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PubMed1988

Clinical and functional results after restorative proctocolectomy.

Of 84 patients who underwent restorative proctocolectomy with an ileoanal reservoir in 21 Italian departments of surgery, 51 had ulcerative colitis, 32 familial polyposis and 1 intractable constipation. Follow-up information is available for all 58 patients who had their ileostomy closed, the length of follow-up ranging between 2 and 78 months. There were no operative deaths. A failure rate (i.e. excision of the pouch) of 3 per cent was observed. Sepsis was the most common postoperative complication, and was most often related to ileoanal anastomosis dehiscence (15 per cent), followed by small-bowel obstruction requiring laparotomy (10 per cent). Clinical 'pouchitis' occurred in 14 per cent of patients after ileostomy closure. The average frequency of defaecation was four motions per 24 h; evacuation was spontaneous in all patients and only 5 per cent complained of troublesome faecal soiling while 34 per cent had occasional incontinence to flatus and mucus. Patients with a short or absent rectal cuff had a lower rate of incontinence (30 versus 48 per cent, difference not statistically significant) without any increase in the frequency of genito-urinary disorders. None of the two most used reservoirs, the J (n = 40) and S pouch (n = 17) showed significant superiority in terms of bowel frequency and continence. Incontinence was more likely in patients whose ileostomy closure had been delayed for more than one year.

Adenomatous Polyposis Coli↗
PubMed1991

Clinical and functional outcome after restorative proctocolectomy.

Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) has been carried out on 88 patients since 1982. Three different pouch designs (J, S and W) were used. Ten pouches had to be removed. Detailed analysis was performed on 61 patients (J = 23, S = 15, W = 23) whose pouches had been functioning for at least 6 months. There was no significant difference in surgical complications before or after ileostomy closure between pouch designs but the hospital stay was greater after construction of an S pouch (P less than 0.05). There were no significant differences in stool frequency, degree of continence or urgency between the three types. Twelve patients with J pouches required antidiarrhoeal medication compared with only one with S and five with W pouches. Only seven patients with S pouches could defaecate spontaneously compared with 22 with W pouches and all patients with J pouches (P less than 0.001). Twenty-five of 29 patients who had preservation of the anal transition zone had perfect continence compared with 23 of 32 with a mucosal proctectomy (P = n.s.). Pouchitis occurred in 13 patients, all of whom had ulcerative colitis. In a subgroup of 23 patients, pouch evacuation was assessed scintigraphically. There was no difference in pouch capacity or total volume evacuated, but spontaneous evacuation was better in J and W pouches compared with S pouches.

Adult↗
PubMed1992

Randomized trial of loop ileostomy in restorative proctocolectomy.

A randomized controlled trial was performed to assess the role of loop ileostomy in totally stapled restorative proctocolectomy. Entry criteria included all patients who were not on corticosteroids in whom on-table testing revealed a watertight pouch with intact ileoanal anastomosis. Of 59 patients undergoing restorative proctocolectomy over 36 months, 45 were eligible and were randomized to loop ileostomy (n = 23) or no ileostomy (n = 22). The age and diagnosis of the groups were similar. There were no deaths; two ileoanal anastomotic leaks occurred, one in each group. Ileoanal stenosis occurred in five patients with and one without an ileostomy. The incidences of wound and pelvic sepsis, bowel obstruction and pouchitis were similar. Twelve patients (52 per cent) developed ileostomy-related complications. The median total hospital stay was 23 (range 13-75) days with ileostomy and 13 (range 7-119) days without (P < 0.001). This study indicates that there is a low risk of pelvic sepsis which is not increased by avoiding a protective ileostomy. Loop ileostomy was associated with a high incidence of complications.

Adolescent↗
PubMed1993

Function of ileal J pouch-anal anastomosis in patients with familial adenomatous polyposis.

Pouch function after proctocolectomy and ileal J pouch-anal anastomosis was assessed at 1 and 5 years in 41 patients with familial adenomatous polyposis. The mean(s.d.) stool frequency per 24 h decreased from 4.4(1.7) to 3.9(1.8) (P < 0.05), the mean(s.d.) nocturnal stool frequency fell from 0.6(1.0) to 0.3(0.6) (P < 0.05), and the number of patients having nocturnal bowel movements decreased from 16 to seven (P < 0.05). At 5 years, only one patient still followed a strict diet (versus ten at 1 year, P < 0.05) and only two needed antidiarrhoeal medication (versus ten at 1 year, P < 0.05). There were no episodes of pouchitis or late reservoir-related complications. The function of ileal pouch-anal anastomosis improves over time in patients with familial adenomatous polyposis.

