Outcome of restorative proctocolectomy with ileal reservoir for ulcerative colitis: comparison of distal colitis with more proximal disease

Exposure to Anti-tumor Necrosis Factor Medications Increases the Incidence of Pouchitis After Restorative Proctocolectomy in Patients With Ulcerative Colitis

BACKGROUND

Pouchitis is the most frequent complication after IPAA in patients with ulcerative colitis. Antibiotics represent the mainstay of treatment, suggesting a crucial role of dysbiosis in the pathogenesis of this condition. Anti-tumor necrosis factor agents have been shown to adversely impact the gut microbiome and local host immunity.

OBJECTIVE

The aim of this study is to assess the effect of prior exposure to biologics on the development of pouchitis in patients who have ulcerative colitis.

DESIGN

This is a retrospective case-control study.

SETTINGS

This study was conducted at a tertiary-care IBD center.

PATIENTS

Consecutive patients with ulcerative colitis who underwent restorative proctocolectomy between 2000 and 2010 were included.

MAIN OUTCOME MEASURES

The primary outcome measured was the incidence of pouchitis.

RESULTS

Four hundred seventeen patients with ulcerative colitis who underwent IPAA were included. The incidence of pouchitis was 40.4%. There were no differences in patient demographics, disease-specific factors, surgical approach, and short-term postoperative complications between patients who developed pouchitis compared to those that did not. Patients exposed to anti-tumor necrosis factor agents or preoperative steroids were significantly more likely to develop pouchitis (anti-tumor necrosis factor: 47.9% vs 36.5%, p = 0.027; steroids: 41.7% vs 23.3%, p = 0.048). However, on multivariable analysis, only anti-tumor necrosis factor therapy was an independent predictor for pouchitis (p = 0.05). Pouchitis was not associated with adverse long-term outcomes.

LIMITATIONS

The retrospective design was a limitation of this study.

CONCLUSION

In a large cohort of patients undergoing IPAA for ulcerative colitis with at least a 5-year follow-up, anti-tumor necrosis factor exposure was the only independent risk factor for the development of pouchitis. These agents may "precondition" the pouch to develop pouchitis through alterations in the microbiome and/or local host immunity of the terminal ileum. See Video Abstract at http://links.lww.com/DCR/B19. LA EXPOSICIÓN A MEDICAMENTOS ANTI-TNF AUMENTA LA INCIDENCIA DE POUCHITIS DESPUÉS DE LA PROCTOCOLECTOMÍA RESTAURADORA EN PACIENTES CON COLITIS ULCEROSA:: La pouchitis es la complicación más frecuente después de la anastomosis anal de bolsa ileal en pacientes con colitis ulcerosa. Los antibióticos representan el pilar del tratamiento, lo que sugiere un papel crucial de la disbiosis en la patogénesis de esta afección. Se ha demostrado que los agentes anti-TNF tienen un impacto adverso en la microbiota intestinal y en la inmunidad local del huésped.El objetivo de este estudio es evaluar el efecto de la exposición previa a terapía biológica sobre el desarrollo de la pouchitis en pacientes con colitis ulcerosa.Estudio retrospectivo de casos y controles.Centro de tercer nivel de atención en enfermedades inflamatorias intestinales.Pacientes consecutivos con colitis ulcerosa que se sometieron a proctocolectomía restaurativa entre 2000-2010.Incidencia de pouchitis.Cuatrocientos diecisiete pacientes con colitis ulcerativa se sometieron a anastomosis anal de bolsa ileal. La incidencia de pouchitis fue del 40.4%. No hubo diferencias en la demografía del paciente, los factores específicos de la enfermedad, el abordaje quirúrgico y las complicaciones postoperatorias a corto plazo entre los pacientes que desarrollaron pouchitis en comparación con los que no lo hicieron. Los pacientes expuestos a agentes anti-TNF o esteroides preoperatorios fueron significativamente más propensos a desarrollar pouchitis (anti-TNF: 47.9% vs 36.5%, p = 0.027; esteroides: 41.7% vs 23.3%, p = 0.048). Sin embargo, en el análisis multivariable, solo la terapia anti-TNF fue un predictor independiente para la pouchitis (p = 0.05). La pouchitis no se asoció con resultados adversos a largo plazo.Diseño retrospectivo.En una gran cohorte de pacientes sometidos a anastomosis anal de bolsa ileal para la colitis ulcerosa con al menos 5 años de seguimiento, la exposición a terapía anti-TNF fue el único factor de riesgo independiente para el desarrollo de pouchitis. Estos agentes pueden "precondicionar" la bolsa para desarrollar una pouchitis a través de alteraciones en el microbioma y / o inmunidad local del huésped del íleon terminal. Vea el Resumen del video en http://links.lww.com/DCR/B19.

