Complications after proctocolectomy and ileal pouch-anal anastomosis in pediatric patients: A systematic review

Background/purposeColectomy with ileal pouch-anal anastomosis (IPAA) is the standard of care for patients with familial adenomatous polyposis (FAP) and refractory ulcerative colitis (UC). The rates of postoperative complications are not well established in children. The objective of this systematic review is to establish benchmark data for morbidity after pediatric IPAA.MethodsPubMed, Embase, and The Cochrane Library were searched for studies of colectomy with IPAA in patients ≤ 21 years old. UC studies were limited to the anti-tumor necrosis factor-α agents era (1998–present). All postoperative complications were extracted.ResultsThirteen studies met the inclusion criteria (763 patients). Compared to patients with FAP, UC patients had a higher prevalence of pouch loss (10.6% vs. 1.5%). Other major complications such as anastomotic leak, abscess, and fistula were uncommon (mean prevalence 4.9%, 4.2%, and 5.0%, respectively, for patients with UC; 8.7%, 4.2%, and 4.3% for FAP). The most frequent complication was pouchitis (36.4% of UC patients).ConclusionsDevastating complications from colectomy and IPAA are rare, but patients with UC have poorer outcomes than those with FAP. Much of the morbidity may therefore stem from patient or disease factors. Multicenter, prospective studies are needed to identify modifiable risks in patients with UC undergoing IPAA.Level of evidencePrognostic, level II.     

Similar functional results and complications after ileal pouch-anal anastomosis in patients with indeterminate vs ulcerative colitis

HYPOTHESIS: Patients who undergo ileal pouch-anal anastomosis (IPAA) for indeterminate colitis (IC) have a pouch complication and pouch loss rate only slightly higher than that associated with ulcerative colitis (UC). The functional outcome in patients with IC is no different from that in patients with UC. DESIGN: Retrospective review of prospectively gathered data comparing complication rates and outcomes of patients with IC vs UC who have undergone IPAA at a single institution during 19 years. SETTING: University teaching hospital. PATIENTS: Between July 1, 1982, and July 1, 2001, 723 patients underwent IPAA, 644 for colonic inflammatory bowel disease. A further breakdown of the latter group revealed 79 patients (12.3%) with IC and 565 (87.7%) with UC. These 2 patient populations were compared with regard to postoperative complications, pouch loss, and functional outcome. MAIN OUTCOME MEASURES: Patients with IC and UC were compared with regard to pouch complications, such as J-pouch leak, fistula, cuff abscess, stricture, redo IPAA, Crohn diagnosis, and pouch loss. They were also compared with regard to 24-hour stool frequency and nighttime incontinence at 1, 3, 6, and 9 months after surgery. RESULTS: Approximately 98% of patients had 1 year of follow-up and 89% had long-term follow-up (mean, 78.5 months). Patients with IC were compared with those with UC with regard to pouch complications, such as cuff abscess (1.3% vs 1.6%), J-pouch leak (5.1% vs 2.3%), intra-abdominal abscess (0% vs 1.1%), stricture (7.6% vs 4.8%), and fistula (2.5% vs 1.6%). These 2 groups were also compared with regard to small bowel obstruction (6.3% vs 5.5%), pouchitis (34.2% vs 25.0%), eventual diagnosis of Crohn disease (1.3% vs 0.7%), redo IPAA (1.3% vs 0.9%), and eventual pouch loss (2.5% vs 1.2%). An evaluation of functional results revealed no significant differences between the 2 groups with regard to 24-hour stool frequency or nighttime incontinence. The pathologists classified patients with IC into 3 groups: IC but favor UC (group 1), IC but favor Crohn (group 2), and IC (group 3). Most of the postoperative complications occurred in group 1 patients, but the only pouch loss occurred in those in group 2. CONCLUSIONS: The incidences of pouch complications after IPAA were slightly higher in the IC group compared with the UC group, but the differences were not statistically significant. Functional results were the same in both groups. Pouch loss was high in group 2 patients, but was otherwise not significantly higher in the IC group overall (P =.36). Most patients with IC can undergo IPAA and expect an outcome equivalent to that of patients with UC.     

