Internal anal sphincter function after total abdominal colectomy and stapled ileal pouch-anal anastomosis without mucosal proctectomy

A comparison, based on results from anal manometry and continence, was made between eight patients after circular stapled ileal J-pouch-anal anastomosis without mucosectomy (Js) and seven patients after endoanal mucosal proctectomy and hand-sewn ileal pouch-anal anastomosis (Jm). The mean and range from ileostomy closure were 3.5 months (1.5 to 12) and 21.7 months (13 to 32), respectively. The mean maximum resting pressure (MRP) ( +/- SEM and range) was 81.3 mm Hg ( +/- 6.0 and 61 to 112.5) and 50.0 mm Hg ( +/- 6.2 and 17 to 62.5), respectively, for the Js and Jm groups (P less than .003). None of the Js patients experienced leakage or wore a pad, while in the Jm group 14 percent experienced minor leakage during the day and 28 percent at night. Seventy-one percent of the Jm group wore a pad at some point. Anal sphincter resting pressures and continence were better in the Js group. The improvement in MRP resulted from avoidance of injury to the internal and sphincter during dilatation and mucosectomy and the maintenance of a normal anal canal that allowed for proper closure.     

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.     

Outcome after proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis

BACKGROUND: During the course of their disease, about 30% of patients with ulcerative colitis (UC) will undergo proctocolectomy with ileal pouch-anal anastomosis (IPAA). We evaluated the outcome of IPAA in a Belgian referral center. METHODS: Clinical charts were reviewed for pre- and postoperative disease course, functional outcome, and complications in all patients with UC (n = 182) and indeterminate colitis (n = 2) who underwent IPAA in 1990-2004. RESULTS: Follow-up data were available in 173 out of 184 patients (67 female, median age at proctocolectomy 39.0 years). Median functional Oresland score 1 year after IPAA was 3 (range 0-11). Early postoperative complications were seen in 27% of patients. After a median (interquartile range) follow-up of 6.5 (3.4-9.9) years, 35% of patients developed septic and/or obstructive complications. Forty-six percent of patients developed at least 1 episode of pouchitis. Risk factors for pouchitis were the presence of extraintestinal manifestations (odds ratio [OR] 1.92 (1.23-3.01), P = 0.004) and younger age at proctocolectomy (P = 0.004). Chronic pouchitis was present in 33 patients and associated with extraintestinal manifestations (OR 2.93 (1.13-7.62), P = 0.027), backwash ileitis (OR 9.28 (1.71-50.49), P = 0.010), and length of follow-up (P = 0.004). Pouch failure occurred in 5% of patients. CONCLUSIONS: Although proctocolectomy with IPAA surgery has a good functional outcome, postoperative complications, especially pouchitis, remain considerable in patients with UC.     

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.     

Functional outcomes in patients with mucosal ulcerative colitis after ileal pouch-anal anastomosis by the double stapling technique

PURPOSE: The aim of this study was to evaluate any differences in functional outcome in patients with mucosal ulcerative colitis after restorative proctocolectomy and ileal pouch-anal anastomosis with use of the double stapling technique relative to the type of tissue in the stapled doughnut. METHODS: Between September 1988 and June 1997, the pathology of all patients with mucosal ulcerative colitis who underwent ileal pouch-anal anastomosis with use of the double stapling technique were reviewed. Information was obtained regarding the tissue types in the distal tissue rings (doughnuts) obtained from the stapled ileal pouchanal anastomosis. The level of anastomosis was classified according to the type of tissue in the distal doughnut: Group I- patients in whom the anal transitional zone was removed and the distal doughnut included squamous epithelium or transitional epithelium and Group II- patients in whom the anal transitional zone was preserved because the distal doughnut revealed only columnar epithelium. Functional outcomes were assessed and compared by detailed questionnaires mailed to all patients at least one year after ileal pouch-anal anastomosis surgery. RESULTS: Distal doughnuts were obtained from the stapled ileal pouch-anal anastomosis in 222 patients with mucosal ulcerative colitis. Follow-up data at a mean of 38 (range, 12-132) months were obtained in 138 (62.2 percent) patients, including 72 males, with a mean age of 46.9 (range, 13-79) years. Group I consisted of 40 patients (29 percent; 35 (25.4 percent) who had squamous epithelium and 5 (3.6 percent) who had transitional epithelium in the distal tissue rings). Group II consisted of 98 patients (71 percent) with columnar epithelium in the distal tissue rings. Age at diagnosis and operation, duration of disease, length of follow-up, and stage of pouch surgery were similar in the two groups. Incontinence scores, frequency of bowel movement, use of a protective pad, discrimination between gas and stool, use of antidiarrheals, life-style alteration, and patient satisfaction showed similar functional results between the two groups. CONCLUSIONS: The tissue type in the stapler distal doughnut did not greatly influence functional outcome. Failure to identify a relationship may attest to the variable height and composition of the anal transitional zone.     

