Anal sphincter-saving operations for chronic ulcerative colitis

Mesenteric Lengthening in Pouch Surgery: Review of Surgical Techniques

Described for the first time in the medical literature in 1978 by Parks and Nicholls, total proctocolectomy with ileal-pouch anal anastomosis (IPAA) is nowadays the procedure of choice for patients with ulcerative colitis in whom the medical therapy has, a selected group of patients with Crohńs disease, and for patients with familial adenomatous polyposis. Despite the advances in medical treatment regarding inflammatory bowel disease, up to 30% of patients still require surgery, and restorative proctocolectomy and IPAA are the mainstay of the surgical treatment. It is considered a demanding and technically-challenging procedure, with the main challenge being the performance of a tension-free IPAA; the main reason for failure of the tension-free anastomosis is a shortened mesentery. With particular attention to detail, sufficient length can be achieved to enable a safe anastomosis in most patients. Herein, we describe the available techniques to lengthen the mesentery of the ileal pouch to perform an easy-to-reach tension-free anastomosis.

Transabdominal Pouch Salvage for Failed Minimally Invasive Versus Open IPAA: A Case-Matched Study

BACKGROUND

Modality of index IPAA creation may affect the results after redo IPAA surgery for IPAA failure. To our knowledge, there is no study evaluating the effects of modality of index IPAA creation on redo IPAA outcomes.

OBJECTIVE

This study aimed to compare short- and long-term outcomes of transabdominal redo IPAA surgery for failed minimally invasive IPAA and open IPAA.

DESIGN

This was a retrospective cohort study.

SETTINGS

This investigation was based on a single-surgeon experience on redo IPAA.

PATIENTS

Patients undergoing transabdominal redo IPAA for a failed minimally invasive IPAA and open IPAA between September 2007 and September 2017 were included.

MAIN OUTCOME MEASURES

Short-term complications and long-term outcomes were compared between 2 groups.

RESULTS

A total of 42 patients with failed index minimally invasive IPAA were case matched with 42 failed index open IPAA counterparts. The interval between index IPAA and redo IPAA operations was shorter in patients who had minimally invasive IPAA (median, 28.5 vs 56.0 mo; p = 0.03). A long rectal stump (>2 cm) was more common after minimally invasive IPAA (26% vs 10%; p = 0.046). Redo IPAAs were constructed more commonly with staplers in the laparoscopy group compared with open counterparts (26% vs 10%; p = 0.046), and other intraoperative details were comparable. Although short-term morbidity was similar between 2 groups, abscess formation (7% vs 24%; p = 0.035) was more frequent in patients who had index IPAA with open technique. Functional outcomes were comparable. Redo IPAA survival for failed minimally invasive IPAA and open IPAA was comparable.

LIMITATIONS

This study was limited by its retrospective, nonrandomized nature and relatively low patient number.

CONCLUSIONS

A long rectal cuff after minimally invasive IPAA is a potential and preventable risk factor for failure. Due to its technical and patient-related complexity, handsewn anastomoses in redo IPAA are associated with increased risk of abscess formation. See Video Abstract at http://links.lww.com/DCR/B252. RESCATE DEL RESERVORIO ILEO-ANAL POR VIA TRANSABDOMINAL EN CASOS DE FUGA ANASTOMÓTICA ENTRE ABORDAGE MINIMAMENTE INVASIVO Y ABORDAJE ABIERTO: ESTUDIO DE EMPAREJAMIENTO DE MUESTRAS Y CASOS: La creación de modalidades e índices de Reservorios Ileo-Anales (RIA) pueden afectar los resultados después de rehacer la cirugía de RIAs por fallas en el reservorio. Hasta donde sabemos, no hay ningún estudio que evalúe los efectos de la modalidad de creación de índices RIA en los resultados para el rescate del reservorio.Este estudio tuvo como objetivo comparar los resultados a corto y largo plazo de la cirugía transabdominal redo RIA en casos de fracaso por via mínimamente invasiva (MI-RIA) o por la vía abierta (A-RIA).Estudio de cohortes tipo retrospectivo.Investigación basada en la experiencia de un solo cirujano en redo del Reservorio Ileo-Anal.Se incluyeron aquellos pacientes sometidos a re-operación transabdominal y re-confección de un RIA por fallas en el MI-RIA y en el A-RIA durante un lapso de tiempo entre septiembre 2007 y septiembre 2017.Las complicaciones a corto plazo y los resultados a largo plazo se compararon entre los dos grupos.Un total de 42 pacientes con índice fallido de MI-RIA fueron emparejados con 42 homólogos con índice fallido de A-RIA. El intervalo entre las operaciones de RIA y redo RIA fué más corto en pacientes que tenían MI-RIA (mediana, 28,5 meses frente a 56 meses, p = 0,03). Un muñón rectal largo (> 2 cm) fue más común después de MI-RIA (26% vs 10%, p = 0.046). Redo RIAs se construyeron más comúnmente con engrampadoras en el grupo Minimalmente Invasivo en comparación con la contraparte abiertas (26% vs 10%, p = 0.046). Aunque la morbilidad a corto plazo fue similar entre los dos grupos, la aparición de abscesos (7% frente a 24%, p = 0.035) fue más frecuente en pacientes que tenían RIA con técnica abierta. Los resultados funcionales fueron comparables. La sobrevida de las redo RIAs para MI-RIA y A-RIA fallidas, también fué comparable.Este estudio estuvo limitado por su naturaleza retrospectiva, no aleatoria y el número relativamente bajo de pacientes.Un muñon rectal largo después de MI-RIA es un factor de riesgo potencial y previsible para el fracaso. Debido a su complejidad técnica y relacionada con el paciente, las anastomosis suturadas a mano en redo RIA están asociadas con un mayor riesgo de formación de abscesos. Consulte Video Resumen en http://links.lww.com/DCR/B252.

The usefulness of the H-pouch configuration in salvage surgery for failed ileal pouches

AIM

Abdominal salvage surgery for a failed ileal pouch-anal anastomosis (5) is safe and feasible in experienced hands. When salvaging an ileal pouch or creating a new J, S or W pouch may not be feasible, construction of an H-pouch may be the final option. This study reports a single colorectal surgeon's experience on H-pouch anal anastomosis in patients referred with a failed ileal pouch.

METHOD

Patients undergoing transabdominal salvage surgery with H-pouch formation for a failed pouch from February 2012 to May 2016 were evaluated.

RESULTS

Five patients were identified with a mean age of 46 (22-63) years. The pathological diagnosis was mucosal ulcerative colitis in all patients. Three patients had an initial traditional two-stage J-pouch creation and two patients had an initial three-stage approach. The median time to redo pouch surgery after the index IPAA creation was 99 (11-158) months. One patient required excision of the pouch and two patients had a complication within 30 days of surgery.

CONCLUSION

The H-pouch is a good alternative for a failed IPAA when another type of reservoir is not an option.

Fate of the Rectum after Colectomy with Ileorectal Anastomosis in Ulcerative Colitis

Objective:

Aim of the study was to evaluate the cumulative success of colectomy and ileorectal anastomosis in 20 patients with ulcerative colitis.

Patients and Methods:

Data were collected from patient histories and cumulative success was calculated by the Kaplan-Meier method.

Results:

Seven of 20 (35 %) ileorectal anastomoses were lost. Cumulative success rate was 84 % at 5 years, 69 % at 10 years and 56 % at 20 years. Most common indication for proctectomy was disabling proctitis. Other reasons for failure were postoperative ileal necrosis and persisting presacral infection. Patients with advanced colonic cancer managed relatively well with ileorectal anastomosis until death. No cases of rectal cancer were detected during postoperative follow-up but one moderate dysplasia was treated locally.

Conclusion:

Ileorectal anastomosis can be chosen for patients who are not suitable for ileoanal operation. Rectal endoscopies are mandatory postoperatively.

Ileo-anal pouch excision: A review of indications and outcomes

Restorative proctocolectomy (RP) is the surgical treatment of choice for ulcerative colitis (UC) and patients with familial adenomatous polyposis (FAP). A devastating complication for both patient and surgeon is failure of the pouch that requires excision. There is currently no single paper in the literature that consolidates the indications for ileo-anal pouch excision and the subsequent outcomes following this procedure. A literature search was carried out to identify articles on RP and ileal pouch-anal anastomosis. The main search terms used were “RP”; “ileal pouch-anal anastomosis” or “ileal reservoir” or “ileal pouch”; “failure of ileal pouch-anal anastomosis” and “excision of ileal pouch-anal anastomosis”. The search was completed using electronic databases MEDLINE, PubMed and EMBASE from 1975 to June 2014. Characteristics of patients with pouch failure differ between institutions. Reported overall excision rates of the pouches vary and in this review ranged from 0.93% to 12.8%. Age and lower institutional volume (less than 3.3 cases) were independent predictors of pouch failure; however surgeon case load was not. The main reasons identified for excision are sepsis (early cause), Crohn’s disease and poor functional outcomes (both late causes). Pouch cancers in UC and FAP are still rare but 135 cases exist in the literature. The most common complication following excision is persistent perineal sinus. The decision to excise a pouch should not be taken lightly and an awareness of the technical pitfalls and complications that can occur should be fully appreciated.

