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PubMed2003

A 5-cm colonic J pouch colo-anal reconstruction following anterior resection for low rectal cancer results in acceptable evacuation and continence in the long term.

BACKGROUND: Optimal treatment for low rectal cancer is total mesorectal excision, with most patients suitable for low colo-rectal or colo-anal anastomosis. A colon pouch has early functional benefits, although long-term function, especially evacuation, might mitigate against its routine use. The aim of this study was to assess evacuation and continence in patients with a colon pouch, and to examine the impact of possible risk factors. METHODS: In 1998, all 102 surviving patients with a colon pouch, whose stoma had been closed for more than one year, were sent a postal questionnaire. A composite incontinence score was calculated from questions on urgency, use of a pad, incontinence of gas, liquid or faeces; and a composite evacuation score from questions on medication taken to evacuate, straining, the need and number of times returned to evacuate. RESULTS: The response rate was 90% (50 M, 42 F), with a median age of 68 years (IQR 60-78) and median follow-up of 2.6 years (IQR 1.7-3.9). The anastomosis was 3 cm or less from the anus in 45/92 (49%), and incontinence scores were worse in this group (P = 0.001). There were significantly higher incontinence scores in females (P = 0.014). Age, preoperative radiotherapy, part of colon used for anastomosis, postoperative leak and length of follow-up had no demonstrable effect on either score. CONCLUSION: Gender and anastomotic height were the only variables which influenced incontinence. Ninety percent of patients reported that their bowel function did not affect their overall wellbeing, and none would have preferred to have a stoma.

Aged↗
PubMed2003

Double stapled ileal pouch anal anastomosis (DS-IPAA) for mucosal ulcerative colitis (MUC): is there a correlation between the tissue type in the circular stapler donuts and in follow-up biopsy?

PURPOSE: This study aims to assess the correlation between the tissue types found in the circular stapler donut at the time of initial double-stapled ileal pouch-anal anastomosis (DS-IPAA) and during subsequent periodic routine random biopsy. Secondarily, we sought to assess the risk of dysplasia, carcinoma or mucosal ulcerative colitis (MUC) recurrence in the retained mucosa. METHODS: The pathology reports of 91 patients (48 males, 43 females) who were operated upon for MUC from September 1988 to June 1997 and were reviewed and had two follow up visits for biopsy. The histological features of the distal donuts and biopsies of retained mucosa obtained at yearly interval follow-up were assessed in order to determine the epithelial tissue type (columnar, transitional and squamous), inflammation, recurrence of MUC and presence of dysplasia or malignancy. RESULTS: Median age at surgery was 43 (range 15-71) years and duration of MUC was 9.6 (range 0.3-42) years prior to surgery. The anastomosis was performed at a median height of 1.0 (range 0-2.5) cm cephalad to the dentate line and biopsy follow-up was undertaken at median 34 (range 2-110) months after DS-IPAA. The distal donuts were analysed in all cases, as were 305 follow-up biopsies (median 3.4; range 1-7 per patient). Although columnar epithelium (CE) was found in 62 (68%) donuts, it was absent on follow-up biopsy in 16 (26%) of these patients. Conversely, although no CE was identified in 29 (32%) donuts, it was identified in 11 (38%) of these patients during follow-up biopsy. CE in the donut was a significant predictor of CE in subsequent biopsies (P = 0.0012). The histological features consistent with MUC were seen in the biopsies from the retained mucosa in 15 (16%) patients from 0.3 to 7.6 years after DS-IPAA. While eight (9%) patients exhibited dysplasia or adenocarcinoma in the excised colon or rectum, none of the patients had either dysplastic changes or carcinoma within the retained mucosal biopsies. CONCLUSION: The correlation between CE in the circular stapler donut and at follow-up biopsy was high. However since CE developed in some patients in whom no CE was present in the distal donuts, regardless of the epithelial tissue type finding at the time of DS-IPAA, periodic follow-up biopsy should be obtained.