Adenomatous Polyposis Coli↗
PubMed1994

Influence of total colectomy on serum antineutrophil cytoplasmic antibodies in inflammatory bowel disease.

Perinuclear antineutrophil cytoplasmic antibodies (pANCAs) have previously been demonstrated in patients with various forms of vasculitis and more recently in those with inflammatory bowel disease (IBD) by an indirect immunofluorescence technique. Sera from 194 patients were tested for pANCAs: 101 with ulcerative colitis (43 with varying grades of disease severity, 19 after subtotal colectomy, 39 following restorative proctocolectomy), 40 with Crohn's disease, five with indeterminate colitis, 24 patients without IBD and 24 healthy volunteers (controls). The overall prevalence of pANCAs in patients with ulcerative colitis was 70.3 per cent (71 of 101). These antibodies were still present in 29 of 39 patients after restorative proctocolectomy, in whom the median follow-up after surgery was 2 years. All five patients who had pouchitis after restorative proctocolectomy were pANCA positive. By contrast, only ten of 40 patients with Crohn's disease had pANCAs, nine of whom had Crohn's colitis. No pANCAs were detected in controls. These results show that pANCAs are more prevalent in colonic IBD, especially ulcerative colitis. The persistence of pANCAs in the sera for 2 years after restorative proctocolectomy suggests that the antigens are not fully eradicated and, therefore, that it is not just the colon that is targeted immunologically in ulcerative colitis.

Adolescent↗
PubMed1995

The ileoanal pouch: a risk-benefit analysis.

This review assesses whether the risk of ileoanal pouch construction in patients with ulcerative colitis, compared with that of 'less dangerous' operations, is compensated by a better postoperative outcome. Even though the mortality rate is not greater for pouch construction, the risk of pelvic sepsis and pouchitis increase morbidity. Bowel function after construction of the ileal pouch, although better than that before operation, is not as good as that of normal controls and does not, in itself, justify increased morbidity. Quality of life measurements suggest that the benefit of the ileal pouch procedure is not much greater than that of ileostomy, even though some dimensions of quality of life are improved. However, most patients wish to avoid an ileostomy and surgeons should respect this wish, remembering that the pouch procedure has some risks and that the gain for the patient may be small.

Colitis, Ulcerative↗
PubMed1996

Salvage surgery for ileal pouch outlet obstruction.

Sixteen patients with ileal pouch outlet mechanical obstruction had major abdominal revision of the ileoanal anastomosis. Before operation all had severe difficulty in evacuation which required catheterization in 11. Eleven patients had a long efferent limb and/or long anorectal cuff, and five had a persistent stricture at the ileoanal anastomosis. None had pouchitis. The pouch was fully mobilized abdominally and the obstructing lesion resected. A new handsewn ileoanal anastomosis was formed. In two cases pouch volume was increased by incorporating an additional loop of ileum. All anastomoses but one were covered by a loop ileostomy. There were no deaths. Major complications occurred in two patients. Function was assessed in 15 patients; in one the ileostomy had not been closed. Median (interquartile range) frequency of defaecation per 24 h fell from 15 (7.3-19.5) to 6 (4.5-6.0) (P = 0.0033). Of the 11 patients who required a catheter before operation six evacuated spontaneously, three were improved but intubated on some occasions and two were unchanged after revisional surgery. Of the ten incontinent patients, five became continent, four were improved and one remained unchanged. There was a new continence disturbance in four (minor nocturnal in three) of the remaining five patients. One patient underwent further abdominal salvage surgery and another required establishment of an ileostomy because of poor function. Combined abdominoanal salvage surgery for outlet mechanical obstruction was successful in averting an ileostomy in 13 of 16 patients, and significantly improved pouch function in 12 of 15.

Adenomatous Polyposis Coli↗
PubMed2003

Salvage surgery after restorative proctocolectomy.

