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PubMed1998

[Mutation localization as a guide for surgical approach in familial adenomatous polyposis?].

Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) is considered the operative therapy of choice for the prophylactic treatment of FAP. Recently, Vasen and coworkers [5] after correlating the incidence of metachronous rectal cancer with the site of the causative APC mutation suggested subtotal colectomy and IRA to be the primary treatment in patients with mutations proximal to codon 1250, whereas IPAA should be performed in those with mutations beyond this codon. Mutation analysis in our patients after IRA, however, shows the majority of APC mutations to be located proximal to codon 1250 even in those patients with severe rectal polyposis and metachronous rectal cancer, thus not supporting the therapeutic recommendations of Vasen and coworkers.

Adenomatous Polyposis Coli↗
PubMed1996

Stapled ileal pouch anal anastomoses are safer than handsewn anastomoses in patients with ulcerative colitis.

BACKGROUND: One of the theoretic advantages of using a stapled versus handsewn ileal pouch anal anastomosis (IPAA) in restorative proctocolectomy is a reduction in septic complications. We performed this study to compare the incidence of early septic complications in patients undergoing restorative proctocolectomy with stapled or handsewn IPAA. PATIENTS AND METHODS: A chart review of 692 patients undergoing restorative proctocolectomy for treatment of ulcerative colitis was performed. The incidence of early septic complications in patients having stapled IPAA was compared to that in patients having handsewn IPAA. Follow-up studies included an annual questionnaire and physical examination. RESULTS: Of the 692 patients, 238 had handsewn IPAA and 454 had stapled IPAA; these two groups were similar in sex, duration of disease, age at surgery, and type of surgical procedure performed. In the handsewn IPAA group, 25 patients (10.5%) had 32 septic complications, and 24 required 89 reparations. In 7 patients, the pouch was excised. In the stapled IPAA group, 21 patients (4.6%) had 23 septic complications, and 14 required 40 reparations. One patient needed pouch excision. There were more patients (P=0.0001) with early septic complications, and more (P<0.0001) pouch excisions because of these complications, in patients with handsewn IPAA than in patients with stapled IPAA. The sepsis-related reoperation rates did not differ significantly. CONCLUSIONS: The stapled technique for IPAA has fewer septic complications and results in fewer sepsis-related pouch excisions, in our hands, than the handsewn technique technique, for treating patients with ulcerative colitis.

Adolescent↗
PubMed2001

Predicting polyposis severity by proctoscopy: how reliable is it?

PURPOSE: Patients with familial adenomatous polyposis need prophylactic colectomy and ileorectal anastomosis or restorative proctocolectomy. Preoperative rectal polyp counts have been used as one factor to determine which operation should be done, triaging patients according to risk of rectal cancer or completion proctectomy after ileorectal anastomosis. This study was designed to examine the reliability of preoperative proctoscopy in predicting familial adenomatous polyposis severity and outcome after ileorectal anastomosis. METHODS: Familial adenomatous polyposis patients were categorized according to preoperative proctoscopy as follows: Group 1, 5 or fewer adenomas; Group 2, 6 to 19 adenomas; Group 3, 20 or more adenomas. Familial adenomatous polyposis severity was defined as mild if there were < 1,000 polyps in the colon at colectomy and severe if there were > 1,000 polyps. RESULTS: A total of 213 patients were reviewed, 80 in Group 1, 59 in Group 2, and 74 in Group 3. There was no difference among the groups in mean age at presentation. Patients with fewer than five rectal adenomas were predominately females. They rarely had symptoms (22.8 percent), had mostly mild polyposis (86.5 percent), and in 74 of 80 cases underwent ileorectal anastomosis. Only six underwent restorative proctocolectomy. Of those having an ileorectal anastomosis, five needed later proctectomy, none for cancer. Patients with 6 to 19 rectal polyps were a similar group to those with 5 or fewer. Most were asymptomatic (67.8 percent), most had mild polyposis (81.6 percent), and 54 of 59 underwent ileorectal anastomosis (5 had restorative proctocolectomy). Only 3 of the 54 having ileorectal anastomosis needed subsequent proctectomy, 2 for rectal cancer. The patients with 20 or more rectal polyps were different. They usually presented with symptoms (86 percent), the majority (56.6 percent) had severe polyposis, and only 50 percent (37/74) underwent ileorectal anastomosis, the other half having restorative proctocolectomy. Of the 37 patients with an ileorectal anastomosis, 13 needed later proctectomy (35.1 percent), 4 for cancer (10.8 percent). CONCLUSION: Fewer than five rectal adenomas at presentation almost always predicts mild disease, and patients do well after ileorectal anastomosis. Twenty or more adenomas usually means severe disease. Patients with 6 to 19 adenomas are often mildly affected, but their phenotype is less benign than that of patients with fewer than five polyps. Although not foolproof, proctoscopy is a useful test in triaging patients with familial adenomatous polyposis according to disease severity.

