Outcomes following surgery for perforating Crohn's disease

BACKGROUND

The most common indications for surgery for patients with ileocolic Crohn's disease are fibrostenotic or perforating disease. The objective was to compare surgical outcomes of patients with perforating versus non-perforating disease following ileocolic resection.

METHODS

This was a retrospective review of all patients who had their first ileocolic resection between 1990 and 2010, identified from a prospectively maintained inflammatory bowel disease database. Demographic information, preoperative medication, intraoperative findings and postoperative outcome data were collected. Outcomes in patients who had an abscess drained before surgery or were found to have a fistula or abscess at surgery or at pathology were compared with outcomes in all others.

RESULTS

A total of 434 patients (56·2 per cent women) were included, 293 with perforating and 141 with non-perforating disease. Median age, tobacco use, and preoperative steroid and biological agent use were similar in the two groups. Forty patients (13·7 per cent) in the perforating group had abscesses drained before surgery and 251 patients had at least one fistula, most commonly to the sigmoid colon. Patients with perforating disease were more likely to require preoperative total parenteral nutrition, need another resection, have an ileostomy and a longer mean postoperative stay, and less likely to undergo a laparoscopic procedure. Patients in this group also developed more postoperative abscesses or leaks (4·8 versus 0 per cent; P = 0·006). The reoperation rate was similar (3·1 versus 0·7 per cent; P = 0·178).

CONCLUSION

Patients with penetrating Crohn's disease are more likely to require a more complex procedure, and an ileostomy, and to a have longer postoperative stay.

Pregnancy, delivery, and pouch function after ileal pouch-anal anastomosis for ulcerative colitis

PURPOSE

This study was designed to evaluate the pregnancies, method of delivery, and functional results of females with chronic ulcerative colitis who have an ileal pouch-anal anastomosis.

METHODS

A mailed questionnaire was sent to all females with an ileal pouch-anal anastomosis for chronic ulcerative colitis. Information on the pregnancy, method of delivery, and outcome was collected. Those females who had a successful pregnancy and delivery were contacted by telephone to clarify results and determine pouch functional results. Other clinical information was obtained from the Mount Sinai Hospital Inflammatory Bowel Disease database.

RESULTS

Thirty-eight subjects had 67 pregnancies. Of these, 29 subjects had 49 deliveries. There were 25 vaginal deliveries and 24 cesarean sections. There were two pouch-related complications during the pregnancies and four pouch-related complications postpartum. All were treated nonoperatively. Stool frequency and day and night incontinence were increased during pregnancy in most subjects, but after delivery, prepregnancy function was restored in 24 (83 percent) of them. Five subjects (17 percent) had some degree of permanent deterioration in pouch function. Of these, three had vaginal deliveries, and two had cesarean sections. Multiple births and birth weight were not found to adversely affect subsequent pouch function.

CONCLUSION

Pregnancy is safe in females with ileal pouch-anal anastomosis. Functional results are altered almost exclusively during the third trimester, but pouch function promptly returns to prepregnancy status in most females. A small proportion of females have long-term disturbances in function, but these are not related to the method of delivery. Thus, the method of delivery should be dictated by obstetric considerations.

Quality of life is excellent after a pelvic pouch for colitis-associated neoplasia

PURPOSE

Despite high patient satisfaction with a pelvic pouch, patients experience some bowel dysfunction. Patients whose indication for surgery is neoplasia may have near-normal preoperative bowel function. We hypothesized that these patients would be less accepting of a poorer functional status after surgery, reflected in a poorer measure of quality of life.

METHOD

Sixteen patients who had dysplasia or cancer as the primary indication for surgery were compared with a matched control group whose indication for surgery was failed medical therapy. Quality of life was assessed using one disease-specific instrument, the Inflammatory Bowel Disease Questionnaire, two generic quality-of-life instruments, the Sickness Impact Profile and the Short Form 36, and two utility assessments.

RESULTS

The groups were well matched with no significant differences in functional outcome. Quality-of-life scores were high in both groups and there were no significant differences in overall quality of life between the two groups using all five instruments. There was evidence of a response shift phenomenon in the failed medical therapy control group.

CONCLUSION

Quality of life of patients who have a pelvic pouch for colitis-associated neoplasia is excellent and the same as that of patients who have a pouch for failure of medical therapy.