Quality of life after proctocolectomy and ileal pouch-anal anastomosis in patients with ulcerative colitis

Purpose

While ileal pouch-anal anastomosis is performed in many patients with ulcerative colitis, conflicting data exist about its effects on quality of life. We aimed to determine quality of life and to identify risk factors for impaired quality of life in these patients.

Methods

Forty-eight of 82 patients (59 %; median follow-up 57 months [range 21–93 months]) after ileal pouch-anal anastomosis for ulcerative colitis were compared to 48 matched healthy controls. Generic, health-, and disease-related, as well as symptom-specific quality of life was analyzed using five well-established quality of life instruments.

Results

Although generic quality of life was comparable between groups, health-related quality of life was impaired after ileal pouch-anal anastomosis. While high stool frequency was associated with impaired health-related and disease-specific quality of life, fecal incontinence and history of pouchitis also caused a deterioration of generic and symptom-related quality of life. Seventy-seven percent of patients reported their quality of life to be better compared to the situation before surgery and 88 % would undergo ileal pouch-anal anastomosis again.

Conclusions

Overall quality of life after ileal pouch-anal anastomosis is good. However, high stool frequency, fecal incontinence, and pouchitis are associated with impaired quality of life and should be prevented or treated to the best possible extent.     

Risk of osteopenia after proctocolectomy and ileal pouch-anal anastomosis for ulcerative colitis

BACKGROUND: The aim of our study was to evaluate the influence of pouchitis and villous atrophy on bone mineral density and metabolism at least 5 years after ileal pouch-anal anastomosis for ulcerative colitis (UC). METHODS: Eighty-eight subjects with a J-pouch operated on between 1985 and 1994, and 20 ulcerative colitis subjects with a conventional ileostomy were enrolled. Endoscopy was performed and spine and femoral neck bone mineral densities measured. Bone metabolism was assessed by measurement of serum levels of parathyroid hormone, osteocalcin, 25-hydroxyvitamin D3, calcium, alkaline phosphatase and urinary N-telopeptide cross-linked of type I collagen (NTX). RESULTS: In the lumbar spine, 37% of the J-pouch subjects with subtotal to total villous atrophy had osteopenia (Z score <-1), whereas none of the subjects with normal villous structure had reduced bone densities in the spine or femoral neck. The highest prevalence of osteopenia (66.7%) and the lowest spine (mean -0.89+/-0.36; P = 0.006) and femoral neck (mean -0.63+/-0.29; P = 0.07) Z scores were found among the patients (n = 12) with inflammation in the proximal limb of the pouch. No biochemical parameters were found to predict osteopenia and in stepwise regression analysis, the only independent risk factors for osteopenia were low body mass index and villous atrophy. CONCLUSIONS: Patients with a J-pouch showing high inflammatory activity and villous atrophy in the pouch need long-term follow-up and should be ensured adequate intake of calcium and vitamin D.     

Double-stapledvs. handsewn ileal pouch-anal anastomosis in patients with chronic ulcerative colitis

Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice for most patients with chronic ulcerative colitis. Whether or not a double-stapled technique, which should preserve the anal transition zone and avoid prolonged anal dilation, facilitates superior fecal continence compared with conventional mucosal resection and handsewn anastomosis is unknown. PURPOSE: The aim of this study was to compare functional results after double-stapled and handsewn IPAA. METHODS: Twenty-seven consecutive patients (13 females, 14 males; mean age, 37 years) who had proctocolectomy and double-stapled IPAA (J) for chronic ulcerative colitis were identified. Each was matched by sex, age, and surgeon to a control who had undergone a conventional handsewn anastomosis. Functional results at six months after ileostomy closure were compared. RESULTS: Median stool frequency in each group was seven. The prevalence of pouchitis was 22 percent in both groups. One pouch failure occurred in each group. The percentage of patients from the double-stapled group with daytime spotting was similar to that of the handsewn group (18 percent vs. 26 percent,P>0.5). Nighttime soiling rates were similar as well (41 percent vs.48 percent,P>0.5). CONCLUSIONS: Double-stapled IPAA appears to convey no early functional advantage over handsewn IPAA for chronic ulcerative colitis.Presented at the Tripartite Meeting, Sydney, Australia, October 1993.     

