Prospective assessment of Cleveland Global Quality of Life (CGQL) as a novel marker of quality of life and disease activity in Crohn's disease

ASSESSMENT OF QUALITY OF LIFE IN ELDERLY PATIENTS WITH INFLAMMATORY BOWEL DISEASE WITH MILD ACTIVITY AND IN CLINICAL REMISSION

BACKGROUND

Inflammatory bowel disease (IBD), represented by Crohn's disease (CD) and ulcerative colitis (UC), is a chronic condition that affects all age groups, predominantly in young individuals. Currently, an increase in the prevalence of IBD has been documented, in parallel with the increase in the elderly population. The scarce number of studies that better characterize the impact of IBD on Quality of Life (QoL) in the elderly motivated the present study.

OBJECTIVE

To evaluate the impact of IBD on the QoL of elderly people treated at a Tertiary IBD Center.

METHODS

Prospective cross-sectional study that included elderly patients (age ≥60 years) with quiescent or mildly active IBD treated at the HU-UFJF IBD Center between March 2019 and December 2022. Elderly companions without severe comorbidities who attended the consultation with the patients were included as a control group. Sociodemographic and IBD-related characteristics were recorded. QoL was assessed using previously validated questionnaires (WHOQOL-BREF and IBDQ). Patients with IBD with moderate to severe activity, history of recent or imminent hospitalization, serious or opportunistic infections in the last 6 months, previous neoplasia, dementia, and difficulty understanding/fulfilling the questionnaires were excluded.

RESULTS

A total of 123 patients were included (74 with IBD and 49 in the control group), with a mean age of 67±6.2 years, 52.7% with CD, and 47.3% with UC. Mild disease activity was observed in 31.1%. Both groups (IBD patients and control) were comparable based on age, sex, BMI, and the Charlson Comorbidity Index. Patients with IBD and controls had similar QoL scores in the different domains assessed by the WHOQOL-BREF. On the other hand, when evaluating the general facet of QoL, IBD patients had significantly lower scores in General QoL (3.71±0.87 versus 4.02±0.62, respectively; P=0.021) and General Health (3.32±1.05 versus 3.69±0.94, respectively; P=0.035). The presence of mildly active IBD negatively impacted the general health score (2.91±0.99 versus 3.47±1.04, respectively; P=0.035) and the physical domain of the WHOQOL-BREF (12.27±2.63 versus 13.86±2.61, respectively; P=0.019) when compared to patients in remission. Conversely, no impact on QoL was observed with the Application of the IBDQ questionnaire regarding the type of the disease (161±38.5 versus 163.1±42.6 for CD and UC, respectively; P=0.84) or the presence of activity (152.5±38.8 versus 166.4±40.5, respectively; P=0.17).

CONCLUSION

No statistically significant differences were found between elderly patients with mildly active or quiescent IBD and elderly patients without IBD when observing global QoL scores. However, IBD negatively impacted the general facet of QoL, just as mild activity was associated with lower scores in general health and the physical domain assessed by the WHOQOL-BREF. Patients with IBD treated with biological therapy had better Qol than those on conventional therapy. Future studies are needed to choose the most appropriate tool for assessing QoL in this population.

Redo IPAA for long rectal cuff syndrome after ileoanal pouch for inflammatory bowel disease

ABTRACT

BACKGROUND: When constructing an ileal pouch-anal anastomosis (IPAA), the rectal cuff should ideally be 1-2 cm long to avoid subsequent complications.

METHODS

We identified patients from our IBD center who underwent redo IPAA for a long rectal cuff. Long rectal cuff syndrome (LRCS) was defined as a symptomatic rectal cuff ≥ 4 cm.

RESULTS

Forty patients met the inclusion criteria: 42.5% female, median age at redo surgery 42.5 years. The presentation was ulcerative proctitis in 77.5% of the cases and outlet obstruction in 22.5%. The index pouch was laparoscopically performed in 18 patients (45%). The median rectal cuff length was 6 cm. The pouch was repaired in 16 (40%) cases, whereas 24 (60%) required the creation of a neo-pouch. At the final pathology, the rectal cuff showed chronic active colitis in 38 (90%) cases. After a median follow-up of 34.5 (IQR 12-109) months, pouch failure occurred in 9 (22.5%) cases. The pouch survival rate was 78% at 3 years. Data on the quality of life were available for 11 (27.5%) patients at a median of 75 months after redo surgery. The median QoL score (0-1) was 0.7 (0.4-0.9).

CONCLUSION

LRCS, a potentially avoidable complication, presents uniformly with symptoms of ulcerative proctitis or stricture. Redo IPAA was restorative for the majority.

Patient-reported Outcome Measures in Ileoanal Pouch Surgery: a Systematic Review

OBJECTIVE

To summarise frequency, type, and heterogeneity of patient-reported outcomes measures [PROMs] in papers reporting on outcomes after ileal pouch anal anastomosis [IPAA].

BACKGROUND

Prevalence of ulcerative colitis [UC] has risen in Western countries, and one in three patients requires surgery. IPAA is a frequently performed procedure for UC, and a lack of standardisation is manifest in reporting outcomes for inflammatory bowel disease [IBD] despite the clear need for inclusion of PROMs as primary outcomes in IBD trials.

METHODS

Scopus, Pubmed, and Web of Science databases were searched from January 2010 to January 2023 for studies investigating outcomes in IPAA surgery. The primary outcome was the proportion of studies reporting outcomes for IPAA surgery for UC, which included PROMs.

RESULTS

The search identified a total of 8028 studies which, after de-duplication and exclusion, were reduced to 79 articles assessing outcomes after IPAA surgery. In all 44 [55.7%] reported PROMs, with 23 including validated questionnaires and 21 papers using authors' questions, 22 different PROMs were identified, with bowel function as the most investigated item. The majority of studies [67/79, 85%] were retrospective, only 14/79 [18%] were prospective papers and only two were [2.5%] randomised, controlled trials.

CONCLUSIONS

Only half of the papers reviewed used PROMs. The main reported item is bowel function and urogenital, social, and psychological functions are the most neglected. There is lack of standardisation for use of PROMs in IPAA. Complexity of UC and of outcomes after IPAA demands a change in clinical practice and follow-up, given how crucial PROMs are, compared with their non-routine use.

Redo ileal pouch-anal anastomosis for early versus late sepsis-related pouch failure

BACKGROUND

Pouch failure after restorative proctocolectomy with ileal pouch-anal anastomosis occurs in 5% to 15% of cases, mostly due to septic complications. We aimed to determine if the timing of pouch failure impacted long-term outcomes for redo ileal pouch-anal anastomosis after sepsis-related complications.

METHOD

We retrospectively analyzed our prospectively collected institutional pouch database. Patients who underwent redo ileal pouch-anal anastomosis for septic complications between 1988 and 2020 were divided into an early (pouch failure within 6 months of stoma closure after index operation, or stoma never closed) and a late failure group (pouch failure after 6 months of stoma closure). The primary endpoint was pouch survival.

RESULTS

In total, 335 patients were included: 241 (72%) in the early and 94 (28%) in the late failure group. The most common indication for failure was an anastomotic leak in the early failure group (163, 68%) and fistula in the late failure group (59, 63%), P < .001. Pouch survival at 3, 5, and 10 years was 77%, 75%, and 72% for the early and 79%, 75%, and 68% for the late failure group (P = .94). The most common reason for redo pouch failure was fistula in both groups. Quality of life was similar in both groups. In multivariate analysis, the only factor associated with pouch failure was the final diagnosis of Crohn's disease.

CONCLUSION

Outcomes after redo ileal pouch-anal anastomosis were comparable between patients with early and late sepsis-related index pouch failure, with acceptable rates of long-term pouch survival and good quality of life.

Long-term Outcomes of Straight Ileoanal Anastomoses Converted to Ileal Pouch Anal Anastomoses

BACKGROUND

While ileal pouch anal anastomosis (IPAA) is the recommended way to restore intestinal continuity after total proctocolectomy, straight ileoanal anastomoses (SIAA) are still selectively performed, especially in the pediatric population. In case of SIAA failure, conversion to IPAA is possible, but reports on its outcomes are scarce.

METHODS

We retrospectively analyzed our prospectively collected database on pelvic pouches, and identified patients with a SIAA that was converted to IPAA. Our aim was long-term functional outcomes.

RESULTS

Twenty-three patients were included (14 females, median age at SIAA 15 years, median age at conversion to IPAA 19 years). The indication for SIAA was ulcerative colitis in 17 (74%) cases, indeterminate colitis in 2 (9%) cases, and familial adenomatous polyposis in 4 (17%) cases. The indication for IPAA conversion was incontinence/poor quality of life in 12 (52%) cases, sepsis in 8 (35%) cases, anastomotic stricture in 2 (9%) cases, and prolapse in one (4%) case. The majority were diverted at IPAA conversion (22, 96%). Three (13%) patients never had stoma closure, due to patient wishes, failed healing of vaginal fistula, and pelvic sepsis, respectively. After a median follow up of 109 months (28-170), pouch failure occurred in 5 additional patients. Overall pouch survival was 71% at 5 years. Median quality of life was 8/10, of health 8/10, and of energy 7/10. Median satisfaction with surgery was 9.5/10.

