Quality of life after Brooke ileostomy and ileal pouch-anal anastomosis. Comparison of performance status.

Although the clinical results of Brooke ileostomy are good, patients are permanently incontinent of stool and gas. Alternative operations designed to restore enteric continence, such as ileal pouch-anal anastomosis, must not only be as safe and effective as Brooke ileostomy, but should provide an improved quality of life in order to establish long-term acceptability. Ileal pouch-anal anastomosis has been performed safely and good functional results have been reported. The quality of life after ileal pouch-anal anastomosis, however, has not been documented. Two hundred ninety-eight ileal pouch patients and 406 Brooke ileostomy patients who had the operations performed for chronic ulcerative colitis or familial adenomatous polyposis formed the basis of the study. After adjusting for age, diagnosis, and reoperation rate, logistic regression analysis of performance scores in seven different categories was used to discriminate between operations. Median follow-up was longer in Brooke ileostomy patients than in ileal pouch patients (104 months vs. 47 months, respectively), and Brooke ileostomy patients were slightly older (38 years vs. 32 years). A great majority of patients in each group were satisfied (93% Brooke ileostomy; 95% ileal pouch-anal anastomosis). Thirty-nine per cent of Brooke ileostomy patients, however, desired a change in the type of ileostomy they had. At 47 months, ileal pouch patients had a median of 5 stools per day and 1 at night, 77% did not experience any daytime incontinence, while 22% reported occasional spotting. In each performance category, the performance score discriminated between operations, with the probability of having had an ileal pouch-anal anastomosis operation increasing with improvement in performance scores (p less than 0.05). We concluded that after ileal pouch-anal anastomosis, patients experienced significant advantages in performing daily activities compared to patients with Brooke ileostomy and thus may experience a better quality of life. These results help further to establish ileal pouch-anal anastomosis as a safe, attractive, and valid alternative to Brooke ileostomy.     

Ileal pouch-anal anastomosis: comparison of results in familial adenomatous polyposis and chronic ulcerative colitis.

The aim of this study was to compare the immediate postoperative results and the long-term outcome of ileal pouch-anal anastomosis in 94 patients with familial adenomatous polyposis to those in 758 patients with ulcerative colitis. Two colitis patients died after operation (0.3%), but no polyposis patients died. Overall operative complications appeared in 26% and 29% of polyposis and colitis patients, respectively (NS). Reoperation for intestinal obstruction did not differ between the two groups, but sepsis requiring reoperation was more common in colitis patients (6%) than in polyposis patients (0%, p less than 0.04). At follow-up (mean, 3 years), polyposis patients had fewer daytime stools (4.5 stools per day), less nighttime fecal spotting (26%), and less pouchitis (7%) than colitis patients (5.8 stools per day; spotting, 40%; pouchitis, 22%; p less than 0.002). The conclusion was that polyposis patients tolerated the operation better and had less long-term disability than did colitis patients. The data suggest that postoperative sepsis, daytime stooling frequency, nocturnal incontinence, and pouchitis may be, at least in part, disease related and not surgeon or operation related.     

Anal sphincter-saving operations for chronic ulcerative colitis.

Three anal sphincter-saving operations--ileorectostomy, ileal pouch-anal anastomosis, and ileal pouch-distal rectal anastomosis--are currently being used in the surgical treatment of chronic ulcerative colitis. All three operations remove the disease, or most of it, and yet they maintain transanal defecation, reasonable fecal continence, and a satisfactory quality of life. All three avoid permanent abdominal ileostomy. Ileorectostomy is the easiest to perform, but it leaves residual disease in the remaining rectum and proximal anal canal that may cause symptoms and that may predispose the patient to cancer. In contrast, ileal pouch-anal anastomosis, although a more technically demanding procedure, totally eradicates the colitis. Its main drawbacks--frequent stooling, nocturnal fecal spotting, and pouchitis--are usually satisfactorily treated with loperamide hydrochloride and metronidazole. Ileal pouch-distal rectal anastomosis is somewhat easier to perform than ileal pouch-anal anastomosis and may result in less nocturnal fecal spotting. Like ileorectostomy, however, the operation leaves residual disease in the distal rectum and proximal anal canal. Considering all of these factors, the ileal pouch-anal operation is preferred today for most patients who require surgery for chronic ulcerative colitis.     

