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Kanakaratne S, Hong J, Solomon MJ, Young CJ. Ileal pouch-anal anastomosis provides good functional and quality of life outcomes following proctocolectomy: A 33-year single centre experience. ANZ J Surg 2024; 94:404-411. [PMID: 38105626 DOI: 10.1111/ans.18827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Restorative proctocolectomy (RP) with ileal pouch-anal anastomosis (IPAA) remains the gold standard for the surgical management of patients with medically refractive mucosal ulcerative colitis. We aimed to identify functional and quality of life (QOL) outcomes in RP and IPAA surgery patients at our institution. METHODS A retrospective observational study was performed including all patients who had undergone RP and IPAA between August 1984 and November 2017 at Royal Prince Alfred Hospital (RPAH). RESULTS 316 consecutive patients were identified, median age 39 (range 5 to 81) years. The median duration of disease was 60 (range 1 to 528) months. Ulcerative colitis was the main preoperative diagnosis with the main RP indication being failure of medical treatment. The median postoperative stay post-IPAA was 11 (range of 5 to 67) days. Pouchitis was the most common late complication (22.1%), bleeding pouch (3.5%) the earliest, with a 6.8% rate of symptomatic anastomotic leak. Visual analogue scale QOL measure (P-value <0.001), St Marks incontinence score (P-value = 0.001) and Cleveland clinic score (P-value = 0.002) all revealed significant improvement in functional outcomes and QOL. CONCLUSION QOL and functional outcomes following RP with IPAA in patients at our institution are excellent and comparable to institutions with larger patient numbers.
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Affiliation(s)
- Shaveen Kanakaratne
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- The University of Sydney, Faculty of Medicine and Health, Sydney Medical School, Sydney, New South Wales, Australia
| | - Jonathan Hong
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- The University of Sydney, Faculty of Medicine and Health, Sydney Medical School, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- The University of Sydney, Faculty of Medicine and Health, Sydney Medical School, Sydney, New South Wales, Australia
| | - Christopher J Young
- The University of Sydney, Faculty of Medicine and Health, Sydney Medical School, Sydney, New South Wales, Australia
- Department of Surgery, University of Kansas School of Medicine, Abilene, Kansas, USA
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Giddings HL, Ng KS, Solomon MJ, Steffens D, Van Buskirk J, Young J. Population outcomes, trends and the future of pouch surgery for ulcerative colitis: a 19-year New South Wales data linkage study. ANZ J Surg 2023; 93:2686-2696. [PMID: 37449791 DOI: 10.1111/ans.18588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/25/2023] [Accepted: 06/27/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Ileal pouch-anal anastomosis (IPAA) is considered the gold standard reconstructive option in ulcerative colitis (UC). Recent efforts to improve pouch outcomes have seen a push towards centralisation of surgery. This study aimed to document outcomes following pouch surgery at a population level within New South Wales (NSW), and identify factors associated with, and temporal trends of these outcomes. METHODS A retrospective data linkage study of the NSW population over a 19-year period was performed. The primary outcome was pouch failure in patients with UC who underwent IPAA. The influence of hospital level factors (including annual volume) and patient demographic variables on this outcome were assessed using Cox proportional hazards modelling. Temporal trends in annual volume and evidence for centralisation over the studied period were assessed using Poisson regression analysis. RESULTS The annual volume of UC pouches reduced over the study period. The pouch failure rates were 8.6% (95% CI 6.3-10.8%) and 10.6% (95% CI 8.0-13.1%) at 5- and 10-years, respectively. Increasing age and non-elective admission were associated with higher failure rates. One-third of UC pouches (31.6%) were performed in a single institution, which averaged 6.5 pouches/year throughout the study period. Three-quarters (19/25) of NSW public hospitals who performed pouches performed less than one UC pouch annually. CONCLUSIONS The outcomes following UC pouch surgery in NSW are comparable with global standards. Concentrating IBD pouch surgery with the aim of producing specialist surgical teams may be a reasonable way forward in NSW and would ensure equity of access and facilitate research and training collaboration.