A Personalized Approach to Managing Patients With an Ileal Pouch-Anal Anastomosis

Quality of life after ileal pouch-anal anastomosis (IPAA) surgery is generally good. However, patients can be troubled by pouch-related symptoms and pouch disorders that can be inflammatory, mechanical/surgical, and functional. Management of patients with IPAA begins with measures to maintain a healthy pouch such as optimizing pouch function, providing tailored advice on a healthy diet and lifestyle, screening for and addressing metabolic complications of IPAA, pouch surveillance, and risk stratification for risk of pouchitis and pouch failure. Pouchitis is the most common inflammatory disorder. Primary pouchitis is a spectrum currently classified into three progressive phases-an antibiotic-responsive, an antibiotic-dependent, and an antibiotic-refractory phase. It is predominately microbially mediated in acute antibiotic-responsive pouchitis and predominately immune mediated in chronic antibiotic-refractory pouchitis (CARP). Secondary prophylaxis is recommended for recurrent antibiotic-responsive and for antibiotic-dependent pouchitis. Secondary causes of antibiotic-refractory pouchitis should be ruled out before a diagnosis of CARP is made. CARP is best classified as primary sclerosing cholangitis associated, immunoglobulin G4-associated, and autoimmune. Primary sclerosing cholangitis-associated CARP can be treated with budesonide or oral vancomycin. Early recognition of immunoglobulin G4-associated pouchitis minimizes ineffective antibiotic use. Autoimmune CARP can be managed in a manner similar to UC. The current place of immunosuppressives in the treatment algorithm depends on availability and early access to biological agents. Vedolizumab and ustekinumab are the preferred first- and second-line biologics for autoimmune CARP owing to their efficacy, better side effect profile, and low immunogenicity and need for concomitant immunomodulatory therapy. Antitumor necrosis factor should be reserved for autoimmune CARP failing the above and for CD of the pouch. There are no guidelines for the surveillance of pouches for dysplasia. Incidence varies based on a patient's risk. Since incidence is low, a risk-stratified approach is recommended.

Predictors of pouchitis after ileal pouch-anal anastomosis in pediatric-onset ulcerative colitis

OBJECTIVES

Few studies have reported on the incidence and risk factors for pouchitis following colectomy and ileal pouch-anal anastomosis (IPAA) in patients with pediatric-onset ulcerative colitis (UC). We aimed to determine clinical predictors for the development of pouchitis following IPAA in this population.

PATIENTS AND METHODS

We performed a retrospective chart review of all pediatric UC cases that were diagnosed at the Schneider Children's Medical Center of Israel between 1981 and 2013 and who underwent colectomy during disease course. Potential predictors for pouchitis and chronic pouchitis including various demographic, clinical, endoscopic, and histological variables at diagnosis and at the time of surgery were assessed.

RESULTS

Of 188 patients with pediatric-onset UC, 33 (18%) underwent colectomy and IPAA surgery. During a median postsurgical follow-up of 7.6 (range: 1-21.5) years following IPAA, 20/33 (60%) patients developed pouchitis including 11/33 (33%) patients who developed chronic pouchitis. Kaplan-Meier survival estimates of the cumulative probability for pouchitis were 9% at 1 year and 36 and 55% at 5 and 10 years, respectively. Multivariate Cox models showed that older age at colectomy (hazard ratio: 0.86, P=0.024) was a protective factor, whereas preoperative vitamin-D deficiency (≤20 ng/ml) (hazard ratio: 4.4, P=0.021) increased the risk for pouchitis. Age at diagnosis, sex, disease extent, and preoperative therapeutic regimens did not affect the risk of pouchitis.

CONCLUSION

Long-term risk for pouchitis is significantly high in pediatric-onset UC after IPAA. Vitamin-D deficiency and younger age at colectomy may increase the risk for pouchitis.

Review article: the pathogenesis of pouchitis

BACKGROUND

A total proctocolectomy followed by ileal pouch-anal anastomosis is a potentially curative surgery for ulcerative colitis or familial adenomatous polyposis. About 5-35% of patients with ulcerative colitis and 0-11% of patients with familial adenomatous polyposis develop subsequent inflammation of the ileal pouch termed pouchitis.