Ileal "J" pouch-anal anastomosis. Clinical outcome.

One hundred eighty-eight patients undergoing abdominal colectomy with distal mucosal proctectomy and endorectal ileal pouch-anal anastomosis were reviewed to assess long-term functional results and to identify factors that might influence them. There was no postoperative mortality, but 10 patients (5.3%) required permanent ileostomy because of postoperative complications or the development of unsuspected Crohn's disease. Immediate postoperative complications, including pelvic sepsis, small bowel obstruction requiring surgery, anastomotic stricture, and ileostomy dysfunction, were observed in 11%, 9%, 14% and 9% of patients, respectively. No males were impotent but nine (9%) developed retrograde ejaculation. Pouchitis occurred in 8% of patients. Among 157 patients assessed at least 60 days after ileostomy closure (mean +/- SD, 375 +/- 216 days), all evacuated their neorectum spontaneously, and stool frequency was 6.0 +/- 2.6 daily and 1.2 +/- 1.3 nightly. While continence was generally good, 2.5% of patients during waking hours and 4.5% during sleep had occasional frank soilage. Moreover, seepage was noted in 25 and 47% of patients during daytime and nighttime, respectively. Both stool frequency and degree of continence improved with time. Patients less than 50 years of age and those with polyposis coli had fewer stools and better continence than those older than 50 or those with ulcerative colitis. It is concluded that ileal "J" pouch-anal anastomosis can be performed safely and will provide acceptable anorectal function without late deterioration.     

Ileal pouch-anal anastomosis. The Emory University experience.

The ileal pouch-anal anastomosis has become a practical alternative to proctocolectomy for the treatment of ulcerative colitis and polyposis coli. To evaluate its success, the Emory University Affiliated Hospital experience from February 1984 to March 1989 was retrospectively reviewed. There were a total of 50 patients identified; 84 per cent had ulcerative colitis, and 16 per cent had polyposis coli (familial polyposis and Gardner's syndrome). The majority of these patients underwent a two-stage operation, but one-third required a three-stage procedure due to difficulty in mucosal proctectomy or toxic megacolon. J-pouch construction was performed in 72 per cent of patients, S-pouch construction in 14 per cent, straight ileo-anal anastomosis in 8 per cent, and lateral isoperistaltic ileo-anal anastomosis in 6 per cent. Of the 50 patients, 36 (72%) have had closure of the temporary ileostomy. Fourteen patients have not had ileostomy closure due to change in diagnosis to Crohn's disease, operative complications, or ileostomy closure pending. The combined operative morbidity per patient for the ileal pouch-anal anastomosis and the closure of the ileostomy was 32 per cent. This included bowel obstruction, 16 per cent; pelvic abscess, 6 per cent; and ileo-anal separation, 4 per cent. Follow-up on patients with ileostomy closure ranged from 6 months to 4 years (mean, 1.3 years). Stool frequency was 5.9 stools per 24 hours at 6 months and improved with time. During the follow-up period, all patients were eventually completely continent of stool during the day, and most became completely continent of stool at night.(ABSTRACT TRUNCATED AT 250 WORDS)     

Complications and risk factors after ileal pouch-anal anastomosis for ulcerative colitis associated with primary sclerosing cholangitis.

OBJECTIVE: This study determined predictive factors for postoperative complications and outcome after ileal pouch-anal anastomosis in patients with ulcerative colitis and primary sclerosing cholangitis. SUMMARY BACKGROUND DATA: Patients with ulcerative colitis and primary sclerosing cholangitis treated by colectomy and ileostomy are at high risk of troublesome bleeding from peristomal varices. METHODS: Postoperative complications and outcome were assessed in 40 patients with ulcerative colitis and sclerosing cholangitis who received an ileal pouch-anal anastomosis between January 1981 and February 1990. RESULTS: Immediate postoperative and remote ileoanal anastomosis-related complications were high but related directly to the severity of liver disease. No patient had perianastomotic anal bleeding. CONCLUSIONS: In patients with both ulcerative colitis and primary sclerosing cholangitis, ileal pouch-anal anastomosis is safe and is not associated with perianastomotic bleeding.     