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Affiliation(s)
- Hugh L Giddings
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kheng-Seong Ng
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
| | - Joe Van Buskirk
- Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, New South Wales, Australia
- Public Health Research Analytics and Methods for Evidence, Sydney Local Health District, New South Wales, Australia
| | - Jane Young
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Abolfotouh S, Rautio T, Klintrup K, Helavirta I, Mäkelä J. Predictors of quality-of-life after ileal pouch-anal anastomosis in patients with ulcerative colitis. Scand J Gastroenterol 2017; 52:1078-1085. [PMID: 28599590 DOI: 10.1080/00365521.2017.1337218] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Predictors of the postoperative quality of life (QoL) following ileal pouch anal anastomosis (IPAA) have not been thoroughly investigated. This study was planned to assess the postoperative QoL following IPAA and to identify its predictors using the 15D instrument. MATERIALS AND METHODS A retrospective cohort study was conducted on IPAA-operated patients with ulcerative colitis in two Finnish tertiary hospitals during the period 1985-2014 (n = 485). Medical records were examined to collect data on baseline, operative and postoperative characteristics. Patients were surveyed using the 15D-instrument to assess their postoperative QoL. Linear regression analyses and receiver operating characteristic curve were applied to identify the predictors of postoperative QoL. RESULTS AND CONCLUSIONS Of all patients, 61.5% experienced worse postoperative QoL, with significantly lower QoL level than that of an age and sex-standardized general population in 12 dimensions of the 15D-instrument, with the highest mean difference QoL scores calculated for excretion, sexual activity and sleeping dimensions. Older age and preoperative hypertension were the only significant predictors of lower overall QoL (p = .003 and p = .03, respectively). A preoperative age of ≥35 years was the most valid predictor of lower postoperative QoL (Sensitivity = 62.4% and Specificity = 49.6%, p = .04). In conclusion, postoperative QoL is generally low using the 15D-instrument after IPAA. Worse postoperative QoL is predicted after the age of 35.
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Affiliation(s)
| | - Tero Rautio
- a Department of Surgery , University of Oulu , Oulu , Finland
| | - Kai Klintrup
- a Department of Surgery , University of Oulu , Oulu , Finland
| | - Ilona Helavirta
- b School of Medicine , University of Tampere , Tampere , Finland.,c Department of Gastroenterology and Alimentary Tract Surgery , Tampere University Hospital , Tampere , Finland
| | - Jyrki Mäkelä
- a Department of Surgery , University of Oulu , Oulu , Finland
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Zahid A, Kumar S, Koorey D, Young CJ. Pouch adenomas in Familial Adenomatous Polyposis after restorative proctocolectomy. Int J Surg 2014; 13:133-136. [PMID: 25498488 DOI: 10.1016/j.ijsu.2014.11.048] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 11/22/2014] [Accepted: 11/27/2014] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Australian Clinical Practice Guidelines suggest six to twelve-monthly endoscopic pouch surveillance in patients after restorative proctocolectomy for Familial Adenomatous Polyposis (FAP). There are several reports of adenomas and carcinomas forming within the ileum, ileal pouch mucosa or residual rectal mucosa. A retrospective clinical study was performed to audit pouch endoscopic surveillance at a large Sydney tertiary referral Hospital. The aim was to evaluate adenoma development after restorative proctocolectomy for FAP and the adherence rate to published clinical guidelines. METHODS Thirty-nine patients who had restorative proctocolectomy for FAP from 1985 to 2011 were identified. Demographic data, details of surgery, original histopathology and details of follow-up pouch endoscopy and pathology findings were obtained. RESULTS Of the thirty-nine patients, twenty-seven patients were included in this study. Adenomas were found in twelve of 27 (44%) patients. Mean time to first polyp formation was 88 months and median time was 72 months (range 18-249 months). All polyps were either tubular or tubulovillous in histology. One polyp had high grade dysplasia. The remainder had mild or moderate dysplasia. Polyps were excised either endo-anally or during pouchoscopy. None of the five patients who had a hand-sewn ileal pouch-anal anastomosis (IPAA) developed polyps on follow-up, compared with 12 of the 22 (55%) with a double stapled anastomosis (fishers exact test; p=0.047 (two-tailed)). Of those who developed pouch adenomas, eight (67%) developed further pouch adenomas on follow-up. CONCLUSIONS This study supports guidelines recommending lifelong pouch surveillance after restorative proctocolectomy for FAP. Those who develop pouch adenomas may be at greater risk of developing further adenomas. Residual rectal mucosa at the pouch-anal anastomosis should be carefully examined.
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Affiliation(s)
- A Zahid
- Royal Prince Alfred Hospital, Australia; University of Sydney, Sydney, NSW, Australia
| | - S Kumar
- Royal Prince Alfred Hospital, Australia
| | - D Koorey
- Royal Prince Alfred Hospital, Australia; University of Sydney, Sydney, NSW, Australia
| | - C J Young
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia; Royal Prince Alfred Hospital, Australia; University of Sydney, Sydney, NSW, Australia; Royal Prince Alfred Hospital Medical Centre, 100 Carillon Ave, Newtown, NSW 2042, Australia.