Internal sphincterotomy is superior to topical nitroglycerin in the treatment of chronic anal fissure: results of a randomized, controlled trial by the Canadian Colorectal Surgical Trials Group

PURPOSE

This was a multicenter, randomized, controlled trial to compare the effectiveness of topical nitroglycerin with internal sphincterotomy in the treatment of chronic anal fissure.

METHODS

Patients with symptomatic chronic anal fissures were randomly assigned to 0.25 percent nitroglycerin tid or internal sphincterotomy. Both groups received stool softeners and fiber supplements and were assessed at six weeks and six months.

RESULTS

Ninety patients were accrued, but 8 were excluded from the analysis because they refused internal sphincterotomy after randomization (6), the fissure healed before surgery (1), or a fissure was not observed at surgery (1). There were 38 patients in the internal sphincterotomy group (22 males; mean age, 40.3 years) and 44 patients in the nitroglycerin group (15 males; mean age, 38.7 years). At six weeks 34 patients (89.5 percent) in the internal sphincterotomy group compared with 13 patients (29.5 percent) in the nitroglycerin group had complete healing of the fissure (P = 5x10(-8)). Five of the 13 patients in the nitroglycerin group relapsed, whereas none in the internal sphincterotomy group did. At six months fissures in 35 (92.1 percent) patients in the internal sphincterotomy group compared with 12 (27.2 percent) patients in the nitroglycerin group had healed (P = 3x10(-9)). One (2.6 percent) patient in the internal sphincterotomy group required further surgery for a superficial fistula compared with 20 (45.4 percent) patients in the nitroglycerin group who required an internal sphincterotomy (P = 9x10(-6)). Eleven (28.9 percent) patients in the internal sphincterotomy group developed side effects compared with 37 (84 percent) patients in the nitroglycerin group (P<0.0001). Nine (20.5 percent) patients discontinued the nitroglycerin because of headaches (8) or a severe syncopal attack (1).

CONCLUSIONS

Internal sphincterotomy is superior to topical nitroglycerin 0.25 percent in the treatment of chronic anal fissure, with a high rate of healing, few side effects, and low risk of early incontinence. Thus, internal sphincterotomy remains the treatment of choice for chronic anal fissure.

Can the standard gamble be used to determine utilities for uncertain health states? An example using postoperative maintenance therapy in Crohn's disease

The objective of this study was to determine whether patients with Crohn's disease (CD) value the absolute reduction in postoperative recurrence risk attributable to therapy with mesalamine (5-ASA). One hundred subjects evaluated state A (taking 5-ASA; 25% risk of recurrence), state B (not taking 5-ASA; 40% risk of recurrence), and state C (100% risk of recurrence) by rank order, visual analog scale (VAS), and standard gamble (SG). Sixty-five of 91 patients (71%) with completed and usable questionnaires had the same preference order for state A (25% risk), state B (40% risk), and state C (100% risk) on both the VAS and the SG. The mean scores for state A (25% risk), state B (40% risk), and state C (100% risk), respectively, were 67.5, 49.8, and 19.8 on the VAS and 0.977, 0.972, and 0.910 on the SG. Subgroup analyses using stepwise logistic regression showed that risk attitude seemed to be predictive of subjects' preferences for 5-ASA. These results suggest that most subjects seem to value the 15% absolute risk reduction offered by 5-ASA. Furthermore, the SG seems to be a feasible method for measuring utilities for uncertain health states in patients with CD.

Comparison of ileal pouch-anal anastomosis and ileorectal anastomosis in patients with familial adenomatous polyposis

PURPOSE

The aim of this study was to evaluate the surgical complications and long-term outcome and assess the functional results and quality of life after ileorectal anastomosis and ileal pouch-anal anastomosis in patients with familial adenomatous polyposis.

METHODS

From 1980 to 1997, 131 patients with familial adenomatous polyposis were operated on or were followed up or both at the Familial Gastrointestinal Cancer Registry at Mount Sinai Hospital. Demographic and operative data were prospectively collected in the ileal pouch-anal anastomosis group, and retrospectively in the ileorectal anastomosis group. A questionnaire or telephone interview or both were undertaken to evaluate functional outcome and quality of life.