Anorectal manometry and ileo-anal anastomosis]

Seventeen patients (12 ulcerative colitis, 5 familial adenomatous polyposis) underwent proctocolectomy and ileal J pouch anastomosis. Anal manometry with determination of maximum tolerable volume and a liquid continence test were perform before ileo-anal anastomosis, before closure of the loop ileostomy and 12 months after closure of the loop ileostomy. All patients were continent during the daytime less 12 months after proctocolectomy. The mean stool frequency was 5 stools per day in our 17 patients. A significant increase in maximum tolerable volume and in the liquid continence test was observed during the first year after closure of the ileostomy. Anal manometry is unnecessary after ileoanal anastomosis, but preoperatively, this test is able to exclude some patients with low anal pressure.     

Adenocarcinoma below stapled ileoanal anastomosis after restorative proctocolectomy for ulcerative colitis

A case of adenocarcinoma arising in a 39-year-old patient after restorative proctocolectomy is reported. The patient underwent an ileal pouch-anal anastomosis with double-stapled technique for severe ulcerative colitis 18 years earlier, without evidence of associated neoplasm or dysplasia in operative specimen. After endoscopic diagnosis of adenocarcinoma, the patient was submitted to excision of the pouch and permanent ileostomy, followed by combined radiotherapy and chemotherapy. Pathology showed an AJCC stage III moderately differentiated mucinous adenocarcinoma. The patient died 24 months after the operation, due to cancer progression. There are 50 reported cases in the indexed medical literature of carcinoma arisen after ileal pouch-anal anastomosis for ulcerative colitis. Twenty-five out of these arose after mucosectomy and hand-sewn anastomosis, and 25 after stapling technique. Furthermore, in 48% of the patients, dysplasia or cancer was already present at the time of the colectomy. The increase of reported cases suggests a routine long-term endoscopic surveillance in patients with long-standing ileal pouches, especially in presence of dysplasia or cancer in the proctocolectomy specimen.     

Preservation of anorectal continence following total colectomy.

The search for continence in the surgical management of ulcerative colitis has resulted in the evolution of a method that has yielded gratifying results in the last 18 patients. The disease process is removed; all patients are continent; they have no postoperative perineal excoriation; the frequency of stools is not excessive and the patients are returning to work or to school within three weeks following ileostomy closure. Their ages were eight to 52 years. The procedure consists of a total of colectomy with mucosal proctectomy, ileoanal anastomosis and construction of a terminal ileal, pelvic reservoir. A proximal ileostomy diverts the fecal stream until healing is complete. The authors are now recommending the operation be considered for patients of all ages who require surgery for chronic ulcerative colitis as well as polyposis.     

Colectomy and endorectal ileal pull-through with lateral ileal reservoir for ulcerative colitis and polyposis in children

Nineteen children with chronic ulcerative colitis refractory to medical therapy and one with multiple polyposis, all under 20 years of age, underwent total colectomy, mucosal proctectomy, and endorectal ileal pull-through with ileoanal anastomosis at the UCLA Medical Center during a 4 1/2-year period (mean age, 14.4 years). Seventeen patients underwent second-stage closure of the ileostomy with construction of a side-to-side isoperistaltic ileal reservoir (mean, 6 months) after the ileal pull-through operation. The anastomosis extended over a 20- to 30-cm distance and the lower end was placed within 6 to 8 cm of the ileoanal anastomosis. Transient reservoir inflammation, which occurred in more than half of the patients, was reduced by the use of oral Metranidazole and was rare 6 months postoperation. Cuff abscess in one patient did not respond to long-term antibiotics and required ileostomy as well as eventual takedown of the reservoir. Two patients developed obstruction of the ileum below the reservoir due to an extended distance between the reservoir and anal anastomosis, requiring transient ileostomy. Fourteen of the 17 children who have undergone lateral reservoir construction have achieved a good-to-excellent result, with complete continence and an average of five stools per 24 hours after 6 months. Seven of the 14 now participate in competitive athletics. Three children await construction of the reservoir.     