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Linden BC, Bairdain S, Zurakowski D, Shamberger RC, Lillehei CW. Comparison of laparoscopic-assisted and open total proctocolectomy and ileal pouch anal anastomosis in children and adolescents. J Pediatr Surg 2013; 48:1546-50. [PMID: 23895970 DOI: 10.1016/j.jpedsurg.2012.08.031] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 08/24/2012] [Accepted: 08/28/2012] [Indexed: 01/01/2023]
Abstract
BACKGROUND Laparoscopic techniques have been applied to restorative proctocolectomy since the early 2000's. We have employed a technique for laparoscopic-assisted total proctocolectomy (TPC) and ileal pouch anal anastomosis (IPAA) for the treatment of children with ulcerative colitis (UC). METHODS We retrospectively reviewed 68 laparoscopic-assisted TPCs and 39 open TPCs performed at our institution for UC between January 1997 and February 2011. Case duration, postoperative length of stay, and complications of the two groups were compared, and multivariable analysis was applied. RESULTS The two groups were comparable with respect to gender, age, and postoperative length of stay. Total abdominal colectomy (TAC) duration was significantly longer in the laparoscopic-assisted group (P < .001). Complications were similar in the laparoscopic and open group, although small bowel obstruction (SBO) was significantly less frequent in the laparoscopic group (log-rank test = 8.88, P = .003). Kaplan-Meier estimated freedom from SBO at 1 year follow-up is 99% for patients treated laparoscopically (95% CI: 98%-100%) and 76% for those undergoing an open surgical approach (95% CI: 64%-88%). CONCLUSIONS The significantly lower SBO rate, low complication rates, and equivalent length of stay favor use of the laparoscopic-assisted approach for TPC and IPAA in children.
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Affiliation(s)
- Bradley C Linden
- Department of Surgery, Boston Children's Hospital-Harvard Medical School Boston, MA 02115, USA.
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Ogawa H, Haneda S, Watanabe K, Suzuki H, Miura K, Ohnuma S, Sasaki H, Shibata C, Unno M. A unique variant of afferent limb syndrome after ileal pouch-anal anastomosis: a case series and review of the literature. J Gastrointest Surg 2012; 16:1581-4. [PMID: 22441759 DOI: 10.1007/s11605-012-1872-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Accepted: 03/07/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Afferent limb syndrome is a relatively rare cause of small bowel obstruction after restorative total proctocolectomy with ileal pouch-anal anastomosis for patients with ulcerative colitis or familial adenomatous polyposis. DISCUSSION This report describes three patients who developed recurrent small bowel obstruction after ileal pouch-anal anastomosis. The bowel obstruction was caused by torsion of the ileum at the inlet of the ileal J-pouch, which was thought to be a variant of afferent limb syndrome. This variant of afferent limb syndrome is characterized by a flexible afferent limb of the pelvic pouch due to the lack adhesion of the ileum in the abdominal cavity. Preoperative diagnosis required multiple series of contrast small bowel enemas. Strictureplasty and ileopexy effectively resolved the recurrent bowel obstruction caused by this variant of afferent limb syndrome.
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Affiliation(s)
- Hitoshi Ogawa
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aobaku, Sendai, Japan.
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Heikens JT, de Vries J, van Laarhoven CJHM. 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. Colorectal Dis 2012; 14:536-44. [PMID: 21176062 DOI: 10.1111/j.1463-1318.2010.02538.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- J T Heikens
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.
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Small bowel obstruction following restorative proctocolectomy: affected by a laparoscopic approach? J Surg Res 2011; 170:202-8. [PMID: 21474147 DOI: 10.1016/j.jss.2011.03.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Revised: 02/17/2011] [Accepted: 03/02/2011] [Indexed: 12/20/2022]
Abstract
BACKGROUND Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the gold standard surgical treatment for chronic ulcerative colitis. More recently, this procedure is being performed laparoscopically assisted. Postoperatively, small bowel obstruction (SBO) is one of the more common associated complications. However, it is unknown whether the addition of a laparoscopic approach has changed this risk. This study aims to assess and compare the incidence of SBOs after both open and laparoscopic restorative proctocolectomy. METHODS All subjects who underwent restorative proctocolectomy from 1998-2008 were identified from a prospective Colorectal Surgery Database. Medical records were reviewed for all cases of SBO, confirmed by a combination of clinical symptoms and radiologic evidence. Comparisons were made between laparoscopic and open approaches. The incidence of SBO was also subdivided into pre-ileostomy takedown, early post-ileostomy takedown (30 d post), and late post-ileostomy takedown (30 d to 1 y post). Several potential risk factors were also evaluated. Statistical analysis was performed utilizing Fisher's exact (for incidence) or t-tests (for means). Significance was defined as P < 0.05 RESULTS A total of 290 open cases and 100 laparoscopic cases were identified during this time period. The overall incidence of SBO at 1 y post-ileostomy takedown was 14% (n = 42) in the open group and 16% (n = 16) laparoscopic (P = NS). In the pre-ileostomy takedown period the incidence of SBO was 7% (n = 21) open and 13% (n = 13) laparoscopic (P = NS). While in the post-takedown period, the early incidence was 4% (n = 12) open and 1% (n = 1) laparoscopic and late incidence was 3% (n = 9) open and 2% (n = 2) laparoscopic (P = NS). Factors associated with an increased risk of SBO include coronary artery disease, prior appendectomy and W and J pouch configurations. CONCLUSIONS The burden of postoperative small bowel obstruction after restorative proctocolectomy is not changed with a laparoscopic approach. Most cases occur in the early postoperative period, especially prior to ileostomy reversal.
