplete evacuation following low anterior resection for rectal carcinoma.

PATIENTS/METHODS

The subjects were 37 consecutive patients who had undergone low anterior resection for rectal tumor (colonic J-pouch in 13 patients, straight anastomosis in 24). Clinical and physiological outcomes were determined at a mean follow-up time of 12 months after the operation, and the parameters were compared between patients with and without postoperative incomplete evacuation.

RESULTS

Although anastomosis level from the anal verge was lower in the J-pouch group (6.5 cm vs 3.9 cm, P<0.05), there was no significant difference between J-pouch and straight reconstruction regarding clinical and physiological outcomes. Postoperative incomplete evacuation was significantly more frequent in the J-pouch group than in the straight group (46% vs 25%, P<0.05). Postoperative large contractions on ano-rectal manometry were also significantly more apparent in the J-pouch group than in the straight group (31% vs 4%, P<0.05). Presence of postoperative large contractions (P=0.004), anastomotic stricture (P=0.019) and smaller postoperative maximum tolerable volume ( P=0.009) were significantly and independently associated with incomplete evacuation by multivariate analysis.

CONCLUSION

Colonic J-pouch reconstruction following ultra-low anterior resection was comparable with higher level straight anastomosis from the clinical and physiological point of view. The presence of large contractions might be an important indicator of incomplete evacuation in patients who are undergoing rectal resection.

Prevalence and management of prolapse of the ileoanal pouch

PURPOSE

Known late complications of ileal pouch-anal anastomoses include chronic pouchitis, poor pouch function, or stricture. These may jeopardize the pouch and may require pouch salvage procedures. Prolapse of the ileoanal pouch is a little-known complication infrequently noted in the literature. The objective of this study was to determine the prevalence of this problem and identify approaches used to correct it and salvage the pouch.

METHODS

The literature was reviewed for publications describing the diagnosis and treatment of patients with ileoanal pouch prolapse. A survey inquiring about experience with ileoanal pouch prolapse was sent to all North American members and fellows of The American Society of Colon and Rectal Surgeons. The survey assessed the number of years that the respondent had been performing ileal pouch-anal anastomoses and the number and type of pouches constructed. The respondents indicated the prevalence of patients with ileoanal pouch prolapse in their practices and length of time from pouch creation to onset of prolapse. They also were asked to indicate presenting symptoms, need for and method of surgical repair, and outcome.

RESULTS

Two hundred and sixty-nine responses were received (response rate, 19.5 percent). Thirty-five respondents indicated that they had assisted in the care of a total of 83 patients with prolapse of the ileoanal pouch. Prolapse symptoms included external prolapse of tissue, sense of obstructed defecation, seepage, and pain. Patients with pouch prolapse most commonly presented within two years of pouch construction. Fifty-two patients required surgery and were managed by a combination of transanal repair, abdominal pouchpexy, and transabdominal revision or removal. The ileoanal pouch was salvaged in all but one case.

CONCLUSIONS

Although the incidence of pouch prolapse is relatively low in this survey, the number of cases reported far exceeds the previous known experience. The possibility of this clinical entity should be considered in the differential diagnosis of ileoanal pouch dysfunction. Such recognition should lead to correction of prolapse and pouch salvage in the great majority of patients.

Results of surgical removal of the pouch after failed restorative proctocolectomy

PURPOSE

Restorative proctocolectomy is the elective surgical procedure of choice for ulcerative colitis and familial adenomatous polyposis. Most patients have a satisfactory outcome, but at ten years 15 percent or more will have failed, needing indefinite defunctioning or excision of the pouch. There is little information on the morbidity of pouch excision. The study was designed to present the early results of surgical removal of the pouch after failed restorative proctocolectomy with reference to the indications and intermediate complications, particularly of the perineal wound.

METHODS

Between 1977 and 2002, 996 patients underwent a restorative proctocolectomy at our hospital and 245 patients were referred for potential salvage. The pouch was excised in 58 and 10 patients respectively. There were 40 females and 28 males (median age, 34 (14-65) years) including 47 with ulcerative colitis, 10 with Crohn's disease, and 11 with familial adenomatous polyposis. The median follow-up was 79 (range, 3-312) months from excision.

RESULTS

There was one (1.4 percent) postoperative death. The overall morbidity rate was 62.3 percent (immediate 30 days (25 percent), late (53.7 percent)). Thirty-six patients (53.7 percent) were readmitted on 67 occasions for a late complication. The risk of readmission from the time of pouch excision was 38 and 58 percent at one and five years, respectively. Surgical treatment was required during 48 of these readmissions. A persistent perineal sinus was the most common late complication. The perineal wound was not healed at 6 months in 27 patients (40 percent) and at 12 months in 7 patients (10 percent). No factor, including age at the time of pouch excision, gender, indication for excision, or final histologic diagnosis, was associated with an unhealed perineal wound. Two males (7 percent) had impotence. One female suffered from short-bowel syndrome with the need of permanent parenteral nutrition. The median overall hospital stay for all admissions was 20 (range, 8-220) days.