Equivalent function,quality of life and pouch survival rates after ileal pouch-anal anastomosis for indeterminate and ulcerative colitis

OBJECTIVE: To compare the function, complications, and quality of life after ileal pouch-anal anastomosis (IPAA) for patients with indeterminate colitis (IndC) and ulcerative colitis (UC). SUMMARY BACKGROUND DATA: Reports on the outcome of IPAA for IndC have been inconclusive because of the small numbers available for analysis. Concerns about functional outcome, infectious perineal complications, pouch loss and the development of Crohn's disease remain, while there is no data on the quality of life after IPAA for IndC. METHODS: One thousand nine hundred and eleven patients undergoing IPAA for Ind and UC from 1983 to 1999 were evaluated. IndC was confirmed by repeat pathologic evaluation in 115 patients. Functional outcome and quality of life were assessed prospectively for all office visits (IndC = 230; UC = 5388) using previously reported systems. Complications were evaluated retrospectively. RESULTS: Functional results and the incidence of anastomotic complications and major pouch fistulae were the same in UC and IndC patients. Although IndC patients were more likely to develop minor perineal fistulae, pelvic abscess, and Crohn's disease, the rate of pouch failure was 3.4%, identical to that of UC patients. There was no clinically significant difference in quality of life, or satisfaction with IPAA surgery. Patients were equally happy to recommend surgery to IndC or UC patients, but 3% fewer IndC would undergo the same surgery again for their disease. CONCLUSIONS: While functional outcome, quality of life, and pouch survival rates are equivalent after IPAA for IndC and UC, there is an increase in some complications and the late diagnosis of Crohn's disease. Over 93% of IndC patients would undergo the same procedure again, and 98% would recommend IPAA to others with IndC. Patients with IndC should not be precluded from having IPAA surgery.     

全大肠切除回肠贮袋肛管吻合术的远期疗效评价

目的　探讨全大肠切除回肠贮袋肛管吻合术治疗溃疡性结肠炎 (UC)和家族性腺瘤性息肉病 (FAP)的远期疗效。方法　 1985～ 2 0 0 2年间共对 6 1例患者行全结肠直肠切除回肠贮袋肛管吻合术 ,其中UC 2 5例、FAP 34例、其他 2例 ,应用S袋 2 5例、S J袋 13例、J袋 17例以及W袋 6例 ,术后随诊 1～ 18年、平均 8年 ,比较分析术后控便功能及并发症。结果　全部患者存活。并发症发生率为 16 % ( 10 / 6 1) ,其中UC患者 ( 2 4 % ,6 / 2 5 )高于FAP患者 ( 12 % ,4 / 34) ,W袋高于其他各袋 ,手法吻合 ( 2 0 % ,8/ 4 1)高于吻合器吻合 ( 10 % ,2 / 2 0 ) ,但差异均无显著性 (P >0 0 5 )。术后 2 4h大便次数平均为 4 2次。日间 84 % ( 4 3/ 5 1)、夜间 75 % ( 38/ 5 1)的患者排便能自控 ,6 % ( 3/ 5 1)的患者有明显的大便失禁。大部分患者对目前的生活质量表示满意。结论　全大肠切除回肠贮袋肛管吻合术治疗可维持UC与FAP患者肛管自控功能和可接受的大便次数 ,术后并发症较少 ,是较为理想的手术方式     

Results and complications after ileal pouch anal anastomosis: a meta-analysis of 43 observational studies comprising 9,317 patients

OBJECTIVE: To analyze the literature of ileal pouch anal anastomosis (IPAA) regarding complications and functional outcome, to provide audit data for individual surgeons and units to assess their own performance against and also to serve as reference standard for the assessment of novel alternatives. BACKGROUND: IPAA is the standard restorative procedure for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). This operation is, however, associated with distinct rates of failure, complications and fecal incontinence. METHODS: A meta-analysis on pooled incidences of complications of IPAA was conducted. Medline search and cross-reference search identified studies on IPAA (n > or = 50). Two authors independently performed the data extraction on study characteristics, diagnosis, type of operation, pouch-related complications, pouch failure and functional results. In case of disagreement consensus was reached by joint review of the study. Estimates of pouch-related complications, pouch failure and functional results are described as pooled percentages with 95% confidence interval. RESULTS: The initial search based on 1,206 abstracts yielded 43 studies eligible for further analysis. Indications for IPAA were UC in 87.5%, FAP in 8.9% and other diagnoses in 3.6%. The median follow-up was 36.7 months. Pouch failure was 6.8%, increasing to 8.5% in case of follow-up of more than 60 months. Pelvic sepsis occurred in 9.5%. Severe, mild and urge fecal incontinence were reported in 3.7, 17, and 7.3%, respectively. No effect of experience, duration of follow-up and type of surgical technique on the incidence of pouch failure and pelvic sepsis was demonstrable. CONCLUSIONS: Current techniques for restorative surgery after proctocolectomy are associated with non-negligible complication rates and leave room for improvement and continuation of development of alternative procedures.     