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↗
PubMed2005

Squamous-cell carcinoma developing after an ileoanal pouch procedure: report of a case.

PURPOSE: This study was designed to report a new variant of a rare but serious complication of restorative proctocolectomy. METHODS: We present a 47-year-old female who underwent restorative proctocolectomy after 16 years of disease. Twenty-five years after her pouch procedure, she underwent pouchoscopy for fever and poor pouch function. A suspicious mass was biopsied and pathology indicated squamous metaplasia. On referral, a mass could be palpated above the anorectal ring. Biopsy of the mass was read as invasive squamous carcinoma in the background of normal intestinal mucosa. This represents the twelfth reported case of carcinoma arising in a pouch, but the first report of a squamous carcinoma, as all previous reports had been of adenocarcinoma. RESULTS: The patient has undergone chemoradiation. Response to therapy, functional status, and biopsy after treatment will determine whether the patient will be able to salvage the pouch. CONCLUSIONS: Diligence and vigilance with regard to active follow-up, and a high index of suspicion, are required to prevent this from becoming a more frequently seen problem.

Carcinoma, Squamous Cell↗
PubMed2003

Patterns of disease and surgical treatment among United States veterans more than 50 years of age with ulcerative colitis.

BACKGROUND: Ulcerative colitis (UC) is a clinical entity that predominantly affects young adults yet large series of middle age or elderly patients with UC are infrequently reported. The aim of this study is to identify patterns of disease, indications for operation, surgical treatment, and outcome of patients more than 50 years of age who required surgery for UC in Department of Veterans Affairs (DVA) Medical Centers. METHODS: A population-based study on all patients in 159 hospitals of the DVA from 1997 to 2001 was carried out. Data were compiled from several national computerized VA data sets. Supplementary information including demographic information, discharge summaries, operative reports and pathology reports were obtained from local medical records. Patient variables were entered into a computerized database and analyzed using the Pearson chi-square and Fisher's exact tests. Statistical significance is designated as P < 0.05. RESULTS: One hundred fifty-eight patients were evaluable. The mean age was 59 years (range 51-81); 99% were male. The mean duration of UC was 23 years (range 2 to 50). One hundred of the 158 patients had proctocolitis; 58 had either left-sided colitis or proctosigmoiditis. The mean dose of prednisone prior to surgery was 20 mg; the mean duration of steroid use was 8 years. The indications for elective surgery were intractability (59%), mass or stricture (27%), and dysplasia (14%). Twenty of the 158 patients (12%) were operated on emergently for either toxic colitis, perforation, or hemorrhage. One hundred three of the 158 underwent proctocolectomy and permanent ileostomy, 55 underwent a restorative proctocolectomy, and underwent a segmental colectomy. Twenty of the 158 patients were found to have dysplasia in their colectomy specimens; an additional 10 (7%) were found to have invasive cancer. Surgical morbidity was 22%. Overall mortality was 4% (7 of 158); all but 1 death occurred after emergent surgery. Mean hospitalization was 36 days (range 2 to 297). CONCLUSIONS: Restorative proctocolectomy was performed in 36% of veterans more than 50 years of age requiring surgery for UC. The majority required surgery for intractable symptoms. Dysplasia and invasive cancer was found in 18% of patients. Mortality after surgery for acute surgical emergencies remains high.