Refractory distal ulcerative colitis: is proctocolectomy always necessary?

Refractory distal ulcerative colitis (RDUC) is defined as persistence of symptoms caused by endoscopically proven colonic inflammation located at the rectum or left colon despite oral/topical steroids and 5-ASA. RDUC affects a small subset of patients and is associated with chronic disabling symptoms and increased social/medical costs. Moreover, patients with long-standing ulcerative colitis (UC) carry an elevated risk of developing colorectal cancer and colonic mucosa high-grade dysplasia. Alternative medical strategies in steroid refractory disease are unlikely to provide durable remission in all patients, carry potential severe side effects and, as immunosuppressants, the risk of other neoplasms, and may increase the short-term complication rate when surgery is finally required. Restorative proctocolectomy with ileal pouch-anal anastomosis (RP-IPAA) allows the complete removal of the diseased rectum and colon, virtually eliminating the risk of malignant transformation and reestablishing intestinal continuity with continence preservation. Since the introduction of this surgical procedure, morbidity and mortality rates have been drastically reduced. Despite the still notable rate of surgical complications, long-term quality of life assessment has shown excellent results in nearly all patients who have undergone RP-IPAA, comparing well with the general population. Furthermore, when performed for distal UC, RP-IPAA produces similar surgical outcomes with respect to pancolitis. In conclusion, RP-IPAA should always be considered in patients with RDUC, and multidisciplinary counseling should provide patients clear information about the advantages of surgery and possible complications as well as the chance to achieve disease remission with medical therapy.

A comparison of the quality of life of ulcerative colitis patients after IPAA vs ileostomy

BACKGROUND

Total proctocolectomy with IPAA is frequently considered the procedure of choice for surgical patients with ulcerative colitis, presumably owing to an expectation of improved quality of life in comparison with an ileostomy.

OBJECTIVE

The goal of our study was to determine whether long-term quality of life among patients with a pelvic pouch is better than those who chose a permanent stoma.

DESIGN

This investigation is a cross-sectional observational study using a prospective database.

SETTING

This study was conducted at an academic medical center.

PATIENTS

Consecutive patients who had undergone IPAA or a permanent ileostomy for ulcerative colitis by a single surgeon, presenting for their annual follow-up visit from July through September 2011, were offered participation in the study. A randomly chosen group of subjects who did not have scheduled appointments during the study period were sent a letter inviting them to participate in the study.

MAIN OUTCOME MEASURES

The primary outcome measures used were EQ-5D-3L, the Short Quality of Life in Inflammatory Bowel Disease questionnaire, the Cleveland Global Quality of Life instrument, the Fecal Incontinence Quality of Life scale, and the Stoma Quality of Life scale.

RESULTS

Thirty-five patients with a pelvic pouch and 24 ostomates were accrued and comprehensively studied. Global quality-of-life scores were virtually identical for the 2 groups. Patients with a pelvic pouch had better subscores in current quality of health and energy level, Fazio score, sexuality/body image, and work/social function.

LIMITATIONS

This study was limited by its small sample size, and some of our patients were enrolled through mailed surveys and, hence, nonresponse bias may be present. The follow-up time since surgery was longer in the pelvic pouch group than in the ileostomy group.

CONCLUSION

Informed patients with ulcerative colitis choosing an ileostomy have a health-related global quality of life very similar to patients with a pelvic pouch. Better outcomes in patients with an ileal pouch were most evident in the areas of sexuality/body image and work/social function.

Quality of life, health-related quality of life and health status in patients having restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis: a systematic review

AIM

There are numerous studies on quality of life (QoL), health-related quality of life (HRQoL), and health status (HS) in patients undergoing surgery for ulcerative colitis. A systematic review of published literature was conducted to establish the quality of these studies and to determine QoL, HRQoL, and HS in patients after ileal pouch-anal anastomosis for ulcerative colitis.

METHOD

All published studies describing QoL, HRQoL, and HS in adult patients in combination with ileal pouch-anal anastomosis for ulcerative colitis were reviewed systematically. No time or language limitations were applied. Relevance was established on the basis of three pre-specified selection criteria: 1) ileal pouch-anal anastomosis was performed for ulcerative colitis, 2) QoL, HRQoL, and HS were reported as outcome of the study and 3) studies reported a minimum follow-up after surgery for 12 months. Outcome variables were results of QoL, HRQoL, and HS, characteristics of the study population, pouch construction, duration of follow-up, and time of assessment in months before and after restorative surgery. Descriptive data synthesis was performed by tabulation displaying the methodological quality, study characteristics and conclusions on QoL, HRQoL, and HS measurements in the studies.

RESULTS

The review included 33 studies comprising 4790 patients. Three were graded to be of high quality, 23 of moderate quality and seven of low quality. All reported improved HS and the majority reported improved HRQoL. However, none of the studies reported on QoL.

CONCLUSION

The HRQoL and HS of patients with ulcerative colitis improved 12 months after restorative proctocolectomy with an ileal pouch-anal anastomosis and were indistinguishable from the HRQoL and HS of the normal healthy population.

Quality of life and health status before and after ileal pouch–anal anastomosis for ulcerative colitis

Background

Ileal pouch–anal anastomosis (IPAA) is considered the surgical treatment of choice for patients with ulcerative colitis. Quality of life (QoL) and health status are the most important patient-related outcomes. Studies investigating QoL are often cross-sectional and focus on health status. This longitudinal study evaluated QoL and health status after IPAA for ulcerative colitis and compared these with reference data from a healthy population.

Methods

Patients with ulcerative colitis who underwent a pouch operation between 2003 and 2008 completed validated questionnaires for QoL and health status. Questionnaires were completed before pouch surgery, and 6, 12, 24 and 36 months after operation. The effect of IPAA on QoL and health status was analysed, and data were compared with reference values from the healthy Dutch population.

Results

Data were obtained for 30 of the 32 patients. Six months after IPAA, QoL was at least comparable with that of the reference population in four of six domains. Twelve months after IPAA, overall QoL had improved, supported by findings in three QoL domains. Six months after IPAA, health status was comparable to that of the reference population in three of eight dimensions, and after 3 years it was at least comparable in five dimensions.

Conclusion

QoL and health status increased after IPAA and reached levels comparable with those of the healthy reference population in a majority of domains and dimensions. QoL was restored first after IPAA, followed by health status.

Reoperative inflammatory bowel disease surgery

With the advent of restorative proctocolectomy or ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC), not only has there been potential for cure of UC but also patients have enjoyed marked improvements in bowel function, continence, and quality of life. However, IPAA can be complicated by postoperative small bowel obstruction, disease recurrence, and pouch failure secondary to pelvic sepsis, pouch dysfunction, mucosal inflammation, and neoplastic transformation. These may necessitate emergent or expeditious elective reoperation to salvage the pouch and preserve adequate function. Local, transanal, and transabdominal approaches to IPAA salvage are described, and their indications, outcomes, and the clinical parameters that affect the need for salvage are discussed. Pouch excision for failed salvage reoperation is reviewed as well. Relaparotomy is also frequently required for recurrent Crohn's disease (CD), especially given the nature of this as yet incurable illness. Risk factors for CD recurrence are examined, and the various surgical options and margins of resection are evaluated with a focus on bowel-sparing policy. Stricturoplasty, its outcomes, and its importance in recurrent disease are discussed, and segmental resection is compared with more extensive procedures such as total colectomy with ileorectal anastomosis. Lastly, laparoscopy is addressed with respect to its long-term outcomes, effect on surgical recurrence, and its application in the management of recurrent CD.

Complications of ileoanal pouches

Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical therapy of choice for patients with chronic ulcerative colitis and the majority of patients with familial adenomatous polyposis. It restores gastrointestinal continuity, re-establishes transanal defecation, and avoids a permanent stoma. Although this technically demanding procedure is associated with low mortality rates, it is frequently accompanied by early and late complications. This article will review these complications and discuss the interventions that are needed to provide appropriate treatment.

Comparison of outcomes after hand-sewn versus stapled ileal pouch-anal anastomosis in 3,109 patients

BACKGROUND

The aim of this study was to compare outcomes after primary hand-sewn versus stapled ileal pouch-anal anastomosis (IPAA).

METHODS

Patients undergoing a primary IPAA (1983-2007) were identified from a prospective pelvic pouch database. Differences between group A (hand-sewn) and group B (stapled) for pre-operative and peri-operative factors, complications, functional outcomes, and quality of life (QOL) were investigated.