BACKGROUND AND METHOD: Restorative proctocolectomy is now the elective surgical procedure of choice for most patients with ulcerative colitis or familial adenomatous polyposis. Complications may lead to failure, defined as removal of the reservoir with establishment of a permanent ileostomy or long-term diversion. Failure may be avoided for some patients by salvage surgery. The causes of failure are identified in this article and the procedures adopted to treat them are defined; a review of the literature was carried out to determine the effectiveness of the procedures. RESULTS: Failure after restorative proctocolectomy results from complications, which may occur indefinitely during follow-up to a cumulative rate of about 15 per cent at 10-15 years. Sepsis accounts for over 50 per cent of these complications. Abdominal salvage procedures are successful in 20 to over 80 per cent of patients but the rate of salvage is dependent on the duration of follow-up, which might explain this variance. Local procedures are successful in 50-60 per cent of patients with pouch-vaginal fistula. Poor function accounts for about 30 per cent of failures. Abdominal salvage for outlet obstruction and low pouch capacitance results in satisfactory or acceptable function in up to 70 per cent of patients. There is no effective surgical salvage for pouchitis. CONCLUSION: Salvage surgery must be discussed carefully with the patient, who should be made aware of the possible complications and the prospect of success, which is less than that in the general population of patients undergoing ileoanal pouch surgery.

Colectomy↗
PubMed2007

Multicenter randomized-controlled clinical trial of probiotics (Lactobacillus johnsonii, LA1) on early endoscopic recurrence of Crohn's disease after lleo-caecal resection.

BACKGROUND: Seventy percent of Crohn's disease (CD) patients exhibit anastomotic recurrence within 1 year after ileo-caecal surgery. Recent clinical trials suggest the beneficial use of probiotics in the control of intestinal inflammation in pouchitis and ulcerative colitis. This study is a multicenter clinical trial evaluating the efficacy of an oral administration of the probiotic LAl on early post-operative endoscopic recurrence of CD. METHODS: Seventy patients with CD were enrolled prior to elective ileo-caecal resection and randomly assigned after surgery to daily treatment with either Lactobacillus johnsonii, LA1, Nestle (1010 colony-forming units, CFU) (group A, n = 34) or placebo (group B, n = 36) for 12 weeks. The primary objective was to assess the effect of LAl on the endoscopic recurrence rate at 12 weeks. Stratification was performed according to smoking status at randomization. RESULTS: Seven and 14 patients were excluded in the LA1 and placebo groups, respectively. In intention-to-treat analysis, the mean endoscopic score was not significantly different between the two treatment groups at 3 months (LA1 versus placebo: 1.50 +/- 1.32 versus 1.22+/-1.37, treatment effect: P = 0.48, smoke effect: P = 0.72). The percentage of patients with severe recurrence (i3 + i4) was 21% and 15% in the LAl and placebo groups, respectively (P = 0.33). Using a per-protocol (PP) analysis, the mean endoscopic score was not significantly different between the two treatment groups (LAl versus placebo groups: 1.44 +/-1.31 versus 1.05 +/- 1.21, P = 0.32). The percentage of patients with severe recurrence (i3 + i4) was 19% and 9% in the LAl and placebo groups, respectively (P = 0.054). Clinical relapse rate (CDAI [CD activity index] > 150, with an increase of CDAI > 70 points or greater from baseline) in the LAl and placebo groups was 15% (4/27) and 13.5% (3/22), respectively (PP analysis: chi-square test, P = 0.91 and log-rank test: P = 0.79). CONCLUSION: Oral administration of the probiotic LA1 in patients with CD failed to prevent early endoscopic recurrence at 12 weeks after ileo-caecal resection.

Adolescent↗
PubMed1993

Pelvic ileo-anal reservoirs: a lectin histochemical study.

Pelvic ileo-anal reservoir (ileal pouch) formation is now a common surgical approach to the management of long-standing inflammatory bowel disease. The ileal mucosa in this new environment responds with changes in morphology and histochemical reactivity, as shown by conventional techniques. In this study, pre-pouch ileum and pouch ileal mucosa from 20 patients have been examined with a large panel of lectins using an avidin-biotin-peroxidase technique, with appropriate negative controls and sugar-inhibition studies. Changes were noted between pre-pouch ileum and the pouch mucosa which were complex, and no single alteration was seen in every case. Most variations related to saccharide sequences near the non-reducing termini of O- and N-linked glycans. Many of these were seen with lectins having requirements for terminal fucosyl residues, and to a lesser extent for galactosyl sequences, and were most obvious in the epithelium. Some of the changes occurred with such frequency as to suggest a direct response to surgery, but many of the variations were likely to be adaptive responses, possibly related to inflammation or infection. The changes in glycans were largely additive and could not be explained as a consequence of the actions of bacterial glycosidases. These alterations suggest that reservoir mucosa undergoes an adaptive response to the new intraluminal environment, without frank colonic metaplasia, and some changes occur to a greater degree in patients with pouchitis.

Adult↗
PubMed1995

Long-term results of restorative proctocolectomy for ulcerative colitis.