CONCLUSIONS

Pouch excision is associated with high morbidity. Perineal wound-delayed healing is the commonest late complication and often requires further surgery.

Complication of jejunal pouch interposition after proximal gastrectomy: case report

Interposition of a jejunal pouch after proximal gastrectomy is a popular reconstruction method in Japan, because it produces a good quality of life soon after surgery. Many reports have described its usefulness. However, there are few reports describing its complications. We report here for the first time a case of pouch stasis needing surgery. A 23-year-old man underwent proximal gastrectomy with interposed jejunal pouch for traumatic strangulated diaphragmatic hernia. Three years later, he complained of persistent vomiting. Since surgery, he had eaten as much as other young people. An upper gastrointestinal series showed dilatation of the jejunal pouch and stasis of contrast medium. Since conservative therapy was not effective, surgery was performed. In the operative findings, the jejunal pouch was extremely dilated, the remaining stomach had become atrophic, and moreover, the anastomosis was severely distorted. It was considered that frequent excessive ingestion caused irreversible dilatation of the jejunal pouch, resulting in pouch stasis. Even though the jejunal pouch is interposed for reconstruction, it is very important to give nutritional guidance to patients, especially young patients, to prevent pouch stasis caused by excessive food ingestion.

Outcome of patients with indeterminate colitis undergoing a double-stapled ileal pouch-anal anastomosis

INTRODUCTION

The aim of this study was to assess the outcome of patients with indeterminate colitis undergoing double-stapled ileal pouch anal anastomosis.

METHODS

A retrospective review of demographic, disease-related, and outcome variables of all patients undergoing double-stapled ileal pouch anal anastomosis from August 1988 to January 2000 was undertaken. All patients were evaluated using the validated American Society of Colon and Rectal Surgeons Fecal Incontinence Severity Index. Patients with familial adenomatous polyposis, those who had undergone pouch revision or had S-configured pouches, and patients with a follow-up of less than three months were excluded from analysis.

RESULTS

Three hundred ninety-five patients underwent the double-stapled ileal pouch anal anastomosis; of these 303 patients were included for analysis. The mean duration of follow-up was 40 months. Fifty-six (18.1 percent) had a preoperative diagnosis of indeterminate colitis. Postoperatively, indeterminate colitis was diagnosed in 13 (4.3 percent), mucosal ulcerative colitis in 285 (94 percent), and Crohn's disease in 5 (1.6 percent). The overall complication rate was 37.7 percent, 60 percent, and (30.7) percent in patients with mucosal ulcerative colitis, Crohn's disease, and indeterminate colitis, respectively. Postoperative hemorrhage, abscess, and fistula occurred in 2.4 percent, 6.3 percent, and 3.9 percent, respectively, in patients with mucosal ulcerative colitis, and 0 percent, 15.3 percent, and 7.7 percent, respectively, in patients with indeterminate colitis. Small-bowel obstruction occurred in 8.5 percent, 20 percent, and 7.7 percent of patients with mucosal ulcerative colitis, Crohn's disease, and indeterminate colitis, respectively. Pouchitis occurred in 4.6 percent of patients with mucosal ulcerative colitis but in none of the patients with indeterminate colitis. Dysplasia of the anal transition zone was seen in one patient each with mucosal ulcerative colitis and indeterminate colitis. These patients had consistent follow-up and neither showed any sign of evolution to neoplastic disease. None of the patients with indeterminate colitis had a postoperative diagnosis of Crohn's disease during the follow-up period. Functional outcome was comparable in all three patient groups.

CONCLUSION

The outcome of the double-stapled ileal pouch anal anastomosis in patients with indeterminate colitis is similar to that of patients with mucosal ulcerative colitis. Therefore, it is a safe option in patients with indeterminate colitis.

Fecal lactoferrin for diagnosis of symptomatic patients with ileal pouch-anal anastomosis

BACKGROUND & AIMS

Increased stool frequency, urgency, and abdominal pain in patients with ileal pouch-anal anastomosis (IPAA) may be due to inflammatory conditions, including pouchitis, cuffitis, or Crohn's disease or noninflammatory conditions such as irritable pouch syndrome. Distinction among these entities requires pouch endoscopy and biopsy. Noninvasive means of diagnosis are preferable.

METHODS

Sixty consecutive subjects with IPAA for inflammatory bowel disease had measurements of fecal lactoferrin and alpha1-antitrypsin and underwent pouch endoscopy with biopsy, with calculation of the pouchitis disease activity index in a prospective cross-sectional study.

