Comparing functional results one year and ten years after ileal pouch-anal anastomosis for chronic ulcerative colitis

Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice for most patients with chronic ulcerative colitis. Long-term results, however remain undefined; the major concern is that function may deteriorate. PURPOSE: The aim of this study was to assess functional outcome in a subgroup of patients who have an IPAA for chronic ulcerative colitis for >10 years. METHODS: Among 1400 IPAA patients, 75 consecutive subjects (31 females and 44 males; median age 31 at operation) were identified who had the procedure prior to 1982. All patients had functional results recorded 1 year and 10 years following ileostomy closure. RESULTS: There were four deaths during the follow-up period; none were pouch related. Two patients refused ileostomy closure. Of the remaining 69 patients, there were 8 (11 percent) failures, leaving 61 subjects available for study. Stool frequency (7±3, mean±SD) remained unchanged. Of the 50 subjects with initially excellent daytime continence, 39 (78 percent) remained the same, 10 (20 percent) developed minor incontinence, and 1 developed poor control after 10 years. Four of 10 subjects (40 percent) with initial minor daytime incontinence remained unchanged, 4 (40 percent) improved, and 2 (20 percent) worsened. The one subject with poor control at one year was unchanged. Nocturnal fecal spotting increased over the 10-year period but not significantly (38 percent vs.52 percent;P=0.08). CONCLUSIONS: After IPAA, functional results in terms of stool frequency and rate of fecal incontinence did not deteriorate with time.Read at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993.     

Previous subtotal colectomy with ileostomy and sigmoidostomy improves the morbidity and early functional results after ileal pouch-anal anastomosis in ulcerative colitis

The aim of this work was to study the effects of previous subtotal colectomy (STC) with ileostomy and sigmoidostomy on the outcome of ileal J-pouch-anal anastomosis (IPAA) in patients with acute ulcerative colitis. Between 1983 and 1991, we conducted a prospective, nonrandomized study of 156 patients who underwent IPAA in our center. Fifty-five patients (34.3 percent) had undergone STC with ileostomy and sigmoidostomy for either severe acute colitis (36.5 percent of cases) or nonresolving acute colitis (63.5 percent) up to six months before IPAA with covering ileostomy. There were no perioperative deaths; six patients (11 percent) developed complications requiring reoperation (three cases of pelvic sepsis, two occlusions, and one stenosis of the ileostomy). IPAA was successfully carried out at a later stage in all cases. The results of IPAA in these patients were compared with those in 78 patients who underwent the classical two-stage IPAA procedure. The rates of pelvic sepsis and postoperative occlusion were lower in the subgroup of patients who underwent the three-step procedure. Three months after closure of the ileostomy, the mean number of daily stools was significantly lower in the patients who had undergone prior STC (5.09 vs.5.9), but there was no significant difference between the two groups with regard to diurnal and nocturnal continence, the need to wear a pad, discrimination between gas and stools, or the use of antidiarrheal medication. In addition, there was no significant difference at one year in terms of functional parameters. We conclude that STC is a simple and safe procedure for the treatment of a severe attack of colitis and that it does not compromise the results of later IPAA. Because it does not increase the morbidity of subsequent IPAA and is associated with more rapid functional recovery, STC appears to be suitable for the treatment of patients with nonresolving acute colitis before the onset of malnutrition or steroid dependency.     

Lymphoma of the pouch after ileal pouch-anal anastomosis

The most common cause of pouch dysfunction after ileal pouch-anal anastomosis is pouchitis. Although low-grade dysplasia in the mucosa of the pouch has been recently described in the presence of pouchitis, there has been no report of carcinoma arising in the pouch itself. We describe a patient who developed a large-cell lymphoma of the ileal pouch after ileal pouch-anal anastomosis.     