Case-Control Studies↗
PubMed1998

[Pre- and postoperative quality of life of patients with ulcerative colitis and familial adenomatous polyposis with ileoanal pouch operation].

After ileal pouch-anal anastomosis in patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP), in addition to postoperative morbidity and functional outcome quality of life is a relevant factor for assessment of the operation's success. Between 1982 and 1997 restorative proctocolectomy was performed in 602 patients (UC: n = 424; FAP: n = 178) at the Department of Surgery, University of Heidelberg. The assessment of pre- and postoperative quality of life was done through a prospective study (before restorative proctocolectomy, before and 1 year after closure of ileostomy). This study (UC: n = 27; FAP: n = 7) revealed a poor preoperative quality of life in patients with ulcerative colitis. Proctocolectomy is the decisive factor for the improvement of quality of life in the surgical treatment in UC. Quality of life could not be further significantly improved by ileostomy closure. Before proctocolectomy, FAP patients showed a quality of life, activity and function similar to that of healthy controls. In FAP patients proctocolectomy led to a significant loss of quality of life. This loss could only partly be regained by ileostomy closure. Quality of life and activity comparable to that of healthy controls can be achieved in UC patients by restorative proctocolectomy.

Activities of Daily Living↗
PubMed2006

Preparing for loop ileostomy surgery: women's accounts from a qualitative study.

Restorative proctocolectomy has become increasingly the surgical treatment of choice for ulcerative colitis and familial adenomatous polyposis since its inception in 1978 [Parks and Nicholls, 1978. British Medical Journal 2(6130), 85-88]. As Keighley, Grobler and Bain [1993. Gut 34(6), 680-684] point out it not only eradicates disease, it preserves the anal sphincter, so enabling patients to void normally. However, for many patients surgery takes place in stages, with the formation of a loop ileostomy as the first stage. As its use increases, so more nurses (both specialist and general trained) will be involved in providing ongoing care and support both pre and post operatively. Although research is available regarding surgery, ileo-anal pouch formation and function together with possible complications, little is known about the immediate post operative period. This paper reports a study of female patients' accounts of their preparation for, and experiences of such surgery. It was part of a larger study into the quality of life of women following restorative proctocolectomy [Notter, 2002. The Quality of Life of Women Following Restorative Proctocolectomy]. A total of 50 women participated in this study, which used descriptive phenomenology to explore their lived experiences. The surgery proved to be a pivotal period in their lives, with surgery the dream of full recovery had gone. The findings reveal a traumatic time with memories dominated by the issues of pain, the changes to their body and in most cases problems with the loop ileostomy. Most were left with a determination to maintain the pouch at all costs. This study identifies major implications for nurse education and training, regarding all aspects of care during this critical time. Findings show the immense and long lasting impact this type of surgery can have on quality of life.

Adaptation, Psychological↗
PubMed1995

Ileal pouch-anal anastomoses complications and function in 1005 patients.

BACKGROUND: Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) has become an established surgery for patients with chronic ulcerative colitis and familial adenomatous polyposis. PURPOSE: The authors report the results of an 11-year experience of restorative proctocolectomy and IPAA at a tertiary referral center. METHODS: Chart review was performed for 1005 patients undergoing IPAA from 1983 through 1993. Preoperative histopathologic diagnoses were ulcerative colitis (n = 858), familial adenomatous polyposis (n = 62), indeterminate colitis (n = 75), and miscellaneous (n = 10). Information was obtained regarding patient demographics, type and duration of diseases, previous operations, and indications for surgery. Data were collected on surgical procedure and postoperative pathologic diagnosis. Early (within 30 days after surgery) and late complications were noted. Follow-up included an annual function and quality-of-life questionnaire, physical examination, and biopsies of the pouch and anal transitional zone. RESULTS: Of the 1005 patients (455 women), postoperative histopathologic diagnoses were as follows: ulcerative colitis (n = 812), familial adenomatous polyposis (n = 62), indeterminate colitis (n = 54), Crohn's disease (n = 67), and miscellaneous (n = 10). During a mean follow-up time of 35 months (range 1-125 months), histopathologic diagnoses were changed for 25 patients. The overall mortality rate was 1% (n = 10 patients, early = 4, late = 6); one death (0.1%) was related to pouch necrosis and sepsis. The overall morbidity rate was 62.7% (1218 complications in 630 patients; early, n = 27.5%; late, n = 50.5%). Septic complication and reoperation rates were 6.8% and 24%, respectively. The ileal pouch was removed in 34 patients (3.4%), and it is nonfunctional in 11 (1%). Functional results and quality of life were good to excellent in 93% of the patients with complete data (n = 645) and are similar for patients with ulcerative colitis, familial adenomatous polyposis, indeterminate colitis, and Crohn's disease. Patients who underwent operations from 1983 through 1988 have similar functional results and quality of life compared with patients who underwent operations after 1988. CONCLUSION: Restorative proctocolectomy with an IPAA is a safe procedure, with low mortality and major morbidity rates. Although total morbidity rate is appreciable, functional results generally are good and patient satisfaction is high.