RESULTS

Of 3,382 patients with a primary IPAA, 3,109 were included. Median follow-up was 7.1 years (0.1-24). Mean age was 37.9 +/- 13.2 years. Overall, 1,741 patients (56%) were male. Group A (n = 474) and group B (n = 2635) had similar age (P = .28), sex (P = .8), albumin level (P = .74), prior colectomy (P = .98), and use of steroids (P = .1). Group A had a greater use of ileostomy (P = .001) and a longer duration of stay (P < .001). Group B had a greater body mass index (P < .001) and J-pouch (P < or = .001). Wound infection (P = .42) and pouchitis (P = .59) were similar. Anastomotic stricture (P = .002), septic complications (P = .019), bowel obstruction (P = .027), and pouch failure (P < .001) were greater in group A. At most recent follow-up, bowel frequency (P = .74) and rate of urgency were similar (P = .71). A greater proportion of patients in group A described incontinence (P < .001), seepage (P < .001), pad usage (P < .001), dietary (P < .001), social (P < .001), and work restrictions (P = .025). The Cleveland Global QOL score (P = .018) was greater in group B.

CONCLUSION

Patients undergoing a stapled IPAA had better outcomes and QOL than those undergoing a hand-sewn IPAA.

Repeat pouch surgery by the abdominal approach safely salvages failed ileal pelvic pouch

PURPOSE

: This study evaluated outcomes of patients with abdominal salvage operations for failed ileal pouch-anal anastomosis.

METHODS

: Patients undergoing laparotomy for ileoanal pouch salvage were reviewed from a prospectively maintained pouch database and records.

RESULTS

: From 1983 to 2007, 241 abdominal reconstructions were performed. The median follow-up was 5 years (range, 0.04-20.8). Diagnoses before primary ileal pouch-anal anastomosis were ulcerative colitis in 187, familial adenomatous polyposis in 22, indeterminate colitis in 20, Crohn's disease in 9, and other in 3. The most common indications for salvage were fistula (n = 67), leak (n = 65), stricture (n = 42) pouch dysfunction (n = 40), pelvic abscess (n = 25). Seventy-one cases had a new pouch constructed. One hundred and seventy cases had the original pouch salvaged. Twenty-nine cases had either pouch excision or ileostomy without pouch excision the result of failure after reconstruction. To assess functional results and quality of life, patients with reconstruction were matched to those with a primary ileal pouch-anal anastomosis. Significantly higher proportions of patients with reconstruction reported seepage during daytime (P = 0.002), at night (P = 0.015), and daytime pad usage (P = 0.02). Other parameters and quality of life were similar between groups.

CONCLUSIONS

: Repeat abdominal surgery was a good alternative for pouch failure. Functional and quality of life outcomes were encouraging.

Comprehensive pouch clinic concept for follow-up of patients after ileal pouch anal anastomosis: report of 3 years' experience in a tertiary referral center

BACKGROUND

We designed and evaluated a novel concept in enhancing postoperative care of patients following restorative proctocolectomy (RPC) for ulcerative colitis (UC) and determined the risk factors, incidence, and nature of RPC-associated complications in this population.

METHODS

The study cohort consisted of consecutive UC patients post-RPC attending a comprehensive pouch clinic run by a gastroenterologist and a colorectal surgeon in a tertiary care medical center (from January 2003 to December 2005). Data were collected on their medical history, physical examination, laboratory tests, pouch endoscopy and biopsies, and anonymous in-house patient satisfaction questionnaires mailed to the first 90 patients. Assessment was also done on data regarding risk factors, incidence, and nature of RPC-associated complications.

RESULTS

A total of 120 UC patients with a functioning pouch visited the clinic: mean age 37 years, range 13-75; 57 males; mean disease duration 11 years; mean follow-up 65 months. Of the 55 patients who responded to the questionnaire, 48 (87%) felt that the comprehensive clinic significantly improved the quality of their care. The major complications were pouchitis (52%), extraintestinal manifestations, pouch-related fistula, and mechanical dysfunction. The risk factors for the development of pouchitis were time since surgery, >1-stage surgery, and reason for surgery (acute exacerbation/intractable disease more than dysplasia/cancer); the latter was the only independent risk factor.

CONCLUSIONS

The pouch clinic concept significantly enhanced patient satisfaction. The most common RPC-associated complication was pouchitis. Risk factors for developing pouchitis were duration since operation, >1-stage operation, and indication for surgery.

Ten years experience of one-stage restorative proctocolectomy for ulcerative colitis

BACKGROUND

Ileal-pouch anal anastomosis has an established role in the treatment of ulcerative colitis. Controversy exists regarding the routine use of a diverting ileostomy. The aim of this study was to review the clinical and functional outcome of patients undergoing restorative proctocolectomy in the absence of a diverting ileostomy (one-stage).

MATERIALS AND METHODS

Between 1990 and 1999, 87 patients with ulcerative colitis underwent a one-stage restorative proctocolectomy. The median age at the time of operation was 34 years (range 12-64 years) and median follow-up was 36 months (range 24-144 months). The clinical notes were reviewed retrospectively.

RESULTS

The median in-patient stay was 15 days (range 9-36). There were no post-operative deaths. The complication rate within 30 days of surgery approximated to 40%. The median daytime pouch evacuation rate was 5. Only 13% of patients had to empty their pouch at night on a regular basis. Pelvic sepsis secondary to anastomotic leakage was the most commonly encountered problem, occurring in 15 patients. Small bowel obstruction was encountered in ten patients. One pouch required excision for a recurrent pouch-vaginal fistula.

CONCLUSION

Despite refinements in the surgical technique, restorative proctocolectomy is associated with significant morbidity. For a selected group of patients undergoing an ileo-anal anastomosis, a defunctioning ileostomy may be avoided.

Ileal pouch-anal anastomosis

BACKGROUND

Since 1977, restorative proctocolectomy with ileoanal anastomosis (IAA) has evolved into the surgical treatment of choice for most patients with intractable ulcerative colitis. Construction of an ileal pouch reservoir is now standard, usually in the form of J pouch (IPAA). The aim of this report is to review selection criteria for, and functional outcomes, follow-up and management of complications of IPAA after 30 years of widespread clinical application.

METHODS AND RESULTS

Literature published in English on the clinical indications, surgical technique, morbidity, complications and outcome following IAA and IPAA was sourced by electronic search, performed independently by two reviewers who selected potentially relevant papers based on title and abstract. Additional articles were identified by cross-referencing from papers retrieved in the initial search.

CONCLUSION

The functional results of IPAA are good. Pouchitis, irritable pouch syndrome and cuffitis are specific long-term complications but rarely result in failure. Pouch salvage is possible in selected patients with poor functional outcomes. One-stage operations are increasingly performed.

Lengthening of small bowel mesentery: stepladder incision technique

The surgical option of choice in most patients with mucosal ulcerative colitis or familial adenomatous polyposis is restorative proctocolectomy with ileal pouch anal anastomosis. The tension-free anastomosis is one of the most critical steps but may be technically difficult or impossible in some patients because of shortened small bowel mesentery. Various techniques have been described to increase the length of small bowel mesentery. These techniques usually involve selective division of mesenteric blood vessels and meticulous dissection. We describe a new technique of stepladder transverse, transmesenteric incisions in the avascular windows of small bowel mesentery. This provides additional small bowel length without compromising blood supply to the pouch and a simple and safe method of increasing the length of small bowel mesentery. To date, no complications have been reported using this technique.

The American Journal of Surgery

For the past 18 months we have been carrying the list of contents of the previous month's issue of The American Journal of Surgery, and that journal has carried our list Qf contents, In an attempt to increase awareness of each other's surgical literature, we are introducing a new venture in which we will exchange ‘digests’ on a quarterly basis. Below we publish the first such digest of The American Journal of Surgery prepared by Dr Hiram Polk, and that journal will carry a reciprocal digest of the last quarter's British Journal of Surgery prepared by our Editor, Professor John Farndon. Next month we will repeat the exercise with the German journal Der Chirurg. Comments specific to the content of individual papers in the digests should be addressed primarily to the source journal, but we would be glad to receive a copy.

Long-term function after restorative proctocolectomy

PURPOSE

Early functional outcome after restorative proctocolectomy and formation of an ileoanal pouch is known to be good, but there are minimal data on the long-term function of the pouch. The aim of this study was to look at the long-term functional outcome in patients who had undergone restorative proctocolectomy and formation of an ileoanal pouch.

METHODS

A total of 151 consecutive patients (96 males, 55 females) who underwent ileoanal pouch surgery between April 1983 and May 1993 were identified. Functional outcomes from the previous 12 months were appraised by a standardized questionnaire.