Adaptative changes in terminal ileum after total colectomy, mucosal proctectomy and straight ileo-anal anastomosis in chronic ulcerative colitis

Total colectomy, mucosal proctectomy and straight ileo-anal anastomosis was performed in four adult patients with chronic ulcerative colitis (three males, one female; mean age 27.4 years). During a follow-up period of one to five years, all patients were continent, had spontaneous bowel evacuation (average 4-5 per day), and had normal bladder and sexual function. Sequential per rectal ileoscopies revealed loss of ileal folds and gradual transformation to a colonic type of mucosa. On barium studies, the anastomosed terminal ileum showed progressive ballooning and assumed a rectosigmoid appearance with complete disappearance of ileal characteristics. The histology showed a progressive transformation from ileal to colonic type of mucosa, with blunting and ultimate disappearance of villi, increasing goblet cell population, and increase in mononuclear cells in the lamina propria. Histochemical studies (high iron diamine and alcian blue stains) revealed a change from small intestinal to colonic mucin, progressing proximally from just above the anastomotic site. Two patients had a single recurrence with ileal histology resembling that of active ulcerative colitis; both responded to short term steroid therapy. The results of straight ileo-anal anastomosis compare well with Western reports of ileal reservoirs. Adaptative changes of 'colonisation' can be consistently demonstrated in the anastomosed ileum on follow-up; these start just above the anastomotic site and ascend proximally. The colonised ileum appears to be susceptible to the ulcerative disease.     

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.     

Water and electrolyte balance after ileal J pouch-anal anastomosis in ulcerative colitis and familial adenomatous polyposis

The water and electrolyte balance was studied in 31 patients with ulcerative colitis (UC) and 22 with familial adenomatous polyposis (FAP) who underwent staged surgery involving colectomy and ileal J pouch-anal anastomosis (IAA), preoperatively, after terminal ileostomy, after high ileostomy, and after ileostomy closure. Serum electrolytes did not differ between each surgical stage. After terminal or high ileostomy, daily urine volume and urinary sodium loss was significantly lower, and daily fecal weight and fecal sodium loss was significantly higher than preoperatively. After ileostomy closure, urinary and fecal sodium loss became closer to preoperative value. Daily urinary potassium loss was significantly higher and fecal loss was lower after terminal and high ileostomy than preoperatively and did not show a significant change after ileostomy closure. The urinary sodium to potassium ratio after ileostomy closure was lower than preoperatively, but was higher than that after terminal and high ileostomy. Plasma aldosterone and renin levels were only significantly increased after high ileostomy. These findings indicate that high or terminal ileostomy caused chronic dehydration, which was compensated for by activation of the renin-aldosterone axis, while the water and electrolyte balance became closer to normal after ileostomy closure following ileoanal anastomosis.

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Résumé Un bilan hydro-électrolytique a été établi chez 31 patients porteurs d'une recto-colite ulcéro-hémorragique et 22 porteurs d'une polypose familiale; tous avaient subi plusieurs temps chirurgicaux comprenant une colectomie et la confection d'une anastomose iléoanale avec une pochen en J. Les dosages ont été réalisés à 4 péeriodes au cours du suivi chirurgical, en particulier en préopératoire, après la colectomie avec confection d'une iléostomie terminale, après l'anastomose iléo-anale sous couvert d'une iléostomie de protection et après fermeture de l'iléostomie de protection. Les taux sériques d'électrolytes ne diffèrent pas entre les 4 périodes chirurgicales. Après iléostomie terminale ou après iléostomie de protection, le volume urinaire quotidien et les pertes de sodium urinaire étaient significativement plus basses alors que le poids fécal quotidien et les pertes de sodium fécales étaient significativement plus élevées qu'en préopératoire. Après fermeture de l'iléostomie, les valeurs d'excrétion du sodium urinaire et fécal étaient voisines à celles de la valeur pré-opératoire. L'élimination journalière de potassium par les urinaires était plus élevée et les pertes fécales plus basses après iléostomie terminale et iléostomie de protection que celles observées en préopératoire; ces valeurs ne changeaient pas de manière significative après fermeture de l'iléostomie. Le rapport sodium/potassium urinaire après fermeture de l'iléostomie est abaissé par rapport à la valeur pré-opératoire mais demeure plus élevé qu'après iléostomie terminale et iléostomie de protection. Le taux d'aldostérone et le taux de rénine plasmatique étaient significativement augmentés après une iléostomie de protection. Ces données tendent à démontrer qu'une iléostomie terminale ou une iléostomie de protection favorisent une déshydratation chronique avec une perte sodique compensée par l'activation du mécanisme rénine-aldostérone.