Risk Factors for Ileoanal J Pouch-Related Septic Complications in Ulcerative Colitis and Familial Adenomatous Polyposis

OBJECTIVE: To analyze the association between pre- and perioperative factors and pouch-related septic complications (PRSC) in ulcerative colitis (UC) and in familial adenomatous polyposis (FAP) after ileal pouch-anal anastomosis (IPAA). SUMMARY BACKGROUND DATA: For patients with UC and FAP, IPAA is the surgical therapy of choice, but in some patients the outcome is compromised by PRSC. METHODS: A total of 706 consecutive patients (494 UC, 212 FAP) were assessed in a study aimed at identifying subgroups of patients who were at high risk for PRSC. The rate of PRSC was analyzed as a time-dependent function (Kaplan-Meier estimation). Patients with UC and FAP were stratified separately according to associated factors (age, sex, surgeon's experience, temporary ileostomy, colectomy before IPAA, anastomotic tension, and several factors specific for UC). RESULTS: In all, 131 (19.2%) patients had PRSC (23.4% UC, 9.4% FAP). In patients with UC, the estimated 1-year PRSC rate was 15.6% and the estimated 3-year PRSC rate was 24.2%. In patients with FAP, the estimated 1-year and 3-year PRSC rates were 9.2%. The difference between the estimated rates of PRSC was significant (P <.001). In the univariate analysis, patients with UC younger than 50 years, with severe proctitis, with preoperative hemoglobin levels less than 10 g/L, or receiving corticoid medication had a significantly higher risk for PRSC (P =.039, P =.037, P =.047, P =.003, respectively). Multivariate analysis showed that patients with UC receiving a systemic prednisolone-equivalent corticoid medication of more than 40 mg/day had a significantly greater risk of developing pouch-related complications than patients with UC receiving 1 to 40 mg/day and patients with UC who were not receiving corticoid medication (RR: 3.78, 2.25, 1, respectively, P <.001). Patients with FAP proved to have a significantly higher risk for PRSC in the univariate and multivariate analyses if anastomotic tension had occurred (RR 3.60, P =.0086). CONCLUSIONS: Pouch-related septic complications occur as late complications and should therefore be considered in regular, specific long-term follow-up examinations. The authors identified significant risk factors for PRSC specific to patients with UC and FAP; these must be considered for each individual surgical strategy.     

Etiology and pathogenesis of pouchitis

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the preferred surgery for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). While this surgical therapy is effective and results in good clinical outcomes and quality of life, patients experience complications, the most common of which is pouchitis. While most pouchitis is considered idiopathic, there is mounting evidence that pouchitis results from aberrant immune response to the bacterial populations found in the pouch in a genetically predisposed patient. Dysbiosis and decreased diversity of the microbiota seem to contribute to this process. Risk factors for pouchitis including inflammatory bowel disease and obesity provide further clues to the etiology of pouchitis. In conclusion, we seek to understand the pathogenesis of pouchitis as both a post-operative complication and a form of inflammatory bowel disease (IBD).     

Ileal pouch anal anastomosis in pediatric familial adenomatous polyposis: A 24-year review of operative technique and patient outcomes

Background

Total proctocolectomy with ileal pouch anal anastomosis (IPAA) is the operative procedure of choice for familial adenomatous polyposis (FAP) patients. We review 24 years of operative experience and outcomes in pediatric patients with FAP.

Methods

Patients with FAP, age < 20 years, presenting to a single institution between 1987 and 2011 were included. Operative technique and outcomes were reviewed retrospectively. Primary outcomes included postoperative complications (30 days), long-term bowel function, and polyp recurrence at the anal anastomosis.