Adenomatous Polyposis Coli↗
PubMed2005

Crohn's disease and indeterminate colitis and the ileal pouch-anal anastomosis: outcomes and patterns of failure.

PURPOSE: This study was designed to determine the outcome of patients with Crohn's disease and indeterminate colitis who have an ileal pouch-anal anastomosis. METHODS: Between 1982 and 2001, 1,270 patients underwent a restorative proctocolectomy at the Mount Sinai Hospital: 1,135 had ulcerative colitis, 36 had Crohn's disease, 21 had indeterminate colitis, and 78 had another diagnosis. Perioperative data were collected prospectively. Functional outcomes were assessed with a 35-question survey mailed to all patients with a functioning pouch of at least six months duration. RESULTS: Pouch complications were significantly more common in patients with Crohn's disease (64 percent) and indeterminate colitis (43 percent) compared with patients with ulcerative colitis (22 percent) (P < 0.05). Similarly, 56 percent of patients with Crohn's disease had their pouch excised or defunctioned, compared with 10 percent of patients with indeterminate colitis and 6 percent with ulcerative colitis (P < 0.01). In the subgroup of patients with a diagnosis of Crohn's disease, multivariate analysis revealed that the pathologist's initial designation of ulcerative colitis (based on the colectomy specimen) and an increasing number of pathologic, clinical, and endoscopic features of Crohn's disease were independently associated with pouch failure. The functional results in patients with Crohn's disease with a successful pouch were not significantly different from those with indeterminate colitis or ulcerative colitis. CONCLUSIONS: Although complication rates may be higher in patients with indeterminate colitis compared with ulcerative colitis, the overall pouch failure rate is similar. On the other hand, more than one-half of patients with Crohn's disease will require pouch excision or diversion. Our data suggest that it is difficult to identify patients with Crohn's disease who are likely to have a successful outcome after restorative proctocolectomy. Thus, Crohn's disease should remain a relative contraindication to restorative proctocolectomy, whereas ileal pouch-anal anastomosis is an acceptable alternative for patients with indeterminate colitis.

Adult↗
PubMed1995

The perfect pelvic pouch--what makes the difference?

The aim of this study was to determine what factors are important for the achievement of perfect anal continence after restorative proctocolectomy. One hundred patients underwent paired studies of anorectal physiology before and one year after restorative proctocolectomy with pelvic ileal reservoir (11 S, 25 J, 64 W) with stapled ileoanal anastomosis, without mucosectomy. Fifty seven patients attained perfect anal continence and were able to discriminate flatus from faeces with such confidence that they were able to release flatus safely without fear of faecal soiling. The remaining 43 patients experienced minor problems in this regard. Four factors were found to correlate significantly with a perfect functional result (median, perfect v imperfect): maximum resting anal pressure (72 v 57 cm H2O, p < 0.02), the sensory threshold in the upper and mid-anal canal (7.3 v 8.6 and 5.3 v 7.0 mA, p < 0.05 and p < 0.02), compliance of the ileal reservoir (12.4 v 7.6 ml/cm H2O, p < 0.01), and the presence of a pouch-anal inhibitory reflex (56 of 57 patients v 29 of 43 patients, p < 0.01). The quality of anal continence depends on several factors: a complaint ileal reservoir, a strong sensitive anal sphincter, and normal reflex coordination of the activities of the reservoir and the sphincter. Excellent pouch-anal coordination is obtainable irrespective of the design of the reservoir, provided that these criteria are satisfied.

