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PubMed1995

Plasma cholecystokinin levels and gallbladder volumes after proctocolectomy with ileal pouch-anal anastomosis.

BACKGROUND: The colon and rectum contain regulatory peptides in mucosal endocrine cells, which suggests a hormonal role. In animal studies colectomy leads to increased plasma levels of cholecystokinin. Little is known about the effects of proctocolectomy with ileal pouch-anal anastomosis on the release of cholecystokinin in human beings. Therefore we studied the effects of this procedure on fasting, postprandial, and bombesin-stimulated plasma cholecystokinin levels and gallbladder volumes. METHODS: Ten patients who had undergone proctocolectomy with ileal pouch-anal anastomosis and 12 healthy volunteers participated in the study. Fasting and postprandial plasma cholecystokinin levels and gallbladder volumes were studied for 3 hours at 15-minute intervals. In a second experiment plasma cholecystokinin levels were measured before and during intravenous administration of bombesin in six patients with ileal pouch and five healthy volunteers. RESULTS: Fasting plasma cholecystokinin levels were higher (p < 0.05) in patients with ileal pouch-anal anastomosis (2.6 +/- 0.3 pmol/L) compared with controls (1.7 +/- 0.2 pmol/L). Integrated postprandial plasma cholecystokinin levels were also distinctly higher (p < 0.01) in patients (978 +/- 126 pmol/L.180 min) than in controls (588 +/- 60 pmol/L.180 min). Mean fasting gallbladder volume was significantly (p < 0.01) decreased in patients with ileal pouch-anal anastomosis (18 +/- 2 ml) compared with controls (28 +/- 2 ml). Postprandial gallbladder emptying as measured by percentage change was similar in both groups. After infusion of bombesin, integrated plasma cholecystokinin responses were higher (p < 0.05) in patients (161 +/- 20 pmol/L.20 min) than in controls (90 +/- 12 pmol/L.20 min). CONCLUSIONS: Fasting, postprandial, and bombesin-stimulated plasma cholecystokinin levels are elevated in patients with ileal pouch-anal anastomosis compared with controls. Fasting gallbladder volume is decreased after ileal pouch-anal anastomosis. These findings suggest that the colon contains a factor that inhibits the release of cholecystokinin.

Adult↗
PubMed1996

Ileal pouch-anal anastomosis as the first choice operation in patients with familial adenomatous polyposis: a ten-year experience.

BACKGROUND: The choice between ileal pouch-anal anastomosis (IPAA) and ileorectal anastomosis (IRA) in the treatment of patients with familial adenomatous polyposis remains controversial. The aims of this study were to assess our 10-year experience with proctocolectomy, endoanal mucosectomy, construction of an ileal reservoir pouch, and IPAA in a series of 171 patients with familial adenomatous polyposis and to compare the functional results after IPAA with those after IRA. METHODS: Data from patients treated by IPAA at one institution were prospectively accumulated from October 1983 to October 1993. Medical records of 171 consecutive patients were studied regarding morbidity and functional results. These functional results were compared with those of a series of 23 patients who underwent IRA at the same institution. RESULTS: One patient (0.6%) died after operation. Sixty-two patients (36%) had concomitant colorectal carcinoma, 36 of which tumors were invasive (15 stage A, 13 stage B, and 8 stage C). Forty-six patients (27%) had at least one postoperative complication, with 14 patients requiring reoperation (8%). Twenty-six patients (15%) had obstruction. Seven patients (4%) had pelvic sepsis, and one had transient impotence (0.6%). Only two patients (1%) had a typical episode of pouchitis. The mean follow-up was 29 months (range, 3 to 100 months); 101 patients were monitored for more than 1 year. Little difference was noted between bowel function after IRA and that after IPAA. The mean daytime stool frequency after IPAA was 4.2 with 26% of patients having an average of 1 bowel movement at nighttime, compared with a stool frequency of 3.0 and 13% of patients having night evacuation after IRA. Daytime continence was normal for 98% of patients after IPAA and for all the patients after IRA. Nighttime continence was normal in 96% and 98% of patients, respectively. CONCLUSIONS: Morbidity and functional results after IPAA for familial adenomatous polyposis do not differ from those reported after IRA. For this reason and because of the risk of rectal cancer after ileorectal anastomosis, IPAA with endoanal mucosectomy is our first choice in the treatment of patients with familial adenomatous polyposis.