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Schnüriger B, Barmparas G, Branco BC, Lustenberger T, Inaba K, Demetriades D. Prevention of postoperative peritoneal adhesions: a review of the literature. Am J Surg 2011; 201:111-21. [PMID: 20817145 DOI: 10.1016/j.amjsurg.2010.02.008] [Citation(s) in RCA: 162] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Revised: 02/16/2010] [Accepted: 02/16/2010] [Indexed: 12/24/2022]
Abstract
BACKGROUND postoperative adhesions are a significant health problem with major implications on quality of life and health care expenses. The purpose of this review was to investigate the efficacy of preventative techniques and adhesion barriers and identify those patients who are most likely to benefit from these strategies. METHODS the National Library of Medicine, Medline, Embase, and Cochrane databases were used to identify articles related to postoperative adhesions. RESULTS ileal pouch-anal anastomosis, open colectomy, and open gynecologic procedures are associated with the highest risk of adhesive small-bowel obstruction (class I evidence). Based on expert opinion (class III evidence) intraoperative preventative principles, such as meticulous hemostasis, avoiding excessive tissue dissection and ischemia, and reducing remaining surgical material have been published. Laparoscopic techniques, with the exception of appendicitis, result in fewer adhesions than open techniques (class I evidence). Available bioabsorbable barriers, such as hyaluronic acid/carboxymethylcellulose and icodextrin 4% solution, have been shown to reduce adhesions (class I evidence). CONCLUSIONS postoperative adhesions are a significant health problem with major implications on quality of life and health care. General intraoperative preventative techniques, laparoscopic techniques, and the use of bioabsorbable mechanical barriers in the appropriate cases reduce the incidence and severity of peritoneal adhesions.
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Affiliation(s)
- Beat Schnüriger
- Los Angeles County Medical Center, University of Southern California, Department of Surgery, Division of Acute Care Surgery, Trauma, Emergency Surgery and Surgical Critical Care, LAC + USC Medical Center, Room 1105, 1200 North State St, Los Angeles, CA, USA
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Barmparas G, Branco BC, Schnüriger B, Lam L, Inaba K, Demetriades D. The incidence and risk factors of post-laparotomy adhesive small bowel obstruction. J Gastrointest Surg 2010; 14:1619-28. [PMID: 20352368 DOI: 10.1007/s11605-010-1189-8] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 02/23/2010] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The purpose of this review was to assess the incidence and risk factors for adhesive small bowel obstruction (SBO) following laparotomy. METHODS The PubMed database was systematically reviewed to identify studies in the English literature delineating the incidence of adhesive SBO and reporting risk factors for the development of this morbidity. RESULTS A total of 446,331 abdominal operations were eligible for inclusion in this analysis. The overall incidence of SBO was 4.6%. The risk of SBO was highly influenced by the type of procedure, with ileal pouch-anal anastomosis being associated with the highest incidence of SBO (1,018 out of 5,268 cases or 19.3%), followed by open colectomy (11,491 out of 121,085 cases or 9.5%). Gynecological procedures were associated with an overall incidence of 11.1% (4,297 out of 38,751 cases) and ranged from 23.9% in open adnexal surgery, to 0.1% after cesarean section. The technique of the procedure (open vs. laparoscopic) also played a major role in the development of adhesive SBO. The incidence was 7.1% in open cholecystectomies vs. 0.2% in laparoscopic; 15.6% in open total abdominal hysterectomies vs. 0.0% in laparoscopic; and 23.9% in open adnexal operations vs. 0.0% in laparoscopic. There was no difference in SBO following laparoscopic or open appendectomies (1.4% vs. 1.3%). Separate closure of the peritoneum, spillage and retention of gallstones during cholecystectomy, and the use of starched gloves all increase the risk for adhesion formation. There is not enough evidence regarding the role of age, gender, and presence of cancer in adhesion formation. CONCLUSION Adhesion-related morbidity comprises a significant burden on healthcare resources and prevention is of major importance, especially in high-risk patients. Preventive techniques and special barriers should be considered in high-risk cases.
