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PubMed1994

The occurrence of colon cancer in patients with known premalignant colonic mucosal diseases.

Both ulcerative colitis and familial polyposis are colonic mucosal diseases which are known to predispose to colon cancer. While colonoscopy is an accurate modality used in screening and surveillance for patients with these two diseases, patients continue to present with colon cancer with these known premalignant diseases. This study was conducted to ascertain why patients with known premalignant disease still develop life-threatening colon cancer and to assess the clinical profile and prognosis of patients with known ulcerative colitis (UC) and familial polyposis coli (FPC) who subsequently develop colon cancer. Total colectomy, mucosal proctectomy, and ileoanal pullthrough was performed on 367 patients with UC and FPC between January 1982 and March 1993 at our institution. Of these, 15 had invasive adenocarcinoma of the colon (4.1%) in addition to the primary disease. These 15 patients were studied in detail. The average duration of disease from diagnosis to definitive treatment of cancer was 17 years. Thirteen of the patients in this series had UC (87%), while only 2 had FPC (13%). Colonoscopy was used to make the diagnosis in 11 patients (73%), while the diagnosis was made only at the time of surgery in 3 (20%). Nine of the patients presented with a Dukes' B2 cancer or worse, representing 60% of the series. A high percentage had synchronous invasive cancers in this series--6 patients (40%). Despite the relatively high percentage of advanced cancers in this series, at a mean follow-up of 47.1 months, 14 of the 15 patients are still living. One patient has known recurrent disease while 1 has an elevated CEA with no other evidence of recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenocarcinoma↗
PubMed1996

Effect of terminal ileal transposition on gallbladder bile composition following proctocolectomy.

Enterohepatic circulation of bile acid is impaired and the percentage of secondary bile acids in bile decreases after proctocolectomy and ileo-anal anastomosis. Moreover, the site-specific function and morphology of the terminal ileum are likely to be damaged by acute and chronic inflammation because the ileum is being used as a reservoir in this procedure. A jejunal segment was interposed between the terminal ileum and the anus to spare the terminal ileum from being used as a reservoir following proctocolectomy in dogs. We performed this study to investigate the effects of this procedure on gallbladder bile lipid composition. Adult mongrel dogs underwent either terminal ileal transposition procedure (n = 7) or conventional ileoanal anastomosis (n = 7) following two-stage proctocolectomy. The animals were laparotomized and gall-bladder bile was collected 12 weeks later. In the terminal ileal transposition group, the total bile acid concentration significantly decreased (P < 0.01), while the secondary bile acid percentage did not. In the conventional group, the percentage of secondary bile acid significantly decreased (P < 0.05), while the total bile acid concentration remained unchanged. Proximal transposition of the terminal ileum may have an advantage in preserving the percentage of secondary bile acid in gallbladder bile. This procedure effects bile lipid metabolism differently than conventional ileo-anal anastomosis.

Animals↗
PubMed2001

Long-term outcomes of the ileal pouch anal anastomosis: the association of bowel function and quality of life 5 years after surgery.

INTRODUCTION: Previous studies have reported that mean health related quality of life (HRQL) levels generally attain normalcy following construction of an ileal pouch anal anastomosis (IPAA). It appears inconsistent, however, that these normal HRQL levels are achieved while bowel function (BF) scores generally remain statistically worse than "normal" (e.g., 4-8 stools/day, possible anal leakage, diaper usage). To investigate this inconsistency, the current study attempts to determine if any statistical associations are present between HRQL and BF, specifically in the long term. Multivariate regression analyses are performed using each of 8 individual HRQL domains against the full model of BF characteristics. METHODS: All patients more than 5 years status post an ileal pouch anal anastomosis (IPAA) procedure for familial adenomatous polyposis (FAP) at a single institution were studied. FAP was chosen because patients are routinely asymptomatic preoperatively. BF (e.g., stool frequency, anal leakage) and HRQL (using the 8 health domains of the SF-36) were assessed by patient interview. Student's t tests and full model multivariate regression analyses were used to analyze associations between BF and HRQL. RESULTS: The sample included 25 patients (14 male). Mean age was 39 years, mean follow-up time was 11 years. Although mean scores for the 8 individual HRQL domains were not statistically different from the general United States population, regression analyses of the different domains did demonstrate significant associations with varying levels of BF. While controlling for age and gender, the analyses show that the physical function domain is improved with the ability to pass flatus independent of stool, and physical role and mental health domains are improved with decreased stool frequency. The social function domain is improved with increased stool retention time, while the perception of general health is improved with less diaper usage and less sexual dysfunction. CONCLUSIONS: This study shows that a statistically significant association between HRQL levels and BF is present. Of the numerous BF characteristics tested, five appear to be of greater importance with regard to certain HRQL domains. This finding may have clinical implications concerning pouch construction and surgical technique. Methodologically, this study demonstrates that merely using mean levels to describe HRQL may not elucidate meaningful relationships between important clinical outcomes, such as function and HRQL.