RESULTS

Symptomatic patients with an inflammatory condition had significantly higher fecal lactoferrin concentrations (median, 176.0 microg/mL, interquartile range [IQR] 79.0-450.8) compared with those with a noninflammatory condition (median, 4.8 microg/mL; IQR, 1.2-11.0) or those who were asymptomatic (median, 7.8 microg/mL; IQR, 1.4-12.9), P < 0.001. At a cutoff level of 7 microg/mL, fecal lactoferrin could distinguish patients with irritable pouch syndrome from those with pouchitis, cuffitis, or Crohn's disease with a sensitivity of 100% and specificity of 85%. Fecal alpha1-antitrypsin was not able to distinguish symptomatic patients with and without an inflammatory condition.

CONCLUSIONS

Fecal lactoferrin can serve as a sensitive and noninvasive initial screening test in an algorithm for evaluation of symptomatic patients with IPAA. If fecal lactoferrin levels are low (<7 microg/mL), IPS can be diagnosed. If fecal lactoferrin levels are high, pouch endoscopy with biopsy is warranted to distinguish among different causes of inflammation. Longitudinal studies are needed to define better the role of this test in the management of patients with IPAA.

Mid pouch strictureplasty for Crohn's disease after ileal pouch-anal anastomosis: an alternative to pouch excision

A 33-year-old female developed an isolated stricture of the mid portion of her ileal pouch nine years after proctocolectomy and J-ileal pouch-anal anastomosis for ulcerative colitis. Repeated episodes of pouchitis and partial small-bowel obstruction led to pouchoscopy and pouchography, which demonstrated pouch inflammation and a long, tight, midpouch stricture. Her diagnosis was changed to Crohn's disease and she was treated with azathioprine, budesonide, and infliximab. Repeat pouchoscopy demonstrated mucosal healing but a persistent fibrotic stricture. Pouch reconstruction was performed with a midpouch strictureplasty alleviating her obstructive symptoms. One year after surgery, the patient has no clinical evidence of obstruction and repeat pouchography demonstrates a wider pouch lumen across the strictureplasty site. Strictureplasty is an alternative to pouch excision in the management of patients with Crohn's disease who have an isolated pouch stricture.

Late-onset fistula presenting as buttock abscess in two patients with ileo-anal J-pouches for ulcerative colitis

Two cases are described of patients who presented with a buttock abscess 3 and 5 years after restorative proctocolectomy for ulcerative colitis. In both the abscess was secondary to a fistula, which was shown on further investigation to be a track traversing the greater sciatic notch. Both patients had had an ileo-anal J-pouch after a proctectomy which had included a mesorectal excision. The possibility that these unusual fistulae might be more common following removal of the mesorectum rather than a close rectal dissection is explored.

Quality of life in patients with ileal pouch for ulcerative colitis

The improvement of surgery in the treatment of ulcerative colitis prompts us to consider its impact on the quality of life of the patients. Obviously, it is mandatory that the results after surgery should be better than the symptoms which elective surgery is designed to treat. A review of the literature was carried out on the current status of quality of life in patients with ulcerative colitis before and after surgery using a PubMed source. The rate of success after restorative proctocolectomy for ulcerative colitis is 95%. The quality of life after restorative proctocolectomy compared with other procedures is better, especially in the long term. About 90% of patients would undergo pouch surgery again after restorative proctocolectomy, while 53% of patients submitted to other procedures would have a restorative proctocolectomy. Restorative proctocolectomy is the gold standard for patients with ulcerative colitis who are suitable for surgical treatment, though future prospective trials are needed in order to establish when elective surgery for ulcerative colitis is indicated.

Functional outcome and quality of life after repeat ileal pouch-anal anastomosis for complications of ileoanal surgery

PURPOSE

Disconnection of an ileal pouch-anal anastomosis with repeat ileal pouch-anal anastomosis has been proposed for treatment of ileal pouch-anal anastomosis failure caused by septic or functional complications. We report our experience with repeat ileal pouch-anal anastomosis, and document functional outcome and quality of life.

METHODS

Of 101 patients undergoing laparotomy, ileoanal disconnection, and repeat ileal pouch-anal anastomosis, 80 were referred from other institutions. Indications included: chronic anastomotic leak (n=27), perineal or pouch-vaginal fistula (n=47), anastomotic stricture (n=22), dysfunction/long efferent limb of S-pouch (n=36), and previous ileal pouch-anal anastomosis excision or exclusion (n=6). In 64 cases a "septic" indication was observed. Pathologic features of Crohn's disease were present in 4 patients preoperatively and 15 more after repeat ileal pouch-anal anastomosis. Four patients had clinical features of Crohn's disease.

