Quality-of-life assessment after ileoanal pull-through for ulcerative colitis and familial adenomatous polyposis

BACKGROUND/PURPOSE: The ileoanal pull-through procedure (IAP) is gaining increasing favor and use in the surgical treatment of children with ulcerative colitis (UC) and familial adenomatous polyposis (FP). Although physiological studies have been performed to assess the outcome of these children, no long-term quality-of-life assessment after the procedure has been performed. METHODS: Forty-three patients were identified who had an IAP at our institution in the last 10 years and were at least 6 months postsurgery. Thirty-four were contacted, and 32 agreed to participate in the survey, which was approved by the Human Studies Committee. Participants completed the standardized Medical Outcome Study Short Form-36 (SF-36), which has well-established normative values. Several supplemental questions were prepared in a similar format dealing with issues specific to the ileoanal pull-through procedure. RESULTS: Of the 32 participants, 19 (59%) were girls and 26 (81%) had ulcerative colitis. Mean age at the time of survey was 18.1 years with 12 less than 18 years and 20 > or =18 years. Data from the latter group could be compared with national normative values for this age. The study group was not statistically different from age-appropriate US population normal values on all assessable scales of physical and mental health in the SF-36 survey including physical functioning, role limitations-physical, bodily pain, general health, vitality, social functioning, role limitations-emotional, and mental health (all P>.05 or mean difference SD units <0.8). The supplemental questionaire demonstrated little adverse effect of the surgery. There was limited consumption of medications to control bowel frequency and little restriction of activity because of the frequency of bowel movements or fear of incontinence. The surgical scar was the sole negative factor of significance. CONCLUSIONS: The ileoanal pull-through procedure is an excellent surgical option for children with ulcerative colitis or familial adenomatous polyposis, and it produced minimal, if any, adverse effects on their long-term quality of life.     

Restorative proctocolectomy without diverting ileostomy in children with ulcerative colitis

PurposeThe safety of performing a restorative proctocolectomy (RP) and J-pouch ileoanal anastomosis (IPAA) without diverting ileostomy for children with ulcerative colitis (UC) is a subject of extensive debate. Our goal was to examine pediatric outcomes of RP and IPAA without ileostomy.MethodsWe performed a single-institution review of UC patients who had RP and IPAA with (+Ostomy) or without (?Ostomy) diverting ileostomy from 2002 to 2010. Surgeon and patient preference determined ileostomy decision. The study included 50 patients (28 +Ostomy, 22 –Ostomy).ResultsPreoperative demographics were similar between 2 groups in age (13.5 ± 3.5 years –Ostomy, 14.3 ± 3 years +Ostomy), serum albumin (3.6 ± 0.7 –Ostomy, 3.6 ± 0.7 +Ostomy), body mass index (20.8 ± 6.9 ?Ostomy, 21.3 ± 8.6 +Ostomy), and daily corticosteroid dose (22.4 ± 17.7 mg ?Ostomy, 23.5 ± 13.7 mg +Ostomy). Operating time was less in –Ostomy with mean times of 6:22 ± 2:04 vs 9:07 ± 2:57. The –Ostomy group required fewer ileoanal anastomotic dilations per patient (0.4 ± 0.8 vs 1.4 ± 1.9). Functional outcomes were not significantly different regarding pouchitis episodes per patient (0.6 ± 1.1 –Ostomy, 0.6 ± 1.1 +Ostomy), daily bowel movements (5.5 ± 1.9 –Ostomy, 6.7 ± 4.0 +Ostomy), and daily postoperative loperamide dose (8.4 ± 4.3 mg –Ostomy, 6.8 ± 4.0 mg +Ostomy).ConclusionShort- and long-term outcomes can be equivalent in patients with and without diverting ileostomy, but questions remain regarding patient selection and quality of life impact.     

Surgery of ulcerative colitis using ileoanal anastomosis

The ideal surgical treatment for ulcerative colitis is the ileoanal anastomosis (IAA), which, however, is not yet generally accepted as a practical procedure because of a suboptimal fecal function, frequent postoperative complications and technical difficulties. Based on one (U.) of the authors experiences on 36(34) polyposis and 19(12) colitis (paracentesis indicate the number of cases in (U.)'s previous appointment, Tokyo Medical and Dental University, 1977-1983). The practical procedure of IAA can be achieved by combining the following basic principles; a direct anastomosis of J-shape ileal pouch to the anal sphincteric mechanism, temporarily exclusion of the anastomosis by a loop-ileostomy, mucosectomy confined to the lower rectum leaving the short muscular cuff, and meticulous dissection of inflamed mucosa of the anal canal minimizing the damage to the internal sphincter which is achieved by the prone ano-abdominal approach. At elective operation, the procedure can be performed either as primary surgery or as the secondary following rectum preserving operation, in which, coeco-rectal anastomosis is advisable for preserving the ileocolic vessels that is helpful for J-pouch construction. In emergency surgical program, IAA is still be preserved as a final restructive surgery following colectomy with an open rectal exclusion or Turnbull' s total colonic exclusion. In this occasion, an ascendicostomy is advisable for preserving the ileocolic vessels.     