CONCLUSION

Conversion of SIAA to IPAA leads to acceptable long-term outcomes and good quality of life, and can safely be offered to patients with problems related to SIAA.

LEVEL OF EVIDENCE

IV.

Patient-Reported Outcomes in Colorectal Surgery

Given the increased life expectancy and improvements in the treatment of colorectal patients, the success of a treatment course can no longer be determined only by objective outcomes. Health care providers ought to take into consideration the impact an intervention will have on the quality of life of patients. Endpoints that take into account the patient's perspective are defined as patient-reported outcomes (PROs). PROs are assessed through patient-reported outcome measures (PROMs), usually in the form of questionnaires. PROs are especially important in colorectal surgery, whose procedures can often be associated with some degree of postoperative functional impairment. Several PROMs are available for colorectal surgery patients. However, while some scientific societies have offered recommendations, there is no standardization in the field and PROMs are seldom implemented in clinical practice. The routine use of validated PROMs can guarantee that functional outcomes are followed over time; this way, they can be addressed in case of worsening. This review will provide an overview of the most commonly used PROMs in colorectal surgery, both generic and disease specific, as well as a summary of the available evidence in support of their routine utilization.

Long-term outcomes after close rectal dissection and total mesorectal excision in ileal pouch-anal anastomosis for ulcerative colitis

BACKGROUND

During ileal pouch-anal anastomosis (IPAA) surgery for ulcerative colitis (UC), rectal dissection can be performed via close rectal dissection (CRD) or in a total mesorectal excision plane (TME). Although CRD should protect autonomic nerve function, this technique may be more challenging than TME. The aim of this study was to compare long-term outcomes of patients undergoing CRD and TME.

METHODS

This single-centre retrospective cohort study included consecutive patients who underwent IPAA surgery for UC between January 2002 and October 2017. Primary outcomes were chronic pouch failure (PF) among patients who underwent CRD and TME and the association between CRD and developing chronic PF. Chronic PF was defined as a pouch-related complication occurring ≥ 3 months after primary IPAA surgery requiring redo pouch surgery, pouch excision or permanent defunctioning ileostomy. Secondary outcomes were risk factors and causes for chronic PF. Pouch function and quality of life were assessed via the Pouch dysfunction score and Cleveland global quality of life score.

RESULTS

Out of 289 patients (155 males, median age 37 years [interquartile range 26.5-45.5 years]), 128 underwent CRD. There was a shorter median postoperative follow-up for CRD patients than for TME patients (3.7 vs 10.9 years, p < 0.01). Chronic PF occurred in 6 (4.7%) CRD patients and 20 (12.4%) TME patients. The failure-free pouch survival rate 3 years after IPAA surgery was comparable among CRD and TME patients (96.1% vs. 93.5%, p = 0.5). CRD was a no predictor for developing chronic PF on univariate analyses (HR 0.7 CI-95 0.3-2.0, p = 0.54). A lower proportion of CRD patients developed chronic PF due to a septic cause (1% vs 6%, p = 0.03).

CONCLUSIONS

Although differences in chronic PF among CRD and TME patients were not observed, a trend toward TME patients developing chronic pelvic sepsis was detected. Surgeons may consider performing CRD during IPAA surgery for UC.

Quality of Life in Inflammatory Bowel Diseases (IBDs) Patients after Surgery

Inflammatory Bowel Diseases (IBDs) are chronic, relapsing and disabling diseases that affect the gastrointestinal tract. This relapsing course is often unpredictable with severe flares and the need for intensive medical treatment, hospitalization, or emergent/urgent surgery, all of which significantly impact patients' quality of life (QoL). QoL in IBD patients is significantly lower than in the general population, and depression and anxiety have been shown to have a higher prevalence than in healthy individuals, especially during disease flares. Complications requiring hospitalization and repeated surgeries are not uncommon during the disease course and significantly affect QoL in IBD patients. Patient-reported outcome measures (PROMs) can be used to measure the impact of chronic disease on QoL from the patient's perspective. The use of PROMs in IBD patients undergoing surgery could help to investigate the impact of the surgical procedure on QoL and determine whether there is any improvement or worsening. This review summarizes the use of PROMs to assess QoL after various surgical procedures required for IBD treatment.

Patient-Reported Outcomes Measures in Perianal Fistulizing Crohn's Disease

Perianal fistulizing Crohn's disease (PFCD) is a disabling complication of Crohn's disease (CD) that can significantly impact on patients' quality of life (QoL) and often requires multidisciplinary care. Clinical trials assessing the efficacy of medical and surgical interventions for fistulas usually evaluate outcomes such as closure of fistula tracts or radiologic healing. However, these traditional outcome assessments fail in capturing the impact of the disease from patients' perspectives. In this context, regulatory authorities have increasingly encouraged the inclusion of validated patient-reported outcomes (PRO) that assess disease activity and reveal how a patient functions and feels. This recent trend towards patient-centered care aims to ensure that improvements in efficacy outcomes are accompanied by meaningful benefits to patients. The aim of this review is to discuss currently available PRO measures (PROMS) for the assessment of PFCD to provide to physicians appropriate tools aiming to optimize patient care and disseminate the use of these instruments in clinical practice.

Nurse-led surveillance of ileoanal pouch patients post-stoma reversal: outcomes at 12-month review

Restorative proctocolectomy with pouch anal anastomosis is the accepted treatment for suitable patients with ulcerative colitis, yet surveillance following stoma reversal remains contentious and involves several issues. While most patients are discharged from routine follow-up between 6 weeks and 3 months, some remain on surveillance pathways indefinitely. A high volume of patients require advice for many months or years after the stoma has been reversed, with the burden of surveillance on consultant-led clinics. Nurse-led follow-up after restorative proctocolectomy has been recognised for decades but has not been validated. This study reports the first protocol-based pathway for nurse-led follow-up. Using validated questionnaires, suitable pouch patients were followed up in nurse-led clinics over a 12-month period then sent an online survey to report on the service they received. Overall, most patients were satisfied with the nurse-led follow-up; however, further engagement and investment in the workforce and infrastructure is required to offer sustainable services.

Patient-Reported Outcomes in Inflammatory Bowel Disease: A Measurement of Effect in Research and Clinical Care

The measurement of outcomes is key in evaluating healthcare or research interventions in inflammatory bowel disease (IBD). In patient-centred care, patient-reported outcome measures (PROMs) are central to this evaluation. In this review, we provide an overview of validated, adult disease-specific PROMs developed for use in IBD. Our aim is to assist clinicians and researchers in selection of PROMs to measure outcomes in their patient cohort. The Consensus-based Standards for the Selection of Health Measurement Instruments database of systematic reviews was the primary resource used to identify PROMs used in IBD. Search terms were ‘Crohn’s disease’, ‘ulcerative colitis’, and ‘IBD’. Seven systematic reviews were identified from this search. In addition, the publication by the IBD Core Outcome Set Working Group was used to identify further PROMs. Three systematic reviews were excluded as they did not meet the inclusion criteria. From the five included systematic reviews, we identified 21 PROMs and their shortened versions. In conclusion, it does not appear that any one PROM is entirely suitable for both research and clinical practice. Overall, the IBDQ-32 is most widely used in research but has the limitation of cost, whereas the IBD-Control has been recommended in the clinical core outcome set.

Laparoscopic Lavage vs Primary Resection for Acute Perforated Diverticulitis: Long-term Outcomes From the Scandinavian Diverticulitis (SCANDIV) Randomized Clinical Trial

Importance

Perforated colonic diverticulitis usually requires surgical resection, with significant morbidity. Short-term results from randomized clinical trials have indicated that laparoscopic lavage is a feasible alternative to resection. However, it appears that no long-term results are available.

Objective

To compare long-term (5-year) outcomes of laparoscopic peritoneal lavage and primary resection as treatments of perforated purulent diverticulitis.

Design, Setting, and Participants

This international multicenter randomized clinical trial was conducted in 21 hospitals in Sweden and Norway, which enrolled patients between February 2010 and June 2014. Long-term follow-up was conducted between March 2018 and November 2019. Patients with symptoms of left-sided acute perforated diverticulitis, indicating urgent surgical need and computed tomography-verified free air, were eligible. Those available for trial intervention (Hinchey stages <IV) were included in the long-term follow-up.

Interventions

Patients were assigned to undergo laparoscopic peritoneal lavage or colon resection based on computer-generated, center-stratified block randomization.

Main Outcomes and Measures

The primary outcome was severe complications within 5 years. Secondary outcomes included mortality, secondary operations, recurrences, stomas, functional outcomes, and quality of life.