RESULTS

The ileorectal anastomosis group consisted of 60 patients (mean age, 31 years; mean follow-up, 7.7 years). In the ileal pouch-anal anastomosis group there were 50 patients (mean age, 35 years; mean follow-up, 6 years). There were no statistically significant differences with respect to anastomotic leak rate in ileal pouch-anal anastomosis vs. ileorectal anastomosis (12 vs. 3 percent; P = 0.21), risk of small-bowel obstruction (24 vs. 15 percent; P = 0.58), and risk of intra-abdominal sepsis (3 vs. 2 percent; P = 0.86). Reoperation rate was similar in the two groups (14 vs. 16 percent; P = 0.94). Twenty-one patients (37 percent) with ileorectal anastomosis were converted to ileal pouch-anal anastomosis (12 patients) or proctocolectomy (9 patients), because of rectal cancer (5 patients), dysplasia (1 patient), or uncontrollable rectal polyps (15 patients). Two pelvic pouches were excised, and another one was defunctioned. Information regarding functional results and quality of life was obtained in 40 patients (66.6 percent) in the ileorectal anastomosis group and in 43 patients (86 percent) in the ileal pouch-anal anastomosis group. Patients with ileorectal anastomosis had a significantly better functional outcome with regard to nighttime continence and perineal skin irritation. But otherwise, functional results and quality of life were similar.

CONCLUSIONS

Although ileorectal anastomosis has a better functional outcome, ileal pouch-anal anastomosis may be preferable because of the lower long-term failure rate. Ileorectal anastomosis is still an option in patients with familial adenomatous polyposis with rectal polyp sparing and good compliance for follow-up.

Functional outcome of conversion of ileorectal anastomosis to ileal pouch-anal anastomosis in patients with familial adenomatous polyposis and ulcerative colitis

PURPOSE

The aim of this study was to review the functional outcome in 20 patients with familial adenomatous polyposis and ulcerative colitis who were converted from ileorectal anastomosis to ileal pouch-anal anastomosis.

METHODS

From 1985 to 1997, 12 patients with familial adenomatous polyposis (5 males; mean age, 39.1 years) and 8 patients with ulcerative colitis (5 males; mean age, 36.7 years) underwent conversion from ileorectal anastomosis to ileal pouch-anal anastomosis. Clinical and operative data were analyzed retrospectively. Functional results were obtained by telephone interview in 16 patients (94 percent) after pouch construction. Four patients were not interviewed (2 were deceased, 1 was lost to follow-up, and 1 was not reachable).

RESULTS

Indications for conversion were uncontrollable rectal polyps (10 patients) and colonic cancer found in the pathology specimen after ileorectal anastomosis in patients with familial adenomatous polyposis (2 patients), intractable proctitis (5 patients), colonic cancer found in the pathology specimen of patients with ulcerative colitis after ileorectal anastomosis (2 patients), and rectal dysplasia (1 patients). Mean follow-up time was 5 (range, 1-11) years. Ileal pouch-anal anastomosis was handsewn in 14 patients, and the remaining cases were double-stapled in 4 patients with ulcerative colitis. No intraoperative difficulties were reported in 13 cases; technical problems were related to adhesions (3 cases), difficult rectal dissection (2 cases), and stapler-related difficulties (2 cases). Postoperative complications after ileal pouch-anal anastomosis included small-bowel obstruction (4 patients) and ileal pouch-anal anastomosis leak (1 patient). Patients with ileorectal anastomosis vs. those with ileal pouch-anal anastomosis had a better functional outcome with regard to nighttime continence (14 (88 percent) vs. 6 (38 percent) patients) and average bowel movements (<6/day; 12 (75 percent) vs. 4 (25 percent) patients). Complete daytime continence, 15 (94 percent) vs. 10 (62 percent) patients, was similar in the two groups. Physical and emotional well-being were similarly rated as very good to excellent.

CONCLUSIONS

In patients with familial adenomatous polyposis and ulcerative colitis with ileorectal anastomosis, conversion to ileal pouch-anal anastomosis may be required. In view of the risk of rectal cancer or intractable proctitis, patients seem to accept the conversion in spite of poorer bowel function.

Risk factors for pelvic pouch failure

PURPOSE

This study was designed to identify factors associated with pelvic pouch failure.

METHOD

A retrospective review of patients undergoing the pelvic pouch procedure with a minimum of 30 months follow-up was conducted.