Results

95 patients with FAP underwent IPAA. Mean age at IPAA was 15.5 years with a mean follow-up of 7.6 years. 29 patients underwent 1-stage IPAA, 65 patients had a two-stage IPAA, and 1 patient underwent a 3-stage procedure. 67 patients had an open procedure, 25 underwent a laparoscopic approach, and more recently 3 patients underwent single incision laparoscopic IPAA. Patients with 1-stage IPAA demonstrate better long term bowel control vs. 2-stage IPAA patients (10.7% vs. 36.0% occasional incontinence, p = 0.018). However, 1-stage IPAA patients suffered increased short-term complications, such as anastomotic leak (17.2% vs. 0%, p = 0.002) and reoperation (20.7% vs. 4.6%, p = 0.02) compared to 2-stage IPAA. Anal anastomosis polyp recurrence occurred in 22.7% of 1-stage patients and 10.0% of 2-stage patients. Short-term complications, polyp recurrence, or long-term continence were equivalent between open and laparoscopic cases.

Conclusion

Single-stage IPAA in children with FAP is associated with better bowel control but increased anastomotic leak, reoperative rate, and polyp recurrence. In experienced hands, laparoscopic IPAA is equivocal to open IPAA.     

Der ileoanale Pouch als Rectumersatz

The ileoanal pouch procedure (IAPP) was the most remarkable breakthrough in the surgical therapy of ulcerative colitis (UC) and familial adenomatous polyposis (FAP) in the last 20 years. The underlying disease is under control, the function preserved and the quality of life markedly improved. Alternative procedures (terminal ileostomy, ileorectal anastomosis) are only indicated in special cases. In the last 16 years we have operated on 662 patients (n = 493 UC; n = 169 FAP) with an ileoanal J-pouch, short rectal cuff, complete mucosectomy and hand-sewn anastomosis. Normally there is a good function for UC and FAP patients after IAPP. Surgical experience, technical modifications concerning the pouch design and the pouch-anal anastomosis, and a differentiated indication lead to a further improvement of these complex procedures with consecutive reduction of complications. Specific complications concerned mainly the pouch-anal anastomosis (fistulas, abscesses, consecutive stenosis) and inflammation of the pouch mucosa (pouchitis). A multivariate analysis showed, that increasing experience of the specialized center is a significant factor reducing inflammatory problems at the anastomosis. The cumulative incidence of pouchitis was 29%. In general there is no problem in successful treatment. But patients with chronic pouchitis are a problematic group (6.2%). Chronic pouchitis is difficult to treat. It is likely that there exists an inflammation dysplasia carcinoma sequence for the ileal pouch mucosa, analogous to the colorectum. Recently we diagnosed the first case of a real ileum pouch carcinoma with associated epithelial dysplasias following chronic pouchitis. Therefore patients with chronic pouchitis must be followed up by endoscopy and random biopsies in a surveillance program. Patients with UC and FAP can gain the life quality of healthy controls, if postoperative complications can be avoided or treated successfully. For the further development of the procedure and the individual long-term success a qualified follow-up and therapy of complications is essential. Both can be carried out only by a specialized center.     

Restorative proctocolectomy. Does ethnicity affect outcome?

Objective  Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) is well-established in the management of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). We review outcome of pouch surgery from a single centre, comparing non-South Asian and South Asian Caucasian populations.
Method  Patients undergoing RPC for UC and FAP during a 10-year period between January 1997 and January 2007 were identified from hospital records. Data were collected retrospectively from case notes on early and long-term results.
Results  A total of 107 patients underwent pouch formation for UC (94%) or FAP (6%) and 22 (21%) were from the Asian subcontinent. Eighty-seven (81%) underwent a three-stage procedure and 20 (19%) a two-stage procedure. Postoperative complications occurred in 40 (37%) patients, being major in 11 (10%) patients with relaparotomy required in 9 (8%) with no difference between South Asian and non-South Asian Caucasian patients. Long-term pouch function, with a median of five times over 24 h (range 2–15), was similar between the two groups. The incidence of pouchitis was 57 (53%) and this was significantly greater in the South Asian population [17/21 (77%); 39/86 (46%); P  = 0.006].
Conclusion  Surgical results were similar in South Asian and non-South Asian Caucasian patients, but the incidence of pouchitis was greater in the former group.     