     

Probiotic administration in patients with ileal pouch-anal anastomosis for ulcerative colitis is associated with expansion of mucosal regulatory cells

BACKGROUND: Probiotics have anti-inflammatory effects in patients with inflammatory bowel disease and appear to regulate mucosal immune response through reductions in proinflammatory cytokines. The probiotic VSL#3 prevents pouchitis if started within a week of ileostomy closure and maintains remission following antibacterial treatment in patients with refractory or recurrent pouchitis. However, the efficacy of probiotics and their effects on regulatory cells if started at a greater time after surgery in patients undergoing ileal pouch anal anastomosis (IPAA) for ulcerative colitis are unknown. METHODS: We conducted an open-label study in which 31 patients at different periods from surgery without signs and symptoms of pouchitis were randomized to 2 sachets of VSL#3 once daily or no treatment for 12 months. Pouchitis disease activity index (PDAI) was evaluated at baseline and after 3, 6, and 12 months. The percentage of CD4+ T lymphocytes expressing CD25 and the inactive form of transforming growth factor-beta [latency-associated peptide (LAP)] were evaluated at baseline and after 3 and 6 months in peripheral-blood mononuclear cells and mucosal biopsies. Variation in tissue interleukin-1beta and Foxp3 mRNA expression was also evaluated. RESULTS: During the study period, VSL#3-treated patients showed a significant reduction in PDAI score and a significant increase in the percentage of mucosal CD4+CD25(high) and CD4+ LAP-positive cells compared with baseline values. Tissue samples at different points showed a significant reduction in IL-1beta mRNA expression, and a significant increase in Foxp3 mRNA expression. CONCLUSIONS: We conclude that VSL#3 administration in patients with IPAA modulates the PDAI and expands the number of mucosal regulatory T cells.     

Effect of systemic steroids on ileal pouch-anal anastomosis in patients with ulcerative colitis

BACKGROUND: Long-term steroid therapy predisposes to postsurgical complications, especially in patients with inflammatory bowel disease. PURPOSE: This study was undertaken to determine incidence of early septic complications after ileal pouch-anal anastomosis (TPAA) in patients who are undergoing prolonged steroid therapy. METHODS: We reviewed charts of 692 patients undergoing restorative proctocolectomy and IPAA to treat ulcerative colitis. Incidence of early (within 30 days) septic complications and sepsis-related reoperations, in patients who were having high-dose (>20 mg of prednisone per day) and low-dose steroid therapy (<20 mg of prednisone per day) for more than one month before surgery, was compared with patients who were not receiving steroid therapy. Follow-up included an annual questionnaire and physical examination. RESULTS: Patients without steroid dose data recorded were excluded (n=21). Of the 671 remaining patients, 310 received no steroids, 169 received low-dose steroids, and 192 received high-dose steroids. These three groups were similar in gender composition, age at surgery, types of anastomosis (stapled or handsewn), and incidence of diabetes mellitus, peripheral vascular disease, and obesity. Early septic complications were found in 18 (6 percent), 14 (8 percent), and 12 (6 percent) patients without steroid therapy, those having low-dose steroid therapy, and those having high-dose steroid therapy (P =0.57), respectively. Sepsis-related reoperation rate (P =0.73) and number of sepsis-related pouch excisions (P =0.79) did not differ between groups. In patients undergoing IPAA without ileostomy, early septic complications were found in one (3.8 percent), two (20 percent), and five (50 percent) patients without steroid treatment, low-dose steroid therapy, and high-dose steroid therapy (P =0.004), respectively. CONCLUSION: In patients who are undergoing IPAA with diversion for ulcerative colitis, prolonged systemic steroid therapy before surgery is not associated with increased septic complications.     