Comparison of postoperative outcomes in ulcerative colitis and familial polyposis patients after ileoanal pouch operations

BACKGROUND: Pouchitis is a poorly understood inflammatory condition that occurs in the ileal pouches of patients who have undergone the ileal-pouch anal anastomosis after restorative proctocolectomy. This postoperative condition is much more common in patients with ulcerative colitis (UC) than familial adenomatous polyposis (FAP) colitis. It has been suggested that, owing to pouchitis, UC patients do not attain the same quality of life that FAP patients do after the ileal-pouch anal anastomosis operation. We hypothesized that health-related quality of life does not differ between FAP and UC patients. METHODS: We analyzed the postoperative morbidity and gastrointestinal function in 110 consecutive patients having undergone the ileal-pouch anal anastomosis for either UC or FAP at OU Medical Center from 1983 to 2000 by retrospective record review. Health-related quality of life was assessed in 83 patients using the Short Inflammatory Bowel Disease Questionnaire (SIBDQ) and the Medical Outcome Study Short-Form 36 (SF-36) questionnaire. RESULTS: With the exception of pouchitis, there was no difference in perioperative outcome, morbidity, or functional status between UC and FAP patients. The SIBDQ and SF-36 revealed no statistically significant difference between FAP and UC patients. CONCLUSIONS: As expected, UC patients are more likely to develop pouchitis. Despite this, our data reveal that both patient groups enjoy a similarly good functional status and quality of life.     

Ileoanal reservoir for ulcerative colitis and familial polyposis

Although total proctocolectomy with permanent ileostomy is regarded as the definitive therapy for ulcerative colitis and familial polyposis, psychologic and physical complications with this operation have stimulated the development of the operation of total abdominal colectomy, mucosal proctectomy, ileal reservoir, and ileoanal anastomosis as an alternative surgical procedure. Since 1980, 104 of these operative procedures have been completed with no operative mortality; experience has been gained with both the J- and S-type reservoirs. Despite an appreciable number of postoperative complications, satisfactory function of the reservoir has been achieved in 86 of 91 patients followed up for at least three months after closure of the ileostomy. The remaining five patients have required reinstitution of fecal diversion. Functional results have not differed between two-limbed and three-limbed reservoirs. This operation must be considered a viable alternative in patients with ulcerative colitis and familial polyposis.     

The J-pouch Swenson procedure for ulcerative colitis and familial polyposis.

Total colectomy with mucosal proctectomy and ileal pouch-anal anastomosis has proven to be a favorable option in the treatment of ulcerative colitis and familial polyposis coli. The main advantages of this procedure are that it obviates the need for a permanent stoma, it preserves anal continence, and it removes all disease-prone mucosa. As an alternative to this procedure, the authors have found success with the Swenson pull-through following proctocolectomy in children. This technique involves resection of the rectum at the dentate line, thus, eliminating the need for mucosal proctectomy. This may be particularly advantageous in patients with severely diseased rectal mucosa. Ileoanal anastomosis is performed after creation of an ileal J-pouch using the terminal ileum. The procedure has been used in two children with familial polyposis coli and in three with ulcerative colitis. Median follow-up after closure of the diverting ileostomy is 13 months (5-33 months). Continence has been preserved in all five patients. There have been no complications involving bladder or sexual dysfunction. This technique provides a reliable alternative for the definitive treatment of ulcerative colitis and familial polyposis coli.     

Adenocarcinoma below stapled ileoanal anastomosis after restorative proctocolectomy for ulcerative colitis

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

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

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

Adenocarcinoma of the ileostomy: the latent risk of cancer after colectomy for ulcerative colitis and familial polyposis

A case of a primary adenocarcinoma of an ileostomy is reported along with 15 other cases collected from the literature. These rare tumors are seen on the average 24 years after colectomy with ileostomy and in all cases are associated with a past history of ulcerative colitis or familial polyposis. Most of the reported cases of these tumors have appeared in the literature within the past 5 years, suggesting that there is a rising incidence of this disease corresponding to completion of a biologic latency period that began when the Brooke ileostomy was introduced for ulcerative colitis in 1951. In our case a mucinous adenocarcinoma occurred at the ileostomy site 34 years after colectomy. Adjacent to the tumor was mucosa showing colonic metaplasia and focal dysplasia. Subsequent biopsy specimens of the revised stoma showed inflammatory lesions morphologically suggestive of inflammatory (pseudo) polyps. The clinical and morphologic features in this case suggest that there is transition from ileal mucosa to colonic mucosa to colonic dysplasia to adenocarcinoma. Annual evaluation of the ileostomy for colonic metaplasia, inflammatory lesions consistent with ulcerative colitis and dysplasia, is recommended. In the presence of dysplasia, stomal revision is advised. Wide local excision is advised for adenocarcinoma.     