RESULTS

A total of 551 patients had pelvic pouch procedures from 1981 to 1992. Forty-nine patients (8.8 percent) have undergone pouch excision, and 9 (1.6 percent) have been defunctioned, for 58 (10.5 percent) patients with pouch failure. Cause of failure was leakage from the ileoanal anastomosis (IAA) in 21 (39 percent) patients, poor functional results in 13 (23 percent), pouchitis in 7 (12 percent), pouch leakage in 7 (12 percent), perianal disease in 7 (12 percent), and miscellaneous in 3 (5.2 percent). Nine of 22 patients (41 percent) had pouch failure during the first two years, with 2 of 147 patients (1 percent) having failure during the last two years of the study. The 58 patients whose pouches failed (Group 1) were compared with the 493 patients whose pouches did not fail (Group 2). Handsewn IAA (P < 0.001), tension on the IAA (P < 0.001), use of a defunctioning ileostomy (P < 0.01), a diagnosis of Crohn's disease (P < 0.001), and a leak from the pouch (P < 0.001) or the IAA (P < 0.001) were associated with pouch failure. Pouchitis was not a risk factor.

CONCLUSION

The majority of pouch failures were caused by leaks at the IAA. Although the leak rate remained stable, leaks following a stapled anastomosis seemed to have a better prognosis than leaks following a handsewn anastomosis. Experience with the pouch procedure and the management of complications likely plays an important role in decreasing the risk of pouch failure.

The effects of a secondary-treated bleached kraft mill effluent on aquatic organisms as assessed by short-term and long-term laboratory tests

The chronic effects of secondary-treated effluent from a bleached kraft mill were assessed by means of long-term and short-term laboratory tests. In the long-term test, the effects of the effluent on the life cycle of fathead minnows (Pimephales promelas) were studied. In this experiment, which began with the egg stage and continued through to sexual maturity and reproduction, the fish were exposed in the laboratory to well water (control) and five concentrations (viz., 1.25, 2.5, 5, 10, or 20%) of effluent for 275 days. The effluent concentrations did not significantly affect the hatching of the eggs, the mortality of the hatched fish, the incidence of visible morphological abnormalities, the mortality and the hatchability of the first generation eggs and larvae, and the weights of minnows at various stages of development. Based on a conservative evaluation of the data, a significant finding of this work was that effluent concentrations > or = 2.5% caused lower egg production as well as changes in the gender balance (i.e., increased numbers of individuals with male secondary sexual characteristics) of the fish. Further work is required to understand the causes and ecological significance of these findings. Two short-term tests, each lasting 7 days, were also run. In one, even 100% effluent did not reduce the survival or growth of minnow larvae, correctly predicting the lack of effluent effects on similar endpoints in the long-term test. In the other short-term test, while the survival of Ceriodaphnia was also unaffected by 100% effluent, their reproductive capacity was reduced, but only at effluent concentrations an order of magnitude greater than those affecting the reproduction of minnows in the long-term test.

Effects of a secondary-treated thermomechanical pulp mill effluent on aquatic organisms as assessed by short- and long-term laboratory tests

The chronic effects of secondary-treated effluent from a thermomechanical pulp (TMP) mill were assessed by means of long-term and short-term laboratory toxicity tests. The effluent used for the tests was sampled at a western Canadian mill using mostly softwoods and < 10% recycled fiber as furnish. In the long-term test, the effects of the effluent on the life cycle of fathead minnows (Pimephales promelas) were studied. In this experiment, which began with the egg stage and continued through to sexual maturity and reproduction, the fish were exposed in the laboratory to well water (control) and five concentrations (1.25%, 2.5%, 5%, 10%, or 20%) of effluent for 202 d. None of the effluent concentrations significantly affected the hatching of the eggs, the mortality, weight, length, gonad size, gender balance, and reproduction of the hatched fish, the prevalence of gross morphological and histopathological changes, and the hatchability of the first generation eggs. Two short-term tests, each lasting 7 d, were also performed. In these tests, 100% effluent caused no change in the survival/growth of minnow larvae or in the survival/reproduction of Ceriodaphnia.

Assessment of peripouch inflammation after ileoanal anastomosis using endoluminal ultrasonography

PURPOSE

This study was designed to assess the impact of endoluminal transpouch ultrasonography in the investigation and management of inflammatory complications of pelvic pouches and to compare endoluminal transpouch ultrasonography to pouchography and computerized axial tomograph scanning.