RESULTS

Three patients had no ileostomy, and 82 patients had temporary ileostomy closure. Of these, 82 percent have a functioning pouch, with a median follow-up of 32 functioning months. Two were rediverted and 13 had the pouch excised. Five-year pouch survival was 74 percent, higher for ulcerative colitis (79 percent) than Crohn's disease (53 percent; P=0.06). No differences were seen between those having repeat ileal pouch-anal anastomosis for septic or nonseptic indications, or whether using a new or repaired pouch. Patients defecated 6.3 +/- 2.8 (mean +/- standard deviation) times per day, and 2 +/- 1.9 per night. Thirty-five percent of patients never described urgency. Fecal seepage occurred in 50 percent during the day and 69 percent at night. Using the Cleveland Global Quality of Life Score to assess the patient's quality of life, health, level of energy, and happiness with surgery (each scored from 0-10), quality of life was 8.2 +/- 1.6, and happiness with surgery was 9 +/- 2. Ninety-seven percent would undergo repeat ileal pouch-anal anastomosis again, and 99 percent would recommend it to others.

CONCLUSIONS

Repeat ileal pouch-anal anastomosis is a valid alternative for patients with ileal pouch-anal anastomosis failure. A controlled septic condition should not preclude salvage surgery. Although pouch failure occurs more frequently than after primary ileal pouch-anal anastomosis, patient satisfaction and quality of life are high.

Functional outcome and quality of life after ileal pouch−anal anastomosis in children and adults

BACKGROUND

In the past, children with ulcerative colitis were treated with a total colectomy, ileostomy and mucous fistula; ileal pouch-anal anastomosis was postponed until adulthood. The aim of the present study was to assess the functional outcome and quality of life after ileal pouch-anal anastomosis and determine whether it is justified to perform the operation in children when surgery is indicated.

METHODS

A retrospective review of 38 medical records was carried out, of which there were 19 paediatric patients and 19 adult patients (control). A questionnaire survey was conducted. Telephone interviews were carried out for the non-respondents.

RESULTS

Sixteen patients in the paediatric group (nine boys, mean age: 12 years) and 16 patients in the adult group (10 men, mean age: 39 years) were available for analysis. There was no operative mortality. The mean bowel frequency per week was 37 and 42. Furthermore, bowel frequency during the day was slightly lower in the paediatric group. Children had marginally better continence than adults. In the quality of life assessment, the mean utilities in the paediatric group were 0.69 and 0.84 in the preoperative and postoperative status, respectively. These were similar to those in the adult group (0.62 and 0.82). Both groups achieved significantly favourable postoperative responses in terms of ability to perform social activity, recreation and enjoying food.

CONCLUSIONS

Ileal pouch-anal anastomosis in children is safe, results in good functional outcome and improves the quality of life. Hence, it is justified to perform ileal pouch-anal anastomosis as soon as surgery is indicated rather than as a delayed procedure.

A cost-effectiveness analysis of diagnostic strategies for symptomatic patients with ileal pouch-anal anastomosis

OBJECTIVE

Pouchitis is often diagnosed based on symptoms and empirically treated with antibiotics (treat-first strategy). However, symptom assessment alone is not reliable for diagnosis, and an initial evaluation with pouch endoscopy (test-first strategy) has been shown to be more accurate. Cost-effectiveness of these strategies has not been compared. The aim of this study was to compare cost-effectiveness of different clinical approaches for patients with symptoms suggestive of pouchitis.

METHODS

Pouchitis was defined as pouchitis disease activity index scores > or =7. The frequency of pouchitis in symptomatic patients with ileal pouch was estimated to be 51%; the efficacy for initial therapy with metronidazole (MTZ) and ciprofloxacin (CIP) was 75% and 85%, respectively. Cost estimates were obtained from Medicare reimbursement data.

RESULTS

Six competing strategies (MTZ trial, CIP trial, MTZ-then-CIP trial, CIP-then-MTZ trial, pouch endoscopy with biopsy, and pouch endoscopy without biopsy) were modeled in a decision tree. Costs per correct diagnosis with appropriate treatment were $194 for MTZ trial, $279 for CIP trial, $208 for MTZ-then-CIP trial, $261 for CIP-then-MTZ trial, $352 for pouch endoscopy with biopsy, and $243 for pouch endoscopy without biopsy. Of the two strategies with the lowest cost, the pouch endoscopy without biopsy strategy costs $50 more per patient than the MTZ trial strategy but results in an additional 15 days for early diagnosis and thus initiation of appropriate treatment (incremental cost-effectiveness ratio $3 per additional day gained). The results of base-case analysis were robust in sensitivity analyses.

CONCLUSIONS

Although the MTZ-trial strategy had the lowest cost, the pouch endoscopy without biopsy strategy was most cost-effective. Therefore, based on its relatively low cost and the avoidance of both diagnostic delay and adverse effects associated with unnecessary antibiotics, pouch endoscopy without biopsy is the recommended strategy among those tested for the diagnosis of pouchitis.

Factors associated with ileal mucosal morphology and inflammation in patients with ileal pouch-anal anastomosis for ulcerative colitis

PURPOSE

Pouchitis has been associated with abnormal bacterial flora responding to antibiotics. Dietary factors may play a role in modifying the qualitative and quantitative components of the microflora. We evaluated interactions between nutritional factors, fecal and mucosal bacterial flora, and mucosal morphology in patients with a history of pouchitis compared with patients with optimal outcome at least five years after ileal pouch-anal anastomosis for ulcerative colitis.

