The ileal pouch-anal anastomosis: success and failure.
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Abscess↗
Biomedical subjects
R R Dozois
Publications and source records attributed to R R Dozois.
J ileal pouch-anal anastomosis for chronic ulcerative colitis: complications and long-term outcome in 1310 patients.
AIM: The purpose of the study was to determine the risk of postoperative complications and the functional outcome after a hand-sewn ileal pouch-anal anastomosis (IPAA) for ulcerative colitis using a single J-shaped pouch design. METHODS: Preoperative function, operative morbidity and long-term functional outcome were assessed prospectively in 1310 patients who underwent IPAA between 1981 and 1994 for ulcerative colitis. RESULTS: Three patients died after operation. Postoperative pelvic sepsis rates decreased from 7 per cent in 1981-1985 to 3 per cent in 1991-1994 (P = 0.02). After mean follow-up of 6.5 (range 2-15) years, the mean number of stools was 5 per day and 1 per night. Frequent daytime and nighttime incontinence occurred in 7 and 12 per cent of patients respectively, and did not change over a 10-year period. The cumulative probability of suffering at least one episode of 'clinical' pouchitis was 18 and 48 per cent at 1 and 10 years and the cumulative probability of pouch failure at 1 and 10 years was 2 and 9 per cent respectively. CONCLUSION: These results indicate that increased experience decreases the risk of pouch-related complications and that with time the functional results remain stable, but the failure rate increases.
Adolescent↗
Surgical treatment of adenocarcinoma of the rectum.
OBJECTIVE: The authors' aim was to determine survival and recurrence rates in patients undergoing resection of rectal cancer achieved by abdominoperineal resection (APR), coloanal anastomosis (CAA), and anterior resection (AR) without adjuvant therapy. SUMMARY BACKGROUND DATA: The surgery of rectal cancer is controversial; so, too, is its adjuvant management. Questions such as preoperative versus postoperative radiation versus no radiation are key. An approach in which the entire mesorectum is excised has been proposed as yielding low recurrence rates. METHODS: Of 1423 patients with resected rectal cancers, 491 patients were excluded, leaving 932 with a primary adenocarcinoma of the rectum treated at Mayo. Eighty-six percent were resected for cure. Surgery plus adjuvant treatment was performed in 418, surgery alone in 514. These 514 patients are the subject of this review. Among the 514 patients who underwent surgery alone, APR was performed in 169, CAA in 19, AR in 272, and other procedures in 54. Eighty-seven percent of patients were operated on with curative intent. The mean follow-up was 5.6 years; follow-up was complete in 92%. APR and CAA were performed excising the envelope of rectal mesentery posteriorly and the supporting tissues laterally from the sacral promontory to the pelvic floor. AR was performed using an appropriately wide rectal mesentery resection technique if the tumor was high; if the tumor was in the middle or low rectum, all mesentery was resected. The mean distal margin achieved by AR was 3 +/- 2 cm. RESULTS: Mortality was 2% (12 of 514). Anastomotic leaks after AR occurred in 5% (16 of 291) and overall transient urinary retention in 15%. Eleven percent of patients had a wound infection (abdominal and perineal wound, 30-day, purulence, or cellulitis). The local recurrence and 5-year disease-free survival rates were 7% and 78%, respectively, after AR; 6% and 83%, respectively, after CAA; and 4% and 80%, respectively, after APR. Patients with stage III disease, had a 60% disease-free survival rate. CONCLUSIONS: Complete resection of the envelope of supporting tissues about the rectum during APR, CAA, and AR when tumors were low in the rectum is associated with low mortality, low morbidity, low local recurrence, and good 5-year survival rates. Appropriate "tumor-specific" mesorectal excision during AR when the tumor is high in the rectum is likewise consistent with a low rate of local recurrence and good long-term survival. However, the overall failure rate of 40% in stage III disease (which is independent of surgical technique) means that surgical approaches alone are not sufficient to achieve better long-term survival rates.
Adenocarcinoma↗
[Rectal carcinomas in HNPCC].
