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PubMed1988

Proctocolectomy with restorative ileoanal reservoir for severe idiopathic constipation. Report of two cases.

The standard surgical therapy for severe idiopathic constipation remains total colectomy with ileorectal anastomosis, but approximately 10 percent of patients develop recurrent severe constipation. The authors have performed rectal excision and formation of an ileal reservoir with ileoanal anastomosis in two patients in whom constipation followed colectomy. Both patients experienced symptomatic relief, and in one patient there was objective improvement in transit studies, sensory testing, and proctography. In both patients a permanent ileostomy was avoided.

Acute Disease↗
PubMedDate not supplied

Familial adenomatous polyposis--which operation?

Familial adenomatous polyposis (FAP) syndromes are well recognized entities that benefit from surgical treatment which should not be delayed. Screening of first degree relatives is important. The aim of removing the colorectal mucosa with significant potential of malignant transformation can be achieved by means of three distinct procedures: pan-proctocolectomy and ileostomy, subtotal colectomy with ileorectal anastomosis, restorative proctocolectomy with ileoanal anastomosis. In a series of eight patients with FAP we performed mostly subtotal colectomy with ileorectal anastomosis. Of five patients who underwent a form of subtotal colonic resection, one was lost from follow up and two developed carcinoma in the remaining rectal mucosa, which necessitated completion of the resection with proctectomy and permanent ileostomy. Nevertheless, in the increasing number of patients amenable to regular outpatient supervision, there are strong points for recommending sphincter-saving operations.

Adenomatous Polyposis Coli↗
PubMed2002

Surgery for ulcerative colitis.

The type of surgery performed for UC varies from patient to patient and must take into account the nutritional status and health of the patient, the presence of dysplasia or cancer, the desire of the patient to maintain continence, the preoperative anorectal function, the degree of confidence in the diagnosis of UC, and the technical constraint because of certain body habituses. A total proctocolectomy is the surgical procedure of choice for UC. A restorative proctocolectomy is the preferred surgical approach that not only cures the patient of the disease and prevents the development of colorectal cancer, but also maintains continence with an improved quality of life.

Colitis, Ulcerative↗
PubMed1994

[Posterior proctomucosectomy and ileal pull-through reconstruction: a new restorative procedure after total proctocolectomy].

We reported a new method of restorative proctocolectomy using posterior approach and pull-through reconstruction. This method obviated transanal manipulation, a major factor causing damage to the internal sphincter, thus preventing fecal incontinence due to sphincter dysfunction. Also, temporary ileostomy was not necessary because the spout of an S-pouch was pulled down below the anal verge and its distal free end acted as a diverting stoma while the more proximal, healing zone (future anastomotic line) was kept from fecal contamination. This method was applied to a 32-year-old woman with familial polyposis coli and a 50-year-old woman with ulcerative colitis. Their bowel movements steadily decreased to three times and five times a day, respectively. There was no fecal leakage or perianal excoriation. The advantages as well as disadvantages of this method compared with the conventional techniques were discussed.

Adenomatous Polyposis Coli↗
PubMedDate not supplied

Factors affecting the bowel function after proctocolectomy and ileal J pouch-anal anastomosis for ulcerative colitis.

The aim was to study determinants of postoperative bowel function after restorative proctocolectomy for ulcerative colitis. Medical records of patients who underwent proctocolectomy with ileal J pouch-anal anastomosis (IPAA) in two- or three-stage operations and whose status of defecation was known via a questionnaire were retrospectively reviewed. Bowel function, including stool frequency, stool consistency, and degree of nighttime soiling, was correlated with age at the time of surgery, time after ileostomy closure, mean resting anal pressure, longitudinal length of ileal J pouch, and duration of fecal diversion by using univariate and multivariate analyses. Stool frequency decreased significantly with time after ileostomy closure in both univariate and multivariate analyses. Stool frequency tended to be less in patients having a long J pouch, but the correlation was not significant (P = 0.071) in univariate analysis. Nighttime soiling ameliorated with time after ileostomy closure in multivariate, but not univariate, analysis. Deterioration of nighttime soiling was seen in patients whose duration for fecal diversion was long, both in univariate (P = 0.068) and multivariate (P = 0.052) analyses. Stool consistency was related to none of the five factors investigated. These results indicate that as the time after surgery increases, stool frequency decreases and nighttime soiling ameliorates. Delaying ileostomy closure because of anticipated postoperative incontinence does not significantly alter postoperative continence.