METHODS

Thirty-two patients were enrolled in the study: 11 (7 males; mean age, 49.8 years) with optimal outcome and 21 (11 males; mean age, 47.3 years) with pouchitis history. A seven-day food diary was recorded, endoscopy performed, and biopsies taken from the pouch for histology, mucin staining, and bacterial culture. Fresh fecal samples were quantitatively cultured, and fecal bile acids analyzed by gas-liquid chromatography.

RESULTS

No differences existed in mean nutrient intake, composition of fecal bile acids, or microbial tissue biopsy cultures between the groups with and without pouchitis. Those with optimal outcome tended to have more benign disease course of ulcerative colitis than patients with pouchitis. In those patients, fecal concentrations (log10 colony-forming unit/g) of anaerobes and aerobes were significantly higher (P = 0.007). Degree of villous atrophy and colonic metaplasia were both associated with fecal anaerobic flora. Low intake of lactose was associated with sulfomucin predominance. A negative correlation existed between fecal aerobes and dietary lactose consumption.

CONCLUSIONS

A higher total load of fecal anaerobic bacterial flora is strongly associated with degree of colonic metaplasia, villous atrophy, and inflammation activity after surgery for ulcerative colitis. An association existed between dietary lactose, fecal bacteria, and pouch morphology. Lactose may have prebiotic properties.

Anal transitional zone cancer after restorative proctocolectomy and ileoanal anastomosis in familial adenomatous polyposis: report of two cases

PURPOSE

Restorative proctocolectomy with ileal pouch-anal anastomosis is accepted as the surgical treatment of choice for many patients with familial adenomatous polyposis. The risk of cancer developing in the ileal pouch after this surgery is unknown. Cancer may arise from the ileal pouch after restorative proctocolectomy, but that arising from the anal transitional zone has not been documented in familial adenomatous polyposis. We report two cases of this cancer from the anal transitional zone in patients with familial adenomatous polyposis, with a review of the literature.

METHODS

All patients with familial adenomatous polyposis treated with restorative proctocolectomy and ileal pouch-anal anastomosis in The Cleveland Clinic were included in the study. Patients whose surveillance biopsy of the anal transitional zone revealed invasive adenocarcinoma were studied.

RESULTS

Among a total of 146 patients with familial adenomatous polyposis who underwent restorative proctocolectomy and ileal pouch-anal anastomosis from 1983 to 2001 in our institution, none developed cancer of the anal transitional zone at up to 18 years of follow-up. However, there were two patients, both of whom underwent surgery elsewhere but who were followed up here, who developed invasive adenocarcinoma of the anal transitional zone. In one of them, cancer was diagnosed three years after a double-stapled ileal pouch-anal anastomosis, whereas in the other, cancer occurred eight years after a straight ileoanal anastomosis with mucosectomy.

CONCLUSIONS

Cancer may develop in the anal transitional zone after restorative proctocolectomy with ileal pouch-anal anastomosis for familial adenomatous polyposis. Long-term surveillance of the anal transitional zone needs to be emphasized.

Patients with extraintestinal manifestations have a higher risk of developing pouchitis in ulcerative colitis: multivariate analysis

BACKGROUND

Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) have been the surgical treatments of choice for ulcerative colitis (UC). However, the IPAA is sometimes complicated with pouchitis. Furthermore, the cumulative risk and risk factors for developing pouchitis in patients with UC undergoing IPAA have not been reported in any Asian population. The aim of our study is to clarify the cumulative risk and risk factors for developing pouchitis in Japanese patients with UC undergoing IPAA.

METHODS

Fifty-eight patients with UC undergoing IPAA were retrospectively evaluated for the presence of pouchitis, gender, age of onset, history of smoking, presence of extraintestinal manifestations (EIMs) and type of operation. The diagnosis of pouchitis was based on the pouchitis disease activity index. The cumulative risk and risk factors for developing pouchitis were assessed.

RESULTS

The cumulative risks for developing pouchitis at 1 and 5 years were 9.0% and 14.4%, respectively. The estimated risks of pouchitis at 5 years was 48.1% in patients with EIMs and 4.6% in those without. Both univariate and multivariate analyses revealed that the presence of EIMs is a significant risk factor (hazard ratio 16.85, 95% confidence interval 3.12-91.00; P=0.001).

CONCLUSIONS

The presence of EIMs is a significant risk factor for the development of pouchitis in Japanese patients with UC undergoing IPAA.

Management of Crohn's disease of the ileoanal pouch with infliximab

OBJECTIVES

The occurrence of Crohn's disease (CD) in a patient with an ileal-pouch anastomosis (IPAA) often results in severe morbidity and significant chance of reservoir loss. We report our experience of the use of infliximab in these patients.