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Affiliation(s)
- Galinos Barmparas
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Los Angeles County Medical Center-University of Southern California, 1200 North State Street, Inpatient Tower (C)-Room C5L100, Los Angeles, CA 90033, USA
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Rink AD, Radinski I, Vestweber KH. Does mesorectal preservation protect the ileoanal anastomosis after restorative proctocolectomy? J Gastrointest Surg 2009; 13:120-8. [PMID: 18766412 DOI: 10.1007/s11605-008-0665-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2008] [Accepted: 08/08/2008] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND AIMS The technique of rectal dissection during restorative proctocolectomy might influence the rate of septic complications. The aim of this study was to analyze the morbidity of restorative proctocolectomy in a consecutive series of patients who had rectal dissection with complete preservation of the mesorectum. PATIENTS AND METHODS One hundred thirty-one patients who had restorative proctocolectomy for chronic inflammatory bowel disease with handsewn ileopouch-anal anastomosis (IPAA) and preservation of the mesorectal tissue were analyzed by chart reviews and a follow-up investigation at a median of 85 (14-169) months after surgery. RESULTS Only one of 131 patients had a leak from the IPAA, and one patient had a pelvic abscess without evidence of leakage, resulting in 1.5% local septic complications. All other complications including the pouch failure rate (7.6%) and the incidence of both fistula (6.4%) and pouchitis (47.9%) were comparable to the data from the literature. CONCLUSION The low incidence of local septic complications in this series might at least in part result from the preservation of the mesorectum. As most studies do not specify the technique of rectal dissection, this theory cannot be verified by an analysis of the literature and needs further approval by a randomized trial.
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Affiliation(s)
- Andreas D Rink
- Deparment of Surgery, Leverkusen General Hospital, Am Gesundheitspark 11, 51375, Leverkusen, Germany.
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12
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Adhesions are common and costly after open pouch surgery. J Gastrointest Surg 2008; 12:1239-45. [PMID: 18278539 DOI: 10.1007/s11605-008-0481-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2007] [Accepted: 01/16/2008] [Indexed: 01/31/2023]
Abstract
PURPOSE Open ileal pouch surgery leads to high rates of adhesive small-bowel obstruction (SBO). A laparoscopic approach may reduce these complications. We aimed to review the incidence of adhesive SBO-related complications after open pouch surgery and to model the potential financial impact of a laparoscopic approach purely as an adhesion prevention strategy. MATERIALS AND METHODS We reviewed cases of open ileal pouch patients kept on a database and examined annually. Case notes were studied for episodes of adhesive SBO requiring admission or reoperation. Similar parameters were studied in a small series undergoing laparoscopic pouch surgery. The financial burden of the open access complications was estimated and potential financial impact of a laparoscopic approach modeled. RESULTS Two hundred seventy-six patients were followed up after open surgery (median, 6.3; range, 0.2-20.1 years). There were 76 (28%) readmissions (median length of stay, 7.4 days) in 53 patients (19%) and 28 (10%) reoperations (43% within 1 year). Laparoscopic patients required less adhesiolysis at second-stage surgery (0% vs 36%, p < 0.0001) and had less SBO episodes within 12 months of surgery (0% vs 14%, p < 0.0001) than open patients. Modeling a laparoscopic approach cost $1,450 and saved $3,282, thus netting $1,832 per pouch constructed. CONCLUSION Open ileal pouch surgery results in significant cumulative long-term access-related complications, particularly adhesions. These impose a large medical burden on patients and financial burden on health-care systems, all of which may be recouped by a laparoscopic approach, despite higher theater costs.
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Kaplan GG, McCarthy EP, Ayanian JZ, Korzenik J, Hodin R, Sands BE. Impact of hospital volume on postoperative morbidity and mortality following a colectomy for ulcerative colitis. Gastroenterology 2008; 134:680-7. [PMID: 18242604 DOI: 10.1053/j.gastro.2008.01.004] [Citation(s) in RCA: 229] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2007] [Accepted: 12/13/2007] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Postoperative morbidity and mortality following a colectomy for ulcerative colitis (UC) has been primarily reported from tertiary care referral centers that perform a high volume of operations; however, the postoperative outcomes among nonselected hospitals are not known. We set out to evaluate postoperative morbidity and mortality using a nationally representative database and to determine the factors that influenced outcomes. METHODS We analyzed the 1995-2005 Nationwide Inpatient Sample to identify 7108 discharges for UC patients who underwent a total abdominal colectomy. The effects of hospital volume on postoperative morbidity and mortality were evaluated in logistic regression models adjusting for demographic and clinical factors. RESULTS Postoperative mortality and morbidity rates were 2.3% and 30.8%, respectively. Most operations were performed in low-volume hospitals that had an increased risk of death (adjusted odds ratio [aOR], 2.42; 95% confidence interval [CI]: 1.26-4.63). In-hospital mortality was increased in patients who were admitted emergently (aOR, 5.40; 95% CI: 3.48-8.40), aged 60-80 years (aOR, 8.70; 95% CI: 3.30-22.92), and those with Medicaid (aOR, 4.29; 95% CI: 2.13-8.66). Emergently admitted UC patients whose surgery was performed 6 days after their admission had significantly increased likelihood of in-hospital death (aOR, 2.12; 95% CI: 1.13-3.97). CONCLUSIONS Postoperative mortality was lowest in hospitals that performed the highest volume of operations. Increasing the proportion of total colectomies performed in high-volume hospitals may improve clinical outcomes for patients with UC.
