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PubMed2006

Systematic review: the management of pouchitis.

Pouchitis is the most common complication following proctocolectomy and ileal pouch-anal anastomosis in patients with ulcerative colitis. We aim at discussing relevant information on epidemiology, clinical features, risk factors, diagnostic testing, differential diagnosis and treatment of this idiopathic inflammatory condition. A computerized search of PubMed was performed with the search term 'pouchitis', limited to English papers on humans. This strategy identified 514 references. Relevant articles were selected from this list. In addition, the reference list for each of the selected articles was reviewed to identify any additional references. Pouchitis occurs in up to 60% of patients after ileal pouch-anal anastomosis for ulcerative colitis, and has characteristic clinical, endoscopic and histological features. The most important test for diagnosis is pouch endoscopy with biopsy. Antibiotics remain the mainstay of treatment, and other options are discussed for those patients who are refractory to antibiotic therapy.

Anti-Bacterial Agents↗
PubMed2007

Review article: Indeterminate colitis--definition, diagnosis and management.

BACKGROUND: The term indeterminate colitis is imprecise and without a generally accepted definition. Nevertheless, it is a term that is commonly used by gastroenterologists, pathologists and surgeons. AIM: To offer an opinion supported by published data, about the appropriate use of the term indeterminate colitis by addressing a series of questions. METHODS: A PubMed database search was performed using the keywords, 'colitis' and 'inflammatory bowel disease' each combined individually with the following adjectives: 'indeterminate', 'unclassified', 'undefined', 'undiagnosed' and 'non-specific'. RESULTS: There is no generally accepted definition of indeterminate colitis. All current applications of the term rely on exclusionary criteria and there is no confirmatory diagnostic test. Nevertheless, the diagnosis of indeterminate colitis appears to be durable in a subgroup of patients, suggesting that this group represents a unique phenotype. CONCLUSIONS: Indeterminate colitis has expanded from a strictly defined, postcolectomy pathological diagnosis to become, in addition, a clinical diagnosis without generally accepted criteria. A diagnosis of indeterminate colitis should be qualified with descriptors for the diagnostic criteria applied.

Anastomosis, Surgical↗
PubMedDate not supplied

Persistent ileitis after ileal salvage from a failed Kock pouch.

A case of persistent ileitis following the refashioning of a Kock ileal pouch into a Brooke ileostomy for severe pouchitis is reported. Preserving the terminal ileum by a salvage procedure may not be a safe alternative to pouch excision with the formation of a new end ileostomy in the surgical management of pouchitis refractory to medical treatment.

Adult↗
PubMed1997

Review: the surgical management of ulcerative colitis.

The treatment of ulcerative colitis requires careful review of the medical and surgical options. The surgical procedure of choice is proctocolectomy with ileal pouch-anal anastomosis. This procedure removes the diseased mucosa, effectively curing the disease whilst maintaining the normal route of defecation and continence. Other surgical options that may be considered in selected patients include proctocolectomy with either a Brooke ileostomy or a Kock pouch, and abdominal colectomy with ileorectal anastomosis. The choice of operation requires consideration of the advantages and disadvantages of a particular procedure and must be tailored to an individual patient's needs and circumstances.

Colectomy↗
PubMed1994

Clinical experience of lower urinary tract reconstruction using a urethral Kock pouch.

The operative procedure used in the present series involved a nerve-sparing radical cystectomy, with anastomosis of the urethra using a pouch made of detubularized ileum. The 36 patients who underwent this operation were all male with an average age of 58. No deaths resulted from the operation. As far as late complications were concerned, malfunction of the antireflux nipple valve was noted in 1 patient and stenosis occurred between the urethra and pouch in 2. One patient was found to have multiple stones in the pouch and reservoir decompensation was recognized in 2. Thus, the late complication rate was 17%. There were no cases of total incontinence, but nocturnal incontinence appeared in 11 out of 31 (35%). A total of 20 out of 25 patients (80%) recovered their erectile function during the postoperative follow-up period and the disease-free survival rate at 5 years was 78%. Therefore, the urethral Kock pouch combined with nerve-sparing cystectomy has proved to be a useful procedure as far as the quality of life is concerned.

Adult↗
PubMed1994

Urinary bacteriology of continent urinary reservoirs and calculus formation.