METHODS

A prospective evaluation was made of the presentation, investigation, treatment, and clinical outcome of 16 patients referred for endoluminal transpouch ultrasonography with dysfunctional pelvic pouches and no evidence of pouchitis on endoscopy.

RESULTS

There were 5 normal and 11 abnormal examinations. Six patients had peripouch inflammatory phlegmons, four patients had peripouch abscesses, and one patient had a rectovaginal fistula. A total of nine patients had anastomotic leaks detected. Two patients had abscesses drained under ultrasound guidance and a pigtail catheter left in situ. Pouchography detected only 3 of 8 (38 percent) anastomotic leaks detected by endoluminal transpouch ultrasonography. Computerized axial tomograph scan detected 2 of 5 (40 percent) peripouch abscesses or phlegmon detected by endoluminal transpouch ultrasonography. Patients with peripouch sepsis had significantly thicker anal wall thickness (23.8 vs. 16.8 mm; P < 0.02) and external sphincter thickness (9.1 vs. 7.3 mm; P < 0.05) than pouches with no sepsis.

CONCLUSIONS

Endoluminal transpouch ultrasonography appears to detect anastomotic leaks and peripouch sepsis and may guide the initial management of patients with dysfunctional pelvic pouches and an inconclusive clinical and endoscopic examination.

Quality of life, nutritional status, and gastrointestinal hormone profile following the Whipple procedure

BACKGROUND

To compare the quality of life, nutritional status, and gastrointestinal profiles of post-Whipple patients and postcholecystectomy patients.

METHODS

A cross-sectional survey of post-Whipple procedure patients and age- and sex-matched postcholecystectomy patients was performed. Quality of life was assessed using six instruments: Time Trade-off Technique, Direct Questioning of Objectives, Gastrointestinal Quality of Life Index, Sickness Impact Profile, Physician Global Assessment, and Visick Scale. A gastrointestinal symptomatology questionnaire was completed. Nutritional status was assessed by weight, the Subjective Global Assessment instrument, and skin anthropometry. Fasting and postprandial serum gastrin, somatostatin, insulin, pancreatic glucagon, enteroglucagon, and pancreatic polypeptide were measured.

RESULTS

The quality of life and gastrointestinal function of the Whipple patients was excellent and was not significantly different from that of the control subjects. There were no significant differences in gastrointestinal symptomatology although 5 Whipple patients complained of greasy bowel movements, and 1 patient reported difficulty maintaining weight. Despite this, nutritional status was within normal limits in all subjects. Six patients in the Whipple group followed a diabetic diet, 1 required insulin, and 3 required an oral hypoglycemic agent, whereas none of the control subjects were diabetic. There were no significant differences in the mean basal, peak, or integrated postprandial responses of the gut hormones with the exception of pancreatic polypeptide and gastrin (in patients having a standard Whipple procedure only).

CONCLUSION

Quality of life and nutritional status are excellent in patients following a Whipple procedure.

A laboratory exposure procedure for screening pulp and paper mill effluents for the potential of causing increased mixed function oxidase activity in fish

To better understand the relationships between pulp manufacturing processes and mixed function oxidase (MFO) enzyme induction in fish, a practical and standardized exposure procedure is required. This study was undertaken to develop a laboratory-based exposure procedure to quantify the relative MFO induction potencies of different types of pulp and paper mill effluents. One major consideration in developing the procedure was to ensure that the protocol was practical so that tests could be performed in a short time, with small volumes of effluents and using simple experimental conditions. A series of concentration-response and time-course experiments were conducted to find the minimum time and effluent concentration which could distinguish the ability of different effluents to cause significant MFO induction in rainbow trout in the laboratory. Experiments were also conducted to determine the effects of biotic and abiotic factors such as loading density, fish size and feeding regime. This study showed that the exposure of rainbow trout in the laboratory to 10% concentration of secondary-treated effluent for 96 h caused significant increases in hepatic MFO activity. The magnitude of MFO induction was comparable to other field and laboratory observations. While fish size, loading density and feeding regime were found to affect the test results, consistent responses within a laboratory using this protocol are possible, provided that these factors are standardized. Therefore, the short-term exposure approach described in this paper could be a relevant tool for assessing the ability of different types of pulp and paper mill effluents to cause MFO induction in fish.