Adolescent↗
PubMed2003

The correlation between quality of life and functional outcome in ulcerative colitis patients after proctocolectomy ileal pouch anal anastomosis.

OBJECTIVE: The aim of this study was to evaluate functional outcome and quality of life (QOL) in patients undergoing proctocolectomy ileal pouch anal anastomosis (IPAA), to assess the correlation between functional outcome and QOL, and to identify factors influencing functional outcome and QOL in these patients. BACKGROUND: IPAA is now considered the procedure of choice for ulcerative colitis. Functional outcome and QOL are important factors in evaluating operative outcome. METHODS: All patients with UC who had undergone IPAA at our institute during the period 1990-2001 were included. QOL and functional outcome were evaluated by mailed questionnaires. QOL was scored using the Short Form 36 (SF-36). Global Assessment of Function Scale was used to evaluate functional outcome. RESULTS: Data were obtained in 77 of 99 patients (78%), with the median age of 38 years. Median follow up time was 4.25 years. The QOL in patients after pelvic pouch procedure was excellent, with scores equal to published norms for the Israeli general population in most scales. Functional outcome and QOL scores correlated strongly (r > 0.5; P < 0.0001) in all dimensions. Older age was associated with lower scores in both functional outcome and QOL scales (P < 0.0001). CONCLUSIONS: This study demonstrates a strong association between functional outcome and QOL in patients after IPAA. These patients, however, have a QOL that is comparable with the general population. Age at time of surgery strongly influences both functional outcome and QOL. This finding has to be taken into consideration in pre-operative counseling.

Adolescent↗
PubMed2003

Quality of life before and after proctocolectomy and IPAA in patients with ulcerative proctocolitis--a prospective study.

OBJECTIVE: The principal aim of the present investigation was to study the general QoL and disease-specific adjustment before, and one-year after, operation with an ileal pouch anal-anastomosis (IPAA) in a consecutive series of patients with ulcerative colitis (UC). PATIENTS AND METHOD: Eleven patients were medically treated and 31 patients underwent colectomy with ileostomy. The patients were interviewed before the IPAA operation and again one-year after closure of the covering loop ileostomy. General quality of life was estimated with a Swedish instrument (according to Kajandi, score range 16-96) and a VA-scale. The instrument for disease-specific adjustment contained specific questions with five factors (score range 34-204). Open questions about quality of life were used to identify areas of concern, which were not included in the other instruments. Postoperative function was described in terms of a functional score (score range 0-15). RESULTS: The results of the general quality of life assessments did not differ significantly when comparing pre-operative to postoperative values. Disease-specific adjustment showed that the medically treated patients had a score of 162; interquartile range (IQR) 145-176. The patients with ileostomy scored 164; IQR 141-180. Postoperatively there was a statistically significant improvement in both groups to 189 (IQR 172-199), an increase of 15%. The open questions revealed restrictions in daily life for both patient groups pre-operatively with improvements after IPAA. The median grading of functional outcome according to the score system was 2. The most frequent problems were: patients who had occasional bowel movements at night, 40%; intermittent perianal soreness, 51%; antidiarrhoeal medication use, 61%. CONCLUSION: General QoL did not change after IPAA. The bowel-specific adjustment in most factors improved in the majority of patients after IPAA. However, half of the IPAA patients had occasional bowel movements at night perianal soreness, and used antidiarrhoeal medication.

Adult↗
PubMed2003

Diagnosis and treatment of pouchitis.