Results

Of 199 randomized patients, 101 were assigned to undergo laparoscopic peritoneal lavage and 98 were assigned to colon resection. At the time of surgery, perforated purulent diverticulitis was confirmed in 145 patients randomized to lavage (n = 74) and resection (n = 71). The median follow-up was 59 (interquartile range, 51-78; full range, 0-110) months, and 3 patients were lost to follow-up, leaving a final analysis of 73 patients who had had laparoscopic lavage (mean [SD] age, 66.4 [13] years; 39 men [53%]) and 69 who had received a resection (mean [SD] age, 63.5 [14] years; 36 men [52%]). Severe complications occurred in 36% (n = 26) in the laparoscopic lavage group and 35% (n = 24) in the resection group (P = .92). Overall mortality was 32% (n = 23) in the laparoscopic lavage group and 25% (n = 17) in the resection group (P = .36). The stoma prevalence was 8% (n = 4) in the laparoscopic lavage group vs 33% (n = 17; P = .002) in the resection group among patients who remained alive, and secondary operations, including stoma reversal, were performed in 36% (n = 26) vs 35% (n = 24; P = .92), respectively. Recurrence of diverticulitis was higher following laparoscopic lavage (21% [n = 15] vs 4% [n = 3]; P = .004). In the laparoscopic lavage group, 30% (n = 21) underwent a sigmoid resection. There were no significant differences in the EuroQoL-5D questionnaire or Cleveland Global Quality of Life scores between the groups.

Conclusions and Relevance

Long-term follow-up showed no differences in severe complications. Recurrence of diverticulitis after laparoscopic lavage was more common, often leading to sigmoid resection. This must be weighed against the lower stoma prevalence in this group. Shared decision-making considering both short-term and long-term consequences is encouraged.

Trial Registration

ClinicalTrials.gov Identifier: NCT01047462.

Ligation of intersphincteric fistula tract (LIFT) with or without injection of platelet-rich plasma (PRP) in management of high trans-sphincteric fistula-in-ano: Short-term outcomes of a prospective, randomized trial

BACKGROUND

Success rate after ligation of the inter-sphincteric fistula tract ranges from 40% to 75%. Platelet-rich plasma is hypothesized to improve healing by slowly releasing growth factors. The objective of the study was to compare the efficacy and outcome of ligation of the inter-sphincteric fistula tract plus platelet-rich plasma local injection versus ligation of the inter-sphincteric fistula tract alone in the management of high trans-sphincteric anal fistula in regards to postoperative pain, time for healing, morbidity, fistula closure rate, recurrence, and quality of life.

METHODS

This was a prospective randomized trial. Patients with trans-sphincteric anal fistulas involving >50% of anal sphincters were included. Patients were randomly assigned to either ligation of the inter-sphincteric fistula tract plus platelet-rich plasma or ligation of the inter-sphincteric fistula tract (49 in each group). The primary endpoints were successful complete fistula closure and duration needed for healing. Secondary endpoints were morbidity, recurrence after 1 year of follow-up, postoperative pain, and quality of life.

RESULTS

Complete primary healing was recorded in 42 patients in the ligation of the inter-sphincteric fistula tract plus platelet-rich plasma group and 32 patients in the ligation of the inter-sphincteric fistula tract group, and the difference was statistically significant (P = .03). The mean time to complete healing after ligation of the inter-sphincteric fistula tract plus platelet-rich plasma was significantly shorter than after ligation of the inter-sphincteric fistula tract alone (15.7 ± 4 days vs 21.6 ± 5.4 days; P = .03). One year after complete healing of anal fistula, recurrence was recorded in 4/42 patients in the ligation of the inter-sphincteric fistula tract plus platelet-rich plasma group and 3/32 patients in the ligation of the inter-sphincteric fistula tract group with no statistically significant difference (P = .99). Patients in the ligation of the inter-sphincteric fistula tract plus platelet-rich plasma group had significantly lower pain scores after both 1 and 7 days. Quality of life and level of happiness were significantly better 1 month after ligation of the inter-sphincteric fistula tract plus platelet-rich plasma.

CONCLUSION

Ligation of the inter-sphincteric fistula tract plus platelet-rich plasma for the treatment of high trans-sphincteric fistula-in-ano is a safe modality with significantly higher successful healing rate, shorter healing time, and less postoperative pain compared with ligation of the inter-sphincteric fistula tract alone. Ligation of the inter-sphincteric fistula tract plus platelet-rich plasma does not improve the rate of recurrence; however, it results in significantly higher short-term quality of life.

Redo IPAA After a Failed Pouch In Patients With Crohn's Disease: Is It Worth Trying?

BACKGROUND

In selected patients with ulcerative colitis and pelvic pouch failure, redo pouch is an option. However, it is unknown whether selected patients with Crohn's disease should be offered a chance to avoid permanent diversion after failure of IPAA.

OBJECTIVE

The objective was to compare the outcomes of redo pouch for ulcerative colitis and Crohn's disease.

DESIGN

This was a retrospective analysis of a prospectively maintained pouch database (1983-2017).

SETTINGS

The setting was the Cleveland Clinic.

PATIENTS

This study included patients who underwent redo pouch with a primary surgical specimen diagnosis of ulcerative or Crohn's colitis at the time of initial pouch.

MAIN OUTCOME MEASURES

Pouch failure was defined as either pouch excision or indefinite pouch diversion. Patient characteristics, perioperative and functional outcomes, pouch survival, and quality of life were compared according to the diagnosis.

RESULTS

Of 422 patients, 392 had ulcerative colitis and 30 had Crohn's disease. Age and sex were comparable. The most common indications for redo pouch included anastomotic separation and fistulas (220 (56.1%) in ulcerative colitis and 21 (70%) in Crohn's disease). The majority of redo pouches required mucosectomy with handsewn anastomosis (310 (79%) in ulcerative colitis and 30 (100%) in Crohn's disease; p = 0.23). A new pouch was constructed in 160 patients (41%) with ulcerative colitis and repair of old pouch in 231 patients (59%) compared with 25 (83%) in Crohn's disease, who had creation of new pouch; only in 5 (17%) was the old pouch re-anastomosed. Stool frequency, seepage, and fecal urgency were comparable between groups. Cumulative 5-year pouch survival was longer in ulcerative colitis versus Crohn's disease (88% vs 55%; p = 0.008). Major causes of redo failure in Crohn's disease were pouch fistulas and/or strictures occurring after ileostomy closure. These were more common in Crohn's disease than in ulcerative colitis (p < 0.001).

LIMITATIONS

This was a retrospective design.

CONCLUSIONS

Redo pouch can be offered to selected patients with colonic Crohn's disease diagnosed at the time of their primary pouch. See Video Abstract at http://links.lww.com/DCR/B206. REHACER LA ANASTOMOSIS ILEOANAL CON RESERVORIO DESPUéS DE UN RESERVORIO ILEAL FALLIDO EN PACIENTES CON ENFERMEDAD DE CROHN: ¿VALE LA PENA INTENTARLO?: En pacientes seleccionados con colitis ulcerativa y falla del reservorio pélvico, rehacer el reservorio es una opción. Sin embargo, se desconoce si en los pacientes seleccionados con enfermedad de Crohn se debería ofrecer la oportunidad de evitar la derivación permanente después de la falla de la anastomosis ileoanal con reservorio ileal.El objetivo fue comparar los resultados de reservorios re-hechos en colitis ulcerosa y la enfermedad de Crohn.El escenario fue la Cleveland Clinic.Análisis retrospectivo de una base de datos de reservorios ileales mantenida prospectivamente (1983-2017).Este estudio incluyó a pacientes que se sometieron a cirugía para rehacer el reservorio ileal con un diagnóstico en el espécimen quirúrgico primario de colitis ulcerosa o de Crohn en el momento del reservorio inicial.La falla del reservorio se definió como la escisión del reservorio o la derivación indefinida del reservorio. Las características del paciente, los resultados perioperatorios y funcionales, la supervivencia del reservorio y la calidad de vida se compararon de acuerdo con el diagnóstico.De 422 pacientes, 392 tenían colitis ulcerativa y 30 tenían enfermedad de Crohn. La edad y el género fueron comparables. Las indicaciones más comunes para rehacer el reservorio incluyeron dehiscencia anastomótica y fístulas [220 (56,1%) en colitis ulcerosa y 21 (70%) en la enfermedad de Crohn]. La mayoría de los reservorios rehechos requirieron mucosectomía con anastomosis manual [310 (79%) en colitis ulcerosa y 30 (100%) en la enfermedad de Crohn, p = 0.23]. Se construyó un nuevo reservorio en 160 (41%) pacientes con colitis ulcerativa y se reparó el reservorio antiguo en 231 (59%) pacientes, en comparación con 25 (83%) en la enfermedad de Crohn, que requirieron creación de un nuevo reservorio, y solo 5 (17%) donde el reservorio antiguo se volvió a anastomosar. La frecuencia de las evacuaciones, el manchado fecal y la urgencia fecal fueron comparables entre grupos. La supervivencia acumulada del reservorio a 5 años fue mayor en la colitis ulcerativa frente a la enfermedad de Crohn (88% frente a 55%, p = 0.008). Las principales causas de falla del reservorio rehecho en la enfermedad de Crohn fueron las fístulas del reservorio y / o las estenosis que ocurrieron después del cierre de ileostomía. Estas fueron más comunes en la enfermedad de Crohn que en la colitis ulcerativa (p <0.001).Este fue un diseño retrospectivo.Rehacer el reservorio ileal se puede ofrecer a pacientes seleccionados con enfermedad de Crohn colónica diagnosticada en el momento de su reservorio primario. Consulte Video Resumen en http://links.lww.com/DCR/B206. (Traducción-Dr Jorge Silva Velazco).