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Affiliation(s)
- Gilaad G Kaplan
- Inflammatory Bowel Disease Clinic, University of Calgary, Calgary, Alberta, Canada.
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Aberg H, Påhlman L, Karlbom U. Small-bowel obstruction after restorative proctocolectomy in patients with ulcerative colitis. Int J Colorectal Dis 2007; 22:637-42. [PMID: 17103178 DOI: 10.1007/s00384-006-0215-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2006] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS The reported risk of small-bowel obstruction (SBO) after major abdominal surgery varies. The aim of this study was to study frequency and risk factors of SBO after ileal pouch-anal anastomosis for ulcerative colitis. METHODS Review of the medical records of 188 patients operated with restorative proctocolectomy between 1985 and 1997. All admissions to the hospital were registered and symptoms and X-ray findings consistent with ileus were analysed in relation to preoperative and operative data. RESULTS SBO was the dominating cause of hospitalization. Forty-eight patients (25.5%) had developed SBO after a median of 76 (range 6-196) months of follow-up, of whom 26 were operated on. The cause of obstruction was adhesion in all but one patient. Early obstruction events were common and accounted for 27% of all operations. Twenty-five of 26 patients who were operated on had a diverting loop-ileostomy compared to 111/162 in the not-operated-on group (p < 0.01). In total, 696 days were spent at the hospital because of SBO. CONCLUSION SBO is common following pouch surgery and is the dominating cause of hospitalization postoperatively. About 25% of patients developed SBO and half of them needed surgery. The use of a diverting loop-ileostomy was related to an increased risk of surgery for SBO.
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Affiliation(s)
- Hanna Aberg
- Department of Surgical Sciences, Section of Surgery, University Hospital, 751 85, Uppsala, Sweden
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15
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Abstract
OBJECTIVE The aim of this project was to establish and maintain an internet-based database of all ileal pouch procedures performed in major centres in Australasia. METHOD The initial three colorectal units contributing data are Auckland, northern Brisbane and Central Sydney Area Health Service. A web-based database was designed. The data collection method was tested on a subgroup of 20 patients to ensure functionality. Data were collected in five main categories: patient demographics, preoperative data, operative details, postoperative complications and functional results. RESULTS Initial data are presented for 516 patients [363 J, (70%), 133 W (26%), 16 S pouches (3%)]. There were two deaths within 30 days (0.4%). The anastomotic leak rate overall, in handsewn (HSA) and stapled anastomoses (SA) respectively was 5.0%, 8.5% and 3.3% (P=0.02 for difference HSA vs SA). Incidence of pouchitis was 20% (ulcerative colitis 23%, Crohn's disease 20%, indeterminate colitis 22%, familial adenomatous polyposis 9%). Incidence of anal stricture requiring intervention (11% overall) was significantly greater in HSAs than in SAs (16%vs 9%, P=0.02). Incidence of small bowel obstruction at any time postoperatively was 16%. Functional data were available for 234 patients. The median frequency of bowel actions during waking hours was significantly less in W pouches than in J pouches (four vs five, P=0.0005). CONCLUSION A national web-based database has been developed for access by all Australasian colorectal units. Initial Australasian data compare favourably with other international studies. Pouchitis continues to be a long-term problem. The leak rate and rate of late anal stricture requiring a procedure are higher if the anastomosis is handsewn rather than stapled. Functional results are better with the W pouch than with the J pouch.
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Lichtenstein GR, Cohen R, Yamashita B, Diamond RH. Quality of life after proctocolectomy with ileoanal anastomosis for patients with ulcerative colitis. J Clin Gastroenterol 2006; 40:669-77. [PMID: 16940876 DOI: 10.1097/00004836-200609000-00002] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Ulcerative colitis, a chronic inflammatory disease of the rectal and colonic mucosa, affects approximately 250,000 to 500,000 people in the United States, with 30% to 40% of patients requiring some form of surgical intervention during the course of their disease. The predominant reason for total proctocolectomy is for symptoms refractory to currently available medical therapy. Less common reasons are dysplasia or cancer. The goal of colectomy is to prevent recurrence of systemic inflammatory disease. Consequently, surgery with total proctocolectomy and creation of an ileal J-pouch-anal anastomosis has become the procedure of choice for many patients without other therapeutic options. Health-related quality of life (QOL) in patients with severe ulcerative colitis is so poor that, after ileal J-pouch-anal anastomosis, QOL is considered to improve in most clinical studies (8 studies, improved QOL; 1 study, no change; 1 study, QOL worse than general population). However, QOL and bowel function after such surgery cannot be considered "normal" in all patients, because a substantial number still have problems with urgency, leakage, nocturnal soiling, sexual dysfunction, and pouchitis, and some require conversion to a permanent ileostomy after ileal J-pouch-anal anastomosis failure. Thus, despite the availability of ileal J-pouch-anal anastomosis, surgery does not always restore all aspects of QOL to normal.