Total proctocolectomy with ileal pouch-anal anastomosis is the surgical procedure of choice for the management of ulcerative colitis. Pouchitis, a non-specific inflammation of the ileal reservoir, is the most frequent complication that patients experience in the long-term. Diagnosis should be made on the basis of clinical, endoscopic and histological aspects. The Pouchitis Disease Activity Index (PDAI) represents an objective and reproducible scoring system for pouchitis: active pouchitis is defined as a score > or = 7 and remission as a score < 7. About 15% of patients develop a chronic disease. Treatment of pouchitis is empirical, and very few controlled studies have been carried out. Antibiotics, particularly metronidazole and ciprofloxacin, are the treatment of choice. Chronic pouchitis may benefit from a prolonged course of a combination of antibiotics. Highly concentrated probiotics are effective for both prevention of relapses and prevention of pouchitis onset. There is no convincing evidence of the efficacy of other therapeutic agents.

Anti-Bacterial Agents↗
PubMed1999

Successful management of Crohn's disease of the ileoanal pouch with infliximab.

This study reports the clinical benefit and safety of the murine chimeric anti-tumor necrosis factor (TNF)-alpha monoclonal antibody, infliximab, in the treatment of patients who developed findings compatible with Crohn's disease after undergoing colectomy with ileal-pouch anal anastomosis (IPAA) for an original diagnosis of ulcerative colitis. Medical records of 7 patients with Crohn's disease and an IPAA treated with infliximab were reviewed. Clinical response was classified as complete response, partial response, and no response. Concurrent treatment with immune modifier agents and/or antibiotics was recorded. Seven patients with active inflammatory or fistulizing Crohn's disease and an IPAA performed for diagnosis of ulcerative colitis were treated with infliximab after they had no response to conventional therapies. Patients received 1-4 infliximab infusions at a dose of 5 mg/kg. All patients improved clinically. Six patients had a complete response, and 1 had a partial response. Four of the 5 patients with complex perianal and fistulizing disease had closure of all fistula tracts, and 1 patient improved temporarily. Six of the 7 patients underwent concurrent treatment with immune modifier drugs. One patient had myalgias and malaise after the first infliximab infusion and flu-like symptoms after the second one. No other adverse effects were observed. This case series demonstrates that the murine chimeric anti-TNF-alpha monoclonal antibody, infliximab, can be used successfully to treat patients with Crohn's disease involving an IPAA who are refractory to conventional therapies.

Adult↗
PubMed2001

Risk of dysplasia in long-term ileal pouches and pouches with chronic pouchitis.

BACKGROUND & AIMS: Recent reports have suggested the mucosa of an ileal reservoir could be at risk of neoplasia. Risk factors may include the age of the pouch, chronic pouchitis, and previous colonic neoplasia. This study examined a group of such patients to determine the risk of dysplasia. METHODS: From a cohort of 1221 patients with ileal pouches, 171 patients with possible risk factors were selected. Successful contact was made with 138 patients who were invited for endoscopy and multiple biopsies. Biopsy specimens were stained with H&E and p53, scored for inflammatory changes including villous atrophy, and analyzed by flow cytometry. RESULTS: One hundred six patients took part and fell into 1 or more of the following clinical categories: chronic pouchitis (n = 34), pelvic pouch for > or =12 years (n = 42); Kock pouch for > or =14 years (n = 29), and neoplasia in colectomy specimen (n = 11). Thirty-three patients had severe villous atrophy. One patient of 106 (95% confidence interval, 0.9% +/- 1.6%) with a long-standing pouch had low-grade dysplasia that was multifocal. DNA analysis by flow cytometry showed aneuploidy in this patient and 2 others. CONCLUSIONS: These data suggest that the development of dysplasia in ileal pouches performed for ulcerative colitis is probably a rare event within 15-20 years of pouch surgery.

Adult↗
PubMed2001

The effect of rectosigmoidectomy and Duhamel-type pull-through procedure on lower urinary tract function in children with Hirschsprung's disease.