In order to investigate urinary bacteriology in relation to calculus formation in continent urinary reservoirs, a retrospective study was conducted of 19 patients with the Kock pouch and 23 patients with the Indiana pouch. Analysis of a total of 151 urine cultures showed that asymptomatic bacteria (any bacterial count) were present in 92% of urines from the Kock pouch and 74% from the Indiana pouch. The incidence of organisms and total bacterial counts were similar for both pouches. The most prevalent organisms were Escherichia coli, Pseudomonas sp., Klebsiella sp., Proteus sp., Enterobacter sp., and Enterococcus sp. Urinary calculi developed in 42% of the Kock pouch patients and 13% of the Indiana pouch patients. More than half of the patients had multiple stone recurrence. Infectious stones developed in 32% of the Kock pouch patients, usually on the foreign materials, and 9% of the Indiana pouch patients. In general, no clear relationship was established between urinary bacteriology and calculus formation although Proteus sp. or Providencia sp. was determined to be the causative organism in some infectious stones. Furthermore, metabolic stones developed in 32% of the Kock pouch patients and 9% of the Indiana pouch patients. Because calcium phosphate was a constituent of 80% of the metabolic stones, the presence of urinary factors promoting calculus formation was suspected.

Humans↗
PubMed1995

Urinary immunoglobulins in patients with continent urinary reservoirs and ileal conduits.

BACKGROUND: Although bowel segments are commonly used for reconstructing the urinary tract, a high incidence of bacteriuria is observed in patients with urinary intestinal diversion. The normal gastrointestinal tract possesses a potent mucosal immune system characterized by secretory immunoglobulin A (sIgA) as the major humoral defense factor. However, the significance of urinary IgA secretion as the mucosal defense mechanism in patients with urinary intestinal diversion has remained obscure. In this study, urinary levels of sIgA as well as serum-type IgA were measured in patients with continent urinary reservoirs (Kock and Indiana pouches) and ileal conduits. METHODS: Twenty-four-hour urine samples were collected in a total of 80 patients with urinary intestinal diversion (22 Kock pouch patients, 21 Indiana pouch patients and 37 ileal conduit patients). The amount of sIgA and serum-type IgA were measured by enzyme-linked immunosorbent assay (ELISA). RESULTS: Urinary IgA levels showed great inter- and intra patient variability in all three groups. Indiana reservoir urine contained significantly greater amounts of sIgA (mean 32.0 mg/24 hrs) than Kock reservoir urine (11.9 mg) and conduit urine (4.9 mg), whereas Kock reservoir urine contained significantly more sIgA than conduit urine. However, the corresponding difference was not observed in regard to serum-type IgA. In none of the three modes of urinary diversion did 24-hour sIgA excretion show any correlation with the length of time after surgery. CONCLUSIONS: Since the amounts of sIgA in these patients were much greater than reported in urinary tract infection as well as in normal subjects, the major portion of urinary sIgA seemed to be secreted by the intestinal segments. Long-term sIgA secretion in urinary intestinal diversion, especially continent urinary reservoirs, may be an important host defense system.

Humans↗
PubMed1996

Management of late complications of continent urinary diversion using the Kock pouch and the Indiana pouch procedures.