Safety of urgent restorative proctocolectomy with ileal pouch-anal anastomosis for fulminant colitis

PURPOSE: Subtotal colectomy with ileostomy is the operation of choice for patients with fulminant colitis. Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) is preferred for patients who undergo elective surgery for ulcerative colitis. We retrospectively evaluated the safety of RPC with IPAA in patients with a moderate form of fulminant colitis. METHODS: A chart review of 737 patients who underwent RPC with IPAA for ulcerative and indeterminate colitis from 1983 through 1992 was performed. Moderate fulminant colitis was defined as acute disease requiring hospitalization and parenteral steroid therapy, but without hypotension (systolic blood pressure, <100 mmHg), tachycardia (>120 beats/min), or megacolon. RESULTS: Twelve patients with moderate fulminant colitis underwent urgent surgery (1.6 percent). They had been treated preoperatively for 5.1±2.3 days with intravenous high-dose steroids, total parenteral nutrition, and antibiotics. These patients had a shorter length of disease ( P =0.01), lower hemoglobin, hematocrit, and albumin (P=0.001), and higher temperature (P=0.002) and leukocyte count (P=0.007) than patients undergoing elective surgery. No early septic complications occurred, although perianal abscess occurred in one patient and pouch-anal fistula in another patient, 13 and 14 months after surgery, respectively. CONCLUSION: In carefully selected, hemodynamically stable patients with fulminant colitis and without megacolon, RPC with IPAA can be safely performed.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994.     

Rediversion after ileal pouch-anal anastomosis

PURPOSE: The aim of this study was to understand better the cause and predictability of pouch failure requiring rediversion after ileal pouch-anal anastomosis and to assess the ultimate outcome of patients in a large ileal pouch series who required rediversion. METHODS: Data from 460 patients completing ileal pouch-anal anastomosis at one institution were recorded from both a prospectively accumulated ileal pouch registry and patient medical records. RESULTS: Of 460 patients, 21 (4.6 percent) who underwent ileal pouch-anal anastomosis required rediversion. Five of these patients subsequently had successful restoration of pouch continuity, leaving a permanent failure rate of 16 of 460 patients (3.5 percent). The most common reasons for rediversion were pouch fistula formation (12) and poor functional results (5). Preoperative factors, including age, previous colectomy, and indication for colectomy, did not predict eventual need for rediversion. Patients requiring rediversion had significantly higher rates of postoperative complications (95 vs.43 percent;P <0.001). Specifically, this group had a higher rate of postoperative pouch fistula (57 vs.3.4 percent;P <0.001). Additionally, a final diagnosis of Crohn's disease significantly predicted the need for rediversion. Permanent pouch failure occurred in 36.8 percent of patients with a final diagnosis of Crohn's disease compared with 1.4 percent of patients with a final diagnosis of ulcerative colitis ( P <0.001). All five salvaged patients had fistula formation in the absence of Crohn's disease. CONCLUSIONS: The overall rate of permanent pouch failure is low. The majority of failures were related to fistula formation associated with Crohn's disease or poor functional results. Pouches complicated by fistulas not associated with Crohn's disease can be salvaged with temporary rediversion.Read in part at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993.     

Consequences of ileal pouch-anal anastomosis for Crohn's colitis

Patients with Crohn's colitis are generally not considered candidates for the ileal pouch-anal anastomosis (IPAA). procedure. We reviewed 362 consecutive patients undergoing IPAA and analyzed the outcome of this procedure on 25 patients with a preoperative diagnosis of mucosal ulcerative colitis who were subsequently proven to have Crohn's disease. The mean follow-up was 38.1 months. Sixteen patients have a functioning pouch, seven have required pouch excision, one is diverted, and one has died. Only one of nine patients in whom there was a preoperative clinical feature suggestive of Crohn's disease has a functioning pouch, with complications uniformly occurring within months of ileostomy closure. In contrast, 15 of 16 patients without preoperative features of Crohn's disease have maintained their pouch, generally with good results. These data suggest that patients in whom there is clinical and pathologic evidence of Crohn's disease do very poorly without meaningful symptom-free intervals. However, patients without any clinical features of Crohn's disease, despite a histopathologic diagnosis of Crohn's colitis, have had a good outcome with IPAA thus far.Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990.     