Adolescent↗
PubMed2005

Ileitis in ulcerative colitis: is it a backwash?

PURPOSE: This study aims to determine the incidence, demography, pathologic nature, and clinical significance of ileitis in ulcerative colitis patients who underwent restorative proctocolectomy. METHODS: A prospectively collected pouch database and the case notes of 100 consecutive patients who underwent restorative proctocolectomy for ulcerative colitis, under the care of a single surgeon, between 1988 and 2003 were reviewed. The original proctocolectomy specimens and pouch biopsies were reexamined and regraded blind, using the current diagnostic criteria. Patients were divided into two groups, those who had ileitis and those who had not. The demographic, clinical, and pathologic characteristics and the incidence of pouchitis of both groups were compared. RESULTS: Twenty-two patients had ileitis (22 percent). Compared with those with noninflamed ileum, patients with ileitis had a significantly shorter disease duration (P < 0.005), many of them presented or progressed to a fulminant state requiring acute surgical intervention (P < 0.01), had strong association with pancolitis and primary sclerosing cholangitis (P < 0.001), and had a higher incidence of subsequent development of pouchitis (P < 0.001). There was no correlation between the presence of ileitis and colitis severity. CONCLUSIONS: Ileitis in ulcerative colitis is not rare and does influence the prognosis, and the term "backw ash" is a misnomer. Ulcerative colitis with ileitis represents a distinct disease-specific subset of patients. Its true incidence and clinical significance can be determined only if detailed microscopic characterization of the terminal ileum is performed routinely in every patient with ulcerative colitis and the clinical outcome of these patients is audited prospectively.

Adolescent↗
PubMed2003

Laparoscopically assisted colectomy and ileoanal pouch procedure with and without protective ileostomy.

BACKGROUND: Apart from an obviously better cosmetic situation, there is controversy on the actual benefit of laparoscopic and laparoscopically assisted techniques in restorative proctocolectomy. The need for a protective ileostomy remains unclear. METHODS: Fifty-nine consecutive patients with ulcerative colitis and familial polyposis were included in this prospective cohort study. The colon was mobilized laparoscopically with a four-trocar technique, facilitating vascular dissection, rectal resection, and ileoanal pouch construction to be done through a Pfannenstiel incision. A protective ileostomy was constructed only in patients where the operation was difficult or where the anastomosis was under tension. Intra- and postoperative data were recorded; statistical analyses were performed by exact logistic regression. RESULTS: Laparoscopic mobilisation was successful in 54 patients (91.2%). Two patients had to be primarily converted because of exceeding the set time limit; 3 other patients had to have an additional median laparotomy. These 5 patients all had an increased body mass index (BMI), which was a statistically significant risk factor for failure of the laparoscopic technique. 18.6% of patients developed major complications (n = 11). Nine patients required secondary ileostomies; all of them either were under high dose immunosuppressants (n = 5) or had an increased BMI (average 28.42 kg/m2). Failure of the laparoscopic technique was associated with major complications. CONCLUSION: Laparoscopically assisted restorative proctocolectomy is technically feasible; an increased BMI is a relevant risk factor for failure. The minimally invasive approach probably does not reduce the need for a protective ileostomy in selected patients. The selection criteria for the addition or omission of a protective ileostomy in minimally invasive restorative proctocolectomy remain to be clearly defined.

Adenomatous Polyposis Coli↗
PubMedDate not supplied

Cumulative risk of developing polyps or malignancy at the ileal pouch-anal anastomosis in patients with familial adenomatous polyposis.