BACKGROUND: Continent urinary diversion (CUD) is performed on patients after total cystourethrectomy due to invasive bladder cancer or other diseases requiring urinary diversion. Since 1984, we have performed CUD using either the Kock pouch procedure or a modified Indiana pouch method. During the long-term follow-up, increasing numbers of late complications occurred, especially after the Kock pouch procedure. We summarized the frequency of postoperative complications, their management, and outcome of CUD using these 2 methods. METHODS: Between 1984 and 1995, CUD using the Kock pouch method was performed on 102 patients, and on 61 patients using the Indiana pouch method, with a mean follow-up period of 83 and 50 months, respectively. The patients were between 24 and 82 years old, with a mean age of 59 years. In most patients, the Kock pouch was constructed according to the original method, except for the use of a Dacron fabric collar, and the Indiana pouch was made using the ileal patch method. RESULTS: Of 95 patients followed up for more than 3 months after CUD using the Kock pouch method, efferent and afferent nipple valve malfunction occurred in 21 (22%) and 26 (27%) patients, respectively. Efferent complications occurred during the first year after surgery, whereas afferent complications occurred several years after surgery. Open repair surgery (excluding ileus) was necessary for 36 (38%) patients. Of 59 patients followed for more than 3 months after CUD using the Indiana pouch method, 7 patients with stomal stenosis, 2 patients with stomal prolapse, and 1 patient with stricture at the ureterocolonic anastomosis were treated surgically. An hourglass-like deformity of the pouch was seen in 2 patients, on whom the original Indiana pouch method was performed. As a whole, 13 patients (22%) were retreated with open surgery. Urinary calculi occurred in 42 (44%) patients after CUD using the Kock pouch method and in 11 patients (19%) using the Indiana pouch method. The outcome was excellent, good, fair, and poor in 31, 37, 24, and 8% of the patients after CUD using the Kock pouch method, and in 36, 17, 42, and 5% of the patients after CUD using the Indiana pouch method. CONCLUSIONS: We performed CUD using either the Kock pouch or the Indiana pouch method with a success rate of approximately 90%. The rates of revision, reoperation and stone formation were higher with the Kock pouch procedure than with the Indiana pouch procedure, while varying degrees of incomplete incontinence and difficulty in catheterization were seen more often in the latter.

Adult↗
PubMed1998

Ileal pouch with an umbilical stoma: a continent mechanism created by the extramural tunnel technique.

We present an initial experience of creating an extramural continent valve in the ileal pouch in 4 patients who required continent urinary diversion. Using the appendix or a tapered ileal segment, the continent valve was created by the extramural tunnel technique along the anterior suture line of the pouch to facilitate the umbilical anastomosis. All patients were continent postoperatively with easy catheterization. This technique can provide a simple and effective continent pouch formed entirely from the ileum.

Follow-Up Studies↗
PubMed1991

Ileo-anal pouch procedure: experience in the Chinese population.

The ileo-anal pouch procedure is now a well-established method for dealing with ulcerative colitis and familial polyposis in many centres in the West. Experience in the Chinese population is not well documented, mainly due to the rarity of inflammatory bowel disease. This report documents the experience of a university teaching hospital in Hong Kong. Despite being a small series, the low complication rates and good functional results show that the pelvic pouch procedure has now evolved to a stage where it can be performed safely even in centres with infrequent experience.

Adenomatous Polyposis Coli↗
PubMed1995

Psoas abscess following ileo-anal pouch surgery.

An unusual case of psoas abscess complicating one of the earliest performed ileo-anal pouch anastomoses is reported. The authors have been unable to find a similar previously published case.

Adult↗
PubMed1995

The ileal pouch-anal anastomosis in challenging patients: stretching the limits.

Total proctocolectomy and ileal pouch-anal anastomosis (IPAA) is the best option in the surgical treatment of ulcerative colitis, and for some patients with familial polyposis. Contraindications to the procedure include old age, obesity, weak sphincters, perianal sepsis and previous enterectomy. In this study the results of IPAA in five patients with one or more of these contraindications are presented and ways of dealing with them are discussed. All patients had a favourable outcome showing that such contraindications are relative, and IPAA may be attempted as long as patients are fully informed and understand the risks to which they are subject.

Adenomatous Polyposis Coli↗
PubMed1997

Colonic J-pouch as a neorectum: functional assessment.

BACKGROUND: Sphincter-saving procedures are now commonly used for low rectal cancer but straight colo-anal anastomosis seemed to produce poor functional outcome. The present study was therefore carried out to compare and contrast the functional outcome of colonic J-pouch and straight colo-anal anastomosis. METHODS: The clinical and functional outcome of 17 patients having a colonic J-pouch-anal anastomosis and 10 patients having a straight colo-anal anastomosis were compared. They were compared in terms of age, sex, distal resection margin, Dukes stage, histological grade, morbidity/mortality and postoperative anal function. RESULTS: There was better bowel function in patients having J-pouch-anal anastomosis, especially in the early period after closure of the covering stoma. Bowel frequency in those patients who had a J-pouch anastomosis was much less compared to those patients in the straight colo-anal group in the 1st and possibly the 2nd year. There was a period of adaptation for the straight colo-anal group which led to a bowel frequency approaching that of the J-pouch group over 1-2 years. Differences in urgency, faecal continence, evacuation function, the use of drugs to slow bowel frequency and ability to discriminate between flatus and faeces were found to favour the J-pouch group in the first postoperative year. The difference between the two groups diminished after that because the straight group improved, especially by the end of the 2nd year. During the study period, there were no constipation problems in the J-pouch group, as noted in some other studies. This was probably associated with the 6-cm length chosen for the pouch. CONCLUSIONS: The use of colonic J-pouch resulted in a significant decrease in stool frequency and more satisfactory anal function for the first postoperative year. This difference lessened during the second postoperative year. There was no demonstrable difficulty with rectal evacuation in the pouch patients.