Comparison of long-term outcomes of primary and redo IPAA for patients with Crohn's disease

BACKGROUND

Crohn's disease (CD) patients after ileal anal pouch anastomosis (IPAA) are subject to CD recurrence, septic complications, and pouch failure. The aim of this study was to compare long-term outcomes of index and redo IPAA for CD.

METHODS

Patients who underwent index and redo IPAA with a diagnosis of CD colitis were identified from a prospectively maintained IPAA database. Charts were reviewed to determine complications and pouch failure rates after index and redo IPAA. Long-term pouch survival and quality of life (QoL) were compared between index and redo IPAAs.

RESULTS

There were 305 patients, 253 with an index IPAA and 52 having a redo IPAA. Their median ages were 33 years (index IPAA) and 32 years (redo IPAA) (p = 0.91); there were 47% and 53% men in each group, respectively (p = 0.54). Pouch salvage with redo IPAA was possible in 75% of redo pouches. Biologic agents were given in 8% of index IPAA and 34% redo IPAA patients (p < 0.01). Cumulative Kaplan Meier 5-year pouch survival was 80% vs. 60% in index and redo IPAA (p < 0.0001), at 10 years 74% vs. 38%, respectively (p < 0.0001). When queried, 78% who underwent redo pouch surgery would have it again and 86% would recommend this surgery to others.

CONCLUSION

IPAA can be offered to selected patients with isolated colonic CD. Failure in this group of patients is related mainly to recurrent CD, not surgical complications. Redo IPAA is a realistic option for salvage in certain patients with failed index IPAA.

Factors Associated with Long-Term Quality of Life After Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis

THE AIM

The aim of this study was to analyze factors associated with quality of life (QoL) after ileal pouch anal anastomosis (IPAA).

METHODS

Patients who underwent IPAA (1983-2015) and replied to QoL questionnaire were identified from an IRB-approved prospectively maintained IPAA-database. QoL was assessed using Cleveland Global Quality of Life (CGQL) questionnaire at 1, 3, 5, and 10 years postoperatively. Patient cohort was divided in two groups: overall QoL score ≤ 0.7 (low) and > 0.7 (high). Demographics, perioperative morbidity, and functional results were analyzed.

RESULTS

A total of 4059 patients replied to the questionnaire at the most recent follow-up and were included. A total of 2889 (71%) had overall QoL > 0.7 (group 1) and 1170 (29%) patients had overall QoL ≤ 0.7 (group 2). Patients in group 1 had lower rates of early (44.6 vs. 50.4%, p = 0.003) and late (55.7 vs. 64.5%, p < 0.003) postoperative complications. Kaplan-Meier survival analysis demonstrated significantly higher rates of pouch failure among patients with lower QoL. Pouchitis, obstruction, fistulas, higher number of stools, and IPAA performed during the most recent decade (2005-2015) were significantly associated with lower QoL (≤ 0.7), while S-pouch configuration was associated with higher QoL (> 0.7).

CONCLUSION

Patient's characteristics and minimal perioperative complications impact patient's QoL following IPAA not only in the short term, but also in the long term.

Quality of life of ulcerative colitis patients treated surgically with proctocolectomy and J-pouch formation: a comparative study before surgery and after closure of the defunctioning ileostomy

Background

Ulcerative colitis (UC) is a lifelong disease with a relapse-remission pattern that affects patients' social and psychological wellbeing. Restorative proctocolectomy and J-pouch formation is the gold-standard surgical procedure in cases where symptoms are refractory to currently available medical treatment. The aim of this study was to assess patients' quality of life (QoL) in order to evaluate the efficiency of surgery and patients' symptomatology.

Methods

We performed a prospective comparative study of the QoL of 47 patients with UC, treated surgically. As research tools, we used the Inflammatory Bowel Disease Questionnaire (IBDQ) and the Cleveland Global Quality of Life (CGQL) questionnaire. Parametric and non-parametric tests were used in order to correlate areas of QoL and other selected factors, such as marital status, sex, age, and education.

Results

The mean scores before and after closure of the ileostomy were 153.29 and 178 for the IBDQ (P=0.0025), and 17.4 and 23.42 for the CGQL (P<0.001), suggesting an overall improvement in QoL. The research showed that there was no specific QoL factor, such as intestinal, systemic, emotional or social life symptoms, that improved significantly more than the others (P=0.99). The IBDQ showed that patients aged less than 20 years (P<0.001), female patients (P=0.03) and patients with secondary education (P<0.001) reported the greatest improvement.

Conclusions

The QoL in UC patients treated surgically improved following closure of the de-functioning ileostomy. QoL studies are encouraged to optimize and maintain high standards of surgical care, and they could potentially be used for assessment of therapeutic efficacy.

Modified Pfannenstiel Open Approach as an Alternative to Laparoscopic Total Proctocolectomy and IPAA: Comparison of Short- and Long-term Outcomes and Quality of Life

BACKGROUND

A laparoscopic approach to total proctocolectomy with IPAA has been suggested to have better short-term outcomes and cosmesis, whereas open surgery by midline incision may result in shorter operative times. We hypothesized that a modified Pfannenstiel open approach would combine the advantages of both techniques.

OBJECTIVE

The purpose of this study was to compare outcomes of open total proctocolectomy with IPAA using a modified Pfannenstiel incision versus those following the laparoscopic approach.

DESIGN

This was a retrospective study comparing patients submitted to open IPAA using modified Pfannenstiel incision versus laparoscopy from 1998 to 2014.

SETTINGS

The study was conducted at a high-volume tertiary referral center.

PATIENTS

Among 1275 patients, 119 patients underwent the laparoscopic approach and 33 underwent the modified Pfannenstiel approach.

MAIN OUTCOME MEASURES

Short- and long-term outcomes were evaluated, and quality-of-life questionnaires were assessed.

RESULTS

Patients who underwent the modified Pfannenstiel approach were younger, more often women, and had lower BMI and ASA classification compared with those who underwent laparoscopy. Surgical time was lower in Pfannenstiel, and no difference was observed in length of hospital stay. No difference was observed in postoperative complications, pouch failure rate, or quality of life. Patients were then matched 1:1 by diagnosis, sex, age (±5 y) and BMI (±5 kg/m). The Pfannenstiel approach still had a shorter surgical time. No difference was observed in the length of hospital stay, complications, pouch failure, or quality of life. In long-term follow-up, pouchitis symptoms occurred more frequently in Pfannenstiel (mean follow-up = 7.3 y), and seepage was more frequently observed in the laparoscopy group (mean follow-up = 4.2 y). These differences were not observed in matched patients.

LIMITATIONS

The study was limited by its retrospective design and inherent selection bias.

CONCLUSIONS

The modified Pfannenstiel approach provides equivalent short- and long-term outcomes and similar quality of life compared with laparoscopy but with a significantly shorter operative time. The modified Pfannenstiel approach to total proctocolectomy with IPAA may be the most efficient method in selected patients. See Video Abstract at http://links.lww.com/DCR/A562.

Quality of Life in Inflammatory Bowel Disease: A Systematic Review and Meta-analyses-Part II

BACKGROUND

There has been burgeoning interest in quality of life (QoL) in inflammatory bowel disease (IBD) in recent decades, with hundreds of studies each year now assessing this outcome. This paper is part 2 of a systematic review evaluating 5 key QoL comparisons within IBD states and relative to others without IBD. Part 1 examined QoL comparing IBD and a healthy/general population and other medically ill groups. Part 2, presented here, examines within-disease comparisons of active/inactive disease, Ulcerative colitis (UC) / Crohn's disease (CD), and change in QoL over time. Outcomes using generic versus IBD-specific QoL measures were also examined.

METHODS

Adult and pediatric studies were identified through systematic searches of 7 databases from the 1940s (where available) to October 2015.

RESULTS

Of 6173 abstracts identified, 466 were selected for final review based on controlled design and validated measurement, of which 83 unique studies (75 adult, 8 pediatric) addressed the within-disease comparisons. The pooled mean QoL scores were significantly lower in active versus inactive IBD (n = 26) and for those with CD versus UC (n = 37), consistent across IBD-specific and generic QoL measures, for almost all comparisons. There was significant improvement in QoL over time (n = 37). Study quality was generally low to moderate. The most common measures of QoL were the disease-specific Inflammatory Bowel Disease Questionnaire and generic 36-Item Short Form Survey (SF-36) (adults) and the IBD-specific IMPACT (children).

CONCLUSIONS

For adults in particular, there was strong confirmation that QoL is poorer during active disease and may be poorer for those with CD. The finding that QoL can improve over time may be encouraging for individuals with this chronic disease.