RESULTS

The median age at surgery was 31 years (range, 6-63 years), with a median follow-up of 142 months (range, 100-221 months). Eighteen patients have had their pouches excised, with another patient being defunctioned. Therefore 19 patients (13 percent) had suffered pouch failure. Altogether, 115 patients were available for follow-up, and 98 patients (85 percent) returned questionnaires. The median pouch-emptying frequency was five times (range, 1-17) during the day and one time (range, 0-6) at night. A total of 74 percent of patients had perfect continence during the day. Most of the patients had no life-style restrictions related to the pouch, and 98 percent of patients would recommend a pouch to others.

CONCLUSIONS

Long-term functional outcome after ileoanal pouch surgery is good in most patients. For patients requiring proctocolectomy, ileoanal pouch surgery can now be recommended as an excellent long-term option.

The fate of the ileal pouch in patients developing Crohn's disease

PURPOSE

Recent studies have suggested that a subset of patients with Crohn's colitis may have a favorable outcome after ileal pouch-anal anastomosis and have advocated elective ileal pouch-anal anastomosis in selected patients with Crohn's disease. We have not offered ileal pouch-anal anastomosis to patients with known Crohn's disease, but because of the overlap in clinical presentation of ulcerative colitis and indeterminate colitis, some patients receiving an ileal pouch-anal anastomosis are subsequently found to have Crohn's disease. We review our experience with these patients to identify potential preoperative predictors of ultimate pouch failure.

METHODS

Patients with a final diagnosis of Crohn's disease were identified from an ileal pouch-anal anastomosis registry. These patients are followed prospectively. Preoperative and postoperative clinical and pathologic characteristics were evaluated as predictors of outcome. Median (range) values are listed.

RESULTS

Thirty-two (18 females) patients (4.1 percent) with a final diagnosis of Crohn's disease were identified from a registry of 790 ileal pouch-anal anastomosis patients (1980-2002). Patients underwent ileal pouch-anal anastomosis in two stages (11 patients) or three stages (21 patients). The preoperative diagnosis was ulcerative colitis in 24 patients and indeterminate colitis in 8 patients. Median follow-up was 153 (range, 13-231) months. The median time from ileal pouch-anal anastomosis to diagnosis of Crohn's disease was 19 (range, 0-188) months. Complications occurred in 93 percent, including perineal abscess/fistula (63 percent), pouchitis (50 percent), and anal stricture (38 percent). Pouch failure (excision or current diversion) occurred in nine patients (29 percent) at a median of 66 (range, 6-187) months. Two of these 9 patients had preoperative anal disease (not significant). Comparing patients with failed pouches (n = 9) to patients with functioning pouches (n = 23), post-ileal pouch-anal anastomosis perineal abscess (67 vs. 26 percent, P = 0.05) and pouch fistula (89 vs. 30 percent, P = 0.01) were more commonly associated with pouch failure. Preoperative clinical, endoscopic, and pathologic features were not predictive of pouch failure or patient outcome. For those with a functional pouch, 50 percent have been or are currently on medication to treat active Crohn's disease. This group had six bowel movements in 24 (range, 3-10) hours, with leakage in 60 percent and pad usage in 45 percent.

CONCLUSIONS

Patients who undergo ileal pouch-anal anastomosis and are subsequently found to have Crohn's disease experience significant morbidity. Preoperative characteristics, including the presence of anal disease, were not predictive of subsequent pouch failure. We choose not to recommend the routine application of ileal pouch-anal anastomosis in any subset of patients with known Crohn's disease.

Inflammatory bowel disease and the eye

Inflammatory bowel disease includes Crohn's disease and ulcerative colitis, and is characterized by chronic inflammation of the intestines. The advances in understanding of the inflammatory process have resulted in improved treatment of inflammatory bowel disease. The systemic complications of inflammatory bowel disease involve many organs, eyes included. The ophthalmic complications are usually of inflammatory origin. Some of these complications, like scleritis, may reflect overall disease activity. Treatment of intestinal inflammation-either medical or surgical-usually helps resolution of ophthalmic complications. This review describes recent developments in the diagnosis and management of the inflammatory bowel disease and its ophthalmic complications.

Effect of ulcerative colitis in the bursting strength of colonic anastomoses in rats

Inflammatory bowel disease may have a deleterious effect on bowel healing, but its role is difficult to demonstrate in clinical practice because of the association of multiple factors. An experiment was conducted in rats. They were divided into two groups: group I, a model of acetic acid induced colitis, and group II, the control group. Both groups underwent a rectal resection and primary anastomosis. On postoperative day 7, the bursting strength of the anastomosis was evaluated. There were 44 rats in group I and 38 in group II. In 91% of group I rats there were histopathological changes compatible with inflammatory bowel disease (IBD). Mean bursting pressure was significantly reduced in rats with acetic-acid induced IBD (142.18 +/- 18.22 mm Hg in group I, and 208.85 +/- 14.8 mm Hg in group II; p < .05). These results suggest the deleterious effect of IBD on bowel healing.

Prospective, age-related analysis of surgical results, functional outcome, and quality of life after ileal pouch-anal anastomosis

OBJECTIVE To evaluate how age affects functional outcome and quality of life after ileal pouch anal anastomosis (IPAA). SUMMARY BACKGROUND DATA Because of the limited number of older patients undergoing IPAA, it has been difficult to assess functional outcome and quality of life stratified by age. METHODS IPAA was performed in 1895 patients. Patients were stratified by age into <45 (n = 1410), 46-55 (n = 289), 56-65 (n = 154), and more than 65 years (n = 42). Outcome was assessed prospectively. Results are presented at 1, 3, 5, and 10 years after surgery.RESULTS Patients were followed for 4.6 +/- 3.7 years (maximum, 17 years). Pouch failure occurred in 4.1% (pouch excision or permanent diversion). Incontinence and night time seepage were more common in older patients. There were minor differences in the quality of life, health, energy and happiness between age groups, with a slight benefit for those under 45 years. Fourteen percent or fewer patients experienced social, sexual or work restrictions. Overall, 96% of patients were happy to have undergone their surgery, and 98% recommended it to others. Although the respective figures were 89% and 96% in the over-65 age group, the difference was not significant. CONCLUSIONS These data provide a unique assessment of outcome after IPAA at multiple time points. Although functional outcome after IPAA is not as good in older patients, appropriate case selection confers acceptable function and quality of life to patients of all ages.

Salvage surgery after restorative proctocolectomy

BACKGROUND AND METHOD

Restorative proctocolectomy is now the elective surgical procedure of choice for most patients with ulcerative colitis or familial adenomatous polyposis. Complications may lead to failure, defined as removal of the reservoir with establishment of a permanent ileostomy or long-term diversion. Failure may be avoided for some patients by salvage surgery. The causes of failure are identified in this article and the procedures adopted to treat them are defined; a review of the literature was carried out to determine the effectiveness of the procedures.

RESULTS

Failure after restorative proctocolectomy results from complications, which may occur indefinitely during follow-up to a cumulative rate of about 15 per cent at 10-15 years. Sepsis accounts for over 50 per cent of these complications. Abdominal salvage procedures are successful in 20 to over 80 per cent of patients but the rate of salvage is dependent on the duration of follow-up, which might explain this variance. Local procedures are successful in 50-60 per cent of patients with pouch-vaginal fistula. Poor function accounts for about 30 per cent of failures. Abdominal salvage for outlet obstruction and low pouch capacitance results in satisfactory or acceptable function in up to 70 per cent of patients. There is no effective surgical salvage for pouchitis.

CONCLUSION

Salvage surgery must be discussed carefully with the patient, who should be made aware of the possible complications and the prospect of success, which is less than that in the general population of patients undergoing ileoanal pouch surgery.

Long-term failure after restorative proctocolectomy for ulcerative colitis

OBJECTIVE

To establish the incidence and causes of late failure in patients undergoing restorative proctocolectomy for a preoperative diagnosis of ulcerative colitis was the objective of this investigation.

SUMMARY BACKGROUND DATA

Restorative proctocolectomy is the elective surgical procedure of choice for ulcerative colitis. Most patients have a satisfactory outcome but failures occur. The reasons and rates of early failure are well documented, but there is little information on long-term failure.

METHODS

A series of 634 patients (298 females, 336 males) underwent restorative proctocolectomy for inflammatory bowel disease between 1976-1997, with a mean follow-up of 85 +/- 58 months. Failure was defined as removal of the pouch or the need for an indefinite ileostomy. It was divided into early and late, occurring within 1 year or more than 1 year postoperatively. RESULTS There were 3 (0.5%) postoperative deaths, leaving 631 patients for analysis. Of these, 23 subsequently died (disseminated large bowel cancer, 12; unrelated causes, 9; related causes, 2). There were 61 (9.7%) failures (15 early [25%], 46 late [75%]) due to pelvic sepsis (32 [52%]: 7 early, 25 late), poor function (18 [30%]: 2 early, 16 late), pouchitis (7 [11%]: 2 early, 5 late) and miscellaneous (4, all early). A final diagnosis of Crohn's disease, type of reservoir (J,S), female gender, postoperative pelvic sepsis and a one-stage procedure were significantly associated with failure. Failure rate rose with time of follow-up from 9% at 5 years to 13% at 10 years.