Indeterminate colitis predisposes to perineal complications after ileal pouch-anal anastomosis

This study retrospectively evaluated 288 patients who had undergone ileal pouch-anal anastomosis to determine the incidence of perineal complications and to relate these findings to the pathologic diagnosis, with the goal of specifically clarifying the appropriate surgical management of patients with indeterminate colitis. Of these 288 patients, 235 patients (82 percent) had a diagnosis of chronic ulcerative colitis, 18 patients (6 percent) had indeterminate colitis, 6 patients (2 percent) had Crohn's disease, and 29 patients (10 percent) had familial polyposis. All complications occurred at least 6 months after closure of the stoma and required operative therapy. Of 18 patients with indeterminate colitis, 9 patients experienced complications (50 percent) vs. 8 of 235 patients with chronic ulcerative colitis (3 percent), a highly significant difference (P <0.001). Furthermore, the risk of eventual ileostomy because of perineal complications was 0.4 percent in patients with chronic ulcerative colitis vs. 28 percent in patients with indeterminate colitis (P< 0.001). We conclude that a diagnosis of indeterminate colitis predisposes the patient undergoing ileal pouchanal anastomosis to perineal complications, with a resultant high chance of reservoir loss. Ileal pouch-anal anastomosis should be considered with caution in the patient with a diagnosis of indeterminate colitis.Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990.     

Carcinoma and the ileal pouch-anal anastomosis

Of 362 patients undergoing ileal pouch-anal anastomosis, 12 (five with chronic ulcerative colitis and seven with familial adenomatous polyposis) had 16 associated carcinomas. Incidental carcinoma was found in four patients who had undergone ileal pouch-anal anastomosis, six patients had known carcinoma, and carcinoma was suspected in two patients with high-grade dysplasia. No tumor was Stage C or D. After a median observation period of 24 months, no evidence of recurrence was documented. Data suggest that patients with carcinoma complicating chronic ulcerative colitis and familial adenomatous polyposis can safely undergo ileal pouch-anal anastomosis; however, it may be prudent to perform resection and later ileal pouch-anal anastomosis after a period of observation and appropriate adjuvant therapy because of the difficulty in intraoperative staging.Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990.     

Complications after ileal pouch-anal anastomosis in Korean patients with ulcerative colitis

AIM: To investigate the outcomes of treatments for complications after ileal pouch-anal anastomosis (IPAA) in Korean patients with ulcerative colitis.METHODS: Between March 1998 and February 2013, 72 patients (28 male and 44 female, median age 43.0 years ± 14.0 years) underwent total proctocolectomy with IPAA. The study cohort was registered prospectively and analyzed retrospectively. Patient characteristics, medical management histories, operative findings, pathology reports and postoperative clinical courses, including early postoperative and late complications and their treatments, were reviewed from a medical record system. All of the ileal pouches were J-pouch and were performed with either the double-stapling technique (n = 69) or a hand-sewn (n = 3) technique.RESULTS: Thirty-one (43.1%) patients had early complications, with 12 (16.7%) patients with complications related to the pouch. Pouch bleeding, pelvic abscesses and anastomosis ruptures were managed conservatively. Patients with pelvic abscesses were treated with surgical drainage. Twenty-seven (38.0%) patients had late complications during the follow-up period (82.5 ± 50.8 mo), with 21 (29.6%) patients with complications related to the pouch. Treatment for pouchitis included antibiotics or anti-inflammatory drugs. Pouch-vaginal fistulas, perianal abscesses or fistulas and anastomosis strictures were treated surgically. Pouch failure developed in two patients (2.8%). Analyses showed that an emergency operation was a significant risk factor for early pouch-related complications compared to elective procedures (55.6% vs 11.1%, P < 0.05). Pouchitis was related to early (35.3%) and the other late pouch-related complications (41.2%) (P < 0.05). The complications did not have an effect on pouch failure nor pouch function.CONCLUSION: The complications following IPAA can be treated successfully. Favorable long-term outcomes were achieved with a lower pouch failure rate than reported in Western patients.     