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Affiliation(s)
- Gary R Lichtenstein
- Center for Inflammatory Bowel Disease, University of Pennsylvania Health System, Philadelphia, PA, USA.
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17
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Abstract
BACKGROUND Fistula between an ileal pouch and the vagina is an uncommon complication of ileal pouch-anal anastomosis. Its optimal management has not been determined because of its low incidence. METHODS The literature describing such fistulas was reviewed to determine the incidence, cause, and appropriate investigation and repair of these lesions. A literature search was performed with the PubMed, MEDLINE, and EMBASE databases. Through this search we located English-language articles from 1970 to 2003 on pouch-vaginal fistulas following ileal pouch-anal anastomosis. References from these articles were searched manually for further references. RESULTS AND CONCLUSION Pouch-vaginal fistula occurs in 6.3 (range, 3.3-15.8) percent of female patients with an ileal pouch-anal anastomosis. Sepsis and technical factors are the most common contributors. It is the cause of considerable morbidity. Management depends on the level of the fistula, the amount of pelvic scar tissue, and previous treatments. An algorithm for surgical treatment is suggested.
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Affiliation(s)
- S Lolohea
- Colorectal Unit, Department of Surgery, Christchurch Hospital, New Zealand
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18
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McGrath DR, Spigelman AD. In the beginning there was colectomy: current surgical options in familial adenomatous polyposis. Hered Cancer Clin Pract 2004; 2:153-60. [PMID: 20233459 PMCID: PMC2840002 DOI: 10.1186/1897-4287-2-4-153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2004] [Accepted: 11/15/2004] [Indexed: 12/11/2022] Open
Abstract
Multiple colonic polyps, almost guaranteed colorectal cancer by the age of forty-five and an increased risk of non-colonic cancers characterise the autosomal dominant condition Familial Adenomatous Polyposis (FAP) [1]. The patients and families faced with such a diagnosis present many difficult management challenges, both surgical and non-surgical. We discuss the current surgical options for treatment of the more significant manifestations of FAP arising in the colorectum and duodenum as well as desmoid disease
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Affiliation(s)
- Daniel R McGrath
- Discipline of Surgical Science, University of Newcastle, Australia.
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Pace DE, Seshadri PA, Chiasson PM, Poulin EC, Schlachta CM, Mamazza J. Early experience with laparoscopic ileal pouch-anal anastomosis for ulcerative colitis. Surg Laparosc Endosc Percutan Tech 2002; 12:337-41. [PMID: 12409700 DOI: 10.1097/00129689-200210000-00006] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The purpose of this study was to describe our minimally invasive technique and outline perioperative and medium-term outcomes in patients undergoing laparoscopic ileal pouch-anal anastomosis (LIPAA) for ulcerative colitis. Data were obtained from a prospectively collected database of 13 LIPPA procedures performed for ulcerative colitis between May 1994 and November 2000. Medium-term quality-of-life follow-up was obtained by telephone interview. Eight males and five females had an LIPAA performed, all of whom had previously undergone total abdominal colectomy with ileostomy. Median operative time was 255 minutes (range, 200-398 minutes) with one conversion (8%) due to adhesions. There were no deaths or intraoperative complications; however, six patients experienced seven postoperative complications within 30 days of final closure of defunctioning ileostomy (two leaks, two wound infections, one pulmonary embolus, and two reoperations for small bowel obstruction). Median length of stay was 7 days (range, 5-13 days). Median follow-up was 24 months (range, 6-66 months). The median number of day and night bowel movements was 6.0 (range, 3-10) and 1.0 (range, 0-3), respectively, with five patients requiring medication to control frequency. None had incontinence of stool or retrograde ejaculation; however, one had occasional incontinence of gas, three had occasional nocturnal soiling, and one was impotent. Three patients (23%) had pouchitis, all treated successfully with oral antibiotics. All patients were satisfied with the outcome of their operation and all preferred their pouch to previous ileostomy. Patients reported their overall social, emotional, and physical well being to be satisfactory to excellent. Results of the SF-36, a generic quality-of-life survey, were similar to those from studies of patients following an open pelvic pouch procedure. The LIPAA is technically feasible in experienced centers. We believe that the technique is still evolving and that more time and experience is required to refine the procedure.