Adolescent↗
PubMed1995

Prospective analysis of perioperative morbidity in one hundred consecutive colectomies for ulcerative colitis.

BACKGROUND: This study was undertaken to evaluate prospectively the indications for surgical treatment and perioperative morbidity for patients with idiopathic ulcerative colitis (UC). METHODS: Between January 1985 and August 1994, 145 patients were referred to the senior author (F.M.) for treatment of UC. Data were prospectively collected. One hundred patients have completed all stages of their surgical treatment and have been followed up for at least 1 year. These 100 patients form the basis of this study. RESULTS: Thirty patients underwent a proctocolectomy with end-ileostomy in one (25) or two (5) stages. Seventy patients underwent a restorative proctocolectomy with ileal J-pouch anal anastomosis in either one (2), two (37), or three stages (31). In total 100 patients underwent 204 procedures. Failure of medical treatment was by far the most common indication. The initial colectomy was performed electively in 61 patients and urgently in the remaining 39. The rate of perioperative complications for elective and urgent colectomy was 26% and 44%, respectively (p < 0.05). CONCLUSIONS: The overall perioperative morbidity rate remains high and almost doubles for urgent cases. Reducing the need for urgent procedures by earlier elective colectomy may allow for a reduction in perioperative morbidity.

Colectomy↗
PubMed1992

[Familial adenomatous polyposis: proctocolectomy with an ileal pouch versus rectal preservation].

UNLABELLED: We assess postoperative complications and functional results of surgery in familial adenomatous polyposis (FAP): Group I (n = 11): restorative proctocolectomy with ileoanal anastomosis (RPIA); Group II (n = 8): colectomy with ileorectal anastomosis (IRA): we also have evaluated the presence of malignancy in the rectum in the latter group. Group I: COMPLICATIONS: pelvic abscess (9.1%); intestinal obstruction (9.1%), both requiring reintervention. There was complete anal continence in 81.8%; only one patient needed catheter drainage of the reservoir (9.1%). There were two cases of pouchitis (16.7%). Group II: One patient suffered anastomotic leakage (12.5%) and another one a leakage of the loop ileostomy closure, with and secondary, abdominal abscess (12.5%). There was no incontinence. In spite of periodic endoscopic surveillance rectal adenocarcinoma appeared in 347 patients with complete follow-up (42.9%). Because of the risk of rectal malignancy with IRA and the good functional results of RPIA we consider the latter as the procedure of choice and also advisable the transformation of IAR into RPIA.

Adenocarcinoma↗
PubMedDate not supplied

Effect of high-dose steroids on anastomotic complications after proctocolectomy with ileal pouch-anal anastomosis.

This review was designed to determine whether "high-dose" steroid therapy (> or =20 mg prednisone/day) increases the likelihood of anastomotic complications after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). The hospital records of 100 patients undergoing proctocolectomy with IPAA were reviewed. Patient characteristics were analyzed to determine what factors were associated with higher rates of anastomosis-related complications. Seventy-one of our patients were given diverting ileostomies, whereas the remaining 29 underwent a single-stage procedure. Fifty-four percent of the patients in our review were taking steroids preoperatively, 39 of whom were on high-dose therapy. The overall anastomosis-related complication rate was 14%. There was no significant difference in complication rates with respect to age, steroid use, steroid dose, use of a diverting ileostomy, type of anastomosis, duration of disease, or presence of backwash ileitis. A trend toward higher leakage rates was found in patients undergoing single-stage procedures (10.3% vs. 2.8%, P=0.14) as well as in patients undergoing single-stage procedures on high-dose steroids (22% vs. 5.0, P=0.22). Nevertheless, neither of these trends was found to be statistically significant, which was likely influenced by the small sample size. Our data suggest that there may be an increase in anastomotic leakage rates in patients on high-dose steroids undergoing a single-stage proctocolectomy with IPAA. Nevertheless, our rate was not as high as the rates seen by other investigators and did not reach statistical significance. During preoperative counseling, patients on high-dose steroids should be informed of this uncertain but real risk of anastomotic leakage.

Adrenal Cortex Hormones↗
PubMed2006

A comparison of hand-sewn versus stapled ileal pouch anal anastomosis (IPAA) following proctocolectomy: a meta-analysis of 4183 patients.