To study the long-term effects of restorative proctocolectomy with J-pouch for ulcerative colitis 100 consecutive patients were examined a mean of 5.6 years after ileal pouch-anal anastomosis (IPAA). Seventy-three percent of patients were on steroids and 22% had a preceding severe attack of colitis before IPAA. The overall early and late complication rates were 40% and 33%, respectively. Failure rate was 5% and all failures requiring pouch excision occurred within the first three postoperative years. Pouchitis (36%) was the commonest late complication. A preceding severe attack of colitis was an important prognostic sign of late anastomotic complications, troublesome incontinence and ultimate failure. The daily mean stool frequency varied from 4.5 to 6.9. After a short learning period continence-stabilised and minor incontinence was common (57%). The majority of patients (72%) were either very satisfied or had no problems in daily activities after IPAA. Ten patients were dissatisfied after surgery due to obvious medical reasons in most of them.

Adolescent↗
PubMed1991

Mucosal morphology and faecal bacteriology after ileoanal anastomosis.

Mucosal morphology and faecal bacteriology were studied in 30 patients with ileoanal anastomosis and J-pouch and 10 patients with conventional ileostomy. Patients with ileoanal anastomosis had more acute and chronic inflammatory changes on histological examination than patients with conventional ileostomy. Patients with ileoanal anastomosis had a greater number of anaerobes and total bacteria and a greater ratio of anaerobes to aerobes in faecal samples than patients with conventional ileostomy. Patients with a history of clinical pouchitis had more acute inflammation than those without. In patients with ileoanal anastomosis there was a significant correlation between acute inflammation and number of aerobes and between chronic inflammation and number of anaerobes and total bacterial counts. These observations suggest that bacterial overgrowth in the pouch may be a possible pathogenic factor in inflammatory changes in the mucosa.

Adult↗
PubMed1993

Treatment of Crohn's disease recurrence after ileoanal anastomosis by azathioprine.

Ileoanal anastomosis is a surgical procedure performed in patients with ulcerative colitis. In a small number of patients operated on for ulcerative colitis, Crohn's disease occurs in the reservoir, mimicking pouchitis, and may lead to pouch excision and to a permanent terminal ileostomy. Two patients with recurrent Crohn's disease in the reservoir after ileoanal anastomosis were treated with azathioprine for 18 and 24 months, respectively. Azathioprine induced a complete clinical and endoscopic remission. These two observations suggested that immunosuppressive drugs were a good option for permanent ileostomy in cases of recurrence of Crohn's disease in the reservoir after ileoanal anastomosis.

Adolescent↗
PubMed1989

The clinical and functional outcome after restorative proctocolectomy. A prospective study in 100 patients.

One hundred consecutive patients treated by restorative proctocolectomy with construction of an ileo-anal anastomosis and a J-shaped (n = 90) or an S-shaped ileal reservoir were studied prospectively to evaluate postoperative complications and functional outcome and to search for factors that might influence results. There were no deaths. Postoperative complications requiring surgery were pelvic sepsis (3 patients), pouch-related fistula (2), peritonitis following ileostomy closure (3) and small bowel obstruction (6), with an overall relaparotomy rate of 14%. The cumulative risk of pouchitis was 30% at 2 years. The average stool frequency decreased gradually, stabilizing at about five evacuations/24 h after 1 year. At that time 9% of patients still had greater than or equal to 7 day-time evacuations and 40% had night evacuations (greater than 1/week). These parameters did not improve further with time. Mucous soiling, a frequent problem initially, also diminished with time, occurring in 30% of patients at 1 year. At 2 years, however, this mucous leak occurred in only 20%, suggesting that improvement of continence can be expected to occur even beyond one year. Despite defects in function patient satisfaction was generally excellent. So far only three patients have preferred conversion to an ileostomy. To establish which factors might influence the functional results a specially designed scoring system, combining all functional variables, was used. It was shown that results deteriorated with increasing age and that elderly women tended to have a poorer result than elderly men. Sex, previous parity or postoperative complications appeared not to affect the functional outcome. Male sexual disturbances occurred in 8%.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1986

Long-term results of continent ileostomy.