Delayed ileal pouch-anal anastomosis

In patients with chronic ulcerative colitis (CUC), ileal pouch-anal anastomosis (IPAA) can be performed either at the time of colectomy or as a delayed procedure after total abdominal colectomy and ileostomy. There has been debate as to whether delayed IPAA results in superior functional results, since patients are frequently steroid-free and have little evidence of active disease. To assess this, we analyzed 95 patients who had undergone total abdominal colectomy, either with ileostomy and Hartmann's procedure or with ileorectostomy, 2–183 months prior to IPAA. Postoperative complications and functional results were compared with those of 776 CUC patients who underwent IPAA at the time of abdominal colectomy. Indications for prior colectomy included toxic megacolon (40 percent), failed medical therapy (36 percent), other reasons (e.g.,iatrogenic perforation, cancer) (6 percent), and reasons unclear (18 percent). Nineteen percent of delayed-IPAA patients were taking steroids at the time of pouch construction. Follow-ups were similar in the two groups. The incidence of septic and obstructive complications after delayed IPAA vs. IPAA at the time of colectomy were 10.5 percent vs.5.4 percent and 6.5 percent vs.14.5 percent, respectively. There were no significant differences in postoperative functional results between the two groups. Delayed IPAA confers no advantage over IPAA performed at the time of colectomy in terms of functional outcome. Delayed IPAA was associated with a significantly higher rate of septic complications but a lower incidence of postoperative obstruction.Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990.     

Alteration in intestinal permeability after ileal pouch-anal anastomosis

PPURPOSE: The physiologic changes that occur when the small bowel is used as a reservoir, as in the ileal pouchanal anastomosis, are poorly understood. Alterations in bowel permeability, which may lead to bacterial translocation that could result in illness or dysfunction of the pouch, may be one such consequence of the pouch procedure. METHODS: Whole-bowel permeability was evaluated in patients with and without the pouch through the use of an orally consumed nonmetabolizable sugar clearance technique. Patients in whom the ileal pouchanal anastomosis was performed for ulcerative colitis (17 patients) and patients with familial polyposis (7 patients) were compared with normal healthy volunteers (10 patients) and patients with ulcerative colitis with and without curative colectomy and ileostomy (6 and 5 patients, respectively). RESULTS: Measured by this technique, no differences were noted in bowel permeability between the volunteers and patients with ulcerative colitis, even after colectomy and ileostomy (1.7±0.4 in normal healthy volunteers, 1.8±0.5 in patients with ulcerative colitis without stoma, and 1.4±0.2 in patients with ulcerative colitis with ileostomy). The group of patients with an ileal reservoir, however, had a significantly increased index of measured bowel permeability (3.5±0.5 in patients with ulcerative colitis and 5.1±0.7 in patients with familial polyposis; P<0.05 by analysis of variance compared with normal healthy volunteers and patients with ulcerative colitis with or without ileostomy). CONCLUSION: The exact site, cause, and consequence of this possible alteration of bowel permeability are unclear but appear to be related to the presence of the pouch and are not caused by the underlying pathologic diagnosis.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to 17, 1991. Winner of the New Jersey Society of Colon and Rectal Surgeons Award, 1991.     

Long-term causes of death following ileal pouch-anal anastomosis

PURPOSE: The aim of this study was to identify the overall long-term causes of death in a large series of patients who were undergoing proctocolectomy with ileal pouch-anal anastomosis (IPAA). METHODS: Records of patients who underwent proctocolectomy with IPAA at the Mayo Clinic affiliated hospitals between January 1981 and October 1994 were reviewed to determine overall mortality, cause, and timing of death. RESULTS: A total of 1,603 patients underwent proctocolectomy with IPAA reconstruction (1,407 for chronic ulcerative colitis (CUC), 187 for familial polyposis (FAP), and 9 for other diagnoses). Thirty-two patients have died, with an overall mortality rate of 2 percent. Mean age at time of death was 40 (23–60) years. There was no significant difference in overall mortality between patients with CUC and patients with FAP. Three deaths occurred postoperatively (0.2 percent) because of pulmonary embolism, perforated gastric ulcer, and subarachnoid hemorrhage. Late deaths occurred in 29 patients (1.8 percent), 10 months to 10.4 years after the operation. The most common cause of late death was cancer, including colon and rectal carcinoma (10 patients), hematologic malignancies (4 patients), cholangiocarcinoma (3 patients), and germ-cell carcinoma (1 patient). Four patients died from unrelated sepsis, two died following myocardial infarction, two patients died from complications of subsequent orthopedic surgery, and one patient died of cirrhosis. Two additional patients committed suicide. No late deaths were directly attributable to the IPAA procedure. CONCLUSIONS: Proctocolectomy with IPAA is a safe procedure. Operative mortality is low, and late deaths are related to carcinogenic and extracolonic manifestations of underlying or unrelated coexisting diseases and events.Read at the meeting of The American Society of Colon and Rectal Surgeons, Montreal, Quebec, Canada, May 7 to 12, 1995.     