OBJECTIVE: Using meta-analytical techniques, the study compared postoperative adverse events and functional outcomes of stapled versus hand-sewn ileal pouch-anal anastomosis (IPAA) following restorative proctocolectomy. BACKGROUND: The choice of mucosectomy and hand-sewn versus stapled pouch-anal anastomosis has been a subject of debate with no clear consensus as to which method provides better functional results and long-term outcomes. METHODS: Comparative studies published between 1988 and 2003, of hand-sewn versus stapled IPAA were included. Endpoints were classified into postoperative complications and functional and physiologic outcomes measured at least 3 months following closure of ileostomy or surgery if no proximal diversion was used, quality of life following surgery, and neoplastic transformation within the anal transition zone. RESULTS: Twenty-one studies, consisting of 4183 patients (2699 hand-sewn and 1484 stapled IPAA) were included. There was no significant difference in the incidence of postoperative complications between the 2 groups. The incidence of nocturnal seepage and pad usage favored the stapled IPAA (odds ratio [OR] = 2.78, P < 0.001 and OR = 4.12, P = 0.007, respectively). The frequency of defecation was not significantly different between the 2 groups (P = 0.562), nor was the use of antidiarrheal medication (OR = 1.27, P = 0.422). Anorectal physiologic measurements demonstrated a significant reduction in the resting and squeeze pressure in the hand-sewn IPAA group by 13.4 and 14.4 mm Hg, respectively (P < 0.018). The stapled IPAA group showed a higher incidence of dysplasia in the anal transition zone that did not reach statistical significance (OR = 0.42, P = 0.080). CONCLUSIONS: Both techniques had similar early postoperative outcomes; however, stapled IPAA offered improved nocturnal continence, which was reflected in higher anorectal physiologic measurements. A risk of increased incidence of dysplasia in the ATZ may exist in the stapled group that cannot be quantified by this study. We describe a decision algorithm for the choice of IPAA, based on the relative risk of long-term neoplastic transformation.

Anastomosis, Surgical↗
PubMedDate not supplied

[Proctocolectomy with ileoanal anastomosis: morbidity and functional results in patients with and without colorectal cancer].

BACKGROUND: The elective prophylaxis for colorectal cancer in patients with familial adenomatous polyposis (FAP) or with ulcerative colitis (UC) is the RPIPAA. AIMS: To evaluate the functional results and the morbidity rate in patients who underwent restorative proctocolectomy with ileal-pouch anal anastomosis (RPIPAA). METHODS: All patient underwent a proctocolectomy with a J reservoir, ileal pouch-anal anastomosis. RESULTS: There were 8 males and 3 females with a mean age of 31 years; the diagnoses were: FAP (n = 4); FAP + colorectal cancer (n = 3); metachronous colorectal cancer (n = 3) and UC + right colon cancer (n = 1). The average surgical time and the intraoperative bleeding were 5.6 h and 600 ml respectively. There were no operative deaths. The surgical complications were: section of left urether (n = 1); hemoperitoneum of 1,200 ml (n = 1); minor pelvic sepsis (n = 1); ileoanal stenosis (n = 1) and pouchitis (n = 1). Tumor staging was: Dukes A (n = 2), B1 (n = 1), B2 (n = 4). The mean follow-up was 22 months. Average of stools at the 3rd, 6th and 12th month was: 7.4, 5.6 and 3.8 respectively. Sexual function was: normal (n = 8), retrograde ejaculation (n = 2) and impotence (n = 1). The use of antidiarrheal agents in 24 hours at the third, sixth and twelfth month was 3, 2 and .8 respectively. CONCLUSIONS: The RPIPAA is associated with a low rate of morbidity and good functional results, similar to previously published results. However, these results should be taken with caution due to the small, selected and retrospective nature of the study.

Adenomatous Polyposis Coli↗
PubMed1995

Surgical management of Crohn's disease in children.

Crohn's disease is a chronic, transmural inflammatory disease of the intestinal tract most frequently involving the terminal ileum and colon. It is a disorder of undetermined etiology that shares many pathophysiologic clinical aspects with chronic ulcerative colitis. Surgical treatment of Crohn's disease continues to be generally limited to the treatment of the complications of the disease. It is being reported with increasing frequency in children of all ages. The surgical principle generally adhered to is to remove only enough intestine to relieve the complication but to maintain as much intestinal length as possible. Because of this requirement, strictureplasty has become a worthwhile surgical adjunct, especially when dealing with multiple minimally inflamed fibrotic strictures in the small intestine. It has been as beneficial in children as in adults. Restorative proctocolectomy and the Kock pouch procedure are discouraged in patients with known Crohn's disease because of numerous subsequent complications. It is very important that surgeons and physicians realize that although the disease process cannot be eradicated by surgery, the health and well-being of a child or teenager can be restored to normal for prolonged periods, if not permanently.