Adenomatous Polyposis Coli↗
PubMed2005

Evacuation of neorectal reservoirs after TME.

Colon pouch reconstruction after deep rectal resection is functionally superior to straight colorectal/anal anastomosis. However, stool evacuation difficulties could jeopardize the functional benefit of neorectal reservoirs. Beside the well proven colon J-pouch, the transverse coloplasty pouch may represent a viable alternative. We examined evacuation and functional outcome after total mesorectal excision and transverse coloplasty pouch reconstruction. Thirty consecutive patients with cancer of the middle and distal third of rectum underwent a total mesorectal excision. In all patients, reconstruction was performed with a transverse coloplasty pouch. Pouch and anastomosis were checked by Gastrografin enema postoperatively. Eight months after surgery, video defecography, anal manometry and pouch volumetry were performed and the patients were interviewed according to a standardized continence questionnaire. Rectal resection and reconstruction with transverse coloplasty pouch anastomosis could be performed in all patients. No insufficiency of the pouch occurred. In the follow-up, no patient had difficulties to evacuate the pouch, none of these patients needed enemas or suppositories to facilitate defecation. All patients were continent for solid stools. Twenty-five of 27 patients had up to three bowel movements per day. Patients with reduced pelvic floor movement in the defecography proved more likely to suffer from urgency, fragmented evacuation and incontinence. Transverse coloplasty pouch reconstruction after total mesorectal excision is not associated with stool evacuation problems. Urgency and incontinence, which are rarely seen after this type of reconstruction, correlate with impaired pelvic floor movement rather than with pouch size or anal sphincter tonus.

Aged↗
PubMed2005

Long-term functional results after straight or colonic J-pouch coloanal anastomosis.

Proctectomy followed by straight coloanal anastomosis (CAA) often results in poor functional outcome known as the anterior resection syndrome. It is now based on evidence that a colonic J-pouch CAA improves outcome in the first 2 years. We assessed the very late functional outcome of CAA patients with or without a pouch. These results show that the functional benefit of the J-pouch anastomoses is sustained over the very long term.

Aged↗
PubMed1993

Antineutrophil cytoplasmic auto-antibodies in sera from patients with ulcerative colitis after proctocolectomy with ileo-anal anastomosis.

Presence of antineutrophil cytoplasmic auto-antibodies (ANCA) in ulcerative colitis could be an epiphenomenon related to colonic inflammation and/or may reflect a primitive disturbance of immune regulation. In this regard, study of ANCA status after the whole colorectal mucosa has been removed could favor one of these two hypothesis. We compared the prevalence of ANCA in a first group of 70 patients with non operated UC and in a second group of 32 patients with UC having had a proctocolectomy with ileoanal anastomosis. Perinuclear ANCA (p-ANCA) were found in 34/70 (49%) of the first group as compared to 11/32 (34%) in the second group (NS). Our results further support that the presence of ANCA in UC reflects an immune disturbance not linked to the presence of the target organ.

Adult↗
PubMed1998

Coloanal J-pouch reconstruction following low rectal resection.