BACKGROUND/PURPOSE: The aim of this study was to investigate the effect of rectosigmoidectomy and Duhamel-type pull-through procedure on lower urinary tract function in children with Hirschsprungs disease. METHODS: During a 3-year period the authors assessed 11 consecutive children with Hirschsprung's disease prospectively by standard urodynamic investigations, before and after surgery. Urodynamics included simultaneous measurement of abdominal pressure, bladder pressure, detrusor pressure, and pelvic floor electromyography during filling and voiding. All children were submitted to laparoscopic resection of the aganglionic bowel segment below the cul de sac and a Duhamel-type pull-through procedure. Postoperatively, the children were assessed urodynamically and evaluated every 3 months for urologic problems. RESULTS: Mean age at first urodynamic study was 5 months (range, 2 to 10). Postoperative urodynamics were performed at a mean age of 10 months (range, 5 to 159). The mean interval between operation and postoperative urodynamic study was 6 months (range, 2 to 10). No child had structural urologic anomalies or urologic problems before surgery, and all had normal preoperative urodynamic findings. After surgery, urodynamics were considered normal in 3 children. In 7 children cystometric bladder capacity (CBC) was abnormally large, and 6 of these children had significant residuals. However, all had detrusor contractility and were able to void spontaneously. One child had low bladder compliance postoperatively. Despite the urodynamic changes, no child had clinical urologic problems at further follow-up. Mean follow-up after surgery was 24 months. CONCLUSIONS: This study found that after rectosigmoidectomy below the cul de sac alterations of bladder function can be observed. In 7 of the 11 patients studied, mean cystometric bladder capacity was 87% higher than capacity estimated for age. Moreover, postoperative residuals were 156% higher than the preoperative values. These findings suggest that partial detrusor denervation is likely in these patients. However, because detrusor contractility was present, and none of the children had retention or any urologic problems, the findings must be interpreted carefully. Because children with Hirschsprung's disease generally do not have preexisting urologic problems, routine preoperative urodynamic screening is not necessary. However, children with voiding problems after operation should be investigated urodynamically. For legal reasons parents should be informed of possible urologic problems, especially if subtotal resection of the aganglionic bowel segment is planned.

Colon, Sigmoid↗
PubMed2001

Delayed neutropenic enterocolitis in a 12-year-old girl treated with total colectomy and J-pouch reservoir.

Neutropenic enterocolitis (NE) is a clinicopathologic condition characterized by bowel wall inflammation, which can proceed to necrosis and perforation. It is mostly seen in neutropenic patients with leukemia who undergo induction treatment with chemotherapy. Most often the cecum is involved. The authors present a 12-year-old girl with acute lymphocytic leukemia who, under maintenance therapy, experienced NE. The disease was localized to the left side of colon, and even the rectum was involved, which is an unusual localization of the disease. An ileoanal anastomosis with a J-pouch was done in a second operation with a good outcome.

Antineoplastic Agents↗
PubMed2001

Ileoanal pouch procedures in children.

PURPOSE: The aim of this study was to review the long-term experience with colectomy and the ileoanal pouch procedure (IAPP) in children from one hospital. METHODS: Between 1977 and 2001, 168 children under 18 years of age underwent colectomy and IAPP. One hundred thirty-one had ulcerative colitis (UC). Twenty-six had familial colonic polyposis (FP), 9 had Hirschsprung's disease (HD), and 2 had colonic inertia. Ninety-seven had a J-pouch, 62 had a lateral pouch, and 9 had a straight pull-through (SP). The mean age was 13.9 years. RESULTS: Complications within 2 years included pouchitis (16%), ileoanal strictures (14%), and adhesions (7%). There were no deaths. Fifty-six patients (33%) required reoperation, including 20 revisions of large pouches and 8 conversions of SP to pouches because of stool frequency. Six children (3.6%) had later pouch removal (3 had Crohn's disease). Stool frequency at 6 months was 3.8 (mean). At 6 months 5% had occasional soiling. Eighty-four percent can delay defecation over 1(1/2) hours; 82% can urinate without a bowel movement. With a mean follow-up of 11.2 years, 94.6% are functioning well. CONCLUSIONS: Colectomy with IAPP is the preferred operation for children with UC, FP, and selected HD. The J-pouch is the preferred technique because of simplicity of construction and sparsity of complications.