Adolescent↗
PubMed1998

Outcome after ileoanal anastomosis in pediatric patients with ulcerative colitis.

BACKGROUND: To review the outcome after restorative proctocolectomy among children and adolescents with ulcerative colitis at a pediatric inflammatory bowel disease center. METHODS: The records of all patients with ulcerative colitis undergoing colectomy and ileoanal anastomosis at The Hospital for Sick Children, Toronto, Canada, were reviewed. Questionnaires concerning functional results were sent to patients with restored transanal defecation. RESULTS: Seventy three patients (mean age, 13.2 years; range, 2.6-18.8 years) underwent ileoanal anastomosis (19 straight ileoanal anastomosis, 41 J pouch, 13 S pouch) between January 1980 and June 1995 and were observed 5.8+/-3.3 years. The ileoanal anastomosis is nonfunctional in 19 (26%) patients. Excision rates according to type of restorative procedure were J pouch, 7% (3 of 41); S pouch, 32% (4 of 13); and straight ileoanal anastomosis, 32% (6 of 19). Failure was usually attributable to intractable diarrhea among patients with straight ileoanal anastomosis but was caused by anastomotic leak or pelvic-perianal sepsis among patients with pouch procedures. Failure rates did not vary with age at ileoanal anastomosis. Among patients retaining ileoanal continuity, continence problems reported in the questionnaire were frequent and tended to be more extreme among younger patients. Overall, 90% of respondents reported satisfaction with the functional outcome of the restorative operation. CONCLUSIONS: The success rate of the ileoanal anastomosis/J-pouch procedure is comparable to that in adult series. The ileoanal anastomosis/J-pouch procedure is the operation of choice for children and adolescents who want ileoanal continuity restored after colectomy for ulcerative colitis.

Adolescent↗
PubMed1999

Eleven years' experience of postoperative morbidity and trends in handsewn ileo-anal anastomosis with pelvic J-pouch for ulcerative colitis.

BACKGROUND AND AIMS: Restorative proctocolectomy with mucosectomy and handsewn J-pouch-anal anastomosis is the curative operation of choice for ulcerative colitis. The aim of this study was to determine frequencies of various complications at perioperative time (within 30 days after surgery) with this operative method. We also evaluated the chances of failure of this restorative operation and the trends in operative management. MATERIAL AND METHODS: Evaluation was based on a register containing data on all patients operated for ulcerative colitis at our department since the beginning of 1985. Statistical analysis was made for all adult patients (over 18 years) who underwent an operation for ulcerative colitis during the 11 years' time period. RESULTS: A total of 170 adult patients underwent an elective operation for ulcerative colitis between March 1985 and December 1995. In 154 cases a restorative procedure was intended. In 142 (92%) cases this proved possible, and in 136 of these a handsewn J-pouch-anal anastomosis was created. The chance of failure in the restorative operation was higher in men (p = 0.0314). During the latter five years' period IAA operations were performed more often as a second-stage procedure. Uneventful recovery was reported in 62 (45.5%) cases. One or more complications were encountered in 74 (55.1%) patients. Corticosteroid treatment did not affect leakage frequency. In spite of the high morbidity there were no perioperative deaths.

Adolescent↗
PubMed1999

Functional outcome after colectomy and ileorectal anastomosis compared with proctocolectomy and ileal pouch-anal anastomosis in familial adenomatous polyposis.