AIM

To provide a comprehensive analysis of the research studying the possible pathogenesis of pouchitis. The goals were to identify promising areas of investigation, to help focus clinicians, researchers and patients on how to better understand and then potentially manage ileal pouchitis, and to provide avenues for future research investigations.

METHODS

This review examined manuscripts from 1981 to 2015 that discussed and/or proposed hypotheses with supportive evidence for the potential underlying pathogenic mechanism for pouchitis.

RESULTS

The pathogenesis of pouchitis is not definitively understood, but various hypotheses have been proposed, including (i) recurrence of ulcerative colitis, (ii) dysbiosis of the ileal pouch microbiota, (iii) deprivation of nutritional short-chain fatty acids, (iv) mucosal ischaemia and oxygen-free radical injury, (v) host genetic susceptibility and (vi) immune dysregulation. However, none of these alone are able to fully explain pouchitis pathogenesis.

CONCLUSIONS

Pouchitis, similar to inflammatory bowel disease, is a complex disorder that is not caused by any one single factor. More likely, pouchitis occurs through a combination of both dysregulated host inflammatory mechanisms and interaction with luminal microbiota.

Predictors of Pouchitis After Ileal Pouch-Anal Anastomosis in Children

OBJECTIVES

Predictive factors for the development of pouchitis after ileal pouch-anal anastomosis (IPAA) in children have not been well studied. In this retrospective study, the incidence and risk factors that predict pouchitis in children with IPAA will be identified.

METHODS

The records of patients who underwent IPAA surgery at Children's Hospital of Wisconsin between January 2000 and December 2013 were reviewed retrospectively. Patients with clinical, endoscopic, and histological findings consistent with pouchitis were identified. The groups of patients with and without pouchitis or chronic pouchitis were compared to determine which demographic, pathological, or disease characteristics may serve as predictive factors for the development of pouchitis or chronic pouchitis.

RESULTS

Out of a total of 60 patients who underwent IPAA, preoperative diagnosis was ulcerative colitis (UC) in 43 and familial adenomatous polyposis (FAP) in 17. Pouchitis was identified in 24 (56%) patients with UC and 2 (12%) patients with FAP. Subgroup analysis of patients with UC revealed that chronic pouchitis occurred in 15 (35%) patients. The median follow-up period from construction of the IPAA was 35 months (range 4.59-104.26 months). The study analysis revealed that a higher Pediatric Ulcerative Colitis Activity Index score at the time of diagnosis was a significant predictive factor for both pouchitis (P = 0.001) and chronic pouchitis (P = 0.02).

CONCLUSIONS

Patients with UC and a higher PUCAI score at the time of diagnosis have a higher risk for developing pouchitis.

Refractory distal ulcerative colitis: is proctocolectomy always necessary?

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

Evaluation of preoperative predictors of development of pouchitis after ileal-pouch-anastomosis in ulcerative colitis

INTRODUCTION

In this retrospective study, we aimed to evaluate preoperative predictive risk factors for development of pouchitis in the ulcerative colitis (UC) patients with ileal pouch-anal anastomosis (IPAA).

METHODS

The records of UC patients who underwent IPAA surgery and were under follow-up in the inflammatory bowel disease (IBD) clinic of our hospital between January 1994 and September 2009 were retrieved. Preoperative clinical, biochemical, and endoscopic findings, as well as preoperative endoscopic activity index (EAI), preoperative disease activity index (DAI) and operative characteristics were recorded. Patients with endoscopic, histological and clinical findings consistent with pouchitis were identified.

RESULTS

Out of a total of 49 patients who underwent IPAA for UC, pouchitis was identified in 20 (40.8%) of them. Overall, 37 (75.5%) patients had chronic active disease, eight (16.3%) patients had chronic intermittent disease with frequent relapses, and four (8.2%) patients had fulminant colitis prior to surgery. There was a statistically significant difference (P=0.02) among these patients for the development of pouchitis in postoperative period. The mean EAI (10.1 vs. 8.7, P=0.02) and DAI (10.0 vs. 8.6, P<0.01) in patients with pouchitis were significantly higher than that of patients who did not develop pouchitis. Multivariate analysis revealed steroid dependency (P=0.02), and a higher DAI (P=0.02) to be independent risk factors for the development of pouchitis.