Restorative proctocolectomy with an ileal pouch-anal anastomosis is performed in an increasing number of patients with familial adenomatous polyposis (FAP). Two techniques are currently used to construct an ileal pouch-anal anastomosis: (1) a double-stapled anastomosis between the pouch and the anal canal and (2) mucosectomy with a hand-sewn ileoanal anastomosis at the dentate line. Although this procedure is thought to abolish the risk of colorectal adenoma, an increasing number of case reports have been published concerning the development of adenoma at the anastomotic site. The purpose of this study was to evaluate the overall cumulative risk of developing adenomatous polyps after ileal pouch-anal anastomosis and to compare the cumulative risk after either anastomotic technique. A total of 126 consecutive FAP patients undergoing a restorative proctocolectomy were identified from polyposis registries in The Netherlands, Denmark, Italy, Germany, and New York. Life-table analysis was used to calculate the cumulative risk of developing polyps in 97 patients with at least 1 year of endoscopic follow-up (median 66 months, range 12 to 188 months). A double-stapled anastomosis was used in 35 patients, whereas in 62 patients a hand-sewn anastomosis with a mucosectomy was performed. In 13 patients polyps developed at the anastomotic site, four with severe and four with moderate dysplasia. None of the patients developed a carcinoma at the anastomotic site. The cumulative risk of developing a polyp at the anastomotic site was 8% (95% confidence interval 2% to 14%) at 3.5 years and 18% (95% confidence interval 8% to 28%) at 7 years, respectively. The risk of developing a polyp at the anastomotic site within 7 years was 31% for patients with a double-stapled vs. 10% for patients with a hand-sewn anastomosis with mucosectomy (P = 0.03 [log-rank test]). Because FAP patients undergoing a restorative proctocolectomy with either a double-stapled or hand-sewn anastomosis have a substantial risk of developing adenomatous polyps at the anastomotic site, lifelong endoscopic surveillance is mandatory in both groups.

Adenoma↗
PubMed1996

Morbidity of medical therapy for ulcerative colitis: what are we really saving?

AIM: The true morbidity, cost and disability of medical therapy for ulcerative colitis are seldom delineated and are even less frequently compared to analogous parameters associated with surgical therapy. Therefore, we sought to assess and contrast medical versus surgical therapy for patients hospitalized due to severe ulcerative colitis. MATERIALS AND METHODS: Patients were matched for age, duration and severity of disease based upon Truelove and Witts' activity index, colonoscopic and histologic appearance and APACHE (Acute Psychological and Chronic Health Evaluation) II scores. Morbidity, cost and disability of 20 medically treated patients who required at least one hospital admission were compared to 20 patients treated by a three stage restorative proctocolectomy. Demographic data, number of hospital admissions, length of stay, total hospital charges including consultant's, surgeon's, and anesthesiologist's fees, morbidity of each approach and disability were assessed. Statistical analysis was performed using Mann-Whitney and Fisher exact tests. Significance was considered as P < 0.05. RESULTS: The mean age was 53.6 years in the medical group and 48.1 years in the surgical group (P = NS) and the average duration of disease was 10.5 years and 9.5 years, respectively (P = NS). The same severity of pancolitis was noted in both groups; APACHE scores of 13 and 14 in the medical and surgical groups, respectively, were noted. The total number of hospital admissions and total combined length of stay per patient in each group were not significant. Total mean hospital cost for the medical group was $28,477.00 per patient versus $33,041.00 for the three stage restorative proctocolectomy (P = NS). The mean duration of disability in the medical group was 6.4 months per patient versus 5.0 months in the surgical group (P = NS). However, patients in the medical group required more transfusions (25%) than did those in the surgical group (0%) (P < 0.05) and significant weight loss was more common in the medical group (45%) compared to the surgical group (5%) (P < 0.01). All patients in the surgical group were permanently weaned from steroids. Furthermore, while 65% of patients in the medical group had significant steroid-related complications, the major surgical complication rate was only 15% (P < 0.01). CONCLUSION: Medical treatment was associated with a significantly higher overall morbidity than surgical therapy. Additionally, a three stage restorative proctocolectomy was performed at no additional hospital cost or subsequent disability in patients with severe ulcerative colitis. The value of prolonged medical therapy in this select group of patients is questionable.