Adenomatous Polyposis Coli↗
PubMed2002

Proctocolectomy and J-pouch ileo-anal anastomosis in children.

BACKGROUND/PURPOSE: The choice of ileo-anal reconstruction method in children undergoing proctocolectomy remains controversial. Although in adults ileo-anal pouch reconstruction has gained overall acceptance, many paediatric surgeons still advocate straight ileo-anal pull-through. The aim of this study was to assess the outcome and long-term functional results in children who have undergone proctocolectomy and ileo-anal anastomosis (IAA) with a J-pouch. METHODS: Medical records of 40 consecutive children who had proctocolectomy and J-pouch IAA between 1991 and 1999 were reviewed for early and late complications, fecal frequency, day- and night-time continence, and pouchitis. The indication for surgery was ulcerative colitis (UC) in 29 (median age at operation, 13 years; range, 9 to 16), Hirschsprung's disease (HD) in 10 (median age at operation, 1.5 years; range, 1 month to 5 years), and familial adenomatous polyposis (FAP) in 1 (age at operation, 6 years). Six of the HD patients had primary pull-through for total colonic aganglionosis and 4 a redo operation for failed primary reconstruction of long segment aganglionosis. RESULTS: There were no fatalities. Early complications (wound infection, early bowel obstruction, prolonged fever) occurred in 12 of 29 (41%) and late complications (bowel obstruction 9, pouch fistula 2) in 11 of 29 (38%) of the UC patients. Overall, 16 of 29 (53%) of the UC patients had complications. All patients with early complications were on systemic steroids at the time of the operation. Pouchitis occurred in 30% of the patients. None of the pouches had to be removed. At last follow-up all patients were continent during the day, 2 patients used protective pads during the night because of occasional staining. The median bowel frequency per 24 hours was 4 (range, 2 to 7); only 2 patients (7%) had to empty their bowel during the night. One (10%) of the HD patients had wound infection, and 3 had episodes of postoperative enterocolitis. Pouchitis-type symptoms have not occurred in HD patients. The median bowel frequency for 24 hours was 3 (range, 2 to 5). None of the HD patients needs to evacuate during the night. The 4 HD patients who are older than 3 years of age are continent. CONCLUSIONS: J-pouch IAA is a feasible method of reconstruction in children requiring proctocolectomy. Major complication are common but occur mainly in immunosuppressed patients suffering from UC. Despite high incidence of complications, long-term functional results in terms of continence and bowel frequency are excellent and ensure good quality of life in the great majority of patients.

Adenomatous Polyposis Coli↗
PubMed2001

Arthritis related to ileal pouchitis following total proctocolectomy for ulcerative colitis.

OBJECTIVE: To draw attention to arthritis that developed in patients who underwent total proctocolectomy with ileal pouch construction for ulcerative colitis (UC). METHODS: The course of 4 patients who developed arthritis for the first time after ileal-anal pouch anastomosis is described. In addition, the relationship to the chronic inflammation of the pouch-pouchitis-is discussed. RESULTS: The clinical manifestations were very similar to seronegative arthritis affecting mainly the joints of the lower extremities. It was accompanied by enthesopathy (2 patients) and by sacroiliitis (2 patients). All had active pouchitis. The abnormal laboratory test results were nonspecific, indicating chronic inflammation. All 4 patients tested negative for human leukocyte antigen (HLA) B27, and none had other concomitant extraintestinal manifestations. Steroids rapidly improved both the arthritis and pouchitis; however, disease-modifying antirheumatic drugs were required to maintain remission with minimal daily steroids. Flares of the arthritis were always associated with active pouchitis, but the opposite was not necessarily true. CONCLUSIONS: Arthritis related to ileal pouchitis after total colectomy for UC has many similarities to the arthritis associated with inflammatory bowel disease and should be added to the list of enteropathic arthropathies.

Adult↗