Evolution of the pelvic pouch procedure at one institution: the first 100 cases.

BACKGROUND: Total extirpation of the colon with pelvic pouch formation, and the avoidance of a permanent stoma, continues to pose a challenge for better results, both technically and functionally. The aims of this study were to investigate the first 100 pelvic ileal-pouch procedures, assessing changes in surgical technique, their relationship to morbidity and long-term outcome, and compare this to the few large international series. METHODS: Between 1984 and 1997, 100 patients had a pelvic J-shaped ileal-pouch formed, 58 two-stage and 42 three-stage procedures. Fifty had a hand-sewn pouch-anal anastomosis and 50 a double-stapled anastomosis. Seventy-three were for ulcerative colitis, five for indeterminate colitis, 20 for familial adenomatous polyposis (FAP), one for multiple primary colorectal cancers, and one for constipation. RESULTS: After a median follow-up of 68 months, 97% of patients still have a functioning pouch. There were two postoperative deaths (one after-pouch formation and one after-stoma closure). Morbidity occurred in 52 patients, including three patients with pouch leaks and three pouch-anal anastomosis leaks (6% leak rate), 27% with a small bowel obstruction (2% early, 20% late, 5% both), a 19% anal stricture rate, and a 9% pouchitis rate. Three pouches have been removed (all for Crohn's disease). Median number of bowel movements per day was six, with 85% of patients reporting a good quality of life. Patients following a double-stapled procedure have less anal seepage and improved continence over those with a hand-sewn ileal pouch-anal anastomosis. CONCLUSIONS: Despite high morbidity rates, pelvic pouch formation provides satisfactory long-term results for patients requiring total proctocolectomy, with functional results and morbidity rates comparable to larger overseas series.     

Endorectal ileoanal anastomosis with isoperistaltic ileal reservoir after colectomy and mucosal proctectomy.

Forty-nine patients with chronic ulcerative colitis refractory to medical therapy and four with multiple polyposis have undergone total colectomy, mucosal protectomy, and endorectal ileal pull-through with ileoanal anastomosis at the UCLA Medical Center during the past 12 years (mean age, 19.4 years). Thirty-eight patients underwent second-stage closure of the ileostomy with construction of a side-to-side isoperistaltic ileal reservoir (mean, 6 months) after the ileal pullthrough operation. The anastomosis extended over a 20-30 cm distance and the lower end was placed within 6-8 cm of the ileonanal anastomosis. Transient reservoir inflammation, which occurred in half of the patients, was reduced by the use of oral metranidazole and was rarely found 6 months after operation. No patients died during the early or late post-operative periods. Cuff abscess in two patients and obstruction of the ileal reservoir outlet have required takedown of the reservoir (two patients) or temporary ileostomy (three patients). Of the 38 patients who have undergone lateral ileal reservoir construction, 33 have achieved a good to excellent result with complete continence and an average of five stools per 24 hours after 6 months. At least 12 patients now participate in competitive athletics; normal sexual activity has been achieved in all but one patient. Seven patients await construction of the reservoir. Although a technically difficult operation, the long-term results (mean, 19.4 months) indicate that the pullthrough operation is a good alternative to standard proctocolectomy.     

Surgical treatment of hemorrhagic proctocolitis]

Surgical treatment of chronic ulcerative colitis requires restorative proctocolectomy with ilial pouch-anal anastomosis to remove all the disease bowel and provide cure. A one-stage or two-stage procedure can be performed after subtotal colectomy with ileostomy and colostomy. Restorative proctocolectomy is not advised for very old patients or patients with anal sphincter insufficiency. In such cases, total colectomy with ileo-rectal anastomosis is proposed. The rectal stump must be examined regularly by rectoscopy because of the risk of cancer. A proctocolectomy with definitive ileostomy is proposed after pouch-anal excision for pelvic septic complications (5% of ileal pouch-anal anastomoses). Surgical treatment of chronic ulcerative colitis is indicated when medical treatment fails, at onset of fulminant acute colitis, or because of colorectal dysplasia.     