From an oncological point of view, a distal resection border of 2 cm is sufficient after deep anterior rectal resection and total mesorectal excision. This conclusion has led to extending the indications for ultradeep rectal resection in recent years. The classical end-to-end coloanal anastomosis, however, has been shown to be associated with several functional drawbacks, for example, increased stool urgency and in some cases incontinence, especially in the first 6-12 months after the operation. It was to improve these aspects that the coloanal pouch was introduced. In a pilot study we performed a coloanal pouch in 25 patients (median age 65 years, range 32-85). The coloanal pouch anastomosis was generally performed by a stapling device. A transanal hand-sewn anastomosis was performed in the section down to the sphincter level. Indications included rectal cancer, recurrent villous adenoma, and in one case recto-vaginal fistula. The pouch was also constructed by a linear stapling device, and its length was usually 5-7 cm. The level of the anastomosis averaged 2 cm above the dentate line. In 16 patients a protective ileostomy was also carried out. We observed four cases of anastomotic leak and in one an abscess. Results showed full continence after 6 months and in 85% after 1 year. Urgency was observed in four patients after 3 months, and in only one after 1 year. In summary, we obtained encouraging results for initiating a randomized trial in the future to confirm the advantages of this type of reconstruction after deep anterior rectal resection.

Adult↗
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↗
PubMed1993

[The expanded ileal pouch as a reservoir in continence preserving proctocolectomy. An experimental study on the pig].

Silicone balloons were inserted into bypassed segments of terminal ileum of five mini-pigs. The balloons were expanded over a period of 3 months, thereby creating pouches with a mean volume of 700 cm3 (a 9.5-fold increase). Functional proctocolectomy was performed and the bypassed segment was than placed in continuity with its terminal end at the previous site of the anus, thus creating a neorectum. One year later, the three pigs were still alive. They were continent and stool frequency was 2-3 times a day. The final mean volume of the pouch was still 360 cm3, corresponding to a 5.7-fold increase. At the end of the experiment significant hypertrophy of the bowel wall thickness was observed compared to the controls. The rectal X-ray contrast study demonstrated a new rectal reservoir without fistula or stenosis.

Animals↗
PubMed1995

Laparoscopically assisted bowel surgery. Analysis of 114 cases.

In order to help determine the risks and benefits, we retrospectively analyzed the results of our first 114 laparoscopically assisted bowel procedures. Procedures performed consisted of partial colectomy (85), total or subtotal abdominal colectomy (8), total proctocolectomy with J-pouch ileal reservoir (11), and diverting procedures (10). Forty-nine procedures were for malignancy. The rate of conversion to laparotomy was 13.2%. Oral feedings were resumed in 2.4 days (range 1-5), and bowel function returned in 3.8 days (range 2-8). The average length of stay was 4.2 days for partial colectomy and 6 days for total, subtotal, and proctocolectomy. The mean return to normal activity for all groups was 16.7 days (10.8 days for partial colectomy). There were no deaths. Major morbidity (6%) consisted of abscess (3), anastomotic leak (2), and hemorrhage (1). Mean operative costs analyzed for the initial 37 patients were higher for laparoscopic colectomies when compared to traditional colectomies; however, the mean total hospital costs were less for the laparoscopic procedures. These data suggest that the laparoscopic approach to colorectal resection is an acceptable alternative to laparotomy for a variety of disease processes, allowing patients an early return to normal activity.

Colectomy↗
PubMed1996

Kock pouch dysfunction during pregnancy. Management of a case.

The Kock continent ileostomy is a surgical alternative to a Brooke ileostomy after total proctocolectomy. Complications resulting from an improperly functioning nipple valve are not infrequent and when they occur most often require surgical revision. A 19-year-old female with a functioning Kock pouch of 4 years presented at 6 months of pregnancy with complete bowel obstruction due to nipple valve dysfunction. Operative management was avoided and her bowel obstruction was relieved by endoscopic placement of a stent through the nipple valve and into the abdominal reservoir. The stent was removed at 1 week postpartum with immediate return to normal function of her Kock pouch nipple valve. Temporary malfunction of the Kock pouch nipple valve can occur during pregnancy, probably due to distortion of the valve mechanism by the enlarging uterus. The endoscopic placement of a stent can maintain proper bowel evacuation until delivery and normal Kock pouch function can be expected after stent removal.

Adult↗
PubMedDate not supplied

Radiology of the continent ileostomy reservoir: I. Method of examination and normal findings.