Adenocarcinoma↗
PubMed2004

Abdominal stapled side-to-end anastomosis (Baker type) in low and high anterior resection: experiences and results in 69 consecutive patients at a regional general hospital in Japan.

OBJECTIVE: The technique of transanally introducing a circular stapled device to accomplish colorectal anastomoses has been widely used. However, the widespread popularity of this technique may have created the potential of anal sphincter injury during transanal insertion of the anastomosing stapler. Thus, to avoid the risk of anal sphincter injury during anal manipulation, we have been performing an abdominal approach, namely abdominal stapled side-to-end anastomosis (ASSEA) using a Purstring and premium curved EEA stapler in low and high anterior resection. This study will present our experience and results of consecutive resections. METHODS: ASSEA following a resection of the rectum and sigmoid colon for carcinomas was consecutively performed between October 1998 and May 2002. Age, sex, pre-operative anal function, the TNM classification by the UICC rules, operative methods, postoperative morbidity, mortality, anal function and bowel frequency were evaluated. RESULTS: Sixty-nine consecutive patients underwent a resection of the rectum and sigmoid colon with ASSEA. There were three (4.3%) clinical anastomotic leakages in the cases studied. Anastomoses that were located above the peritoneal reflection leaked in one (2.5%) of 40 cases, while anastomoses below the peritoneal reflection leaked in two (6.9%) of 29 cases. A diverting stoma was performed in five (17%) of the 29 cases with low anastomosis. Postoperative anal function was stable without soiling or faecal leakage and bowel frequency two months after surgery was less than four times in all 61 patients. There was no postoperative mortality related to the anastomosis. CONCLUSIONS: Abdominal stapled side-to-end anastomosis (Baker type) was found to be a safe and relatively easy method in both low and high anterior resection in association with a good quality of life.

Abdomen↗
PubMed2004

Is routine pouchogram prior to ileostomy closure in colonic J-pouch really necessary?

INTRODUCTION: Colonic J-pouch with coloanal anastomosis has gained popularity in the surgical treatment of middle and lower rectal pathologies. If a diverting ileostomy is performed, a pouchogram is frequently performed prior to ileostomy closure. The aim of this study was to assess the routine use of pouchogram prior to ileostomy closure in patients with colonic J pouch-anal anastomosis. METHODS: All patients who underwent a colonic J pouch-anal anastomosis between 1990 and 2000 were retrospectively reviewed. Patients with temporary loop ileostomy who had pouchogram prior to ileostomy closure were included. Pouchogram results were compared to the patient's post ileostomy closure clinical outcome. Sensitivity, specificity and predictive values of pouchogram were assessed. RESULTS: Eighty-four patients had a pouchogram prior to ileostomy closure. Radiological abnormalities were evident in 6 patients, including 4 strictures, 1 pouch-vaginal fistula and 1 leak. Of these findings, 4 were false positives (3 strictures and 1 leak) and two were true positives (1 stricture and 1 pouch-vaginal fistula). The actual rate of pouch complications was 9.5% (8 complications) including 3 anastomotic leaks, all with normal pouchogram, 3 strictures requiring dilatation under anaesthesia, only one detected by pouchogram, and 2 pouch-vaginal fistulas, only one diagnosed by pouchogram. The sensitivity and specificity of pouchogram, respectively, was 0 and 98% for anastomotic leak, 33 and 96% for stricture, and 50 and 100% for pouch-vaginal fistula. Overall, pouchogram changed the management in only 1 of 84 patients. CONCLUSION: Pouchogram has a low sensitivity in predicting complications following ileostomy closure in patients after colonic J-pouch anal anastomosis and rarely changes the management of these patients. The use of pouchogram prior to ileostomy closure may be unnecessary and should be reserved in cases of clinical suspicion of complications.

Adult↗