Long-term quality of life after conservative treatment versus surgery for different stages of acute sigmoid diverticulitis

PURPOSE

It is controversial whether patients fare better with conservative or surgical treatment in certain stages of acute diverticulitis (AD), in particular when phlegmonous inflammation or covered micro- or macro-perforation are present. The aim of this study was to determine long-term quality of life (QoL) for AD patients who received either surgery or conservative treatment in different stages.

METHODS

We included patients treated for AD at the University Hospital Grosshadern, Munich, Germany, between January 1, 2000, and December 31, 2010. Patients were classified by the Hansen and Stock (HS) classification, the modified Hinchey classification, and the German classification of diverticular disease (CDD). Pre-therapeutic staging was based on multidetector computed tomography. Long-term QoL was assessed by the Cleveland Global Quality of Life (CGQL) questionnaire, the Short Form 36 (SF-36), and the Gastrointestinal Quality of Life Index (GIQLI). Data are mean ± SEM.

RESULTS

Patients with phlegmonous AD (HS type 2a, Hinchey Ia and CDD 1b, respectively) had a better long-term QoL on the GIQLI when they were operated (78.5 ± 2.5 vs. 70.7 ± 2.1; p < 0.05). Patients with micro-abscess (CDD 2a) had a better long-term QoL on the GIQLI, CGQL, and the "Role Physical" scale of the SF-36 when they were not operated (GIQLI 86.9 ± 2.1 vs. 76.8 ± 1.0; p = 0.10; CGQL 82.8 ± 5.1 vs. 65.3 ± 11.0; p = 0.08; SF-36/Role Physical 100 ± 0.0 vs. 41.7 ± 13.9; p < 0.001). Patients with macro-abscess (CDD 2b) had a better long-term QoL when they were operated (GIQLI 89.3 ± 1.4 vs. 69.5 ± 4.5; p < 0.01; CGQL 80.3 ± 7.6 vs. 60.5 ± 5.8; p < 0.05; SF-36/Role Physical 95.8 ± 4.2 vs. 47.9 ± 13.6; p < 0.001).

CONCLUSION

Considering long-term QoL, phlegmonous AD (HS type 2a, Hinchey Ia and CDD 1b, respectively) should be treated conservatively. In patients with covered perforation, abscess size should guide the decision on whether to perform surgery later on or not. In the light of long-term quality of life, patients fare better after elective sigmoid colectomy when abscess size exceeds 1 cm.

One-year results of the SCANDIV randomized clinical trial of laparoscopic lavage versus primary resection for acute perforated diverticulitis

Background

Recent randomized trials demonstrated that laparoscopic lavage compared with resection for Hinchey III perforated diverticulitis was associated with similar mortality, less stoma formation but a higher rate of early reintervention. The aim of this study was to compare 1-year outcomes in patients who participated in the randomized Scandinavian Diverticulitis (SCANDIV) trial.

Methods

Between February 2010 and June 2014, patients from 21 hospitals in Norway and Sweden presenting with suspected perforated diverticulitis were enrolled in a multicentre RCT comparing laparoscopic lavage and sigmoid resection. All patients with perforated diverticulitis confirmed during surgery were included in a modified intention-to-treat analysis of 1-year results.

Results

Of 199 enrolled patients, 101 were assigned randomly to laparoscopic lavage and 98 to colonic resection. Perforated diverticulitis was confirmed at the time of surgery in 89 and 83 patients respectively. Within 1 year after surgery, neither severe complications (34 versus 27 per cent; P = 0·323) nor disease-related mortality (12 versus 11 per cent) differed significantly between the lavage and surgery groups. Among the 144 patients with purulent peritonitis, the rate of severe complications (27 per cent (20 of 74) versus 21 per cent (15 of 70) respectively; P = 0·445) and disease-related mortality (8 versus 9 per cent) were similar. Laparoscopic lavage was associated with more deep surgical-site infections (32 versus 13 per cent; P = 0·006) but fewer superficial surgical-site infections (1 versus 17 per cent; P = 0·001). More patients in the lavage group underwent unplanned reoperations (27 versus 10 per cent; P = 0·010). Including stoma reversals, a similar proportion of patients required a secondary operation (28 versus 29 per cent). The stoma rate at 1 year was lower in the lavage group (14 versus 42 per cent in the resection group; P &lt; 0·001); however, the Cleveland Global Quality of Life score did not differ between groups.

Conclusion

The advantages of laparoscopic lavage should be weighed against the risk of secondary intervention (if sepsis is unresolved). Assessment to exclude malignancy (although uncommon) is advised. Registration number: NCT01047462 (http://www.clinicaltrials.gov).

Long-term Quality of Life of Patients With Permanent End Ileostomy: Results of a Nationwide Cross-Sectional Survey

BACKGROUND

Patients with permanent end ileostomy are at high risk for detrimental stomal effects on their quality of life. However, little is known about the long-term quality of life of these patients.

OBJECTIVE

The purpose of this study was to assess long-term quality of life in patients with permanent end ileostomy.

DATA SOURCES

Registration at the German self-help organization ILCO was used for this study.

STUDY SELECTION

Selection included a cross-sectional survey of 1434 patients with permanent end ileostomy.

MAIN OUTCOME MEASURES

Quality of life was assessed using the Medical Outcomes Study Short Form 36, including physical and mental component summary scores, the Gastrointestinal Quality of Life Index, and the Cleveland Global Quality of Life Index. Multivariate risk factor analysis was performed.

RESULTS

A total of 783 responders were included. Indications for ileostomy included ulcerative colitis (44%), Crohn's disease (38%), and colorectal cancer (7%). Adverse effects on daily life because of stoma were reported by 72% of participants. Quality of life was significantly impaired compared with the general population on all of the summary scores and several subscales (physical component summary: 44.6 ± 10.4 (mean ± SD) vs 50.2 ± 10.2, p < 0.001; mental component summary: 47.5 ± 10.7 vs 51.5 ± 10.2, p < 0.001; Gastrointestinal Quality of Life Index: 94.4 ± 16.4 vs 126.0, p < 0.001). Stoma care problems affecting quality of life were reported by 63% of respondents. These included parastomal hernia (p < 0.001), stenosis (p = 0.003), and prolapse (p = 0.008). Vitamin B12, iron, and zinc deficiencies were also associated with diminished quality of life; in particular, vitamin B12 deficiency was associated with reduced mental and emotional quality of life.

LIMITATIONS

Not all patients undergoing ileostomy in Germany are registered at ILCO, and there were many nonresponders. In addition, the inherent limitations of cross-sectional studies should be considered, including the response-shift phenomenon.

CONCLUSIONS

Quality of life was markedly impaired in patients with permanent end ileostomy as compared with the general population. The main reasons were stoma-associated morbidity and nutritional deficiency syndromes. These findings highlight the importance of prevention, screening, and adequate treatment.

Impact of drug therapy and surgery on quality of life in Crohn's disease: a systematic review

Crohn's disease is associated with substantially impaired health-related quality of life (HRQoL). Even in the absence of active disease, patients with Crohn's disease report lower HRQoL, poorer function, and greater concerns, than those without disease. Achievement of disease remission in Crohn's disease, whether by pharmacological or surgical means, is associated with improved HRQoL, although the durability of the improvement seen after intestinal resection is uncertain because of the high rate of postoperative disease recurrence. This review focuses on the available literature on HRQoL in patients with Crohn's disease with an emphasis on the effects of intestinal resection and immunomodulatory therapy.

Getting personal: a review of sexual functioning, body image, and their impact on quality of life in patients with inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD), which includes Crohn's disease and ulcerative colitis, is a chronic relapsing disorder associated with distressing physical and psychological symptoms. Many patients with IBD have impaired quality of life. Sexual functioning and body image are rated high among concerns of patients with IBD and may impact quality of life. A better understanding of the roles of sexual functioning and body image in quality of life for patients with IBD is needed because improvement in quality of life is a primary therapeutic goal. The aim of this review was to summarize the current literature on sexual functioning and body image in patients with IBD, emphasizing their impact on quality of life.

METHODS

An electronic search of the literature was conducted using the PubMed, PsycINFO, and Cochrane databases. Key phrases included: "Ulcerative Colitis/Crohn's disease/Inflammatory Bowel Disease and sexual function," and "Ulcerative Colitis/Crohn's disease/Inflammatory Bowel Disease and body image." The search produced 1284 citations. We identified 56 studies, which were conducted from 1990 through April 2014, written in English, and included at least 10 adults with IBD.

CONCLUSIONS

Few studies have tested directly the association between quality of life and sexual functioning and body image among patients with IBD. Results preliminarily suggest a positive relationship between quality of life and sexual functioning and body image postoperatively among patients with IBD. Future studies comprised of patients who have not had surgery are necessary to better understand the relationship between sexual functioning, body image, and quality of life in patients with active and inactive IBD.