直肠手术各种储袋的应用与评价

结肠储袋能改善低位直肠切除保肛术后早期控制排粪功能障碍,但其对患者术后远期（2年以上）控制排粪功能方面不具有优势。同时,随着时间的延长,排空障碍的发生率将逐渐提高,很多患者出现排粪困难,需要长期应用栓剂和灌肠。而储袋的制作延长了手术时间,增加了治疗费用。所以,低位直肠切除术后结肠储袋的价值正在遭受质疑,它的应用也变得越来越少。在溃疡性结肠炎（UC）和家族性腺瘤性息肉病（FAP）行全结肠切除术后,如果行回肠储袋肛管吻合（IPAA）,可通过增加新建直肠的容积并改变肠管的生理学动力,使排粪次数减少;且术后短期和长期控制排粪功能更好,生活质量更高。所以,IPAA是手术治疗UC和FAP的首选。     

家族性腺瘤性息肉病两种术式的对比研究

目的探讨家族性腺瘤性息肉病采用回肠贮袋肛管吻合术与回肠直肠吻合术两种术式的手术效果。方法回顾性分析两组在手术结果、术后排便功能和生活质量的差异。结果30例患者中行回肠直肠吻合术12例,贮袋吻合术18例,术后无死亡,无吻合口瘘等严重并发症,均无膀胱和性功能障碍。平均住院时间、手术时间和失血量直接吻合组优于贮袋组(P<0 01),在并发症发生率、术后排气排便时间和肠蠕动次数两组相似(P>0 05)。随访时间最短6个月,最长16年。3例(25% )直接吻合者术后直肠息肉癌变需切除直肠。两种术式的术后排便功能相似,仅在白天排便次数和肛周刺激方面IRA组优于IPAA组(P<0 05)。结论两组患者术后排便功能和术后生活质量相似,但回肠贮袋肛管吻合术可减少术后残留的直肠黏膜癌变机会,因而是较理想的手术方式。     

储袋炎及回肠肛管储袋功能障碍的诊断与治疗

对于经内科治疗无效或出现不典型增生的溃疡性结肠炎以及家族性腺瘤性息肉病患者．回肠储袋肛管吻合（IPAA）的重建性结直肠切除术已成为外科治疗的首选。但溃疡性结肠炎患者IPAA术后除了一般手术并发症外,还容易出现一系列炎性或非炎性并发症,如储袋炎、储袋克罗恩病、直肠残端封套炎或储袋易激综合征,从而影响患者的手术效果及生活质量。储袋炎是溃疡性结肠炎患者IPAA术后最常见的远期并发症．累计患病率可达50％。储袋镜是储袋功能障碍诊断及鉴别诊断的重要手段。储袋炎可根据病因分为“特发性”与“继发性”．其治疗也不尽相同。抗生素治疗是急性储袋炎的主要治疗方法．一些抗生素依赖的患者则需要长期的维持治疗。对抗生素耐药及依赖的储袋炎的处理是比较棘手的．另外．引起继发性储袋炎的病因亦需尽量发现并进行纠正。     

Pathological subgroups may predict complications but not late failure after ileal pouch‐anal anastomosis for indeterminate colitis

Introduction Ileal pouch‐anal anastomosis (IPAA) for indeterminate colitis (IndC) may lead to an increased risk of perineal complications and pouch loss. This study evaluated pathological subgroups of IndC to identify a predictor of increased complication rates after IPAA for IndC. Patients and methods Of 171 IPAAs with a postoperative diagnosis of IndC, IndC was confirmed in 115 of the 140 specimens available for re‐examination. These were divided into IndC favouring ulcerative colitis (Group I; n = 99), ‘true’ IndC (Group II; n = 8), and IndC favouring Crohn's (Group III; n = 8). 61 presented with fulminant colitis. Patients in Group I were subdivided into having (A) deep ulcers (B) transmural lymphoid aggregates (C) skip lesions (D) terminal ileal inflammation and/or (E) a caecal patch. Outcome was determined by chart analysis, and compared to 231 randomly selected patients with IPAA for ulcerative colitis (UC) matched for age, gender, and follow‐up. Results Only patients with evidence of deep ulceration (Group IA) had a significant increase in the incidence of Crohn's disease (4.3%vs. 0.43%, P = 0.04), complex perianal fistulae (4.3%vs. 0.43%, P = 0.04), and pelvic abscess (12.9%vs. 2.2%, P < 0.001). No pathological subgroup of IndC patients had a significantly different rate of pouch failure or pouch loss. Conclusions Pathological stratification may predict those more likely to develop Crohn's disease or other complications, but not pouch failure. On this basis, we feel that patients with IndC should not be precluded from having IPAA surgery.     