The true incidence of rectal cancer in HNPCC is still unknown. In our retrospective series analyzing 42 probands from HNPCC families, we found rectal cancer primaries in 29% of our probands. Patients with a first cancer diagnosed in the rectum developed metachronous colon cancer in 54% of the cases. These numbers indicate a requirement to discuss the most appropriate surgical procedure for preventive intervention (ileorectal anastomosis versus ileoanal pouch procedure).
Adult↗
Surgical management of ileosigmoid fistulas in Crohn's disease.
UNLABELLED: Ileosigmoid fistulas are found in Crohn's disease and may present a surgical dilemma. PURPOSE: This study was designed to examine surgical practice to determine types of intervention, enumerate complications, and elicit guidelines for surgical management. METHOD: The medical records of patients with ileosigmoid fistula and Crohn's disease from 1975 to 1995 were reviewed. RESULTS: Ninety patients (44 men) were studied. A preoperative diagnosis of ileosigmoid fistula was made in 77 percent of patients. Sigmoid repair was performed in 43 patients (47.8 percent), sigmoid resection in 32 patients (35.6 percent), 12 patients (13.3 percent) underwent more extensive procedures, and 3 patients (3.3 percent) either had surgery elsewhere or were observed. The fistula was never directly responsible for a stoma. The repair and resection groups were similar with respect to age, length of Crohn's disease, and preoperative symptoms. There was no significant difference between groups in the incidence of postoperative complications; there were no postoperative deaths. Average length of stay was 8.3 days following repair and 9.9 days after resection. Reasons for resection included significant purulence or inflammation, a large fistula defect, a defect on the mesenteric border of the sigmoid, and active sigmoid Crohn's disease. Surgeon's assessment of the presence of Crohn's disease in the sigmoid correlated with pathologic examination and was aided by knowledge of recent endoscopic appearance and biopsy results; intraoperative frozen section and colonoscopy were helpful in distinguishing serosal inflammation from active Crohn's disease. CONCLUSION: Contrast studies identified 77 percent of ileosigmoid fistulas preoperatively. Performing repair rather than resection does not increase the risk of complications, if standard surgical principles are followed. Preoperative or intraoperative endoscopy assists the surgical evaluation of the sigmoid.
Adolescent↗
Avoiding a stoma: role for segmental or abdominal colectomy in Crohn's colitis.
UNLABELLED: Total proctocolectomy and ileostomy for Crohn's colitis offers a low recurrence rate but commits patients to a permanent ileostomy. In contrast, segmental resection may predispose patients to recurrence and further surgery but may delay or avoid a stoma in select individuals. AIM: This study was undertaken to determine the risk of recurrence and the need for permanent stoma in patients treated with segmental or abdominal colectomy for Crohn's colitis. METHODS: Between 1976 and 1985, 699 patients underwent surgery for Crohn's colitis at the Mayo Clinic. Patients who had a total proctocolectomy and end ileostomy or primary ileal or anorectal disease were excluded from further study. Fifty-three patients had a colon resection without a permanent stoma, and 49 were alive and available for follow-up. During a mean follow-up of 14 years, completed questionnaires provided current details on subsequent medical and surgical therapies and/or stomas that were required. In these 49 patients, Crohn's of the colon involved the right, left, and both sides of the colon in 12, 31, and 6 patients, respectively, and involved less than one-third, one to two-thirds, and greater than two-thirds of the colon in 23, 25, and 1 patients, respectively. RESULTS: Twenty-two of forty-nine patients (45 percent) required no further therapy. In 27 patients (55 percent), further treatment was required, including 11 (22 percent) patients who were managed medically (only 4 >1 year) and 16 (33 percent) patients who were managed surgically. Three recurrences developed in the small bowel; the remaining 24 developed in the colon. For the 16 patients with recurrence requiring surgery, mean time to recurrence was 51 +/- 14 months; in all cases, recurrent disease involved the colon, with four anastomotic recurrences. At first recurrence, ten patients underwent another limited colon resection, and six patients underwent completion proctectomy with permanent ileostomy. Five patients required a third procedure, only one of which resulted in a permanent ileostomy. Therefore, 42 patients (86 percent) remained stoma-free, and 7 (14 percent) ultimately required permanent ileostomy, with a mean stoma-free interval of 23 +/- 4 months. CONCLUSION: Colon resection without proctectomy in select patients with limited colonic Crohn's disease can delay or avoid the necessity of a permanent stoma.