The aim of the present study is to describe the radiologic methods used to study continent ileostomy reservoirs and to depict the normal radiologic features and variations identified by these procedures. During an 8-year period, 408 double-contrast studies were performed in 261 patients. The present study comprises 170 examinations in 99 patients with normal findings. A high-density barium contrast medium and air were used. Modes variation in the size and shape of the reservoirs was observed. The mucosal pattern of the reservoirs resembled that of the ileum but the folds were slightly wider. The continence-providing valves were 3-5 cm long and had a diameter of 2.5-4.0 cm. The diameter of the afferent ileal segments was usually slightly larger than that of more proximal ileal segments, with an upper limit of approximately 4 cm. The efferent ileal segments generally had a straight course without widening or out-pouches. Retrograde barium double-contrast examination is a satisfactory method for the evaluation of continent ileostomy reservoirs. Here we define the range of normal variations of such reservoirs as seen on retrograde double-contrast radiologic examinations.

Barium Sulfate↗
PubMedDate not supplied

Radiology of the continent ileostomy reservoir: II. Findings in patients with late complications.

During an 8-year period, 238 barium double-contrast studies performed in 162 patients with continent ileostomy reservoirs who had signs and symptoms of late complications (malfunction of the valve, nonspecific inflammation of the mucosa, stenoses, hernias, and fistulas) showed radiologic abnormalities. The aim of the present study is to depict the radiologic findings in patients with late complications of continent ileostomy reservoirs. With radiologic examination, the correct diagnosis of valve malfunction was made in 96% of patients with surgically proven valve defects. We were able to differentiate between various types of valve dysfunction and complications related to the fixation of the reservoir to the abdominal wall. Inflammatory mucosal changes and fistulas of the reservoir and the afferent ileal segment were depicted with a high degree of accuracy. Barium double-contrast radiologic examination proved to be very valuable in the work-up of patients with dysfunction of continent ileostomy reservoirs. The method was of particular value in assessing the cause of valve dysfunction and in the appraisal of the afferent ileal segment.

Barium Sulfate↗
PubMed1995

Stapled ileal pouch-anal anastomosis with resection of the anal transition zone.

We assessed the outcome of stapled ileal J-pouch-anal anastomosis with intersphincteric resection of the anal transition zone in 83 consecutive patients with ulcerative colitis (n = 71) or familial adenomatous polyposis (n = 12). There was no postoperative mortality. Two patients (2.4%) required permanent ileostomy for manifestation of unsuspected Crohn's disease. Major postoperative complications consisted of pelvic sepsis, anastomotic leakage, and pancreatitis with 3.6% each. Both, frequency of bowel movements and degree of continence improved with time. Two years after takedown of the diverting ileostomy 45 patients with ulcerative colitis and 12 with familial adenomatous polyposis were assessed with a frequency of bowel movements of 5.6 +/- 2 and 3.2 +/- 1 per 24 h, respectively (P < 0.05). At this time none of them had major daytime or nighttime incontinence. Minor incontinence was reported by 9% and 14% of the patients with ulcerative colitis during day-time and night-time, respectively. The patients with familial adenomatous polyposis demonstrated better results, without day-time seepage and intermittent nocturnal seepage in only 9%. It is concluded that direct ileal J-pouch-anal anastomosis is a safe procedure with excellent functional results for patients with ulcerative colitis and familial adenomatous polyposis.

Adenomatous Polyposis Coli↗
PubMed1991

Decreased absorption of 22Na and 36Cl in ileal reservoirs after exposure to urine. An experimental study in patients with continent ileal reservoirs for urinary or fecal diversion.

After urinary diversion to intestinal segments, reabsorption of chloride, ammonium, and hydrogen ions occurs, sometimes leading to hyperchloremic acidosis. The mucosa of ileal reservoirs exposed to urine show substantial atrophy, indicating a loss of absorptive capacity. In ten patients with urinary diversion via a continent ileal reservoir, the absorption of [22Na] and [36Cl] was studied after instillation for 15 min into the reservoir of a test solution containing 50 kBq [22Na] and 50 kBq [36Cl]. The activity of the radionuclides was determined in serum samples after 60 and 180 min and the fractions absorbed were calculated. Absorption of the two radionuclides was also calculated by comparison of the activities in samples of the test solution taken before and 15 min after instillation into the reservoir. The same investigations were performed in seven patients with continent ileostomy reservoirs. The study demonstrated a decreased capacity to absorb [22Na] and [36Cl] across the mucosa of the reservoirs exposed to urine compared to the mucosa of those exposed to feces. Due to the transformation of the ileal mucosa after exposure to urine, the risk for development of metabolic disturbances should be minimal after urinary diversion to a continent ileal reservoir.

Chlorine↗