CONCLUSION

A more severe preoperative clinical course and steroid dependency, as well as higher endoscopic and disease activity scores may be useful as preoperative predictors of subsequent pouchitis in UC patients undergoing IPAA surgery.

Risk factors for chronic pouchitis after ileal pouch-anal anastomosis: a prospective cohort study

AIM

The association between various demographic, clinical and pathological parameters and the evolution of chronic pouchitis was evaluated.

METHOD

All ulcerative colitis patients who underwent ileal pouch anal anastomosis (1981-2009) were followed prospectively in a comprehensive pouch clinic. We examined risk factors including the presence of appendiceal inflammation and backwash ileitis in the colonic specimen, gender, ethnicity, age at disease onset, disease duration, extent of colitis, presence of extraintestinal manifestations (e.g. primary sclerosing cholangitis), family history of inflammatory bowel disease, indication for surgery, medical treatment, age at operation, staged procedure, diverting ileostomy and length of follow-up. Univariate analysis was performed on all risk factors followed by logistic regression analysis.

RESULTS

The 201 enrolled patients (106 women, age at surgery 35 ± 15 years) were followed for a mean of 108 months. One hundred and thirty-eight (69%) had either a normal pouch or episodes of acute pouchitis and 63 (31%) developed chronic pouchitis. On univariate analysis the presence of an ileostomy (P = 0.017), pancolitis (P = 0.008), shorter disease duration (P = 0.04) and longer follow-up (P = 0.01) were identified as risk factors for chronic pouchitis. Multivariate analysis showed that patients with pancolitis (OR 3.26, 95% CI 1.20-8.85) and longer follow-up (OR 1.09, 95% CI 1.01-1.18) were more likely to develop chronic pouchitis. There was also an association to disease duration but this did not reach a level of significance.

CONCLUSIONS

Pancolitis and longer follow-up are directly related to the development of chronic pouchitis.

Predictors for acute and chronic pouchitis following restorative proctocolectomy for ulcerative colitis

OBJECTIVE

This study was undertaken to evaluate the cumulative incidence, onset and risk predicting factors for acute and chronic pouchitis.

METHOD

A consecutive series of patients (n = 210), who underwent restorative proctocolectomy (RPC) and had a minimum follow-up of 12 months was reviewed. The cumulative incidence and onset of pouchitis was determined. Univariate analysis, followed by logistic regression analysis was used to evaluate the association of various demographic, clinical and histopathologic variables with the subsequent development of acute and chronic pouchitis.

RESULTS

A total of 198 patients were included. The mean follow-up was 64 months (range, 12-180). Sixty-four patients (32%) developed pouchitis, 35 acute and 29 chronic. The first episode of pouchitis occurred within the first year in 70% of cases. The presence of backwash ileitis (OR, 2.6; P = 0.015), primary sclerosing cholangitis (PSC; OR, 2; P = 0.018) and the duration of follow-up (OR, 1.1; P = 0.043) were associated with a higher incidence of pouchitis. The duration of follow-up was the only variable associated with acute pouchitis (P = 0.007). The presence of backwash ileitis and PSC were independent risk factors for chronic pouchitis (OR, 5.9; P < 0.001; OR, 2.8; P = 0.001 respectively).

CONCLUSION

Pouchitis is a heterogeneous disease which tends to occur early after restoration of gastrointestinal continuity. Patients with backwash ileitis and/or PSC are at considerable risk of developing chronic pouchitis. The strong association between backwash ileitis, PSC and chronic pouchitis suggests a common link in their pathogenesis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Sulphomucin expression in ileal pouches: emerging differences between ulcerative colitis and familial adenomatous polyposis pouches

PURPOSE

We characterized the expression of sialomucin and sulphomucin in pouches fashioned for familial adenomatous polyposis and ulcerative colitis. We correlated sulphomucin expression with bacterial colonization and mucosal inflammation.

METHODS

Ethical approval and informed consent were obtained. Mucosal biopsies from 9 patients with familial adenomatous polyposis and 12 with ulcerative colitis were obtained. Sulphomucin levels were assessed by using the high iron-diamine stain. Mucous gel layer composition was correlated with villous height, crypt depth, and total mucosal thickness. Mucous gel layer composition was correlated with acute and chronic inflammatory infiltrates. Colonization by a panel of seven bacterial species (including sulphate reducing bacteria) was established and correlated with sulphomucin levels.