Social and sexual function following ileal pouch-anal anastomosis

PURPOSE: Patiens who undergo surgery for ulcerative colitis are usually young and active. When surgery becomes necessary, their future social and sexual function is of major concern. This study was performed to be able to give more detailed information of what is to be expected. METHODS: Forty-nine consecutive patients (26 men and 23 women) who underwent ileal J-pouch-anal anastomosis for ulcerative colitis between November 1983 and September 1986 in the authors' institution were personally interviewed regarding details of their preoperative and postoperative social and sexual functions. RESULTS: Eighty-eight percent had reduced capacity to work preoperatively compared with 6 percent postoperatively. Thirty-one percent resumed work in the period with diverting ileostomy. Leisure time activities were reduced in 47 percent preoperatively, whereas 6 percent had limitations postoperatively. In 35 percent of women, frequency of intercourse was increased postoperatively, and none reported a decreased frequency. None of the women who were able to achieve orgasm preoperatively reported a postoperative disturbance of this ability, and 16 percent experienced an increased quality of orgasm. Postoperatively none reported dyspareunia, vaginal discharge, or changes in their menstrual cycle. Frequency of intercourse and ability to achieve orgasm remained unchanged for the majority of men; however, one developed erectile dysfunction, and one complained of retrograde ejaculation. Sexual activity in men was less affected by the presence of an ileostomy, and 69 percent had intercourse in the period with ileostomy compared with 30 percent of women. None of the patients complained of anal pain, soiling, or fecal leakage during intercourse, but one woman reported some discomfort from the pouch during intercourse. None of the patients wanted to return to a life with an ileostomy. CONCLUSION: The social and sexual function, quality of life, after ileal J-pouch anastomosis is improved when compared with the period with ulcerative colitis and the time with diverting ileostomy. In men, however, a frequency of sexual dysfunction similar to what is seen after proctectomy for benign diseases should be underlined.     

Afferent limb obstruction complicating ileal pouch-anal anastomosis

PURPOSE: Small-bowel obstruction is a common complication after ileal pouch-anal anastomosis (IPAA). Acute angulation of the afferent limb at the pouch inlet is the cause of obstruction in a subset of patients requiring laparotomy. METHODS: Patients were identified from the Lahey Clinic ileoanal pouch registry, a prospective computerized database of all patients who have undergone IPAA since 1980. Records of patients who were identified as having afferent limb obstruction as a cause of bowel obstruction after IPAA were reviewed. RESULTS: A total of 567 patients had undergone total proctocolectomy and ileoanal J-pouch at time of the study. Of 122 patients with one or more episodes of obstruction after IPAA, 48 required operative intervention. Afferent limb obstruction was identified as the cause of obstruction in six patients (12 percent). The most common presentation was recurrent partial obstruction (4 of 6 patients). Contrast small-bowel series and enemas were suggestive of obstruction in four of six patients, the most consistent radiographic finding being small-bowel dilation to the level of the pouch inlet. All patients underwent laparotomy for unresolved obstruction. Intraoperatively, the afferent limb was found to be adherent posterior to the pouch, causing acute angulation at the pouch inlet. Rather than risk injury to the pouch or its mesentery, the obstruction was bypassed by side-to-side anastomosis of the afferent limb to the pouch (enteroenterostomy) in five of six patients. One patient underwent ileostomy only because of technical considerations. Two patients required re-exploration and pexy of the afferent limb to the pelvic sidewall (pouchopexy) to relieve recurrent afferent limb obstruction. CONCLUSION: Afferent limb obstruction should be suspected in patients with recurrent obstruction after IPAA. Bypass of the obstructed segment from distal ileum to the pouch is safe and effective treatment. Because of the risk of recurrent afferent limb angulation, concurrent pouchopexy should be considered.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996.     