OBJECTIVE: To compare the long-term functional results of ileorectal anastomosis (IRA) with those of ileal pouch-anal anastomosis (IPAA) in patients with familial adenomatous polyposis (FAP). SUMMARY BACKGROUND DATA: In patients with FAP, hundreds of colorectal adenomas develop, and the patient will die of colorectal cancer if left untreated. The surgeon must choose between colectomy with IRA and restorative proctocolectomy with IPAA. One factor crucial to decision making is the functional outcome after either procedure. To date, studies on this issue have reported conflicting results and have been based on small series of patients. METHODS: To assess various functional variables, a questionnaire was sent to 323 patients with FAP who underwent either IRA or IPAA and who were registered at the Netherlands Foundation for the Detection of Hereditary Tumors. The overall response rate was 86%; the responders comprised 161 patients who underwent IRA and 118 patients who underwent IPAA. RESULTS: Patients who underwent IRA scored significantly better for daytime and nighttime stool frequency, soiling, occasional passive incontinence, flatus and feces discrimination, stool consistency, and need for antidiarrheal medication. There was no difference with regard to perianal irritation, episodes of bowel discomfort, or dietary restrictions. The functional results according to the aggregate score of the Gastro-Intestinal Functional Outcome Scale, where the items specified above were integrated (0 indicating a poor and 100 a good overall function), were significantly better in patients with an IRA (74.5) than in patients with an IPAA (66.0) (p < 0.01). CONCLUSION: The functional outcome after IRA is significantly better than after IPAA. On the basis of these results, IRA might still be considered in patients with a mild phenotypic expression of the disease in the rectum.

Adenomatous Polyposis Coli↗
PubMed1998

[Technique and results of ileoanal pouches in ulcerative colitis after colectomy and proctomucosectomy].

The continence preserving restorative proctocolectomy is the operation of choice for ulcerative colitis. Many technical aspects of the J-pouch procedure have been standardised. We prefer the hand-sewn pouch-anal anastomoses and construct a protective ileostomy in most patients. Latter allows to carefully assess the sphincter function postoperatively and--if necessary--to train the sphincter before restoring continence. The frequency of postoperative ileus is comparable to that after other major intraabdominal surgery. Septic pelvic complications occur in up to 10% of patients and determine the long-term prognosis of pouch function. Following pouch reconstruction, the stool frequency remains increased (4-6 per day) and continence may be partially impaired especially at night. These consequences are accepted by most patients. Because the ileoanal pouch procedure is a difficult and complicated operation, it should be performed by experienced surgeons only.

Adolescent↗
PubMed1998

Proctocolectomy and ileostomy to pouch surgery for ulcerative colitis.

The development of continence-preserving and sphincter-preserving procedures for operation of ulcerative colitis has a long and interesting history. Reported clinical results on the continent ileostomy (Kock pouch) and the pelvic pouch procedure have often been enthusiastic; and when confronted with the options patients have mostly been in no doubt in selecting "the best operation." However, even if the continent ileostomy and subsequently restorative proctocolectomy were great innovations, it is by no means obvious that they should be recommended as the first choice for all patients. For patients old enough to join in a responsible discussion the pros and cons of the various operations available today must first be carefully described and a decision reached that reasonably meets the patient's wishes and that seems to the surgeon to be soundly based. When comparing the postoperative morbidity, long-term outcome, and quality of life assessment of the options, such a decision is in fact far from easy. Thus panproctocolectomy and ileostomy for ulcerative colitis can be considered a comparatively safe, predictable operation that can cure the patient and allow a short hospital stay, a quick recovery, and rehabilitation. It should also enable the patient to be free of hospital supervision after a year or so. Although there is a major change in body image and sexual disturbances may occur, the operation is in fact still the yardstick by which the other options should be compared. Despite the great attraction of rectum- and sphincter-preserving operations, there will always be patients for whom panproctocolectomy and a conventional end-ileostomy is the superior alternative. The ileal pouch operations are technically demanding and should probably best be restricted to specialist centers even in the future. Complications, if they arise, are often serious, and the hospital stay is often counted in weeks. The functional result may be good, but defects in continence are common and sexual dysfunction is a problem for many of these patients. The pouchitis syndrome is a great disappointment, and recent reports on subsequent epithelial dysplasia and even development of cancer are alarming. The long-term results are in this respect still uncertain. Careful patient selection, with full discussion with the patient and his or her family are essential before a decision on a continent ileostomy or a pelvic pouch is reached. Strong motivation toward avoidance of a conventional ileostomy is important. When compared with the imperfect functional results and the high morbidity associated with the pelvic pouch procedure, there is at present a great revival of interest for total colectomy with ileorectal anastomosis. It is still a useful operation and should be seriously considered particularly in the young. The functional results are comparatively good. Sexual function is well preserved. The use of the operation may enable the teenager to regain good health and finish education and family planning. Due to the cancer risk the need for subsequent supervision must be made clear, however. The operation may also be valuable in elderly patients who would be much bothered by an ileostomy and who are unlikely to live long enough for carcinoma to become a problem. The great advantage is that should a failure occur the other options remain.

Colitis, Ulcerative↗