RESULTS

High-iron-diamine positivity (i.e., sulphomucin expression) was greater in ulcerative colitis pouch mucous gel (2.083 +/- 0.5 vs. 0.556 +/- 0.4, P = 0.003). Sulphomucin expression correlated with reduced crypt depth, villous height, and total mucosal thickness. In the ulcerative colitis group, chronic inflammatory infiltrate scores were significantly greater for high-iron-diamine-positive patients. Colonization by sulphate reducing bacteria was increased in high-iron-diamine-positive patients.

CONCLUSIONS

Sulphomucin expression is increased in the mucous gel layer of the ulcerative colitis pouch compared with that of the familial adenomatous polyposis pouch. Sulphomucin expression is associated with colonization by sulphate-reducing bacteria and increased chronic inflammation.

Surgery for ulcerative colitis

Ulcerative colitis is an inflammatory condition of unknown aetiology affecting all or part of the rectum and colon. The mainstay of treatment is medical but there are specific indications for surgical intervention. This article reviews the evolution of surgical management and in particular compares outcome from proctocolectomy and pouch surgery. A number of factors determining choice of procedure are examined, including elective or emergency presentation, patient selection, technical issues, morbidity and quality of life. Emphasis is made regarding a full explanation of these factors so that the patient is fully involved in the final decision regarding choice of procedure.

Ileal pouch anal anastomosis for ulcerative colitis is feasible for septuagenarians

OBJECTIVE

Proctocolectomy and ileal pouch anal anastomosis (IPAA) has become the standard surgery for patients with mucosal ulcerative colitis (MUC). Although there is no absolute age limitation, there are concerns as to its use in elderly patients due to the risks of potential complications and poor function. The aim of this study was to assess the complications and outcome of patients over the age of 70 years with MUC who underwent IPAA. Results in these patients were compared to the results in a group of patients aged less than 70 years who had IPAA.

METHODS

After Institutional Review Board approval, a retrospective review of the medical records of patients with MUC who underwent IPAA was undertaken. These patients were divided into four age groups: <30 years of age, 30-49 years, 50-69 years, >or=70 years.

RESULTS

From 1989 to 2001, 330 patients underwent IPAA for preoperative clinical and histopathological and postoperative histopathologically confirmed MUC; 17 were aged>or=70 years. The mean hospital stay was 5.8 (SEM 0.7) days in the patients aged<70 years and 6.0 (SEM 0.4) days in the patients aged>or=70 years (P=0.911). Postoperative complications occurred in 39% of patients>or=70 years and in 40% in the <70 years group (P=0.08). Pouch failure occurred in two (11.8%) patients>or=70 years and in 6 (1.9%)<70 (P=0.2).

CONCLUSION

IPAA is a safe and feasible option in MUC patients over the age of 70 with functional results similar to results seen in younger patients.

Diagnostic difficulties in inflammatory bowel disease pathology

This review summarizes some of the common diagnostic problems encountered by pathologists when evaluating patients with chronic colitis and in whom inflammatory bowel disease (IBD) is either suspected or within the differential diagnosis. Both ulcerative colitis (UC) and Crohn's disease (CD) show characteristic, but non-specific, pathological features that may overlap and result in a diagnosis of 'indeterminate colitis' (IC). However, other reasons why pathologists may entertain a diagnosis of IC include failure to recognize or accept certain 'hardcore' histological features as indicative of CD, an attempt to classify cases of chronic colitis based on mucosal biopsy material or in the absence of adequate clinical and radiographic information, and the presence of other disease processes that mask, or mimic, IBD. In addition, some cases of UC may show unusual CD-like features, such as discontinuous or patchy disease, ileal inflammation, extracolonic inflammation, granulomatous inflammation in response to ruptured crypts, aphthous ulcers, or transmural inflammation. Furthermore, other forms of colitis, such as microscopic colitis, diverticulitis and diversion colitis may, on occasion, also show IBD-like changes. The clinical and pathological features that aid in the distinction between these entities, and others, are covered in detail in this review.