Assessing patient reported outcome measures: A practical guide for gastroenterologists

Gastrointestinal illnesses cause physical, emotional and social impact on patients. Patient reported outcome measures (PROMs) are increasingly used in clinical decision-making, clinical research and approval of new therapies. In the last decade, there has been a rapid increase in the number of PROMs in gastroenterology and, therefore, the choice between which of these PROMs to use can be difficult. Not all PROM instruments currently used in research and clinical practice in gastroenterology have gone through a rigorous development methodology. New drugs and therapies will not have access to the market if the PROMs used in their clinical trials are not validated according to the guidelines of the international agencies. Therefore, it is important to know the required properties of PROMs when choosing or evaluating a drug or a clinical intervention. This paper reviews the current literature on how to assess the validity and reliability of PROMs. It summarises the required properties into a practical guide for gastroenterologists to use in assessing an instrument for use in clinical practice or research.

Ligation of intersphincteric fistula tract versus mucosal advancement flap in patients with high transsphincteric fistula-in-ano: a prospective randomized trial

PURPOSE

The aim of this study was to compare the ligation of the intersphincteric fistula track with the mucosal advancement flap in the treatment of high transsphincteric anal fistulas.

DESIGN AND SETTING

This was a prospective randomized study performed at academic medical centers.

PATIENTS

Patients with transsphincteric anal fistulas involving the upper part of anal sphincter were included.

INTERVENTION

Patients were randomly assigned to either ligation of intersphincteric fistula track or mucosal advancement flap.

MAIN OUTCOME MEASURES

The primary end points of the study were fistula closure, recurrence within 1 year, and continence by using the Wexner score. Secondary end points were morbidity, postoperative pain with the use of the visual analog scale, and quality of life with the use of the Cleveland Global Quality of Life score.

RESULTS

There were 70 patients (35 in each group). Mean age was 36.1 years in patients undergoing ligation of the intersphincteric fistula track vs 32.9 years in patients undergoing mucosal advancement flap (p = 0.33). Mean visual analog scale after 1 week was significantly higher in the mucosal advancement flap group than in the ligation of intersphincteric fistula track group (3.1 vs 4.8, p = 0.04), but no significant difference was found after 4 weeks. Primary healing was achieved in 33 patients undergoing ligation of the intersphincteric fistula track vs 32 patients undergoing mucosal advancement flap (p = 0.99). Mean healing time was 22.6 days in the ligation of intersphincteric fistula track group vs 32.1 days in mucosal advancement flap group (p = 0.01). After 1 year of follow-up, successful outcome was achieved in 26 patients (74.3%) undergoing ligation of intersphincteric fistula track and in 20 patients (65.7%) undergoing mucosal advancement flap (p = 0.58). No significant change in Wexner score occurred 4 weeks postoperatively. There was no significant difference between groups regarding Cleveland Global Quality of Life score (p = 0.5 and 0.07 after 4 and 12 weeks).

LIMITATIONS

The short-term follow-up is a probable limitation. Although the sample size was calculated to detect difference with 80% power at a significance level of 5%, the negative result within this relatively small number of patients might have resulted from type II statistical error.

CONCLUSIONS

In patients with high transsphincteric anal fistulas, both ligation of intersphincteric fistula track procedure and mucosal advancement flap have a similar long-term healing rate, recurrences, continence, and quality of life. However, ligation of the intersphincteric fistula track has the advantage of less postoperative pain.

Patient-reported outcomes as primary end points in clinical trials of inflammatory bowel disease

The Food and Drug Administration (FDA) is moving from the Crohn's Disease Activity Index to patient-reported outcomes (PROs) and objective measures of disease, such as findings from endoscopy. PROs will become an important aspect of assessing activity of inflammatory bowel disease (IBD) and for labeling specific drugs for this disease. PROs always have been considered in the management of patients with rheumatoid arthritis or multiple sclerosis, and have included measurements of quality of life, disability, or fatigue. Several disease-specific scales have been developed to assess these PROs and commonly are used in clinical trials. Outcomes reported by patients in clinical trials of IBD initially focused on quality of life, measured by the Short-Form 36 questionnaire or disease-specific scales such as the Inflammatory Bowel Disease Questionnaire or its shorter version. Recently considered factors include fatigue, depression and anxiety, and work productivity, as measured by the Functional Assessment Chronic Illness Therapy-Fatigue, the Hospital Anxiety Depression, and the Work Productivity Activity Impairment Questionnaire, respectively. However, few data are available on how treatment affects these factors in patients with IBD. Although disability generally is recognized in patients with IBD, it is not measured. The international IBD disability index currently is being validated. None of the PROs currently used in IBD were developed according to FDA guidance for PRO development. PROs will be a major primary end point of future trials. FDA guidance is needed to develop additional PROs for IBD that can be incorporated into trials, to better compare patients' experience with different therapies.

Advancement flap repair: a good option for complex anorectal fistulas

BACKGROUND

Rectal advancement flap is a popular option for treatment of complex anal fistula. Although early outcomes vary, concerns remain about postoperative continence, long-term healing, and its role in patients with Crohn's disease and anovaginal fistulas.

PURPOSE

This study aimed to report long-term outcomes in patients with complex fistula disease.

PATIENTS

Patients who were undergoing rectal advancement flap for anal fistula were included in the study.

DESIGN

Patients were contacted to determine the status of their fistula disease, their bowel function, and their degree of fecal incontinence.

MAIN OUTCOME MEASURES

The main outcomes measured were healing rate and continence.

RESULTS

There were 98 patients, 43 men and 55 women, mean age 53 ± 14 years. Fifty-eight had cryptoglandular fistulas, and 40 (41%) had IBD (33 had Crohn's disease). Seventy-seven of 98 patients had perianal fistulas, and all 77 underwent seton drainage before advancement flap. Twenty-one women had anovaginal fistulas. Average postoperative length of stay was 3 ± 1 days. There were no mortalities. Follow-up was possible in 75 patients, a mean of 7 ± 3 years after surgery. Primary healing occurred in 54 (72%) patients. Twenty-one patients (28%) underwent further treatment, and 12 (57%) healed after a second advancement flap. Four more patients healed after more than 2 flaps or fistulotomy leading to an overall healing rate of 70 of 75 (93%). Patients with Crohn's disease had lower healing rates than those with cryptoglandular fistulas (87% vs 98%). Thirty-two patients (43%) had normal fecal continence before flap, and 43 (57%) had normal fecal continence after flap.

CONCLUSION

Advancement flap is a good option for patients with complex anal fistulas.

Impact of smoking on disease phenotype and postoperative outcomes for Crohn's disease patients undergoing surgery

AIM

Whether smoking affects disease distribution, phenotype, and perioperative outcomes for Crohn's disease (CD) patients undergoing surgery is not well characterized. The aim of this study is to evaluate the impact of smoking on disease phenotype and postoperative outcomes for CD patients undergoing surgery

METHODS

Prospectively collected data of CD patients undergoing colorectal resection were evaluated. CD patients who were current smokers (CS) were compared to nonsmokers (NS) and ex-smokers (ES) for disease phenotype, anatomic site involved, procedures performed, postoperative outcomes, and quality of life using the Cleveland Global Quality of Life instrument (CGQL).

RESULTS

Of 691 patients with a diagnosis of CD requiring surgery 314 were classified as CS, 330 as NS, and 47 as ES. CS and ES in comparison to NS were significantly older at diagnosis of Crohn's disease (mean, 29.3 vs. 29.2 vs. 26.3 years) (P = 0.001) and older at the time of primary surgery (mean, 42.9 vs. 48.4 vs. 39 years) (P = 0.001) with a greater frequency of diabetes. In all groups requiring surgery, there was a significant change in disease phenotype from the time of diagnosis to surgical intervention. The predominant phenotype at diagnosis was inflammatory which changed to stricturing and penetrating as the dominant phenotypes at time of surgery. All groups had a significant improvement in CGQL scores post-surgery with the greatest benefit observed in NS. Postoperative complications and 30-day readmission rates were similar between all groups.

CONCLUSIONS

The findings of this study show that in patients with CD, disease phenotype changes over time. This occurs independent of smoking. Smoking does not appear to predispose to complications for CD patients undergoing surgery. CS and ES have a persistently reduced quality of life in comparison to NS post-surgery.

The role of primary surgical procedure in maintaining intestinal continuity for patients with Crohn's colitis

OBJECTIVE

This study evaluates surgical procedures for Crohn's colitis. The risk of recurrence and how it interacts with future avoidance of permanent stoma and quality of life (QoL) is studied.

BACKGROUND

Segmental and subtotal colectomy are widely used surgical options in isolated Crohn's colitis. It is not clear which procedure offers the best outcomes.

METHODS

Patients undergoing index resection for isolated colonic Crohn's disease (CD) from 1995 to 2009, were identified from a prospectively maintained CD database. Patients were categorized into subtotal colectomy or segmental groups. Demographics, disease characteristics, operative details, morbidity, stoma formation, recurrence requiring surgery and QoL data were extracted. Recurrence and stoma free survival was calculated for each group and independent risk factors for recurrence and stoma formation identified.