Immediate and long-term results in ileoanastomosis with reservoir in 335 consecutive cases

Restorative proctocolectomy with ileal pouch anal anastomosis is the first choice procedure for the treatment of ulcerative colitis and familial adenomatous polyposis. The introduction of the stapled technique has shortened the duration of the procedure and reduced the complication rates. Data on 335 consecutive patients undergoing ileal pouch anal anastomosis for ulcerative colitis (277 pts), Indeterminate colitis (20 pts) and familial adenomatous polyposis (38 pts) between 1984 and 1998 were prospectively collected. Parameters evaluated included diagnosis, surgical technique, functional outcome, early and late complications and their management and results. Twenty-nine patients (8.6%) presented with pelvic sepsis. Twelve patients (3.5%) experienced late perianal fistulas. The pouch failure rate was 3.4%. Six patients required a re-do pouch procedure, with 75.9% preservation of sphincter function. No correlation was found between complication rates and diagnosis. The mean number of stools was 5.2/24 h. The study confirmed the safety and effectiveness of the procedure. In particular, morbidity rates are comparable to those of major abdominal procedures and the long-term functional results are satisfactory. However, a number of technical aspects, such as the anastomosis technique, the need for temporary ileostomy and the treatment of indeterminate colitis, still remain controversial.     

Poor outcome of a defunctioning stoma after pouch construction for ulcerative colitis

BACKGROUND: Restorative proctocolectomy for ulcerative colitis can have complications necessitating a later defunctioning ileostomy with uncertain outcome. This analysis was undertaken to assess the outcome in patients needing a later defunctioning ileostomy after pouch construction in patients with ulcerative colitis. METHOD: The notes of our series of 154 patients who underwent restorative proctocolectomy and ileal pouch-anal anastomosis for ulcerative colitis were reviewed and 28 patients identified who needed a later defunctioning ileostomy to deal with complications. RESULTS: A later defunctioning ileostomy was necessary in 28 patients to deal with the following complications: sepsis in 11 patients (5 pouches failed), fistulas in 7 (5 pouches failed), poor function including ileoanal stenosis in 5 (all 5 failed), postoperative intraabdominal bleeding in 2 (both saved), pouchitis in 2 (1 excised) and small bowel obstruction in 1 (saved). 16 pouches were eventually excised or permanently defunctioned (59%). CONCLUSION: Complications necessitating a later defunctioning stoma after pouch construction carry a poor prognosis, especially when used for ileoanal stenosis and fistulae.     

Late functional adaptation after colectomy, mucosal proctectomy, and ileal pouch-anal anastomosis

Ileal pouch-anal anastomosis (IPAA) is currently an alternative to proctocolectomy and ileostomy for patients with ulcerative colitis or familial polyposis. Some studies have suggested significant anal sphincter damage after mucosal proctectomy. Our aim was to assess prospectively late sphincter function after IPAA. In 250 patients, anorectal pressures were assessed with a pneumohydraulic perfused catheter manometry system. Each patient underwent colectomy, mucosal proctectomy, ileoanal anastomosis of a 15 cm ileal J-pouch, and loop ileostomy. Eight weeks after IPAA, anal manometry was repeated, and the ileostomy was closed. Manometry was repeated at yearly intervals. A decline in resting tone of the anal sphincter occurred early after IPAA with a gradual recovery toward control. External sphincter squeeze after pressures were not affected by IPAA and steadily increased to 8 years after operation. During this time, a progressive increase in J-pouch capacity was noted, and 24-hour stool frequency declined from 7.9 +/- 0.3 stools to 6.5 +/- 0.3 stools (p less than 0.05). We conclude that mucosal proctectomy results in internal anal sphincter trauma but is associated with long-term sphincter recovery, coupled with a significant improvement in external sphincter capacity, ileal pouch volume, and stool frequency.     