Practice parameters for the surgical treatment of ulcerative colitis

The American Society of Colon and Rectal Surgeons is dedicated to assuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Standards Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Histologic predictors of pouchitis in patients with chronic ulcerative colitis

Inflammation of ileal reservoir mucosa ("pouchitis") is a common sequelae in ulcerative colitis (UC) patients who have had a colectomy with ileal pouch anal-anastomosis (IPAA). Although several clinical, genetic, and laboratory parameters have been evaluated, reliable pathologic predictors for the development of pouchitis are lacking. The purpose of this case-control study was to determine whether there are any pathologic features in UC colectomy specimens that may help predict the subsequent development of pouchitis after an IPAA procedure. The study group consisted of 39 UC patients (male/female ratio: 21/18, mean age: 35 years), who had at least 1 episode of pouchitis after an IPAA procedure during the follow-up period (mean: 57 months, range: 12-121 months). There were 26 control patients (male/female ratio: 11/15, mean age: 37 years), all of whom also underwent a total colectomy and IPAA procedure for UC, but did not develop pouchitis during the follow-up period (mean: 78 months, range: 14-223 months). Routinely processed tissues from each colectomy specimen were evaluated for a variety of histologic features, such as extent of colitis, severity of colitis, extent of severe colitis, type and extent of ulceration, presence and severity of appendiceal inflammation, and the presence of active ileitis, and compared between the study and control patients. Pathologic features that were associated with the subsequent development of pouchitis included the presence of severe colitis that extended into the cecum (severe pancolitis), which was present in 7/39 (18%) pouchitis patients, but in none (0%) of the control patients (P = 0.03), early fissuring ulcers [9/39 (23%) pouchitis cases versus 1/26 (4%) controls (P = 0.04)], active inflammation of the appendix [20/32 (63%) pouchitis patients versus 7/19 (31%) controls (P = 0.03)], and appendiceal ulceration [13/32 (41%) pouchitis patients versus none (0%) of the controls (P = 0.002)]. No significant differences in patient gender or age, depth or extent of ulceration, or the presence or absence of "backwash ileitis" were identified between the 2 groups. In conclusion, there are several histologic features in colectomy specimens from UC patients who have undergone an IPAA procedure that may help predict the subsequent development of pouchitis. Of these features, appendiceal ulceration is highly associated with pouchitis.

Restorative proctocolectomy with ileal pouch-anal anastomosis in very young patients with refractory ulcerative colitis

BACKGROUND/PURPOSE

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the standard surgical treatment for ulcerative colitis (UC). The purpose of the current study was to determine the outcome of very young patients (< or =10 years of age) with UC undergoing IPAA.

METHODS

Between 1978 and 2002, 13 patients 10 years of age or younger underwent IPAA for management of UC at the authors' institution. Charts were reviewed for patient characteristics, and a standardized telephone interview was performed.

RESULTS

Average age at diagnosis was 4.0 years (range, 1.0 to 8.4 years), and patients underwent IPAA at a mean of 6.8 years (range, 3.7 to 10.8 years). Pancolitis was present in 100%. The mean follow-up was 9.1 years (1.0 to 16.1 years), the average number of stools per day was 5 (3 to 8). All patients are continent while awake. Pouchitis was documented in 9 patients (75%). All patients or their parents rated the outcome of their procedures as "excellent."

CONCLUSIONS

When compared with older children, very young patients with UC tend to have more frequent total colonic involvement and a greater frequency of pouchitis after IPAA. The functional outcome and patient/family satisfaction with the procedure endorse IPAA as an attractive procedure even in the very young population with UC.

Outcome of patients undergoing ileal pouch-anal anastomosis for left-sided chronic ulcerative colitis

Chronic ulcerative colitis is not a uniform disease entity because the clinical pattern and disease characteristics differ on the basis of the anatomic location of the inflammation. The aim of this study was to compare the preoperative characteristics, postoperative complications, and long-term functional outcome of ileal pouch-anal anastomosis (IPAA) in patients with left-sided colitis to those same characteristics in patients with pancolitis. Between 1990 and 1996, a total of 565 patients underwent IPAA for chronic ulcerative colitis at our institution. Of these, 111 patients were determined to have left-sided involvement, whereas 283 patients had pancolitis. The mean age at surgery was greater in the patients with left-sided colitis (37 years vs. 34 years, P = 0.01), and the mean duration of disease (8.7 years vs. 7.7 years, P = 0.05) tended toward a significant difference between the left-sided colitis and pancolitis groups. The complication rates were similar with the exception of small bowel obstructions, for which there was a higher incidence in the group with left-sided colitis (27% vs. 13%, P = 0.002) at 5 years. The incidence of pouchitis (43% vs. 39%) at 5 years was comparable. Long-term functional results and quality-of-life assessment did not show any significant differences between the two groups. We were unable to detect any correlation between the extent of colon involvement and the subsequent incidence of pouchitis, long-term pouch function, and quality of life. Patients with left-sided colitis were older, had a relatively longer duration of disease, and were at increased risk for postoperative small bowel obstruction as compared to patients with pancolitis.