二期与三期全结直肠切除联合回肠储袋肛管吻合术对溃疡性结肠炎临床结局影响比较分析

目的 比较溃疡性结肠炎(UC)行二期或三期全结直肠切除(TPC)联合回肠储袋肛管吻合术(IPAA)后的近期并发症及远期临床结局.方法 回顾性分析2014-2020年南京大学医学院附属金陵医院普通外科炎症性肠病治疗中心行TPC+IPAA的188例病人临床资料,比较术后近期(二期手术的第一期及三期手术的第一、二期)并发症及...     

Restorative Proctocolectomy or Rectum-Preserving Surgery in Patients with Familial Adenomatous Polyposis: Results of a Prospective Study

Surgical treatment of familial adenomatous polyposis (FAP) is still controversial. From 1984 we carried out a prospective evaluation of total colectomy with ileorectal anastomosis (IRA) and restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) to determine differences in postoperative complications, functional results, occurrence of desmoids, and recurrence of polyps in the rectal stump. IRA was performed below the peritoneal reflection and was indicated in the absence of rectal cancer and in the presence of fewer than 10 polyps or minute polyposis in the last 10 cm of the rectal mucosa. IRA patients underwent a regular endoscopic follow-up and prolonged sulindac administration (100 mg twice daily). When criteria for IRA were absent, IPAA was performed adopting a manual anastomosis at the pectinate line. Fourteen patients were operated with IRA and 24 with IPAA. There was no difference in sex and age between the two groups of patients. The number of rectal polyps was significantly different in the two groups. Immediate postoperative complications were observed in only five IPAA patients, three of whom (12%) required reoperation. Late postoperative complications occurred more frequently in IRA patients (14%) than in IPAA patients (4%). Desmoids developed in both groups (five in the IRA group and four in IPAA group). The number of bowel movements was similar in both groups, but 25% of IPAA patients complained of nocturnal fecal soiling. Fulguration or polypectomy for recurrent polyps was necessary in all but two IRA patients at follow-up. The rectal stump was easily eradicated by polyps in all but four patients with minute polyps at surgery. In the latter patients a diffuse or carpeting rectal polyposis occurred. IPAA can give optimum control of colorectal polyposis in FAP patients with an acceptable incidence of postoperative complications and satisfactory functional results. This type of surgical procedure is indicated in most FAP patients, and IRA should be reserved for patients without polyps or with fewer than 10 polyps in the rectal stump; otherwise growth of polyps cannot be adequately controlled.     

Incidence and therapeutic outcome of pouchitis for ulcerative colitis in Japanese patients

AIM: The aim of this study was to examine the cumulative risk of pouchitis following restorative proctocolectomy for UC and FAP in Japanese patients, and to assess the response to medical treatment and its outcome. PATIENTS AND METHODS: 521 patients with UC and 117 FAP patients underwent proctocolectomy and received a J-shaped IPAA at our department of surgery. We investigated these patients using PDAI for the diagnostic criteria of pouchitis. RESULTS: Pouchitis occurred in only 32 UC patients (6.1%). The cumulative risk of developing pouchitis for a UC patient was 7% at 5 years after and 12% at 10 years after surgery. The medical treatment of acute pouchitis was usually oral metronidazole (250 mg twice daily) for 2 weeks or oral ciprofloxacin (200 mg thrice daily) in patients who could not tolerate metronidazole. Single episodes of pouchitis occurred in 21 patients (65.6%) and chronic or frequent relapses of pouchitis in 11 patients (34.4%). Three patients (9.4%) required re-ileostomy. Two patients (6.3%) required pouch excision. There were no patients with complicated dysplasia. CONCLUSION: The cumulative risk of pouchitis in Japanese UC patients is lower than that of western countries.     