Adolescent↗
Ileal pouch-anal canal anastomosis for familial adenomatous polyposis: early and late results.
OBJECTIVE: The objective was to review the early and late results of ileal pouch-anal anastomosis (IPAA) done for patients with familial adenomatous polyposis (FAP). SUMMARY BACKGROUND DATA: Patients with FAP will have colorectal adenomas develop and die of colorectal cancer if left untreated. Ileal pouch-anal anastomosis removes all disease-bearing mucosa while preserving transanal passage of stools. METHODS: Between 1981 and 1994, 187 patients with FAP, 11 to 59 years of age with a mean follow-up of 60 months (range, 5-170 months) had proctocolectomy and IPAA at Mayo Medical Center in Rochester, Minnesota. All patients had a proximal anal canal mucosal excision and a hand-sewn anastomosis of the pouch to the anal canal at the dentate line. A temporary ileostomy was used in 85% of the patients. RESULTS: No early postoperative deaths occurred, although two patients died later of metastatic colorectal carcinoma present at their initial operation. More important, no patient had a new cancer develop after IPAA. The overall morbidity after operation was 24%, with small bowel obstruction being the most common complication (13%). Patients had four bowel movements/24 hours and good fecal control, which continued during follow-up. CONCLUSIONS: The IPAA eradicates the risk of colorectal cancer in patients with FAP. It can be performed with low mortality, acceptable morbidity, and good functional results over the long term.
Adenomatous Polyposis Coli↗
Locally recurrent colorectal cancer: IOERT and EBRT +/-5-FU and maximal resection.
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Adult↗
Locally advanced primary colorectal cancer: IOERT and EBRT +/-5-FU.
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Antimetabolites, Antineoplastic↗
Disconnection, pouch revision and reconnection of the ileal pouch-anal anastomosis.
The aim of this retrospective study was to determine the outcome of patients with a dysfunctional pelvic ileal reservoir in whom disconnection of an ileal pouch-anal anastomosis (IPAA), pouch revision and reanastomosis had been carried out. There were 23 patients (15 women). At the revision operation functional problems were found to be due to a long efferent spout (nine patients), sepsis and/or fistula (four), a redundant blind limb (three), a twisted pouch (three), anastomotic problems (three) or no reservoir (one). The pouch was salvaged in 16 patients and a new pouch was constructed in seven. The pouch-anal anastomosis was resutured in 22 patients and stapled in one. Postoperative complications (all minor) occurred in six patients. Two patients underwent two revision of IPAA. At a median follow-up of 5 (range 1-10) years, 11 patients reported good to excellent function, five reported fair function and one reported recurrent pouchitis. Revision surgery was unsuccessful in six of 23 patients (three had gross incontinence, two excessive bowel movements and one Crohn's disease), and they subsequently underwent pouch excision. It is concluded that revision of an ileal reservoir and IPAA can be undertaken safely with good results in carefully selected patients.
Adenomatous Polyposis Coli↗
Long-term results of ileal pouch-anal anastomosis in patients with Crohn's disease.