Risk factors for ileoanal J pouch-related septic complications in ulcerative colitis and familial adenomatous polyposis

OBJECTIVE

To analyze the association between pre- and perioperative factors and pouch-related septic complications (PRSC) in ulcerative colitis (UC) and in familial adenomatous polyposis (FAP) after ileal pouch-anal anastomosis (IPAA).

SUMMARY BACKGROUND DATA

For patients with UC and FAP, IPAA is the surgical therapy of choice, but in some patients the outcome is compromised by PRSC.

METHODS

A total of 706 consecutive patients (494 UC, 212 FAP) were assessed in a study aimed at identifying subgroups of patients who were at high risk for PRSC. The rate of PRSC was analyzed as a time-dependent function (Kaplan-Meier estimation). Patients with UC and FAP were stratified separately according to associated factors (age, sex, surgeon's experience, temporary ileostomy, colectomy before IPAA, anastomotic tension, and several factors specific for UC).

RESULTS

In all, 131 (19.2%) patients had PRSC (23.4% UC, 9.4% FAP). In patients with UC, the estimated 1-year PRSC rate was 15.6% and the estimated 3-year PRSC rate was 24.2%. In patients with FAP, the estimated 1-year and 3-year PRSC rates were 9.2%. The difference between the estimated rates of PRSC was significant (P <.001). In the univariate analysis, patients with UC younger than 50 years, with severe proctitis, with preoperative hemoglobin levels less than 10 g/L, or receiving corticoid medication had a significantly higher risk for PRSC (P =.039, P =.037, P =.047, P =.003, respectively). Multivariate analysis showed that patients with UC receiving a systemic prednisolone-equivalent corticoid medication of more than 40 mg/day had a significantly greater risk of developing pouch-related complications than patients with UC receiving 1 to 40 mg/day and patients with UC who were not receiving corticoid medication (RR: 3.78, 2.25, 1, respectively, P <.001). Patients with FAP proved to have a significantly higher risk for PRSC in the univariate and multivariate analyses if anastomotic tension had occurred (RR 3.60, P =.0086).

CONCLUSIONS

Pouch-related septic complications occur as late complications and should therefore be considered in regular, specific long-term follow-up examinations. The authors identified significant risk factors for PRSC specific to patients with UC and FAP; these must be considered for each individual surgical strategy.

Pouch and pouchitis

Pouchitis is an inflammation of unknown origin occurring in the ileal pouch after IPAA. It is considered by many to be a form of ulcerative colitis that recurs in the pouch and rarely, if ever, occurs in patients with FAP. Most patients respond to a short course of antibiotics. When remission cannot be maintained or the disease is nonresponsive to prolonged treatment with antibiotics, anti-inflammatory agents or steroids may be useful. A variety of alternative drugs have been tried with mixed success and should be considered as experimental. Rarely, when pouchitis is refractory to medical management, excision of the pouch may be required.

Restorative proctocolectomy for distal ulcerative colitis

BACKGROUND

Chronic distal colitis may cause troublesome symptoms and alter quality of life. When medical treatment fails to control symptoms, patients and doctors are often reluctant to consider surgical resection because of the relatively small portion of the large bowel affected by the disease.

AIM

To assess the outcome of restorative proctocolectomy (RP) in patients with distal colitis who required surgery for chronic debilitating symptoms and failed medical management.

PATIENTS/METHODS

From 1986 to 1996, of 263 patients receiving RP for ulcerative colitis, 27 (16 men) were operated on for distal ulcerative colitis limited to the rectum and sigmoid colon. Bowel function and quality of life were compared before and one year after RP.

RESULTS

The mean (SD) duration of ulcerative colitis was 11 (6) years. RP was performed at a mean age of 46 (10) years. All the pouches were J-shaped, and a diverting loop ileostomy was always performed. Mean (SD) hospital stay was 25 (10) days. Seven complications occurred in six patients. Previously unknown severe dysplasia was discovered on the colectomy specimen in two patients. After RP there was a significant decrease in mean (SD) daytime stool frequency (8.2 (4) v 4.7 (2), p<0.05), night-time stool frequency (2 (2) v 1 (1), p = 0.05), and the number of patients with urgency to defecate (26/27 v 1/27, p<0.001). Sex life was improved in eight patients, social life in 26, and professional life in eight. Twenty six patients were satisfied with the results, and 25 wished that they had received surgery earlier in the course of their disease.