METHODS

Medical records of 26 patients with an IPAA and CD-related complications were reviewed. The median time between the IPAA and the diagnosis of CD was 4.5 yr (range 0.1-16 yr). The main reasons for changing the original ulcerative colitis diagnosis to CD were complex perianal or pouch fistulizing disease in 14 patients (54%), prepouch ileitis in five (19%), and both prepouch ileitis and complex fistula in seven (27%). Patients received one to three doses of infliximab over 8 wk as induction therapy. Subsequently the patients received a variable number of maintenance infusions.

RESULTS

At a short term follow-up, 16/26 patients (62%) had a complete response, six of 26 (23%) had a partial response, and four of 26 (15%) had no response. Information regarding long term follow-up was available in 24 patients. After a median follow-up of 21.5 months (range 3-44 months), eight patients (33%) either had their pouch resected or had a persistent diverting ileostomy. The pouch was functional in 16/24 (67%) patients, with either good (n = 7) or acceptable (n = 7) clinical results in 14/24 (58%). Of those 14 patients, 11 were under long term, on demand, or systematic maintenance treatment with infliximab.

CONCLUSIONS

Infliximab is beneficial in both the short and long term treatment of patients with an IPAA performed for a presumed diagnosis of ulcerative colitis who subsequently develop CD-related complications. Good pouch function requires long term treatment with infliximab in most patients.

Ideal reconstruction after total gastrectomy by the interposition of a jejunal pouch considered by emptying time

To establish the ideal form of the pouch for jejunal pouch interposition reconstruction (JPI) after total gastrectomy, the postoperative gastrointestinal function and symptoms were investigated in comparison with jejunal interposition reconstruction (JI). A total of 20 patients who underwent curative surgery for gastric cancer were enrolled in this study. In the JI group (n = 9), an isoperistaltic jejunum about 40 cm in length was interposed between the esophagus and the duodenum. In the JPI group n = 11), a proximal pouch about 15 cm in length with a 10-cm conduit was also interposed between the esophagus and the duodenum. At follow-up 6 months postoperatively, food transit was evaluated using a radiolabeled semisolid test meal. The half-emptying time was 6.9 minutes in the JI group and 46 minutes in the JPI group. The reservoir function influenced the recovery of the patients' body weight and development of the serum total protein in the early postoperative period. An early half-emptying time caused dumping symptoms in JI group. In the JPI group, there were no dumping symptoms; however, extended food clearance of pouch causes postprandial symptoms such as reflux (1 patient), vomiting (2 patients), and discomfort (2 patients). In those patients with symptoms, half-emptying times were longer than 60 minutes. There was a statistically significant correlation between the pouch length and the half-emptying time of the gastric substitute in JPI group (p = 0.0039, r = 0.789). If we estimate that the appropriate half-emptying time is 20 to 60 minutes, correlation of the pouch length and the half-emptying time shows that the ideal pouch length is about 12-15 cm in JPI. In jejunal pouch interposition reconstruction after total gastrectomy, an adequate procedure leads to nutritional advantage and prevents postoperative symptoms.

Long-term results of salvage surgery for septic complications after restorative proctocolectomy: does fecal diversion improve outcome?

PURPOSE

Septic complications related to the ileal pouch-anal anastomosis after restorative proctocolectomy have been reported in up to 16 percent of patients in major series. Management strategies are not well established. The aim of this study was to evaluate the results of salvage surgery and to assess the impact diversion had on the outcome.

METHODS

Patients who developed ileal pouch-anal anastomosis-related septic complications after restorative proctocolectomy were identified from a prospectively maintained database. Surgical procedures and follow-up data were obtained at the time of hospital and office visits. Successful salvage was defined as the absence of clinical evidence of fistula, sinus, or abscess at least three months after salvage surgery or closure of ileostomy.

RESULTS

Fifty-one patients with ileal pouch-anal anastomosis-related sepsis were identified. All patients had sinus or fistulous tracts from pouch-anal anastomoses. Eighty-nine salvage procedures were performed among these 51 patients (range, 1-4 procedures per patient). Forty-eight transanal anastomotic revisions were performed in nondiverted patients. Thirty-seven transanal revisions and four abdominoperineal revisions were performed in diverted patients. At a median follow-up of 65.2 (range, 3 to 166) months after salvage surgery or closure of the diverting stoma, 21 patients (41 percent) had complete resolution of their septic problems. Bowel frequency and continence for these patients were similar to patients who had not had ileal pouch-anal anastomotic problems. Eleven (29.7 percent) of 37 transanal procedures with diversion succeeded, whereas 10 (20.8 percent) of 48 nondiverted procedures succeeded. This difference was not significant (11/37 vs. 10/48; P = 0.448). None of the four abdominoperineal revisions succeeded. Of 51 patients, 34 (66.7 percent) retained their pouches and 21 (41.2 percent) were successfully revised. Seventeen patients (33.3 percent) had pouch excision. Five (9.8 percent) had persistent fistulas and remained diverted, and 8 (15.7 percent) had persistent fistulas and were not diverted. Thus, pouch function was retained in 29 patients (56.9 percent).