CONCLUSIONS

Pelvic sepsis and poor function were the main reasons for later failure. Failure rates should be reported based on the duration of follow-up.

Surgery for ulcerative colitis

The type of surgery performed for UC varies from patient to patient and must take into account the nutritional status and health of the patient, the presence of dysplasia or cancer, the desire of the patient to maintain continence, the preoperative anorectal function, the degree of confidence in the diagnosis of UC, and the technical constraint because of certain body habituses. A total proctocolectomy is the surgical procedure of choice for UC. A restorative proctocolectomy is the preferred surgical approach that not only cures the patient of the disease and prevents the development of colorectal cancer, but also maintains continence with an improved quality of life.

Sulfate-reducing bacteria colonize pouches formed for ulcerative colitis but not for familial adenomatous polyposis

PURPOSE

Ileal pouch-anal anastomosis remains the "gold standard" in surgical treatment of ulcerative colitis and familial adenomatous polyposis. Pouchitis occurs mainly in patients with a background of ulcerative colitis, although the reasons for this are unknown. The aim of this study was to characterize differences in pouch bacterial populations between ulcerative colitis and familial adenomatous pouches.

METHODS

After ethical approval was obtained, fresh stool samples were collected from patients with ulcerative colitis pouches (n = 10), familial adenomatous polyposis (n = 7) pouches, and ulcerative colitis ileostomies (n = 8). Quantitative measurements of aerobic and anaerobic bacteria were performed.

RESULTS

Sulfate-reducing bacteria were isolated from 80 percent (n = 8) of ulcerative colitis pouches. Sulfate-reducing bacteria were absent from familial adenomatous polyposis pouches and also from ulcerative colitis ileostomy effluent. Pouch Lactobacilli, Bifidobacterium, Bacteroides sp, and Clostridium perfringens counts were increased relative to ileostomy counts in patients with ulcerative colitis. Total pouch enterococci and coliform counts were also increased relative to ileostomy levels. There were no significant quantitative or qualitative differences between pouch types when these bacteria were evaluated.

CONCLUSIONS

Sulfate-reducing bacteria are exclusive to patients with a background of ulcerative colitis. Not all ulcerative colitis pouches harbor sulfate-reducing bacteria because two ulcerative colitis pouches in this study were free of the latter. They are not present in familial adenomatous polyposis pouches or in ileostomy effluent collected from patients with ulcerative colitis. Total bacterial counts increase in ulcerative colitis pouches after stoma closure. Levels of Lactobacilli, Bifidobacterium, Bacteroides sp, Clostridium perfringens, enterococci, and coliforms were similar in both pouch groups. Because sulfate-reducing bacteria are specific to ulcerative colitis pouches, they may play a role in the pathogenesis of pouchitis.

Salvage abdominal surgery in patients with a retained rectal stump after restorative proctocolectomy and stapled anastomosis

BACKGROUND

The introduction of surgical stapling instruments has widened the use of restorative proctocolectomy. Too high a distal transection of the rectum can, however, produce a retained rectal stump, which may cause symptoms. A study of the operative and functional data in a consecutive series of patients undergoing salvage surgery for retained rectal stump was undertaken.

METHODS

Twenty-five patients referred between January 1990 and September 2000 for pouch dysfunction were identified as having a retained rectal stump. Twenty-two underwent abdominoanal revision. The hospital notes were reviewed and function was assessed during outpatient visits, by postal questionnaire and by telephone interview.

RESULTS

Median operating time was 225 (range 170-340) min and median hospital stay was 15 (range 8-48) days. There was no operative death. Five pouches were excised. Seventeen patients were available for functional assessment. Median follow-up was 22.5 (range 4-114) months. Median 24-h frequency before and after operation was 12 (range 4-20) and 6 (range 3-12) respectively, and median night-time frequency was 4 (range 0-8) and 0.5 (range 0-4) respectively. Fifteen patients reported marked subjective improvement in pouch function and quality of life.

CONCLUSION

Major revisional surgery for symptomatic retained rectal stump after restorative proctocolectomy with stapled anastomosis was successful in 15 of 22 patients. These results are worse than the outcome following first-time restorative proctocolectomy with anastomosis constructed at the anal level. Pouch-rectal anastomosis should be avoided.

One- or two-stage procedure for restorative proctocolectomy: rationale for a surgical strategy in ulcerative colitis

OBJECTIVE

To analyze the results of different strategies for restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) in ulcerative colitis.

SUMMARY BACKGROUND DATA

No commonly accepted criteria exist for choosing between the one-stage or the two-stage procedure (with or without temporary diverting ileostomy) for IPAA. The authors analyzed the outcome of patients principally suitable for either of the two alternative surgical strategies.

METHODS

A matched-pair control study was performed, comparing surgical details and the early and late outcome of the one-stage (study group, n = 57) versus the two-stage procedure (control group, n = 114), for IPAA.

RESULTS

No differences were found between the study group and the control group regarding the matching criteria gender, median age at IPAA, systemic corticoid medication, or activity of colitis. Comparing the patients who underwent a one-stage procedure with those who underwent a two-stage procedure, the proportion of patients without complications was significantly higher (P =.0042) and the frequency of late complications was significantly lower (P =.0022) in patients who underwent the one-stage procedure. The percentage of patients with anastomotic strictures was significantly higher in the control group than in the study group (P =.0022). No significant difference was found between the two groups regarding early complications, pouch-related septic complications, pouchitis, median duration of surgery for IPAA, median blood loss, need for transfusion, or median hospital stay.

CONCLUSIONS

In patients with ulcerative colitis in whom there is a choice between a one-stage procedure or a two-stage procedure with a defunctioning ileostomy, the one-stage procedure is clearly superior. This finding is of great clinical relevance both for the subjective interests of the patient and from an economic point of view.

Postoperative adhesions: ten-year follow-up of 12,584 patients undergoing lower abdominal surgery

PURPOSE

Postoperative adhesions are a significant problem after colorectal surgery. However, the basic epidemiology and clinical burden are unknown. The Surgical and Clinical Adhesions Research Study has investigated the scale of the problem in a population of 5 million.

METHODS

Validated data from the Scottish National Health Service Medical Record Linkage Database were used to define a cohort of 12,584 patients undergoing open lower abdominal surgery in 1986. Readmissions for potential adhesion-related disease in the subsequent ten years were analyzed. The methodology was conservative in interpreting adhesion-related disease.

RESULTS

In the study cohort 32.6 percent of patients were readmitted a mean of 2.2 times in the subsequent ten years for a potential adhesion-related problem. Although 25.4 percent of readmissions were in the first postoperative year, they continued steadily throughout the study period. After open lower abdominal surgery 7.3 percent (643) of readmissions (8,861) were directly related to adhesions. This varied according to operation site: colon (7.1 percent), rectum (8.8 percent), and small intestine (7.6 percent). The readmission rate was assessed to provide an indicator of relative risk of adhesion-related problems after initial surgery. The overall average rate of readmissions was 70.4 per 100 initial operations, with 5.1 directly related to adhesions. This rose to 116.4 and 116.5, respectively, after colonic or rectal surgery-with 8.2 and 10.3 directly related to adhesions.

CONCLUSIONS

There is a high relative risk of adhesion-related problems after open lower abdominal surgery and a correspondingly high workload associated with these readmissions. This is influenced by the initial site of surgery, colon and rectum having both the greatest impact on workload and highest relative risk of directly adhesion-related problems. The study provides sound justification for improved adhesion prevention strategies.

The incidence and outcome of pelvic sepsis following handsewn and stapled ileal pouch anal anastomoses

The incidence and outcome of pelvic sepsis was analyzed in 210 patients who underwent restorative proctocolectomy for ulcerative colitis (UC) in 197 patients, and for familial adenomatous polyposis (FAP) in 13 patients. Pelvic sepsis developed in 18 patients (8.6%) and a significantly higher incidence was seen in men than in women, at 13.6% vs 3.7%, respectively (P < 0.05). The incidence of pelvic sepsis in patients with UC complicated by toxic megacolon and/or fulminant colitis was significantly higher that in those without any preoperative complications, at 36.4% vs 7.4% (P < 0.05). The incidence of pelvic sepsis following handsewn anastomosis was significantly higher than that following stapled anastomosis, at 15.6% vs 5.5% (P < 0.05). The outcome of pelvic sepsis in patients with a stapled anastomosis was better than that in those with a handsewn anastomosis. The prognosis of women who developed pelvic sepsis was better than that of men who developed pelvic sepsis. The risk factors predisposing to pelvic sepsis were UC, especially when complicated by toxic megacolon and/or fulminant colitis, and male sex, while a handsewn anastomosis was more vulnerable than a stapled anastomosis.