Aneuploidy and columnar cuff surveillance after stapled ileal pouch-anal anastomosis in ulcerative colitis

PURPOSE: A stapled pouch-anal anastomosis without mucosectomy is widely used in restorative proctocolectomy. Uncertainty exists about the longer-term outcome of retaining a columnar cuff of epithelium in the anal canal and about the need for surveillance of the columnar cuff. The aim of this article was to assess the ability to obtain biopsies of the columnar cuff, to assess the risk of dysplasia, and to search for the presence of aneuploidy as an early of marker of dysplasia in nondysplastic epithelium. METHOD: A total of 457 biopsy specimens were taken during 203 examinations of 113 patients. All biopsy specimens were stained with hematoxylin and eosin and examined by microscopy. One hundred thirty-two of these biopsy specimens from 67 patients were frozen and analyzed by flow cytometry for aneuploidy. RESULTS: Mean follow-up after pouch formation was 2.5 years, and the time after diagnosis of ulcerative colitis was 10.1 years. Successful columnar cuff biopsies were done on 93 percent of patients. There was no dysplasia. Two biopsy specimens from one patient had aneuploidy. CONCLUSION: To date, neoplastic change in the columnar cuff is rare. A selective policy of surveillance biopsies is recommended that includes patients greater than ten years after the diagnosis of ulcerative colitis and patients with dysplasia or cancer in their proctocolectomy specimen, but long-term follow-up data are needed.Mr. Thompson-Fawcett was funded by the Oxford Radcliffe Colorectal Surgery Research Trust Fund, Oxford Radcliffe NHS Trust, United Kingdom.Presented in part at the European Council of Coloproctology Biennial Meeting, Edinburgh, United Kingdom, June 17 to 19, 1997. Published in abstract form: Thompson-Fawcett M, Warren B, Mortensen N. Surveillance of the columnar cuff after restorative proctocolectomy. Int J Colorectal Dis 1997;12:163.     

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.     

Possible role of human cytomegalovirus in pouchitis after proctocolectomy with ileal pouch-anal anastomosis in patients with ulcerative colitis

AIMTo detect the presence of human cytomegalovirus(HCMV)proteins and genes on the ileal pouch of patients with ulcerative colitis who have undergone proctocolectomy with ileal pouch-anal anastomosis(IPAA).METHODSImmunohistochemistry,polymerase chain reaction(PCR)and PCR sequencing methods were utilized to test the presence of HCMV in pouch specimens taken from 34 patients in 86 endoscopies.RESULTSHCMV genes and proteins were detected in samples from 12(35.2%)patients.The rate of detection was significant in the endoscopies from patients diagnosed with pouchitis(5 of 12,41.6%),according to the Japanese classification of pouchitis,in comparison to patients with normal pouch(7 of 62,11.2%;P = 0.021).In all patients with pouchitis in which the HCMV was detected,it was the first episode of pouchitis.The virus was not detected in previous biopsies taken in normal endoscopies of these patients.During the followup,HCMV was detected in one patient with recurrent pouchitis and in 3 patients whose pouchitis episodes improved but whose positive endoscopic findings persisted.CONCLUSIONHCMV can take part in the inflammatory process of the pouch in some patients with ulcerative colitis who have undergone proctocolectomy with IPAA.     

Incidence and subsequent impact of pelvic abscess after ileal pouch-anal anastomosis for chronic ulcerative colitis

PURPOSE: This study was designed to measure the impact of pelvic abscess on eventual pouch failure and functional outcome after ileal pouch-anal anastomosis in patients with chronic ulcerative colitis. PATIENTS AND METHODS: The outcome of 1,508 patients who underwent ileal pouch-anal anastomosis for chronic ulcerative colitis at the Mayo Clinic was determined from a central patient registry; data were collected prospectively. RESULTS: Seventy-three patients developed a pelvic abscess as a complication of ileal pouch-anal anastomosis. Pouch failure occurred in 19 (26 percent). Forty-eight patients (55 percent) required transabdominal salvage surgery, 6 (8 percent) underwent local surgery, and the remaining 27 (37 percent) were treated nonsurgically. Wound infection was more common in patients who experienced pelvic abscess. The majority of pouch failures secondary to pelvic abscess formation occurred within two years of ileal pouch-anal anastomosis. Daytime incontinence, the use of a protective pad, and the need for constipating or bulking medication were significantly more common among patients who had an abscess but kept their reservoir. Ability to perform work and domestic activities and to undertake recreational activities were significantly more restricted among these patients. CONCLUSIONS: Pouch failure occurs in one-fourth of patients who retain their pouch despite pelvic abscess after ileal pouch-anal anastomosis. Among patients who retain their pouch despite postoperative pelvic abscess, functional outcome and quality of life are significantly poorer than in patients in whom no sepsis occurred.