CONCLUSIONS

This study shows that anastomotic failure after restorative proctocolectomy is associated with a high rate of pouch failure. Ileal pouch-anal anastomosis-related fistula or sinus warrants an aggressive surgical approach in selected, highly motivated patients because acceptable functional results are possible. Multiple procedures may often be necessary to achieve complete healing. Successful repair can be achieved after one or more unsuccessful attempts. Repeat procedures can be performed safely without adversely affecting ultimate outcome.

Short- and long-term outcomes of ileal pouch-anal anastomosis for ulcerative colitis

Ileal pouch-anal anastomosis was an important advancement in the treatment of ulcerative colitis. The aim of this study was to determine whether early complications of ileal pouch-anal anastomosis in patients with ulcerative colitis are associated with poor late functional results.

PATIENTS AND METHODS

Eighty patients were operated on from 1986 to 2000, 62 patients with ileostomy and 18 without. The early and late complications were recorded. Specific emphasis has been placed on the incidence of pouchitis with prolonged follow-up.

RESULTS

The ileostomy was closed an average of 9.2 months after the first operation. Fourteen patients were excluded from the long-term evaluation; 6 patients were lost to regular follow-up, 4 died, and 4 patients still have the ileostomy. Of the 4 patients that died, 1 died from surgical complications. Early complications after operation (41) occurred in 34 patients (42.5%). Late complications (29) occurred in 25 patients as follows: 16 had pouchitis, 3 associated with stenosis and 1 with sexual dysfunction; 5 had stenosis; and there was 1 case each of incisional hernia, ileoanal fistula, hepatic cancer, and endometriosis. Pouchitis occurred in 6 patients (9.8%) 1 year after ileal pouch-anal anastomosis, 9 (14.8%) after 3 years, 13 (21.3%) after 5 years, and 16 (26.2%) after more than 6 years. The mean daily stool frequency was 12 before and 5.8 after operation. One pouch was removed because of fistulas that appeared 2 years later.

CONCLUSIONS

Ileal pouch-anal anastomosis is associated with a considerable number of early complications. There was no correlation between pouchitis and severe disease, operation with or without ileostomy, or early postoperative complications. The incidence of pouchitis was directly proportional to duration of time of follow-up.

Management and treatment outcome of pouch-vaginal fistulas following restorative proctocolectomy

PURPOSE

The purpose of the study was to evaluate the outcome of surgical management of pouch-vaginal fistulas in females who had undergone restorative proctocolectomy.

METHODS

This study was designed as a retrospective chart review of females treated for pouch-vaginal fistulas from 1983 to 2000. All patients were followed up using our prospective pouch registry, with additional data collected by interview or mailed questionnaire.

RESULTS

Sixty females were identified (mean age, 33.3 +/- 1.3 years), of whom 33 had their initial restorative proctocolectomy done at our institution. Preoperative diagnosis was ulcerative colitis (88 percent), indeterminate colitis (10 percent), and familial adenomatous polyposis (2 percent). Average time to pouch-vaginal fistula following restorative proctocolectomy was 21 months (range, 1-132 months). Postoperative pelvic sepsis had occurred in 17 (28 percent) patients. Primary treatment modalities included the following: local repairs (n = 46, 77 percent), the majority of which were ileal advancement flaps; redo restorative proctocolectomy (n = 6, 10 percent); and pouch excision (n = 5, 8 percent). Initial healing was achieved in 20 patients. An additional 11 patients with recurrences healed after repeat procedures. The overall healing rate was 52 percent at 49.4 +/- 3.8 months follow-up. Pouch failure was the eventual outcome in 13 (22 percent) patients and 16 (27 percent) patients had persistent pouch-vaginal fistula. A delayed diagnosis of Crohn's disease was made in 24 patients. Crohn's disease patients had lower success rates following ileal advancement flaps compared with the non-Crohn's group (25 vs. 48 percent, respectively), much lower overall healing rates of their pouch-vaginal fistulas (17 vs. 75 percent, respectively), and a higher incidence of pouch failure (33 vs. 14 percent, respectively).

CONCLUSION

Pouch-vaginal fistulas are a difficult problem in females following restorative proctocolectomy. However, local repair can be successful with good functional outcomes. Redo restorative proctocolectomy may also achieve healing if local repairs are not possible or have failed. A delayed diagnosis of Crohn's disease results in worse treatment outcome and higher pouch failure rates.

Pathological subgroups may predict complications but not late failure after ileal pouch-anal anastomosis for indeterminate colitis

INTRODUCTION

Ileal pouch-anal anastomosis (IPAA) for indeterminate colitis (IndC) may lead to an increased risk of perineal complications and pouch loss. This study evaluated pathological subgroups of IndC to identify a predictor of increased complication rates after IPAA for IndC.