Familial adenomatous polyposis: Results following ileal pouch-anal anastomosis and ileorectostomy

To compare the clinical and functional results of ileorectostomy (IR) and ileal pouch-anal anastomosis (IPAA) in patients with familial adenomatous polyposis (FAP), we reviewed the results of 94 IPAA patients and 21 IR patients who were operated upon between 1978 and 1988. The groups were similar with respect to age and sex. None of the patients died postoperatiyely. Postoperative complications occurred in 28 percent of the IPAA group and in 17 percent of the IR group (P >0.1). Seven percent of IPAA patients described symptoms compatible with pouchitis. Sixty-one percent of IR patients required subsequent fulguration of rectal polyps at least once. IR patients had a mean (±SD) of 4 (±2) stools per day, while IPAA patients had 5 (±2) stools per day (P >0.05). No significant difference in daytime soiling was present between IR (6 percent) and IPAA (4 percent). Nighttime spotting was also similar between the two groups. Nighttime soiling, however, was reported by 4 percent of IPAA patients but not by IR patients (P <0.05). One IPAA patient (1 percent) required pouch excision for a desmoid tumor, while two IR patients (11 percent) required proctectomy and ileostomy for recurrent dysplastic polyps (P <0.05). Adhesions and a shortened ileal mesentery prevented the construction of an ileoapal procedure in these latter patients. In conclusion, the postoperative complication rate and functional results are similar after IR and IPAA in patients with FAP; however, IR does not eradicate rectal polyps and may indeed preclude IPAA for those requiring subsequent proctectomy.Read in part at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990.     

Obstruction after ileal pouch-anal anastomosis: A preventable complication?

Small bowel obstruction is a common complication after ileal pouch-anal anastomosis. This review of 460 patients examines the frequency of small bowel obstruction and determines potential risk factors. The leading indication for ileal pouch-anal anastomosis was ulcerative colitis (83 percent). In 142 patients (31 percent), loop ileostomy was rotated 180° to facilitate emptying of the ileostomy. Ninety-four patients (20 percent) had 109 episodes of obstruction. Obstruction occurred after creation of the pouch (40 episodes), closure of the ileostomy (29 episodes), or developed during the subsequent followup period (40 episodes). Operative intervention was required in 39 percent of the episodes (7 percent of all patients). At operation, the most common point of obstruction was at closure of the ileostomy (n=22/42, 52 percent). In 16 of these patients, the ileostomy had been rotated. Multiple risk factors, including age, sex, primary diagnosis, surgeon incidence, pouch type, prior colectomy, steroid usage, stomal rotation, technique of closure of the ileostomy, and prior obstruction, were examined by univariate and multivariate analysis. Of all factors, only stomal rotation was statistically significant (P = 0.0005, chi-squared analysis). Rotation of the loop ileostomy during ileal pouch-anal anastomosis, although an apparent technical refinement, is unnecessary and predisposes to obstruction.Dr. Marcello was supported by a grant from the Eleanor Naylor Dana Charitable Trust, New York, New York.Read at the meeting of The American Society of Colon and Rectal Surgeons, San Francisco, California, June 7 to 12, 1992.     