Redo ileal pouch-anal anastomosis for malfunctioning pouches-acceptable alternative to permanent ileostomy?

BACKGROUND

Pouch complications after ileal pouch-anal anastomosis (IPAA) can result in morbidity and pouch loss. Recent reports describe success with redo IPAA. This study was conducted to assess the outcome of malfunctioning pouches treated by redo IPAA.

METHODS

All patients undergoing redo IPAA between 1983 and 1999 were identified and clinical records studied. Redo IPAA was defined as an operation for malfunctioning pouch with pelvic dissection and disconnection, pouch revision, and reanastomosis. Analyzed were etiology, presentation, diagnostic modalities, surgical management, pouch loss, and outcome. Follow-up was obtained by telephone or mailed survey.

RESULTS

Between 1983 and 1999, 650 IPAA procedures were performed, 6 (0.9%) of which required redo IPAA. Ten referred patients required redo IPAA. These 16 cases included 7 anastomotic disruptions, 3 pouch-vaginal fistulae, 2 recurrent polyps after stapled IPAA, 2 megapouches, 1 cuff abscess, and 1 straight pullthrough. All patients underwent redo IPAA with pouch salvage 100% in this series. Twelve had the original pouch repaired and 4 new pouches. Six patients (37%) had complications and outcome was acceptable with 7.8 stools per day and nighttime incontinence "rarely" or "never" in 7 patients. Eight described results as "good," 6 as "fair.".

CONCLUSION

Redo IPAA can be performed with few complications, an acceptable outcome, and should result in low pouch loss.

Retocolectomia total e anastomose íleo-anal com reservatório ileal: experiência de 16 anos

O reservatório ileal pélvico tem sido a melhor opção cirúrgica para a retocolite ulcerativa (RCU) e polipose adenomatosa familiar (PAF). Desde 1983 esta técnica vem sendo empregada, e o objetivo deste trabalho é apresentar revisão desta casuística, analisando seus resultados e seus pontos controversos. Setenta e três pacientes, com média de idade de 34,6 (13-63) anos e com predomínio do sexo feminino (42 pacientes, 56,7%) se submeteram ao procedimento para tratamento de RCU (46 pacientes - 63,0%) e PAF(27 - 37,0%). Foram utilizadas as seguintes variantes técnicas: em S, de grande tamanho e ramo eferente longo (oito); em S pequeno e ramo eferente reduzido (22); em "dupla câmara" (20); em J (23). Todos os procedimentos foram seguidos da construção de ileostomia de proteção. De 1993 em diante, todos os pacientes tiveram a arcada do colo direito preservada. Setenta pacientes têm pelo menos um ano de pós-operatório e 61 têm dois anos ou mais com média de 7,01 (1-16) anos. Foram consideradas complicações precoces aquelas que ocorreram até o 30º dia de pós- operatório e tardias, após esse tempo. Resultados funcionais foram analisados após um ano do fechamento da ileostomia. Ocorreram 35 complicações precoces em 22 pacientes e 39 complicações tardias em 35 pacientes. Vinte e cinco pacientes não apresentaram complicações. As principais complicações foram: obstrução intestinal (19,1 %), fistulizações cutâneas, com vagina ou trato urinário (10,9%), isquemia de reservatório (parcial ou total), (9,5%), e ileíte do reservatório (pouchitis) (6,8%). Nove pacientes (12,3%) têm ileostomia funcionante, sendo que sete pacientes têm ainda o reservatório mantido no lugar e dois tiveram-no ressecado. A mortalidade diretamente relacionada ao procedimento foi em dois pacientes, mas outros quatro pacientes evoluíram tardiamente ao óbito, por causas como desnutrição crônica e tumor de cerebelo. Em conclusão, apesar da morbidade e da existência ainda de questões controversas, as perspectivas tardias têm sido animadoras e têm estimulado a indicação deste tipo de procedimento.

Magnetic resonance imaging to distinguish the type and severity of pediatric inflammatory bowel diseases

BACKGROUND

The distinction between ulcerative colitis and Crohn's disease is important, because treatment options and clinical course may vary. Magnetic resonance imaging (MRI) allows noninvasive transmural assessment of the intestine and may facilitate differentiation of ulcerative colitis from Crohn's disease. The objective of this prospective study was to determine whether MRI differentiates Crohn's disease from ulcerative colitis in children as effectively as colonoscopy with mucosal biopsies.

METHODS

Fifteen patients underwent colonoscopy with biopsies followed by abdominal MRI. The MRI diagnosis, determined by two radiologists independently completing a standardized form was compared with the gastroenterologic diagnosis.

RESULTS

After colonoscopy and review of histology, Crohn's disease was diagnosed in nine patients, ulcerative colitis in five, and indeterminate colitis in one, who was excluded from study. Agreement of the MRI diagnosis with the gastroenterologic diagnosis was 4 of 4 (100%) for ulcerative colitis, 4 of 10 (40%) for Crohn's disease considering both radiologists, and 5 of 10 (50%) for Crohn's disease for each radiologist individually. Percentage of enhancement by MRI did not correlate with the severity of inflammation determined at endoscopy among the patients with Crohn's disease (r = -0.3, P = 0.366). There was agreement on severity of inflammation in three of four patients with ulcerative colitis.

CONCLUSIONS

Current MRI interpretation of inflammatory bowel disease did not adequately recognize Crohn's disease in children. Therefore, colonoscopy with biopsy remains the most accurate tool for determining the type and severity of inflammatory bowel disease in children and adolescents.

Long-term functional outcome and quality of life after stapled restorative proctocolectomy

OBJECTIVE

To evaluate prospectively long-term quality of life and functional outcome after restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis, and to evaluate and validate a novel quality-of-life indicator in this group of patients.

SUMMARY BACKGROUND DATA

Restorative proctocolectomy with ileal pouch-anal anastomosis is now the preferred option when total proctocolectomy is required for ulcerative colitis or familial adenomatous polyposis, but long-term data on functional outcome and quality of life after the procedure are lacking.

METHODS

Patients (n = 977) who underwent RPC with stapled anastomosis for colitis or polyposis coli and who were followed for > or =12 months were included. Quality of life, fecal incontinence, and satisfaction with surgery were prospectively evaluated by structured interview or questionnaire for 1 to 12 years after surgery (median 5.0). Quality of life was scored using the Cleveland Global Quality of Life (CGQL) instrument (Fazio Score). This is a novel score developed over the past 15 years by the senior author. Quality of life was also evaluated in a subgroup of patients with the Short Form 36 (SF-36). The CGQL was validated by determining its reliability, responsiveness, and validity as well as its correlation with the SF-36 score.

RESULTS

Postoperative quality of life as measured by SF-36 was excellent and compared well with published norms for the general U.S. population. The CGQL was found to be reliable, responsive, and valid, and there was a high correlation with the SF-36 scores. Using the CGQL, quality of life was shown to increase after the first 2 years after surgery, and there was no deterioration thereafter. The prevalence of perfect continence increased from 75.5% before surgery to 82.4% after surgery, and although this deteriorated somewhat >2 years after surgery, it was no worse than preoperative values. Ninety-eight percent of patients would recommend the surgery to others.

CONCLUSIONS

Long-term quality of life after ileal pouch surgery is excellent and the level of continence is satisfactory. This surgery is an excellent long-term option in patients requiring total proctocolectomy. The CGQL is a simple, valid, and reliable measure of quality of life after pelvic pouch surgery and may well be applicable in many other clinical conditions.

Long-term functional outcome and quality of life after stapled restorative proctocolectomy

OBJECTIVE

To evaluate prospectively long-term quality of life and functional outcome after restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis, and to evaluate and validate a novel quality-of-life indicator in this group of patients.

SUMMARY BACKGROUND DATA

Restorative proctocolectomy with ileal pouch-anal anastomosis is now the preferred option when total proctocolectomy is required for ulcerative colitis or familial adenomatous polyposis, but long-term data on functional outcome and quality of life after the procedure are lacking.

METHODS

Patients (n = 977) who underwent RPC with stapled anastomosis for colitis or polyposis coli and who were followed for > or =12 months were included. Quality of life, fecal incontinence, and satisfaction with surgery were prospectively evaluated by structured interview or questionnaire for 1 to 12 years after surgery (median 5.0). Quality of life was scored using the Cleveland Global Quality of Life (CGQL) instrument (Fazio Score). This is a novel score developed over the past 15 years by the senior author. Quality of life was also evaluated in a subgroup of patients with the Short Form 36 (SF-36). The CGQL was validated by determining its reliability, responsiveness, and validity as well as its correlation with the SF-36 score.