PATIENTS AND METHODS

Of 171 IPAAs with a postoperative diagnosis of IndC, IndC was confirmed in 115 of the 140 specimens available for re-examination. These were divided into IndC favouring ulcerative colitis (Group I; n = 99), 'true' IndC (Group II; n = 8), and IndC favouring Crohn's (Group III; n = 8). 61 presented with fulminant colitis. Patients in Group I were subdivided into having (A) deep ulcers (B) transmural lymphoid aggregates (C) skip lesions (D) terminal ileal inflammation and/or (E) a caecal patch. Outcome was determined by chart analysis, and compared to 231 randomly selected patients with IPAA for ulcerative colitis (UC) matched for age, gender, and follow-up.

RESULTS

Only patients with evidence of deep ulceration (Group IA) had a significant increase in the incidence of Crohn's disease (4.3%vs. 0.43%, P = 0.04), complex perianal fistulae (4.3%vs. 0.43%, P = 0.04), and pelvic abscess (12.9%vs. 2.2%, P < 0.001). No pathological subgroup of IndC patients had a significantly different rate of pouch failure or pouch loss.

CONCLUSIONS

Pathological stratification may predict those more likely to develop Crohn's disease or other complications, but not pouch failure. On this basis, we feel that patients with IndC should not be precluded from having IPAA surgery.

Factors affecting cost and length of stay associated with the ileal pouch-anal anastomosis

PURPOSE

The purpose of this study was to evaluate the costs associated with the ileal pouch-anal anastomosis procedure and identify those factors that most affected or determined such costs. Specifically evaluated were the costs, complication rates, and length of stay associated with the ileal pouch-anal anastomosis done as a one-stage, two-stage, two-stage modified, or three-stage procedure.

METHODS

Costs from the hospital accounting database and clinical data from retrospective chart review of 135 ileal pouch-anal anastomosis patients from a ten-year period were compiled. Overall costs and length of stay (the sum of all hospitalizations for all surgeries and any related complications) for each group were compared by analysis of variance. Linear regression was used to compute net costs and length of stay excluding contributions from other relevant factors such as number of operative stages, complications, demographics, and nonelective operations.

RESULTS

The average overall cost and length of stay of the ileal pouch-anal anastomosis ranged from a low of $12,738 and 13.5 days for the one-stage procedure to a high of $32,758 and 23.9 days for the three-stage pathway. Overall costs, length of stay, and incidence of complications increased with the number of operations necessary to complete the ileal pouch-anal anastomosis. This pattern of increased costs and length of stay with the greater number of stages persisted even after demographic and preoperative characteristics were controlled for in the analyses. The occurrence of a complication added an average of $9,304 (P < 0.0001) and 7.4 days to the procedure (P = 0.0002), whereas an urgent presentation added an average of $5,258 (P = 0.15) and 6.1 days (P = 0.04).

CONCLUSIONS

The two most definitive determinants of cost and length of stay after ileal pouch-anal anastomosis are complications and number of operative stages used to complete the operation. Elective ileal pouch-anal anastomosis operations done in the fewest stages with the least complications provide the least costly result and the shortest hospital stay. For patients with severe disease, the two-stage modified pathway (total abdominal colectomy followed by pouch creation without a protecting ileostomy) appears to have fewer complications, lower costs, and a shorter length of stay than the traditional three-stage pathway.

The correlation between quality of life and functional outcome in ulcerative colitis patients after proctocolectomy ileal pouch anal anastomosis

OBJECTIVE

The aim of this study was to evaluate functional outcome and quality of life (QOL) in patients undergoing proctocolectomy ileal pouch anal anastomosis (IPAA), to assess the correlation between functional outcome and QOL, and to identify factors influencing functional outcome and QOL in these patients.

BACKGROUND

IPAA is now considered the procedure of choice for ulcerative colitis. Functional outcome and QOL are important factors in evaluating operative outcome.

METHODS

All patients with UC who had undergone IPAA at our institute during the period 1990-2001 were included. QOL and functional outcome were evaluated by mailed questionnaires. QOL was scored using the Short Form 36 (SF-36). Global Assessment of Function Scale was used to evaluate functional outcome.

RESULTS

Data were obtained in 77 of 99 patients (78%), with the median age of 38 years. Median follow up time was 4.25 years. The QOL in patients after pelvic pouch procedure was excellent, with scores equal to published norms for the Israeli general population in most scales. Functional outcome and QOL scores correlated strongly (r > 0.5; P < 0.0001) in all dimensions. Older age was associated with lower scores in both functional outcome and QOL scales (P < 0.0001).

CONCLUSIONS

This study demonstrates a strong association between functional outcome and QOL in patients after IPAA. These patients, however, have a QOL that is comparable with the general population. Age at time of surgery strongly influences both functional outcome and QOL. This finding has to be taken into consideration in pre-operative counseling.