The long-term results of 76 Kock continent ileostomy operations were evaluated at an average 9 years postoperatively. The early complication rate was 36%: 11 (14%) patients underwent reoperation including one (1.3%) pouch removal, and one patient died. Late complications occurred in 54 (73%) patients. These included two (2.7%) pouch-related deaths, 30 (41%) cases of nipple-valve sliding, 22 (30%) clinically observed cases of pouchitis, 12 (16%) patients with stomal strictures, and intestinal obstruction (7), ventral hernia (4), nipple-valve fistula (7), intra-abdominal abscess (4) and foreign body in the reservoir (7). Revisional surgery was required in 49 (66%) patients. Despite this high cumulative complication rate a good functional result was ultimately attained in 62 (83%) patients. Only four reservoirs were removed, and only three patients had to wear an appliance. Increasing experience with the method resulted in a marked decrease of both early and late complications. The high degree of patient satisfaction supports continuation of Kock ileostomy constructions even though prolonged follow-up and frequent reoperations may be required.

Adolescent↗
PubMedDate not supplied

Complications associated with ileal pouch-anal anastomosis.

Seventy-three patients underwent total colectomy, rectal mucosectomy, creation of J or S ileal reservoir, and ileal pouch-anal anastomosis from 1982 to 1989. Mean follow-up was 38 months, with a minimum of 3 months in 15 patients being followed long-term at another institution. Forty-eight (66%) patients had histologically proven ulcerative colitis and 25 (34%) patients had familial polyposis. Thirty-eight J reservoirs and 35 S reservoirs were constructed. There were no perioperative deaths. The failure rate (loss of pouch) was 3%. Thirty-six complications in 34 (47%) patients were reported, 14 (19%) patients required surgery. Bowel obstruction was the most common postoperative complication (16%), followed by pouchitis (15%), and cuff infection (5%). Seventy-eight percent of the complications were associated with the J pouch. Average stool frequency at 1 year was 4 per 24-hour period. Other complications included postoperative pneumonia (1), peroneal nerve palsy (1), and temporary sexual dysfunction (1). Seven of 15 complications requiring surgical intervention occurred in the first 2 years of the study period, illustrating the learning curve associated with the procedure. Blood loss, transfusion requirements, and length of operation were not associated with higher complication rates. Use of the J pouch and experience of the individual surgeon affected morbidity.

Adenomatous Polyposis Coli↗
PubMed1995

Paradoxical puborectalis contraction in patients after pelvic pouch construction.

UNLABELLED: Normal defecation is associated with relaxation of sphincters during the evacuation process. However, obstructive defecation is sometimes seen clinically manifested by abnormal contraction of the puborectalis during defecation rather than relaxing. This condition has not previously been described after pelvic pouch construction. PURPOSE: This study was done to evaluate patients for defecation difficulties caused by paradoxical puborectalis contraction after pelvic pouch procedures. METHODS: Prospectively, patients with defecation difficulties were questioned. They then underwent electromyography if they met particular criteria. Biofeedback was offered to all patients demonstrating paradox on electromyography. Follow-up was by clinic visits and interviews. RESULTS: After pelvic pouch construction, 13 patients were found to have paradoxical puborectalis contraction. Twelve of 13 patients elected to have biofeedback therapy. Eleven of these 12 were available for follow-up an average of eight (1-15) months after biofeedback. Nine improved, and two had no change in their defecation difficulty. Of the initial 13, 10 had an event, either pouchitis or abdominal trauma, directly before their defecation problems. CONCLUSION: Paradoxical puborectalis contraction can occur in patients after pelvic pouch surgery. It should be suspected in patients with defecation difficulties in the absence of an anatomic abnormality. Biofeedback is effective treatment.

Biofeedback, Psychology↗
PubMed1994

Obstructing inflammatory fibroid polyp in pelvic ileal reservoir after restorative proctocolectomy in ulcerative colitis. Report of a case.

PURPOSE: This study was designed to describe clinical, endoscopic, and histopathologic features of an inflammatory fibroid polyp occurring in the pelvic ileal reservoir after restorative proctocolectomy in ulcerative colitis. METHOD: A case report describing the clinical course of such a patient is presented. RESULTS: Three years postoperatively, the patient developed diarrhea, anemia, weight loss of 10 kg, and symptoms of obstructed defecation. Ileoscopy showed pouchitis and a polypoid tumor filling the pouch. Biopsies revealed chronic inflammation without signs of malignancy. At laparotomy, a 5 cm x 3.5 cm x 3.5 cm submucosal, solid, circumscribed tumor was found within the pouch, and histopathologic examination yielded the diagnosis. The pelvic pouch was resected and replaced by a Brooke ileostomy. During 18 months of follow-up, the course has been uneventful. CONCLUSION: Inflammatory fibroid polyp is a rare, reactive, non-neoplastic lesion, which, for the first time, is reported in a pelvic ileal reservoir. It may cause pouch dysfunction. It is always benign but may masquerade as a malignant tumor.

Adult↗