PURPOSE: Ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for most patients with chronic ulcerative colitis. Crohn's disease is, however, a contraindication. Because distinction between UC and Crohn's disease can be difficult, some patients with Crohn's disease inadvertently undergo IPAA. The aim of this study was to determine the long-term outcome of patients with Crohn's disease who have undergone IPAA. METHODS: A total of 37 patients (20 men) were studied. Each had undergone mucosectomy with handsewn IPAA (J-pouch, n = 35; S-pouch, n = 1; W-pouch, n = 1). Histologic examination of the resected specimen at time of IPAA showed features of ulcerative colitiis (n = 22), indeterminate colitis (n = 9), or Crohn's disease (n = 6). The stoma was closed in all patients. RESULTS: A total of 11 of 37 patients developed complex fistulas (pouch-cutaneous (n = 6), pouch-vaginal (n = 4), or pouch-vesical (n = 1). Crohn's disease has recurred in the pouch (n = 20), anal canal (n = 4), pouch and anal canal (n = 10), and elsewhere (n = 3). After ten years (range, 3-14), the pouch remains in situ in 20 patients in whom frequency of bowel movement is seven times (3-10)/24 hours, in situ but defunctioned in seven patients, and excised in ten patients (failure rate, 45 percent). CONCLUSIONS: Inadvertent IPAA for Crohn's disease is associated with a high rate of failure (45 percent) but an acceptable long-term functional result if the pouch can be kept in situ.
Adult↗
Curative reoperations for locally recurrent rectal cancer.
PURPOSE: Our aims were to determine the morbidity, survival and its influencing factors, and patterns of failure for patients who underwent further surgery with the hope of cure for locally recurrent rectal cancer. METHODS: Between January 1981 and December 1988, 224 patients with a preoperative diagnosis of recurrent rectal cancer underwent additional surgery at Mayo Medical Center in Rochester, Minnesota. Of these, 65 underwent further surgery with the hope of cure, i.e., no gross/microscopic residual disease at tumor margins after reoperation. Factors assessed included type of original operation, time interval between operation for primary tumor and initial operation for recurrence, symptom status, degree of fixation, types of reoperations for recurrence, and adjuvant therapy. RESULTS: None of the patients died within 30 days of reoperation. Seventeen complications requiring hospitalization and/or surgical procedure were observed in 14 patients. Extended operations (involving partial or complete removal of surrounding organs/structures) required more time to perform, a greater number of transfusions, and a longer hospital stay than more limited operations. Three-year, five-year, and median survival were 57, 34, and 44.7 months, respectively. Survival was greater after curative than after palliative resection (P < 0.001). Survival tended to be greater in females (P < 0.075) and in patients without pain (P < 0.065). Cumulative probability of local failure was 24, 41, and 47 percent at 1, 3, and 5 years, respectively. Cumulative risk of distant metastasis was 30, 51, and 62 percent at 1, 3, and 5 years, respectively. CONCLUSIONS: Our results indicate that complete excision of locally recurrent rectal cancer can provide a significant number of patients with long-term survival and can be accomplished safely in select patients.
Antimetabolites, Antineoplastic↗
Long-term causes of death following ileal pouch-anal anastomosis.
PURPOSE: The aim of this study was to identify the overall long-term causes of death in a large series of patients who were undergoing proctocolectomy with ileal pouch-anal anastomosis (IPAA). METHODS: Records of patients who underwent proctocolectomy with IPAA at the Mayo Clinic affiliated hospitals between January 1981 and October 1994 were reviewed to determine overall mortality, cause, and timing of death. RESULTS: A total of 1,603 patients underwent proctocolectomy with IPAA reconstruction (1,407 for chronic ulcerative colitis (CUC), 187 for familial polyposis (FAP), and 9 for other diagnoses). Thirty-two patients have died, with an overall mortality rate of 2 percent. Mean age at time of death was 40 (23-60) years. There was no significant difference in overall mortality between patients with CUC and patients with FAP. Three deaths occurred postoperatively (0.2 percent) because of pulmonary embolism, perforated gastric ulcer, and subarachnoid hemorrhage. Late deaths occurred in 29 patients (1.8 percent), 10 months to 10.4 years after the operation. The most common cause of late death was cancer, including colon and rectal carcinoma (10 patients), hematologic malignancies (4 patients), cholangiocarcinoma (3 patients), and germ-cell carcinoma (1 patient). Four patients died from unrelated sepsis, two died following myocardial infarction, two patients died from complications of subsequent orthopedic surgery, and one patient died of cirrhosis. Two additional patients committed suicide. No late deaths were directly attributable to the IPAA procedure. CONCLUSIONS: Proctocolectomy with IPAA is a safe procedure. Operative mortality is low, and late deaths are related to carcinogenic and extracolonic manifestations of underlying or unrelated coexisting diseases and events.