Adenomatous Polyposis Coli↗
PubMed1997

Implementation of a clinical pathway decreases length of stay and hospital charges for patients undergoing total colectomy and ileal pouch/anal anastomosis.

BACKGROUND: Clinical pathways are increasingly being used by hospitals to improve efficiency in the care of certain patient populations; however, little prospective data are available to support their use. This study examined whether using a clinical pathway for patients undergoing ileal pouch/anal anastomosis, a complex procedure in which we had extensive practical experience, affected hospital charges or length of stay (LOS). METHODS: A clinical pathway was developed to serve patients undergoing elective total colectomy and ileal pouch/anal anastomosis. All operations were performed by two attending physicians (J.E.F., M.S.N.). Before implementation, 10 pilot patients were prospectively monitored to ensure that hospital charges were accurately generated. In addition, charge audits were performed by an outside agency to verify the accuracy of the hospital bills. The pathway was then implemented, and 14 patients were prospectively analyzed. RESULTS: In all patients the principal diagnosis was ulcerative colitis, with the exception of three patients with familial polyposis. Mean external audit charges were within 2% of the hospital bills; therefore the hospital bills were used in all calculations. The mean LOS decreased from 10.3 days to 7.5 days (p = 0.046) for patients on the pathway versus pilot patients. Mean hospital charges also decreased significantly, from $21,650 to $17,958 per patient (p = 0.005). CONCLUSIONS: Implementation of a clinical pathway, even for an operation in which the surgeon has much experience, is an effective method for reducing LOS and charges for patients. This is likely the result of interdisciplinary cooperation, elimination of unnecessary interventions, and streamlined involvement of ancillary services. These results support the development of clinical pathways for procedures that involve routine preoperative and postoperative care. In addition, the benefits of clinical pathways should increase proportionally with increasing case volume for a particular procedure.

Adenomatous Polyposis Coli↗
PubMed2001

Crohn's disease of the colon.

The surgical treatment of Crohn's disease of the colon is distinct from that used in treating ulcerative colitis. Crohn's disease often involves the small bowel and is not "cured" by colorectal resection. The popular ileo-anal pouch procedures used in the management of ulcerative colitis generally are not used for the treatment of Crohn's colitis, because of higher complication rates. Commonly performed operations include ileostomy, segmental colon resection, subtotal colectomy, and proctocolectomy. The general surgeon, therefore, is provided with many options when faced with complications of Crohn's colitis. This article examines the attributes of and results reported for each of these options.

Colectomy↗
PubMed1997

Surgical options in ulcerative colitis.

The length of ileum used rather than pouch configuration per se is related to eventual functional outcome: A pouch constructed from 15- to 20-cm limbs is ideal. One-stage procedures appear feasible in those patients who are not malnourished or taking steroids and in whom a tension-free anastomosis may be achieved. Because most of our patients do not satisfy these criteria, single-stage IPAA is rarely used at the Mayo Clinic. The decision to excise the ATZ should relate to the risk of developing subsequent neoplasia. All patients with FAP should have a mucosectomy performed. Patients with CUC who do not have a mucosectomy should have life-long surveillance. Indeed, an argument can be made that all patients should undergo surveillance after IPAA. The decision to staple the anastomosis impacts little on eventual functional outcome but does preserve the ATZ with the attendant risk of recurrent disease, polyps, and neoplasia. When cancer is a presenting feature, the decision to perform IPAA should be based on the stage of the tumor and the subsequent need for radiation therapy. Patients with early-stage tumors not requiring adjuvant radiation therapy attain long-term function comparable to that of patients who have had an IPAA for benign disease.

Anastomosis, Surgical↗
PubMed1993

The ileal pouch operation for ulcerative colitis.

Ileal pouch-anal anastomosis cures chronic ulcerative colitis with an acceptable perioperative morbidity and mortality. The great majority of patients achieve satisfactory continence with an excellent quality of life. However, continence is not perfect, and fecal soilage is a troublesome problem for a small number of patients. Moreover, as many as one third of patients develop pouchitis, for which an effective means of long-term prevention or treatment has yet to be developed. Finally, controversial issues such as optimal pouch design or technique of anastomosis will be resolved only when long-term follow-up of randomized trials has been completed.

Colitis, Ulcerative↗
PubMed2001

Conservative treatment of iatrogenic urinary fistulas: the value of cyanoacrylic glue.