CONCLUSION

RP can improve bowel function and quality of life in patients with disabling chronic symptoms of distal ulcerative colitis.

Restorative proctocolectomy for distal proctocolitis

BACKGROUND

Restorative proctocolectomy (RP) is usually the surgical treatment of choice for severe ulcerative colitis, but patients with distal disease (rectosigmoid only) are frequently denied operation on the grounds that they are not systemically ill. Nevertheless, they may continue to have high frequency, low volume diarrhoea with severe urgency and bleeding, despite medical therapy.

OBJECTIVE

To report the outcome of RP in `distal disease' compared with `more extensive' disease.

PATIENTS AND METHODS

The results of all patients having RP for ulcerative colitis between February 1983 and February 1997 were reviewed. We excluded patients later found to have Crohn's disease.

RESULTS

RP was used for 34 with `distal' disease compared with 134 with `more extensive' disease. Pre-operative steroids were used in 9% of the `distal' group compared with 34% in the `more extensive' group. Anastomotic leaks and pelvic sepsis occurred in 3% and 9%, respectively, in the `distal' group compared with 13% and 17% in the `more extensive' group, but these differences were not statistically significant. Pre-operative steroids significantly influenced anastomotic leaks 22% vs 5% (P = 0.006). Pouch-related fistulas occurred in 12% of the `distal' group compared with 15% in the remainder. Pouchitis occurred in 44% of the `distal' group: 44% compared with 33% in the remainder. Pouch failure occurred in 3% in `distal' compared with 15% in those with `more extensive' disease.

CONCLUSION

These results imply that RP has a role in the treatment of intractable `distal' colitis, that morbidity is low and urgency is usually eliminated.

Quality of life after pouch excision

BACKGROUND

Pouch excision is a devastating experience for patients having restorative proctocolectomy for ulcerative colitis.

METHODS

The quality of life among patients having pouch excision for ulcerative colitis was compared with that in those having proctocolectomy and ileostomy for ulcerative colitis using a validated standardized self-administered questionnaire.

RESULTS

After pouch excision patients (n = 9) had more troublesome bowel symptoms (mainly from liquid stoma output) than those in the proctocolectomy group (n = 14) (mean(s.d.) score 5.64(0.92) versus 6.13(0.37), P = 0.03). However, the mean scores for the other parameters (systemic symptoms, functional, social and emotional impairment) did not differ significantly.

CONCLUSION

Patients having pouch excision for ulcerative colitis have more liquid ileostomy loss but a comparable quality of life to those treated by standard proctocolectomy and ileostomy.

Functional results after restorative proctocolectomy complicated by pouchitis

This study aimed to examine the incidence and cumulative risk of pouchitis after restorative proctocolectomy for ulcerative colitis and to evaluate the clinical and functional results in patients with pouchitis.

METHODS

A total of 291 patients had proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis between January 1985 and January 1996. During follow-up, 65 patients had one or more episodes of pouchitis based on clinical, histologic, and endoscopic criteria. Functional results and patient satisfaction in these patients were compared with those of 65 matched control patients who had experienced no episodes of pouchitis.

RESULTS

Pouchitis developed in 65 patients (22 percent), giving rise to a cumulative frequency of 28 percent at 11 years after the operation. Only 13 patients (4.5 percent) had chronic pouchitis that required long-lasting treatment. A permanent ileostomy had to be constructed in one patient (0.3 percent) because of pouchitis. During the last year (1995), 60 percent of patients with pouchitis had medication, most often metronidazole and/or corticosteroids. Defecation frequency per 24 hours was 6.7 for all patients with pouchitis, 8.2 for those with chronic pouchitis (P < 0.05), and 6.3 for patients without pouchitis. Nighttime defecation occurred in 44 (80 percent) patients with pouchitis, compared with 37 (67 percent) of those without pouchitis (P > 0.05). Frequencies of soiling or flatus incontinence did not differ between the two groups. During the last year, 43 (80 percent) of the pouchitis patients, who answered the questionnaire, were working all the year or were on sick-leave less than one month.

CONCLUSIONS

Episodic pouchitis is easily treated and causes minimum functional consequences, whereas chronic pouchitis increases defecation frequency and needs prolonged medication. Pouchitis seems not to be a major threat to preventing the use of restorative proctocolectomy in ulcerative colitis, but still the small group of chronic pouchitis patients remains a problem.