RESULTS

One hundred and eight patients (49 segmental, 59 subtotal) underwent primary colectomy with anastomosis. Segmental colectomy patients had significantly reduced recurrence free survival (P = 0.032) but not stoma free survival P = 0.62 on univariate analysis. On multivariate analysis, the presence of perianal sepsis (P = 0.032) and >1 medical comorbidity (P = 0.01), but not segmental colectomy, were associated with reduced SFS. There was no difference in Cleveland Global Quality of Life (P = 0.88), or Short Form Inflammatory Bowel Disease Questionnaire scores between groups (P = 0.92).

CONCLUSIONS

Using a strictly defined cohort of patients, we were unable to identify segmental resection as an independent risk factor for recurrence or stoma formation and no reduction in QoL scores to suggest an adverse effect of recurrence was observed. Segmental colectomy affords good function, and our data supports the practice of a conservative approach with anastomosis in anatomically linked CD.

Stapled haemorrhoidopexy: extent of tissue excision and clinical implications in the early postoperative period

AIM

This study quantified prospectively the amount of rectal wall removed during stapled haemorrhoidopexy and assessed its effect on ano-rectal function and health-related quality of life.

METHOD

Thirty-three consecutive patients who underwent stapled haemorrhoidopexy for second- or third- degree haemorrhoids, or for failed medical treatment, in the Department of Surgery and Gastroenterological Sciences at the University of Padova were included. All patients were assessed preoperatively and postoperatively using a structured questionnaire to determine the number of defecations per week, incomplete defecations, time taken to defecate any difficulty in defecating, soiling, the use of drugs and continence. All patients were reassessed at 1 and 2 weeks and at 30 days after the procedure using the Cleveland Global Quality of Life (CGQL) questionnaire. All patients underwent preoperative and postoperative ano-rectal manometry at least 30 days after stapled haemorrhoidopexy.

RESULTS

The median surface area of the resected rectal wall was 10.5 (range, 9-15) mm(2) and the median thickness was 3 (range, 2-4) mm. Muscle tissue was included in all specimens. The median thickness of the resected rectal wall correlated inversely with the rectal volume when the recto-anal inhibitory reflex (RAIR) was initiated during postoperative manometry (ρ = -0.50, P = 0.07). A significant, direct correlation was found between the surface area of the resected rectal wall and the rectal volume during postoperative manometry (ρ = 0.53, P = 0.08) and the use of analgesic drugs after 2 weeks (ρ = 0.63, P = 0.04). Significant correlations were found between being female and postoperative resting pressure (ρ = -0.74, P < 0.01), squeeze pressure (ρ = -0.64, P = 0.01) and maximum tolerated volume (ρ = -0.78, P < 0.01).

CONCLUSION

Stapled haemorrhoidopexy is safe and effective. The thicker the resected rectal wall, the lower the volume of initiation of the RAIR.

Long-term health-related quality of life after minimally invasive surgery for diverticular disease

BACKGROUND AND AIMS

The aim of this multicentric study was to evaluate the disease specific and the generic quality of life in patients affected by colonic diverticular disease (DD) who had undergone minimally invasive or open colonic resection or who had been treated with medical therapy in the long-term follow-up.

PATIENTS AND METHODS

Seventy-one consecutive patients admitted to the departments of surgery of Padova and Arzignano Hospitals for DD were interviewed: 22 underwent minimally invasive colonic resection, 24 had open resection, and 25 had only medical therapy. The interview focused on disease specific and generic quality of life, body image, and disease activity.

RESULTS

Padova Inflammatory Bowel Disease Quality of Life (PIBDQL) was validated for the use in DD patients. PIBDQL scores were significantly worse in all patients with DD than those obtained by healthy subjects and it correlated with the symptoms score. The generic quality of life seemed similar in patients who had minimally invasive colonic resection compared with healthy subjects. Body Image Questionnaire scores correlated inversely with the presence of a stoma.

CONCLUSIONS

Disease activity resulted as the only independent predictor of the disease-specific quality of life. In fact, DD affected bowel function and quality of life of patients in the long-term follow-up regardless of the type of therapy adopted. The presence of a stoma affected the patients' body image.

Do preoperative factors predict subsequent diagnosis of Crohn's disease after ileal pouch-anal anastomosis for ulcerative or indeterminate colitis?

AIM

The aim of this study was to determine preoperative clinical factors associated with subsequent diagnosis revision to Crohn's disease (CD) following total proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) or indeterminate colitis (IC) patients.

METHOD

Presumed UC and IC patients undergoing IPAA from a large single-institution prospective database with change of diagnosis to CD were identified and compared with patients without diagnosis change.

RESULTS

A total of 2814 patients (47% male, median age 37 years) with presumed UC (85%) or IC (15%) underwent primary IPAA. At a median follow up of 9.6 years, 184 (7%) had the diagnosis revised to CD from histopathological examination of the colectomy specimen immediately in 97 (53%) or at a median interval of 36 months in 87 (47%). CD and UC/IC patients had had a similar operative technique, length of stay and 30-day morbidity. The postoperative CD diagnosis was associated with a preoperative diagnosis of IC (P < 0.0001) and perianal fistula (P = 0.002). Patients with a delayed diagnosis of CD were associated with a 3-stage procedure (P < 0.0001, OR = 2.8) (95% CI = 1.8-4.4), colonic stricture (P = 0.04, OR = 2.9 [95% CI = 1.1-7.4]), perianal fistula (P = 0.02, OR = 2.9 [95% CI = 1.2-7.2]), oral ulceration (P = 0.009, OR = 3.8 [95% CI = 1.2-9.6]) and younger age (P < 0.0001, OR = 0.048 [95% CI = 0.011-0.19]).

CONCLUSION

A few patients having IPAA for presumed UC/IC were subsequently diagnosed to have CD which was associated with perianal fistula and the diagnosis of postoperative preoperative IC. The delayed diagnosis of CD was associated with a three-stage procedure, colorectal stricture, anal fissure, mouth ulceration and younger age.

Health related quality of life after surgery for colonic diverticular disease

Diverticular disease (DD) of the colon is very common in developed countries and is ranked the fifth most important gastrointestinal disease worldwide. The management of acute diverticulitis without perforation and peritonitis is still debated. Health related quality of life (HRQL), subjectively perceived by patients, is becoming a major issue in the evaluation of any therapeutic intervention, mainly in patients with chronic disease. To date only a few published studies can be found on Medline examining HRQL in patients with DD. The aim of this study was to review the impact of surgery for DD on HRQL. All Medline articles regarding HRQL after surgery for colonic DD, particularly those comparing different surgical approaches, were reviewed. DD has a negative impact on HRQL with lower scores in bowel function and systemic symptoms. Both surgery-related complications and disease activity have a significant impact on patients' HRQL. While no significant differences in HRQL between different operations for DD in non-randomized studies were revealed, the only prospective double-blind randomized study that compared laparoscopic and open colectomy found that patients undergoing laparoscopic colectomy had significantly reduced major postoperative complication rates and subsequently had better HRQL scores. Formal assessment of HRQL could be a good instrument in the selection of appropriate patients for elective surgery as well as in the assessment of surgical outcome.

Outcome of salvage surgery for ileal pouches referred with a diagnosis of Crohn's disease

INTRODUCTION

Technical complications after ileal pouch-anal anastomosis may be mislabeled as Crohn's disease. The purpose of our study is to evaluate the presentation, treatment, and outcomes of patients with a potential misdiagnosis of Crohn's disease who have undergone redo ileal pouch-anal anastomosis.

METHODS

We evaluated a historical cohort of patients, initially referred from outside institutions with a diagnosis of Crohn's disease of the pouch, who subsequently had redo ileal pouch-anal anastomosis (redo pouch or pouch revision for pouch failure) at our institution. With the use of validated questionnaires, the functional outcomes and quality of life of this cohort were compared with a control group of patients who underwent primary ileal pouch-anal anastomosis to assess whether a change in the diagnosis from Crohn's disease to technical complications was appropriate.

RESULTS

Thirty-three patients underwent a redo pouch procedure for a previous diagnosis of Crohn's disease of the pouch. Precolectomy diagnosis included ulcerative colitis (31 patients) and indeterminate colitis (2 patients). Findings on our further evaluation and subsequent indications for repeat pouch surgery included pouch fistula (20 patients), pelvic sepsis or anastomotic leak (17 patients), stricture (4 patients), refractory pouchitis (2 patients), long exit conduit (1 patient), and retained rectal stump (1 patient). All patients had medical treatment for Crohn's disease before referral. Median time between primary and redo pouch was 2.1 years (interquartile range, 1.8-4.9). Median follow-up was 1.7 years (interquartile range, 1.0-3.5). Pouch retention rate was 84.8%. Five patients (15.2%) had pouch failure. Seven patients (21.2%) ultimately had pathology consistent with Crohn's disease. Comparison of the redo pouch and control groups revealed that functional outcomes and quality of life were similar between groups.

CONCLUSION

Patients identified as having Crohn's disease need to be carefully reevaluated because some of these patients may actually have surgery-associated complications and can have a favorable long-term outcome after redo ileal pouch-anal anastomosis.

Intestinal surgery for Crohn's disease: predictors of recovery, quality of life, and costs

INTRODUCTION

The aim of this prospective study was to analyze the impact of different surgical techniques on patients undergoing intestinal surgery for Crohn's disease (CD) in terms of recovery, quality of life, and direct and indirect costs.