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Affiliation(s)
- D E Pace
- The Center for Minimally Invasive Surgery, St. Michael's Hospital, University of Toronto, Ontario, Canada
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MacLean AR, O'Connor B, Parkes R, Cohen Z, McLeod RS. Reconstructive surgery for failed ileal pouch-anal anastomosis: a viable surgical option with acceptable results. Dis Colon Rectum 2002; 45:880-6. [PMID: 12130874 DOI: 10.1007/s10350-004-6321-y] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Salvage procedures for failed ileal pouch-anal anastomoses frequently require total reconstruction with a combined abdominal and perineal approach. The aim of this study was to determine the indications for surgery and the outcomes in this group of patients. METHODS All patients who underwent combined abdominal and perineal ileal pouch-anal anastomosis reconstruction at the Mount Sinai Hospital between 1982 and 2000 were reviewed. Data were collected prospectively in the inflammatory bowel disease database. RESULTS Sixty-three reconstructive procedures were performed in 57 patients, with a mean age of 33.9 (+/-10.4) years at the time of reconstruction. There were 14 males. The mean follow-up was 69.1 months. The initial indication for ileal pouch-anal anastomosis was ulcerative colitis in 98 percent. The primary indication for reconstruction was pouch-vaginal fistula in 21 patients, long outlet in 14, pelvic sepsis in 14, ileoanal anastomotic stricture in 5, pouch-perineal fistula in 2, and chronic pouchitis in 1. The mean operative time was four hours (+/-1.1), the average blood loss was 500 mL (+/-400), and the average length of stay was 10.3 days (+/-4.6). All patients had a diverting ileostomy. Forty-two (73.6 percent) of the patients have a functioning pouch. Seven (12.3 percent) patients have had their pouch excised. The ileostomy has not yet been closed in 8 (14 percent) patients; 3 of these patients are awaiting closure, whereas the remaining 5 have a permanently defunctioning ileostomy. Eighty-nine percent have ten or fewer bowel movements per day. No patients are incontinent of stool during the day, whereas two patients are incontinent at night. Seventeen percent complain of frequent urgency. Despite this, more than 80 percent rate their physical and psychological health as good to excellent. CONCLUSION Reconstructive pouch surgery has a high success rate in experienced hands. The functional results in those whose pouch is in use are good.
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Affiliation(s)
- Anthony R MacLean
- Inflammatory Bowel Disease Research Unit, Department of Surgery, Department of Health, Health Policy, Management, and Evaluation, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
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MacLean AR, Cohen Z, MacRae HM, O'Connor BI, Mukraj D, Kennedy ED, Parkes R, McLeod RS. Risk of small bowel obstruction after the ileal pouch-anal anastomosis. Ann Surg 2002; 235:200-6. [PMID: 11807359 PMCID: PMC1422415 DOI: 10.1097/00000658-200202000-00007] [Citation(s) in RCA: 130] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To determine the incidence of small bowel obstruction (SBO), to identify risk factors for its development, and to determine the most common sites of adhesions causing SBO in patients undergoing ileal pouch-anal anastomosis (IPAA). METHODS All patients undergoing IPAA at Mount Sinai Hospital were included. Data were obtained from the institution's database, patient charts, and a mailed questionnaire. SBO was based on clinical, radiologic, and surgical findings. Early SBO was defined as a hospital stay greater than 10 or 14 days because of delayed bowel function, or need for reoperation or readmission for SBO within 30 days. All patients readmitted after 30 days with a discharge diagnosis of SBO were considered to have late SBO. RESULTS Between 1981 and 1999, 1,178 patients underwent IPAA (664 men, 514 women; mean age 40.7 years). A total of 351 episodes of SBO were documented in 272 (23%) patients during a mean follow-up of 8.7 years (mean 1.29 episodes/patient). Fifty-four patients had more than one SBO. One hundred fifty-four (44%) of the SBOs occurred in the first 30 days; 197 (56%) were late SBOs. The cumulative risk of SBO was 8.7% at 30 days, 18.1% at 1 year, 26.7% at 5 years, and 31.4% at 10 years. The need for surgery for SBO was 0.8% at 30 days, 2.7% at 1 year, 6.7% at 5 years, and 7.5% at 10 years. In patients requiring laparotomy, the obstruction was most commonly due to pelvic adhesions (32%), followed by adhesions at the ileostomy closure site (21%). A multivariate analysis showed that when only late SBOs were considered, performance of a diverting ileostomy and pouch reconstruction both led to a significantly higher risk of SBO. CONCLUSIONS The risk of SBO after IPAA is high, although most do not require surgical intervention. Thus, strategies that reduce the risk of adhesions are warranted in this group of patients to improve patient outcome and decrease healthcare costs.
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Affiliation(s)
- Anthony R MacLean
- IBD Research Unit, Department of Surgery, Mount Sinai Hospital and University of Toronto, Canada
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What Functional Outcomes and Complications Should be Taught to the Patient with Ulcerative Colitis or Familial Adenomatous Polyposis Who Undergoes Ileal Pouch Anal Anastomosis? J Wound Ostomy Continence Nurs 2001. [DOI: 10.1097/00152192-200107000-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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