Once previously attempted conservative maneuvers have failed, iatrogenic persistent urinary fistulas usually require difficult repeated operations. We describe 3 patients in whom cyanoacrylic glue was used to repair endoscopically persistent urinary fistulas occurring after major pelvic surgery. At a mean follow-up of 21 months, all patients were free of urinary leakage and had no evidence of recurrent urinary fistulas. This approach may represent a safe and effective way to repair postoperative urinary fistulas.

Aged↗
PubMed1997

Management of neurogenic fecal incontinence in myelodysplastic children by a modified continent appendiceal stoma and antegrade colonic enema.

OBJECTIVES: Antegrade colonic enemas for neurogenic fecal incontinence via reverse reimplanted appendices (Mitrofanoff principle) have been primarily reported by Malone and coworkers in 1990. We used a modification of the described surgical technique and treated the first 10 patients with neurogenic fecal incontinence due to spina bifida. The surgical procedure and the results are reported. METHODS: Since November 1991, we have used a surgical procedure similar to the appendiceal continence mechanism in urinary diversion to establish a continent colonic cutaneous stoma for antegrade enemas in 10 myelodysplastic patients (4 females, 6 males; median age 13.2 years [range 6 to 26]) with severe neurogenic fecal incontinence. The average follow-up is now 26.4 months (range 12.5 to 50). All patients had neurogenic bladder dysfunction successfully managed by clean intermittent catheterization, anticholinergic drugs, or artificial sphincter implantation. The surgical technique for fecal incontinence included the partial orthotopic submucosal imbedding of the appendix into a cecal tenia and the fixation of the ileocecal region at the inner side of the abdominal wall after creation of an appendicocutaneous catheterizable stoma. RESULTS: All patients reached fecal continence for at least 38 hours (median 45.3) by using antegrade colonic enemas with 1.5% saline solution (n = 9) or GoLYTELY solution (n = 1), 0.5 to 1.5 L every 2 to 3 days. All other therapies (diet, oral medication, rectal purgative, or enema) to reach fecal continence had previously failed. There were only two complications seen at the follow-up. One boy with an artificial urinary sphincter presented with infection of the sphincter system, which led to explantation. Another boy presented 15 months after creation of the colonic appendiceal stoma with saline intoxication possibly due to a homemade saline solution. CONCLUSIONS: We conclude that the antegrade colonic enema via an orthotopic continent appendiceal stoma is a safe and highly effective treatment modality for fecal incontinence in patients with neurogenic bowel dysfunction if nonsurgical management has failed.

Adolescent↗
PubMed1996

Ileal pouch/anal anastomosis for Crohn's disease.

BACKGROUND: Patients with Crohn's disease (CD) are not commonly considered as candidates for ileal pouch/anal anastomosis (IPAA). This approach has been avoided because of the poor results observed, retrospectively, in patients with an initial diagnosis of ulcerative colitis who were found to have CD on examination of the resected specimen. However, in 1985, we decided to investigate an alternative to coloproctectomy with definitive end-ileostomy by a prospective study of IPAA for selected patients with CD. METHODS: Between 1985 and 1992, 31 patients with CD, but with no evidence of anoperineal or small-bowel disease, were recruited to our study. They comprised 15 men and 16 women whose mean age was 36 years (SD 14; range 16-72). All CD patients underwent IPAA. The short-term and long-term functional results of this procedure were compared with those of 71 ulcerative colitis patients who also underwent IPAA during the same period in our unit. Mean follow-up was 59 (SD 25) months. FINDINGS: No significant differences were observed between patients with CD and ulcerative colitis in the postoperative complication rate. Of the 31 CD patients, six (19%) experienced specific complications 9 months to 6 years after surgery: three had pouch-perineal fistulas, which required pouch excision in two cases; one had a pouch-vaginal fistula that was treated by gracilis muscle interposition; and one had an extrasphincteric abscess, which was treated surgically. Two patients (6%), one of whom was treated for an extrasphincteric abscess, experienced CD recurrence on the reservoir, and were treated successfully with azathioprine. At 5-year follow-up, there were no significant differences between patients with CD and ulcerative colitis in stool frequency (5.0 [2.0] vs 4.7 [1.4] per day; p=0.68), continence, gas/stool discrimination, leak or need for protective pads, and sexual activity. INTERPRETATION: Our results show that in selected cases of CD without anoperineal or small-bowel manifestations, IPPA can be recommended as an alternative to coloprotectomy with definitive end-ileostomy, when rectal resection is essential.

Adult↗
PubMed1997

Cholesterol metabolism and non-cholesterol sterols in patients with ileal pouch anastomosis.