A longitudinal study of long-term quality of life after ileal pouch-anal anastomosis

BACKGROUND: There is a lack of longitudinal long-term studies of quality of life (QOL) after surgery with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis, where cohorts of patients are used as their own controls. METHODS: Forty ulcerative colitis patients who had undergone IPAA were prospectively assessed while they had a temporary ileostomy, and at a median of 18 months and 7 years after ileostomy closure. QOL was measured with the Psychosocial Adjustment to Illness Scale and the Well-Being Profile. RESULTS: QOL was good at all three time points and, with some exceptions, did not change significantly between the assessments. There was a high degree of stability in the patients' evaluation of their QOL over time. CONCLUSIONS: QOL was already good when the patients had a temporary ileostomy and generally did neither improve nor deteriorate during 7 years after ileostomy closure. QOL was also quite stable in terms of individual differences.     

Restorative proctocolectomy

Restorative proctocolectomy is considered the procedure of choice in the surgical treatment of ulcerative colitis and familial adenomatous polyposis coli. It is considered a therapeutically option that can cure both diseases avoiding permanent ileostomy and having good functional results. The operative procedure consists of total rectocolectomy excepting the anus, preserving the sphincter but with rectal mucosectomy. Digestive continuity is established by an ileal pouch and ileal pouch-anal anastomosis. Despite the high morbidity rate, functional results after restorative proctocolectomy seems to be better after one year after closure of the diverting ileostomy.     

Acute histologic inflammatory activity and postoperative outcomes in pediatric patients with ulcerative colitis

BackgroundThe aim of this study was to determine whether acute histologic inflammatory activity at the rectal margin predicts postoperative complications in children with ulcerative colitis following ileal pouch-anal anastomoses (IPAA).MethodsPatients who underwent IPAA following previous total abdominal colectomy for ulcerative colitis between 2006 and 2014 were included. Data collected included demographics, operative and postoperative data, histologic grading of the rectal margin at time of IPAA, and stooling outcomes at one, six and 12 months following ileostomy closure.ResultsTwenty-seven patients were included. Acute inflammation scores ranged between 2 and 13. Unadjusted and adjusted models showed no statistically significant relationship between inflammation and presence of any postoperative complications, number of daily stools, nighttime stooling, soiling, or stool-altering medication usage.ConclusionAcute histologic inflammatory activity at the rectal margin is not associated with increased rates of postoperative complications following IPAA creation in children, nor with poorer continence outcomes following ileostomy closure.     

Ileal pouch-anal anastomosis. A single surgeon's experience with 100 consecutive cases.

Between August 1982 and November 1985, 100 patients underwent ileal "J" pouch-anal anastomosis (IPAA) at the University of Utah. All operations were performed in a standard fashion by a single surgeon. Seventy-eight patients were operated on for chronic ulcerative colitis and 22 for familial polyposis coli. Sixty of the patients were male and 40 were female with a mean age of 33.2 years and a range of 11-63 years. Mean +/- SEM operating time was 5.9 +/- 0.4 hours, blood loss was 666 +/- 49 ml, and total hospitalization was 10.1 +/- 0.3 days. No operative deaths occurred. The overall operative morbidity was 13% after IPAA. Clinical "pouchitis" was observed in 18 patients, all of whom were operated on for chronic ulcerative colitis. No patients had frank incontinence. Twenty per cent of patients experienced frequent nocturnal leakage in the early postoperative period with a significant improvement over the ensuing 6 months. Stool frequency at 1, 3, 6, 12, and 24 months was 7.5 +/- 0.2, 6.5 +/- 0.1, 6.2 +/- 0.3, 5.4 +/- 0.1, and 5.4 +/- 0.2, respectively. Stool frequency at 12 months correlated inversely with ileal pouch capacity and the diagnosis of familial polyposis. It is concluded that ileal pouch-anal anastomosis is a safe and effective operation for patients with chronic ulcerative colitis and familial polyposis coli.