结直肠切除术的应用体会

目的：探讨全结肠直肠切除术在家族性腺瘤性鼻肉病（ＦＡＰ）、溃疡性结肠炎（ＵＣ）及结肠克隆病（ＣＣ）外科治疗中的应用。方法：对２２例ＦＡＰ,３例ＵＣ及２例ＣＣ病人施行全结肠直肠切除术,其中回肠贮袋肛管吻合（ＩＰＡＡ）２２例、回肠造口５例。在ＩＰＡＡ中,Ｊ型贮袋３例,Ｈ型贮袋２例,Ｓ型贮袋１７例,就手术适应证、手术操作、术后处理等进行讨论。结果：回肠造口中以加部分倒置者效果较好,ＩＰＡＡ术后排便功能较     

Postoperative defecatory function of an ileal pouch-anal anastomosis after a restorative proctocolectomy for ulcerative colitis: evaluation using fecoflowmetry

An ileal pouch is usually reconstructed as an alternative to a neorectum after a total proctocolectomy for ulcerative colitis (UC). However, the real defecatory function of an ileal pouch is uncertain. This study was designed to analyze the functional and clinical outcomes after a proctocolectomy and ileal pouch-anal anastomosis (IPAA) for UC using fecoflowmetry (FFM). Sixteen patients who underwent IPAA for UC between 1990 and 2005 were studied. They were evaluated by FFM, together with Kelly's clinical score (KCS), and anorectal manometric assessments were also performed. FFM showed that the fecoflow pattern (FFP) of 14 patients (87%) was the block type and of 2 patients (13%) was the segmental type. The clinical score and tolerance volume showed no improvement 1 year or more after IPAA. However, the value of the maximum fecal stream flow rate (Fmax) improved with time. FFM shows that the defecatory function improved after IPAA, and it may therefore contribute to a good long-term outcome after the surgery.     

Repeat ileal pouch-anal anastomosis to salvage septic complications of pelvic pouches: clinical outcome and quality of life assessment.

OBJECTIVE: To evaluate the outcome of repeat ileal pouch-anal anastomosis (IPAA) for septic complications of pelvic pouch surgery; to assess the relationship between diagnosis and outcome; to assess quality of life after surgery. SUMMARY BACKGROUND DATA: Pelvic and perineal sepsis due to ileal pouch-anal anastomotic leaks frequently results in pouch loss. Many surgeons believe that pelvic sepsis and/or dense pelvic fibrosis makes salvage surgery unsafe or that pouches salvaged under these circumstances may not function well. As a result, there are few studies of pouch salvage procedures for septic indications. METHODS: The authors reviewed records of Cleveland Clinic Foundation patients who had undergone repeat IPAA surgery after septic complications from previous pelvic pouch surgery and who had completed at least 6 months of follow-up. Final diagnoses included ulcerative colitis (n = 22), Crohn's disease (n = 10), indeterminate colitis (n = 1), and familial polyposis (n = 2). Patients with functioning pouches were interviewed about functional problems and quality of life using an in-house questionnaire and the validated SF-36 Health Survey. RESULTS: Of 35 patients, 30 (86%) had a functioning pouch 6 months after repeat IPAA. In 4 patients, complications led to pouch removal or fecal diversion. One patient declined stoma closure. Of the patients with mucosal ulcerative colitis (MUC), 95% (21/22) had a functioning pouch 6 months after surgery. For patients with Crohn's disease (CD) 60% (6/10) have maintained a functioning pouch. Of the 30 patients with functioning pouches, 17 (57%) rated their quality of life as either "good" or "excellent," the remaining 13 (43%) selected "fair" or "poor." All said they would choose repeat IPAA surgery again. An SF-36 Health Survey completed by all patients with a functioning pouch at follow-up showed a mean physical component scale of 46.4 and a mean mental component scale of 47.6, scores well within the normal limit. CONCLUSIONS: Repeat IPAA can often salvage pelvic pouches in patients with MUC who suffer major chronic perianastomotic and pelvic sepsis. Patients who had successful repeat IPAA surgery often report functional problems but would still choose to have the surgery again. For patients with CD, ultimate pouch excision or fecal diversion have been required in 40% indicating a guarded prognosis for these patients. Data on the success of the procedure for patients with indeterminate colitis and familial adenomatous polyposis were inconclusive because of small sample sizes.