PATIENTS AND METHODS

Forty-seven consecutive patients admitted for intestinal surgery for CD were enrolled in this prospective study. Surgical procedures were evaluated as possible predictors of outcome in terms of disability status (Barthel's Index), quality of life (Cleveland Global Quality of Life score), body image, disease activity (Harvey-Bradshaw Activity Index), and costs (calculated in 2008 Euros). Univariate and multivariate analyses were performed.

RESULTS

Significant predictors of a long postoperative hospital stay were the creation of a stoma, postoperative complications, disability status on the third post-operative day, and surgical access (R (2) = 0.59, p < 0.01). Barthel's index at discharge was independently predicted by laparoscopic-assisted approach, ileal CD, and colonic CD (R (2) = 0.53, p < 0.01). The disability status at admission showed to be an independent predictor of quality of life score at follow-up. The overall cost for intestinal surgery for CD was 12,037 (10,117-15,795) euro per patient and stoma creation revealed to be its only predictor (p = 0.006).

CONCLUSIONS

Laparoscopy was associated with a shorter postoperative length of stay; stoma creation was associated with a long and expensive postoperative hospital stay, and stricturoplasty was associated with a slower recovery of bowel function.

Restorative proctocolectomy for inflammatory bowel disease: the Padova prognostic score for colitis in predicting long-term outcome and quality of life

BACKGROUND

In 10-20% of cases, it is impossible to distinguish between ulcerative colitis and Crohn's colitis, affecting the possibility to predict the long-term outcome after restorative proctocolectomy (RPC). The study aimed to assess the accuracy of a new prognostic score for inflammatory bowel diseases (IBD) colitis [the Padova Prognostic Score for Colitis (PPSC)] in predicting long-term clinical/functional outcome and quality of life after RPC.

MATERIALS AND METHODS

The PPSC was created by the integration of histological and clinical information. The accuracy of the PPSC was tested in predicting long-term clinical outcome (i.e. pouch complications/survival) and quality of life of 58 consecutive patients who had undergone RPC in our institute from 1984 to 2004. Clinical outcome was assessed with an ad hoc functional questionnaire and the revision of the hospital and outpatients clinic notes. Quality of life surveys were carried out with the Padova IBD Quality of Life (PIBDQL) and with Cleveland Global Quality of Life (CGQL) scores.

RESULTS

The PPSC predicted pouch fistulae (accuracy = 84.5%; sensitivity = 50%; specificity = 90%) and changes in sexual life (accuracy = 71%; sensitivity = 23%; specificity = 87%). The PPSC also predicted the PIBDQL score with an accuracy of 62%, a sensitivity of 28% and a specificity of 97%, whilst it predicted the CGQL score with an accuracy of 29%, a sensitivity of 12% and a specificity of 80%. The PPSC failed to predict pouchitis or pouch failure.

CONCLUSIONS

The Padova Prognostic Score for Colitis proved effective in predicting pouch fistulae or abscesses, but not pouchitis and pouch failure. The PPSC was accurate in predicting disease-specific quality of life.

Validation of a novel postoperative quality-of-life scoring system

BACKGROUND

No specific scoring system exists for the assessment of postoperative quality of life (QOL) after major abdominal surgery. This study prospectively validates PQL, a novel prospective scoring system in patients having laparoscopic or open major abdominal colorectal surgery.

METHODS

Six experienced surgeons developed the questionnaire. Twenty patients reviewed and selected the most relevant questions, yielding 14 questions. One hundred patients undergoing a variety of colorectal procedures completed the questionnaire preoperatively, and on postoperative days (POD) 1, 2, 4, 8, 12, 30, and 60. Internal validation was assessed by Cronbach's alpha and factor analysis.

RESULTS

Cronbach's alpha revealed excellent internal consistency, ranging from .84 to .94 at all time points, even at POD 1 when Cronbach's alpha was .79, demonstrating that the items in the questionnaire measured the same underlying construct. Factor analysis consistently loaded at each follow-up time on the same 2 factors.

CONCLUSIONS

Factor analysis consistently loaded at each follow-up time on the same 2 factors, designated the PQL Symptom Score and the PQL Recover Score.

Health-related quality of life after colonic resection for diverticular disease: long-term results

BACKGROUND AND AIMS

While colonic resection is standard practice in complicated colonic diverticular disease (DD), treatment of uncomplicated diverticulitis is, as yet, unclear. The aim of the present study was to evaluate the long-term clinical outcome and quality of life in DD patients undergoing colonic resection compared to those receiving medical treatment only.

PATIENTS AND METHODS

Seventy-one consecutive patients who were admitted to our surgical department with left iliac pain and endoscopical or radiological diagnosis of DD were enrolled in this trial. Disease severity was assessed with Hinchey scale. Twenty-five of the patients underwent colonic resection, while 46 were treated with medical therapy alone. After a median follow-up of 47 (3-102) months from the time of their first hospital admission, the patients responded to the questions of the Cleveland Global Quality of Life (CGQL) questionnaire and to a symptoms questionnaire during a telephone interview. Admittance and surgical procedures for DD were also investigated, and surgery- and symptoms-free survival rates were calculated. Nonparametric tests and survival analysis were used.

RESULTS

The CGQL total scores and symptom frequency rate were found to be similar in the two groups (resection vs nonresection). Only current quality of health item was significantly worse in patients who had undergone colonic resection (p = 0.05). No difference was found in the rate and in the timing of surgical procedures and hospital admitting for DD in the two groups. In particular, the nine patients classified as Hinchey 1 who underwent surgery reported the same quality of life, symptoms frequency, operation, and hospital admitting rate as those who had been admitted with the same disease class but who received medical treatment only.

CONCLUSIONS

Our results indicate that there does not seem to be any long-term advantage to colonic resection which should be considered only in patients presenting complicated DD.

Health-related quality of life after colonic resection for diverticular disease: long-term results

BACKGROUND AND AIMS

While colonic resection is standard practice in complicated colonic diverticular disease (DD), treatment of uncomplicated diverticulitis is, as yet, unclear. The aim of the present study was to evaluate the long-term clinical outcome and quality of life in DD patients undergoing colonic resection compared to those receiving medical treatment only.

PATIENTS AND METHODS

Seventy-one consecutive patients who were admitted to our surgical department with left iliac pain and endoscopical or radiological diagnosis of DD were enrolled in this trial. Disease severity was assessed with Hinchey scale. Twenty-five of the patients underwent colonic resection, while 46 were treated with medical therapy alone. After a median follow-up of 47 (3-102) months from the time of their first hospital admission, the patients responded to the questions of the Cleveland Global Quality of Life (CGQL) questionnaire and to a symptoms questionnaire during a telephone interview. Admittance and surgical procedures for DD were also investigated, and surgery- and symptoms-free survival rates were calculated. Nonparametric tests and survival analysis were used.

RESULTS

The CGQL total scores and symptom frequency rate were found to be similar in the two groups (resection vs nonresection). Only current quality of health item was significantly worse in patients who had undergone colonic resection (p = 0.05). No difference was found in the rate and in the timing of surgical procedures and hospital admitting for DD in the two groups. In particular, the nine patients classified as Hinchey 1 who underwent surgery reported the same quality of life, symptoms frequency, operation, and hospital admitting rate as those who had been admitted with the same disease class but who received medical treatment only.

CONCLUSIONS

Our results indicate that there does not seem to be any long-term advantage to colonic resection which should be considered only in patients presenting complicated DD.

Motivational interviewing to change quality of life for people with chronic heart failure: A randomised controlled trial

BACKGROUND

Patients with chronic heart failure have a reduced quality of life due in part to their limited range of physical activity and independence.

OBJECTIVES

The paper examines whether a physical activity 'lifestyle' intervention, based on motivational interviewing, will improve quality of life at five months from baseline, compared with conventional treatment.

METHODS

Sixty older patients with chronic heart failure were randomly assigned to either a 'standard care', 'motivational interviewing' or 'both' treatment groups for five months in 2002. The primary outcome measures were the Medical Outcomes Short Form-36 Health Survey, the disease-specific Minnesota Living with Heart Failure questionnaire and the Motivation Readiness for Physical Activity scale.

RESULTS

There were non-significant differences between the groups at baseline for age, coronary risk factors, severity of chronic heart failure, ejection fraction, specific laboratory tests, length of hospitalisation, medication and social support. Following treatment there was a significant increase (p<0.05) for three of the dimensions of the health survey in the 'motivational interviewing' group. All groups improved their scores (p<0.05) on the heart failure questionnaire. Over the five month period there was a general trend towards improvements in self-efficacy and motivation scores.

CONCLUSIONS

This study has demonstrated that a 'motivational interviewing' intervention, incorporating behaviour change principles to promote physical activity, is effective in increasing selected aspects of a general quality of life questionnaire and a disease-specific quality of life questionnaire. Thus a 'motivational interviewing' approach is a viable option compared with traditional exercise programming. It is important to test these motivational interviewing interventions more widely, especially to match individuals to treatments.