Adenomatous Polyposis Coli↗
Laser photoablation of ileal reservoir adenomas.
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Adenoma↗
Changing referral patterns for surgical treatment of ulcerative colitis.
OBJECTIVE: To determine whether referral patterns for surgical treatment among patients with chronic ulcerative colitis have changed in recent years, especially in view of the introduction of a new operation, the ileal pouch-anal anastomosis (IPAA). MATERIAL AND METHODS: Between January 1976 and December 1986, 981 patients underwent proctocolectomy at Mayo Clinic Rochester. Brooke ileostomy (N = 300), colectomy with ileorectal anastomosis (N = 33), proctocolectomy with Kock pouch (N = 180), or ileal pouch-anal anastomosis (IPAA) (N = 468) was performed. The indications for surgical intervention were categorized as emergent or elective, the latter including intractability, cancer, and cancer prophylaxis. For analysis, the duration from diagnosis of disease to operation, indications for surgical treatment, and types of operation were subdivided into pre-IPAA era (before 1981) and post-IPAA era (from 1981 onward) for the entire group and for distant versus local patients. RESULTS: More continence-preserving operations were done in 1981 and thereafter (76%) than before 1981 (46%). In the later segment of the study period in comparison with before 1981, fewer operations were done for emergent reasons (4% versus 8%) and a greater percentage of operations were done for elective indications, especially intractability (74% versus 61%). With the advent of IPAA in 1981, patients underwent operation sooner after the diagnosis was made (7.4 years versus 8.6 years before 1981). A smaller proportion of patients underwent operation for cancer prophylaxis during 1981 through 1986 (19%), however, than before 1981 (28%). CONCLUSION: Referral patterns for surgical treatment of patients with ulcerative colitis have changed in recent years--patients are being referred for operation sooner, before complications develop that necessitate emergent procedures. Although the changed referral pattern may be due to the availability of IPAA, other factors may also have a role.
Adult↗
Comparison of surgical treatment of ulcerative colitis associated with primary sclerosing cholangitis: ileal pouch-anal anastomosis versus Brooke ileostomy.
OBJECTIVE: To compare the operative risks, operative complications, and late outcome of two homogeneous groups of patients with chronic ulcerative colitis (CUC) and primary sclerosing cholangitis (PSC) who underwent either Brooke ileostomy or ileal pouch-anal anastomosis (IPAA). MATERIAL AND METHODS: Between 1970 and 1990, 72 patients with CUC and PSC underwent proctocolectomy with either Brooke ileostomy (group I; N = 32) or IPAA (group II; N = 40). Postoperative data included operative mortality, need for blood transfusion, general postoperative complications, liver-related complications, and proctocolectomy-related complications. RESULTS: Eight group I patients and nine group II patients had a total of 12 and 11 general complications, respectively. Liver-related complications were diagnosed in 16% and 10% of group I and group II patients, respectively. Proctocolectomy-specific complications occurred in 34% of group I and 20% of group II patients. The overall need for blood transfusion was 94% in group I and 47% in group II (P < 0.001). The cumulative probability of proctocolectomy-related complications at 5 years was 23% for group I and 64% for group II patients (P < 0.002). The difference, however, was primarily due to the high frequency of pouchitis after IPAA, estimated at 57% at 4 years. The cumulative 5-year risk of liver-related complications was 37% and 28% for group I and group II, respectively. Peristomal varices and bleeding occurred in eight group I patients but in none of group II. CONCLUSION: Because IPAA avoids bleeding problems, it is the surgical treatment of choice in patients with PSC and CUC.
Adult↗
Intraoperative irradiation after palliative surgery for locally recurrent rectal cancer.