Mucosal dysplasia and DNA content in ulcerative colitis patients with ileorectal anastomosis

In a follow-up study of an epidemiologically defined patient group comprising 1,274 patients with ulcerative colitis diagnosed in Stockholm County during 1955–1979, 55 patients had undergone colectomy with ileorectal anastomosis (IRA). Nine of these were found to have Crohn's disease after histopathologic review of the colectomy specimens. Of the 46 patients with ulcerative colitis remaining for evaluation, two died postoperatively. Twenty-five patients were subsequently reoperated with rectal excision owing to intractable inflammatory activity (n=22, one postoperative death) or owing to dysplasia (n=3). Of 19 patients with their IRA still intact at time of follow-up, 15 patients (median disease duration 23 years) had a flexible sigmoidoscopy with multiple biopsies performed. The average length of the remaining rectum and sigmoid colon was 26 cm. No patient had findings of dysplasia, carcinoma, or DNA aneuploidy. None of the four remaining patients had developed dysplasia or carcinoma at the time of the latest regular rigid sigmoidoscopy. The risk of malignant transformation in this selected group of patients with ulcerative colitis operated upon with colectomy and IRA derived from an epidemiologically defined population seems to be low.This study was supported by grants from the Cancer Society in Stockholm.     

Long-term results of ileal pouch-anal anastomosis in patients with Crohn's disease

PURPOSE: Ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for most patients with chronic ulcerative colitis. Crohn's disease is, however, a contraindication. Because distinction between UC and Crohn's disease can be difficult, some patients with Crohn's disease inadvertently undergo IPAA. The aim of this study was to determine the long-term outcome of patients with Crohn's disease who have undergone IPAA. METHODS: A total of 37 patients (20 men) were studied. Each had undergone mucosectomy with handsewn IPAA (J-pouch, n=35; S-pouch, n=1; W-pouch, n=1). Histologic examination of the resected specimen at time of IPAA showed features of ulcerative colitis (n=22), indeterminate colitis (n=9), or Crohn's disease (n=6). The stoma was closed in all patients. RESULTS: A total of 11 of 37 patients developed complex fistulas (pouch-cutaneous (n=6), pouch-vaginal (n=4), or pouch-vesical (n=1). Crohn's disease has recurred in the pouch (n=20), anal canal (n=4), pouch and anal canal (n=10), and elsewhere (n=3). After ten years (range, 3–14), the pouch remains in situ in 20 patients in whom frequency of bowel movement is seven times (3–10)/24 hours,in situ but defunctioned in seven patients, and excised in ten patients (failure rate, 45 percent). CONCLUSIONS: Inadvertent IPAA for Crohn's disease is associated with a high rate of failure (45 percent) but an acceptable long-term functional result if the pouch can be kept in situ.Read at the meeting of the Association of Surgeons of Great Britain and Ireland, Glasgow, United Kingdom, May 22 to 24, 1996.     

Predictors of quality-of-life after ileal pouch-anal anastomosis in patients with ulcerative colitis

Objectives: Predictors of the postoperative quality of life (QoL) following ileal pouch anal anastomosis (IPAA) have not been thoroughly investigated. This study was planned to assess the postoperative QoL following IPAA and to identify its predictors using the 15D instrument.

Materials and methods: A retrospective cohort study was conducted on IPAA-operated patients with ulcerative colitis in two Finnish tertiary hospitals during the period 1985–2014 (n?=?485). Medical records were examined to collect data on baseline, operative and postoperative characteristics. Patients were surveyed using the 15D-instrument to assess their postoperative QoL. Linear regression analyses and receiver operating characteristic curve were applied to identify the predictors of postoperative QoL.

Results and conclusions: Of all patients, 61.5% experienced worse postoperative QoL, with significantly lower QoL level than that of an age and sex-standardized general population in 12 dimensions of the 15D-instrument, with the highest mean difference QoL scores calculated for excretion, sexual activity and sleeping dimensions. Older age and preoperative hypertension were the only significant predictors of lower overall QoL (p?=?.003 and p?=?.03, respectively). A preoperative age of ≥35 years was the most valid predictor of lower postoperative QoL (Sensitivity?=?62.4% and Specificity?=?49.6%, p?=?.04). In conclusion, postoperative QoL is generally low using the 15D-instrument after IPAA. Worse postoperative QoL is predicted after the age of 35.