BACKGROUND: Previous studies suggest only minor changes in bile acid metabolism after panproctocolectomy with ileal pouch construction. AIMS/METHODS: To investigate these changes further, we studied cholesterol absorption and serum, biliary and fecal non-cholesterol sterols and lipids in 12 ileal pouch patients and 10 controls. RESULTS: In patients, cholesterol absorption was markedly reduced and was associated with low serum total and LDL cholesterol and LDL triglyceride levels, but surprisingly, cholesterol synthesis, as indicated by sterol-balance data or serum cholesterol precursor levels, was within low normal limits. The high proportions of serum plant sterol to cholesterol, particularly that of campesterol, were not related to cholesterol absorption, but were attributable to a markedly reduced biliary cholesterol secretion. Interestingly, in these patients the fractional absorption of campesterol was normal, whereas that of sitosterol, like cholesterol, was reduced and was positively related to the intestinal influx of cholesterol. The patients' serum cholestanol proportion was normal, but the proportion of the cholestanol formed during intestinal passage was significantly reduced (17.9% vs 65.2% in controls). CONCLUSIONS: Thus ileal pouch patients are characterized by sterol malabsorption, lowered serum total and LDL-cholesterol levels, but unexpectedly without any increase in cholesterol synthesis. The lack of high serum cholestanol, shown earlier frequently in unoperated patients with ulcerative colitis, may indicate reversible cholestasis, a finding deserving further exploration.

Bile↗
PubMed1997

Pitfalls and outcome in ileo-anal pouch surgery for ulcerative colitis.

We have examined the long-term results of pouch surgery in 154 patients initially thought to have ulcerative colitis. Pouch survival was 81% at 5 years and 72% at 10 years. Chronic sepsis was the commonest factor for pouch failure (P < 0.001). Re-operations were required in 60 patients (39%). Pouch salvage was used in 30 patients and was successful in 16. Function using a 12-point score was good (0-3) in 40%, moderate (4-6) in 31% or poor (> 6) in 29%. Quality-of-life assessment indicated that 81% were satisfied, but anxiety was associated with a poor outcome. Age over 60 years was not associated with impaired function. So far, 21 patients are thought to have Crohn's disease, of whom 5 have small bowel involvement above the pouch, 11 have had their pouch excised or are permanently defunctioned.

Colitis, Ulcerative↗
PubMed1998

Is there a place for ileal pouch-anal anastomosis in patients with Crohn's colitis?

It is generally agreed that ileal pouch-anal anastomosis (IPAA) is contraindicated in patients with Crohn's disease (CD), since recurrent disease will frequently necessitate pouch excision, thereby fostering to the ultimate development of a short bowel syndrome. For these reasons, patients with CD requiring coloproctectomy have up till now undergone definitive end ileostomy. However, when faced with the prospect of definitive ileostomy in young patients, the possibility to keep, even for a few years before the disease recurs, acceptable continence and defecation must be stressed. Although the failure rate is higher in patients with CD than in patients with ulcerative colitis, long-term results from recent reports, as well as from our own experience, demonstrated that in selected patients with CD (i.e. without anoperineal or ileal manifestations), pouch can be maintain in function in 55 to 90% of the patients. In these patients functional results are similar to those of patients with ulcerative colitis. In conclusion, unlike the authors who consider that IPPA is definitely contraindicated in CD, we believe that IPAA could be proposed for selected patients with CD for whom rectal resection is mandatory, as an alternative to coloproctectomy with definitive end ileostomy. The patients concerned are those with no history of anal manifestations and no evidence of small bowel involvement.

Adolescent↗
PubMed1997

Inflammatory fibroid polyp in a continent ileo-anal pouch after colectomy for ulcerative colitis--case report.

The most frequent complication occurring in continent ileo-anal pouches after colectomy for ulcerative colitis (UC) is pouchitis. Recurrences of adenomas or carcinomas in pouches of familial adenomatous polyposis (FAP) patients are exceptional, whereas in those with ulcerative colitis dysplasia it is a very rare occurrence. We describe the case of a young woman who developed a mass in a J pouch three years after its construction following colectomy for ulcerative colitis. Histological and immunohistochemical studies showed that this mass had the features of an inflammatory fibroid polyp. A review of the literature of lesions observed in continent ileo-anal pouches after colectomy for UC would suggest that this lesion is an exceedingly rare complication of those devices.

Adult↗