RESULTS

Postoperative quality of life as measured by SF-36 was excellent and compared well with published norms for the general U.S. population. The CGQL was found to be reliable, responsive, and valid, and there was a high correlation with the SF-36 scores. Using the CGQL, quality of life was shown to increase after the first 2 years after surgery, and there was no deterioration thereafter. The prevalence of perfect continence increased from 75.5% before surgery to 82.4% after surgery, and although this deteriorated somewhat >2 years after surgery, it was no worse than preoperative values. Ninety-eight percent of patients would recommend the surgery to others.

CONCLUSIONS

Long-term quality of life after ileal pouch surgery is excellent and the level of continence is satisfactory. This surgery is an excellent long-term option in patients requiring total proctocolectomy. The CGQL is a simple, valid, and reliable measure of quality of life after pelvic pouch surgery and may well be applicable in many other clinical conditions.

Evolution of the pelvic pouch procedure at one institution: the first 100 cases

BACKGROUND

Total extirpation of the colon with pelvic pouch formation, and the avoidance of a permanent stoma, continues to pose a challenge for better results, both technically and functionally. The aims of this study were to investigate the first 100 pelvic ileal-pouch procedures, assessing changes in surgical technique, their relationship to morbidity and long-term outcome, and compare this to the few large international series.

METHODS

Between 1984 and 1997, 100 patients had a pelvic J-shaped ileal-pouch formed, 58 two-stage and 42 three-stage procedures. Fifty had a hand-sewn pouch-anal anastomosis and 50 a double-stapled anastomosis. Seventy-three were for ulcerative colitis, five for indeterminate colitis, 20 for familial adenomatous polyposis (FAP), one for multiple primary colorectal cancers, and one for constipation.

RESULTS

After a median follow-up of 68 months, 97% of patients still have a functioning pouch. There were two postoperative deaths (one after-pouch formation and one after-stoma closure). Morbidity occurred in 52 patients, including three patients with pouch leaks and three pouch-anal anastomosis leaks (6% leak rate), 27% with a small bowel obstruction (2% early, 20% late, 5% both), a 19% anal stricture rate, and a 9% pouchitis rate. Three pouches have been removed (all for Crohn's disease). Median number of bowel movements per day was six, with 85% of patients reporting a good quality of life. Patients following a double-stapled procedure have less anal seepage and improved continence over those with a hand-sewn ileal pouch-anal anastomosis.

CONCLUSIONS

Despite high morbidity rates, pelvic pouch formation provides satisfactory long-term results for patients requiring total proctocolectomy, with functional results and morbidity rates comparable to larger overseas series.

Restorative proctocolectomy in children with ulcerative colitis utilizing rectal mucosectomy with or without diverting ileostomy

BACKGROUND

Controversies continue concerning the best way to perform restorative proctectomy (RP) for ulcerative colitis (UC). Can rectal mucosectomy and hand-sewn ileoanal anastomosis (IAA) withstand the challenge posed by extrarectal dissection with a double-stapled technique and no mucosectomy? Is a diverting ileostomy mandatory after RP?

METHODS

The authors describe 30 consecutive children with UC who underwent RP with rectal mucosectomy and hand-sewn IAA. The authors assess the results and compare the first 14 patients (group 1) treated with temporary diverting ileostomies with the next 16 consecutive patients (group 2) without diverting ileostomies.

RESULTS

The average age (13.8 years in group 1 v 10.4 in group 2), duration of illness before resection (3.2 years in group 1 v 1.5 in group 2), and gender breakdown (10 of 14 were girls in group 1, 10 of 16 were girls in group 2) were similar between the two groups. Outcome was not significantly different between the two groups. Average bowel movements per 24-hour period was 5.5 in group 1 and 4.2 in Group 2. Occasional nighttime staining occurred in two patients in group 1 and five in group 2. No one suffered daytime staining in group 1, and one patient had occasional daytime staining in group 2. Average quality of life (on a scale of 0 to 5) as assessed by the patients or parents was 4.4 in group 1 and 4.9 in group 2. There were 10 total complications in group 1. One child required a permanent stoma for ileoanal separation. Two patients required reoperations for complications caused by the diverting ileostomy. The single instance of peritonitis was in group 1 caused by anastomotic leak after ileostomy closure. There were five total complications in group 2, of which, two required temporary stomas for ileoanal separations.

CONCLUSIONS

RP with rectal mucosectomy and hand-sewn IAA in children with UC provides good functional results. Peritonitis did not occur in the absence of diversion. Eliminating routine diverting ileostomy avoids the considerable complications and morbidity from the stoma and its closure.

Reconstruction for chronic dysfunction of ileoanal pouches

OBJECTIVE

A retrospective review was performed to determine the results after surgical reconstruction for chronic dysfunction of ileal pouch-anal procedures for ulcerative colitis and familial colonic polyposis at a university medical center.

METHODS

During the 20-year period from 1978 to 1998, 601 patients underwent colectomy and ileal pouch-anal anastomosis (IPAA) for ulcerative colitis, familial colonic polyposis, or Hirschsprung's disease. A J pouch was used for 351 patients, a lateral pouch for 221, an S pouch for 6, and a straight pull-through for 23. Acute complications after pouch construction have been detailed in previous publications and are not included in this study. Chronic pouch stasis with diarrhea, frequency, urgency, and soiling gradually became more severe in 164 patients (27.3%), associated with pouch enlargement, an elongated efferent limb, and obstruction to pouch outflow, largely related to the pouch configuration used during the authors' early clinical experience. These patients were sufficiently symptomatic to be considered for reconstruction (mean 68 months after IPAA). Transanal resection of an elongated IPAA spout was performed on 58 patients; abdominoperineal mobilization of the pouch with resection and tapering of the lower end (AP reconstruction) and ileoanal anastomosis on 83; pouch removal and new pouch construction on 7; and conversion of a straight pull-through to a pouch on 16.

RESULTS

Good long-term results (mean 7.7 years) with improvement in symptoms occurred in 98% of transanal resections, 91.5% of AP reconstructions, 86% of new pouch constructions, and 100% of conversions of a straight pull-through to a pouch. The average number of bowel movements per 24 hours at 6 months was 4.8. Complications occurred in 11.6% of reconstructed patients. Five of the 164 patients (3.1%) required eventual pouch removal and permanent ileostomy. The high rate of pouch revision in this series of patients undergoing IPAA is due to a policy of aggressive correction when patients do not experience an optimal functional result, or have a progressive worsening of their status.

CONCLUSIONS

Although occasionally a major undertaking, reconstruction of ileoanal pouches with progressive dysfunction due to large size or a long efferent limb has resulted in marked improvement in intestinal function in >93% of patients and has reduced the need for late pouch removal.

Is ileal pouch-anal anastomosis really the procedure of choice for patients with ulcerative colitis?

PURPOSE

Ileal pouch-anal anastomosis is widely claimed to have replaced total proctocolectomy with ileostomy as the "procedure of choice" for ulcerative colitis, largely on the basis of a perceived improved quality of life. There exists relatively little support for this assertion in the literature. Our aim was to determine if educated patients choosing total proctocolectomy with ileostomy have a similar quality of life as with ileal pouch-anal anastomosis.

METHODS

All patients with ulcerative colitis referred to a single surgeon and deemed an appropriate surgical candidate were educated and then offered ileal pouch-anal anastomosis or total proctocolectomy with ileostomy. Age, gender, and complications (including pouchitis) were recorded prospectively, and all patients were questioned regarding functional outcome and level of satisfaction. They were then asked to complete a slightly modified Inflammatory Bowel Disease Questionnaire, which was analyzed by categoric and overall scores.

RESULTS

Sixty-seven patients underwent elective surgery for ulcerative colitis during the study period. Fifty-five patients chose ileal pouch-anal anastomosis, and 12 had total proctocolectomy with ileostomy. The groups were similar except for younger age and longer follow-up in the ileal pouch-anal anastomosis group. Patients undergoing ileal pouch-anal anastomosis had significantly more short-term or long-term complications (49 vs. 8 percent), with pouchitis being the most frequent complication. There was no difference in level of satisfaction between the two groups, and no patient in either group wishes they had undergone the other procedure. There was no difference in the overall or any categoric Inflammatory Bowel Disease Questionnaire score.

CONCLUSION

Patient satisfaction with both procedures was similarly high. Patients who undergo ileal pouch-anal anastomosis can expect a high level of satisfaction, with a good quality of life. However, educated patients choosing an ileostomy can achieve the same quality of life, without the higher complication rate associated with a pelvic pouch.