APACHE↗
PubMed1995

Ileal pouch anal function after endoanal mucosectomy and handsewn ileoanal anastomosis compared with stapled anastomosis without mucosectomy.

OBJECTIVE: To compare manovolumetric results and functional outcome after restorative proctocolectomy with either mucosal proctectomy and handsewn pouch-anal anastomosis or stapling. DESIGN: Prospective randomised study. SETTING: University hospital, Sweden. SUBJECTS: 80 Consecutive patients undergoing restorative proctocolectomy. INTERVENTIONS: 37 patients were randomised to have mucosectomy and a handsewn anastomosis and 43 patients to have a stapled anastomosis. MAIN OUTCOME MEASURES: Comparisons of anal sphincter function and clinical outcome in terms of continence and overall functional score between the two groups of patients. RESULTS: There was persistent reduction in anal resting tone at one year amounting to 29% in the handsewn group and and to 21% in the stapled group (p < 0.001 compared with preoperative in both groups). Daytime continence was similar, but patients with stapled anastomoses experienced less soiling during sleep, especially in the early postoperative period (5/43, 12% compared with 15/33, 45% at one month, p < 0.001). The arbitrary overall functional score was, however, similar in both groups. CONCLUSION: Handsewn and stapled ileal pouch-anal anastomoses result in similar postoperative anal sphincter impairment and overall clinical outcome.

Adolescent↗
PubMed1993

[Single-stage proctocolectomy and ileo-anal anastomosis: benefits and risk factors].

A collective experience of restorative proctocolectomy with "J" pouch over seven and a half years is presented comparing 63 patients with covering ileostomy and 122 patients with no ileostomy. There was no postoperative mortality in either group, and permanent failure resulted in four (6.3%) and one (0.8%) of patients with and without covering ileostomy, respectively. Total number of postoperative complications was slightly more in the ileostomy group (38 vs. 30%), and significant ileostomy related complications or anastomosis leakage were more common in patients with covering ileostomy (24%) than anastomosis leakage needing later covering ileostomy in the no ileostomy group (14%). There was a median saving of 12 hospital days and 30 sick-leave days in favor of no ileostomy. Severe active ulcerative colitis and male sex (indicating technically difficult anastomosis) emerged as significant risk factors of anastomosis leakage in the no ileostomy group, while steroid use as such seemed not to be a special risk. It was concluded that one stage restorative proctocolectomy suits well for most patients in good general condition when a technically sound anastomosis without tension can be done.

Adenomatous Polyposis Coli↗
PubMed2002

How consistent is the anal transitional zone in the double-stapled ileoanal reservoir?

BACKGROUND AND AIMS: The double-stapled ileoanal reservoir (DSIAR) has become a preferred method for ileal pouch anal anastomosis in restorative proctocolectomy. This investigation assessed the relative ratio of epithelial tissue types within the anal transition zone after a DSIAR and reviewed functional physiological differences. PATIENTS AND METHODS: All 138 patients who underwent restorative proctocolectomy with a DSIAR for mucosal ulcerative colitis were stratified into two groups according to histological evidence of epithelium types in the distal excised rectal donut. In group I a squamous or a squamous mixed with columnar epithelium was present (n=40) whereas in group II only columnar epithelium was seen (n=98). Anal physiological parameters were measured by anal manometry preoperatively, prior to ileostomy closure, and 1 year after surgery. RESULTS: None of the preoperative resting and squeeze pressure parameters showed a significant difference between the two groups. Postoperative mean and maximal resting pressures were significantly decreased in both groups. Postoperative mean and maximum squeeze pressures were decreased in group I. Postoperative mean length of the high-pressure zone tended to be decreased in both groups. The decrease in rectoanal inhibitory reflex was significant in both groups. Postoperative functional parameters measured as maximal tolerable volume and compliance were significantly improved from preoperative values in both groups. CONCLUSION: The tissue type in the anal transitional zone after DSIAR has a wide variability at a similar level (height) of the anastomosis. However, these different epithelial types were not associated with substantial physiological functional differences. Thus, if technically feasible, it is desirable for DSIAR to construct the anastomosis as close to the dentate line as possible.

Adolescent↗