BACKGROUND: In patients with locally recurrent rectal cancer, long-term disease control and survival is uncommon with single-modality therapy. This report evaluates results achieved at the Mayo Clinic (Rochester, MN) with single- or combined-modality treatment, including intraoperative irradiation. METHODS: From 1981 to 1988, 106 patients underwent palliative surgical resections at the Mayo Clinic for locally recurrent rectal cancer. None had evidence of extrapelvic disease, and 42 received intraoperative electron beam irradiation (IORT) as a component of treatment. Gross residual disease remained after maximal surgical resection in 34 of the 42 patients and 61 of the patients who did not receive IORT. The IORT dose was 15-20 Gy in 39 patients and 10, 25, and 30 Gy in the other 3. External beam irradiation (EBRT) was administered to 41 of the 42 patients (doses > or = 45 Gy to 38 patients). RESULTS: Kaplan-Meier survival estimates at 3 and 5 years were analyzed for the 106 patients. Palliative surgical resection alone (12 patients) resulted in a 3-year survival of 8% and a 5-year survival of 0%. Statistically significant factors relative to survival based on the univariate analysis of all patients included amount of residual tumor (microscopic vs. gross, P = 0.032) treatment method (P = 0.005), IORT versus no IORT (P = 0.0006), type of symptoms (P = 0.0075), type of fixation (P < 0.0001), and preoperative Eastern Cooperative Oncology Group status (P = 0.03). For patients who received IORT, 3-year survival with gross residual tumor or presentation with pain was 44% and 43%, respectively. Factors not associated with survival (univariate) included extended versus conventional surgical resection, grade, age, and sex. The 3-year cumulative probability of distant metastasis was 60% in the patients who received IORT and 54% in those who did not. The 3-year local relapse rates were 40% versus 93% in patients who received IORT versus those who did not. CONCLUSIONS: Although the addition of IORT to external irradiation and maximal surgical resection appears to improve local tumor control and survival in patients who undergo palliative surgical resection for locally recurrent rectal cancer, further gains in treatment are necessary. Considering the high rates of distant metastasis, more routine systemic therapy with 5-fluorouracil (5-FU) leucovorin, 5-FU levamisole, or all three needs to be incorporated into aggressive treatment approaches. In patients with gross residual tumor after maximum surgical resection, local tumor control is inadequate despite treatment combinations including IORT. The evaluation of radiation sensitizers or biologic modifiers during external irradiation and IORT is indicated.
Adult↗
Ileal pouch-anal anastomosis function following childbirth. An extended evaluation.
PURPOSE: Women undergoing ileal pouch-anal anastomosis (IPAA) are frequently within reproductive years and eager to bear children. Management issues have been raised regarding the effects of pregnancy and delivery on the pouch, particularly with respect to obstetric care. Our experience is updated to search for delayed sequelae of pregnancy and delivery and to establish whether other factors have an adverse effect on pouch function. These results are also compared with the outcome of pregnancy and delivery in patients with ileostomy or Kock pouch. METHODS: Records of 43 women who had a successful pregnancy and delivery following IPAA were reviewed, including 8 women who had more than 1 pregnancy. RESULTS: Pregnancy was generally well tolerated, with complications being managed nonoperatively. Stool frequency (P < 0.01), incontinence (P < 0.01), and pad usage (P < 0.05; sign rank test) were significantly increased during pregnancy, but prepregnancy function was restored following delivery. Vaginal delivery, multiple births, length of labor, and birth weight had no adverse permanent effect on subsequent pouch function. Longer follow-up after vaginal delivery (mean, 2.4 years) demonstrated no compromise of pouch function. CONCLUSIONS: Incidence of pouch-related complications in patients with IPAA compares favorably with incidence in patients with ileostomy or Kock pouch. Operative rate for complications was 0 percent in IPAA patients compared with 9 percent in patients with ileostomy and 19 percent in patients with Kock pouch. The cesarean section rate was higher in patients with IPAA than in those with ileostomy or Kock pouch, and this may be caused by uncertainty about how to manage delivery in patients with IPAA. Pregnancy and childbirth are well tolerated in women with IPAA, with a lower complication rate and a higher cesarean section rate than women with ileostomy or Kock pouch. Type of delivery should be influenced by obstetric considerations, with vaginal delivery avoided in patients with a noncompliant, rigid perineum.
Adult↗