Outcome of pouch-related complications after ileal pouch-anal anastomosis

BACKGROUND

Creation of a small intestinal reservoir after ileal pouch-anal anastomosis (IPAA) results in an improved quality of life because of significantly diminished stool frequency. However, a number of complications associated with the pouch may jeopardize these sphincter-sparing procedures and occasionally result in permanent ileostomy. This study was conducted to assess the incidence, risk factors, clinical characteristics, management strategies, and outcome of pouch-related complications after IPAA.

METHODS

Data on all patients undergoing IPAA with a J pouch between 1983 and Spring 1997 were prospectively gathered. Patients with pouch-specific complications were identified, and both inpatient and outpatient records analyzed in detail. When necessary, telephone contact was made to update functional data. Other parameters evaluated included age, gender, diagnosis, medication history, diagnostic modalities, laboratory values, time course, management strategies, reoperative procedures, and final results.

RESULTS

Some 510 IPAA procedures were performed between 1983 and Spring 1997; 87% of patients had inflammatory bowel disease. Operative mortality was 0%. In the entire series, 27 (5.3%) had complications related to the J pouch. Of those, 22 (81%) had ulcerative colitis and were on a mean dose of 32 mg/day of prednisone. Computed tomography scan made the diagnosis in 18 (67%) and the mean white blood cell count on admission was 14,400. In 11 (41%), the complications occurred after IPAA whereas in the other 16 (59%) it occurred after ileostomy closure. In 5 (19%), the complication resolved with intravenous antibiotics and percutaneous drainage, and 22 (81%) required reoperation. Proximal (11, or 41%) and distal (8, or 30%) pouch leaks or cuff abscesses were the most common complication and accounted for 19 (70%) of the complications observed. In this series, 3 patients (11%) had complications severe enough to warrant J pouch excision, and 1 patient had a permanent ileostomy without excision. Overall pouch excision/ failure in this series was 0.78%.

CONCLUSION

Complications involving the J pouch are a seemingly unavoidable part of sphincter-sparing surgery for colonic mucosal diseases. However, if therapy is timely, aggressive, and judicious for these complex patients, pouch loss should be uncommon and long-term results acceptable.

Total abdominal colectomy and ileorectal anastomosis for inflammatory bowel disease

PURPOSE

This retrospective study assesses the results of total colectomy and ileorectostomy for inflammatory bowel disease.

METHODS

Between January 1974 and December 1990, 90 patients underwent total colectomy and ileorectal anastomosis for chronic ulcerative colitis (n = 48) or Crohn's colitis (n = 42) at the Mayo Clinic. Patients' records were reviewed retrospectively. Long-term results were assessed by chart reviews and postal questionnaires. Conversion to a permanent ileostomy, with or without proctectomy, was considered a failure of the procedure. The Kaplan-Meier method was used to estimate survivorship free of failure. The log-rank test was used to compare survivorship curves. Ninety-five percent confidence intervals were calculated at selected time points. P values < 0.05 were considered to be statistically significant.

RESULTS

The main indication for surgery was refractory chronic disease. There were no immediate postoperative deaths. The anastomotic leakage rate was 4.4 percent, and small-bowel obstruction occurred in 15.6 percent. At the time of follow-up (mean, 6.5 +/- 4.8 years), 46 patients (58.9 percent) had recurrence or exacerbation of the disease. This was the most common indication for subsequent proctectomy/permanent ileostomy in the follow-up period. There were 8 failures in 48 patients with ulcerative colitis (16.7 percent) and 11 failures in 42 patients with Crohn's disease (26.2 percent), although this difference was not statistically significant. Cumulative probability of having a functioning ileorectal anastomosis at five years was 84.2 percent (95 percent confidence interval, 71-95.9 percent) for ulcerative colitis and 73.8 percent (95 percent confidence interval, 58.6-88.6 percent) for Crohn's disease. In the latter group, females showed a significantly lower cumulative probability of having a functioning ileorectal anastomosis (females, 63.4 percent; males, 92.3 percent; P = 0.04). Crohn's patients 36 years of age or younger also showed a lower probability of success (patients < or = 36 years, 57 percent; patients > 36 years, 93.8 percent; P = 0.03). In the group with chronic ulcerative colitis, younger patients also seemed to require additional surgery more frequently; however, this difference was not statistically significant. Previous duration of symptoms, with mild or moderate disease in a distensible rectum, had no effect on results in either disease group. Functional results were acceptable in 63.6 and 87.5 percent of patients with Crohn's and ulcerative colitis, respectively. Eighty-four percent of ulcerative colitis patients and 91 percent of Crohn's disease patients reported an improvement in their quality of life, and overall, more than 90 percent considered their health status to be better than before surgery. One patient with ulcerative colitis developed carcinoma of the rectal stump 11.5 years after the colectomy and ileorectal anastomosis (cumulative probability of remaining free of cancer, 85.7 percent at 12 years; 95 percent confidence interval, 57.7-100 percent).

CONCLUSIONS

These results demonstrate that, in selected patients with a relatively spared rectum and without severe perineal disease, total colectomy and ileorectal anastomosis still remains a viable option to total proctocolectomy with extensive Crohn's colitis. In addition, ileorectal anastomosis, as a sphincter-saving procedure, continues to have a place in the surgical treatment of chronic ulcerative colitis for high-risk or older patients who are not good candidates for ileal pouch-anal anastomosis, when the latter procedure cannot be done because of technical reasons and in the presence of advanced carcinoma concomitant with colitis, when life expectancy is limited.

Efficacy of the straight endorectal pull-through in the management of familial adenomatous polyposis--a 16-year experience

From 1979 to 1995, 27 patients who had familial adenomatous polyposis (FAP) were treated at the authors' institution. Most patients (n = 23) presented as a result of a previous family history of FAP. Eighteen patients presented with symptomatic colonic disease that included bloody stools (n = 14), diarrhea (n = 10), and abdominal pain (n = 6). Treatment consisted of a total colectomy, rectal mucosectomy, and straight endorectal pull-through (ERPT) in 26 of 27 patients. One patient preferred to undergo an ileoanal J pouch reconstruction. A temporary diverting loop ileostomy was performed in 25 patients and closed at an average of 100 days after the ERPT. Follow-up has been achieved in 100% of the patients and ranges from 6 to 182 months with an average of 48 months. Postoperative complications included partial bowel obstruction (two patients, one requiring enterolysis); and mild pouchitis (one patient). Two of the 27 patients required proctectomy and permanent ileostomy procedures, one for rectal cancer that was present microscopically in the initial rectal specimen from the ERPT and the other because of recurrent anastomotic complications. No patient required revision of the straight pull-through to a pouch or takedown of the pull-through as a result of persistent diarrhea or dissatisfaction. All of the patients are continent, and 80% deny any soiling during bouts of gastroenteritis. The mean number of bowel movements reported was 10 per day at the first postoperative clinic visit with a gradual decreased to six per day after 2 years. Initial use of bulking (62%) and antimotility agents (88%) decreased significantly over the course of follow-up to 29% and 67%, respectively at the most recent follow-up (average, 48 months) of each patient. Pelvic sepsis, which occurs in 8% of most series of patients who have pouches, did not occur in any of our patients. Pouchitis, a common complication with pouches (23%), occurred in only one of the patients and was mild and easily treated medically. This series demonstrates that total colectomy with rectal mucosectomy and straight ERPT eliminates the risk of colorectal cancer and achieves continence with a low complication rate and excellent functional results and patient satisfaction.

Should older patients undergo ileal pouch-anal anastomosis?

BACKGROUND

Ileal pouch-anal anastomosis (IPAA) is a technically demanding, lengthy procedure with substantial associated morbidity. Some have suggested that this procedure should not be performed in older patients. This study was conducted to evaluate whether older patients have a poorer functional outcome and higher complication rate than younger patients who undergo IPAA.

METHODS

The 455 patients who have undergone IPAA at this institution were stratified according to age (< 55 versus > 55) to compare functional outcome and complication rates. The data were prospectively collected. The groups included 32 patients > 55 (7%) and 423 patients < 55. Comparisons were made with regard to stool frequency, incontinence rates, post-IPAA complications, postileostomy closure complications, and results 12 months postileostomy closure.

RESULTS

Preoperative anal sphincter resting and squeeze pressures were significantly lower in the > 55 group. Most complication rates were similar after IPAA except dehydration rates, which were higher in the older patients than the younger ones (27% versus 11%, respectively). Pre-ileostomy closure anal sphincter resting and squeeze pressures were not significantly lower in patients older than 55. Twenty-four hour daytime and nighttime stool frequencies were significantly higher in the > 55 group, as were daytime and nighttime stool incontinence.

CONCLUSION

Although functional outcome is poorer and some complications are higher in the > 55 group, the procedure can be safely performed with acceptable results and is greatly preferred by this population over permanent ileostomy.