Gasless laparoscopic surgery for ulcerative colitis and familial adenomatous polyposis

PURPOSE: We evaluated the data on initial experience of gasless laparoscopic surgery for patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). PATIENTS AND METHODS: Seven patients (male/female = 3:4, median age 23, UC/FAP=5:2) underwent gasless laparoscopic total (procto) colectomy. Our basic surgical procedure involved (1) a 6- to 8-cm incision made at the beginning of the operation, (2) the wound pulled upward and/or laterally by retractors, and (3) conventional surgical instruments used through the wound; occasionally laparoscopic assistance and abdominal lifting were employed. The results were compared to those of 7 patients who had undergone conventional open surgery. RESULTS: Oral intake started earlier (p = 0.03) and C-reactive protein level on POD 4 was lower (p = 0.03) in the gasless group than in the control group. Duration of surgery, blood loss, requirement of analgesia, and morbidity rate were not significantly different between the groups. CONCLUSION: Our preliminary results suggest that gasless laparoscopic surgery for UC and FAP is feasible and can be an alternative method for minimally invasive surgery.     

Pseudomembranous colitis treated with completely diverting ileostomy.

A seriously ill patient with pseudomembranous colitis of obscure origin responsed promptly to a completely diverting ileostomy. The ileostomy was successfully closed three months later when the colon appeared to be normal. In an unusually severe case of pseudomembranous colitis, where operation is required and where pseudomembranous colitis is the sole operative finding, a completely diverting ileostomy should be considered rather than a more extensive procedure.     

腹腔镜全结直肠切除并拖出式直肠黏膜剥离术治疗FAP及UC

目的探讨腹腔镜全结直肠切除并拖出式直肠黏膜剥离术治疗家族性腺瘤性息肉病(FAP)及溃疡性结肠炎(UC)的可行性及安全性。方法自2007年12月至2009年9月,应用腹腔镜全结直肠切除治疗FAP9例及UC4例,除2例因直肠癌变行回肠造口外,其余11例均在腹腔镜下游离全结直肠后,将直肠外翻拖出后行直肠黏膜剥离,再将回肠J型储袋与齿线行手工吻合。结果 13例手术均在腹腔镜辅助下成功完成,平均手术时间(248.8±27.8)min,平均出血量(61.0±27.7)ml,辅助切口平均长度(3.8±1.0)cm,术后2~3d排气。所有患者术后恢复顺利,无严重并发症。所有患者随访超过4个月,肛门功能恢复较满意。结论腹腔镜辅助全结直肠切除、拖出式直肠黏膜剥离并回肠储袋肛管吻合术是可行、安全及微创的,在保证对疾病治疗彻底性的同时,能取得较满意的近期效果。     

Long-term pathophysiological studies on loop ileostomy and ileoanal anastomosis

Mucosal proctectomy with ileoanal anastomosis (IAA) had been performed on 37 patients with adenomatosis coli and 16 with ulcerative colitis between 1978 and 1987. These patients were followed up for a mean of 7.5 years. In 38 cases (73%), this procedure was completed by closure of loop ileostomy. The mean number of bowel movements per 24 hours was 6.0. Seven patients had occasional episodes of minor nocturnal soiling. The postoperative maximum resting anal pressure was the most important parameter reflecting clinical results and it rose from 72 to 92 cm of water during 5.3 year follow-up period after IAA. The pathophysiological studies on loop ileostomy and IAA were performed in these patients. Postoperative small bowel transit time evaluated by radioopaque markers was shortened. Daily output of water and sodium, and Na/K ratio in the ileal excreta increased and total counts of anaerobes in feces decreased. On the other hand, daily volume, Na/K ratio and PH of urine fell significantly. These phenomena were remarkable in patients who received loop ileostomy with about 60 cm defunctioning terminal ileum. These results indicate that it is necessary to maintain intestinal continuity in the ileal pouch-anal procedures.     

Laparoscopic total proctocolectomy with ileal pouch anal anastomosis for ulcerative colitis and familial adenomatous polyposis: initial experience in Mexico

Background Since the introduction of laparoscopic colectomy in 1991, experience in laparoscopic bowel surgery has gradually increased. Several reports from specialized centers have demonstrated that laparoscopic colorectal resections are feasible and safe, providing an acceptable alternative to laparotomy for a variety of diseases. Some studies have shown the feasibility, safety, and good functional outcome of the minimally invasive procedures for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). No known studies have investigated laparoscopic proctocolectomy in México. This report aims to describe the first laparoscopic proctocolectomies with ileal pouch anal anastomosis (IPAA) performed at the Instituto Nacional de Ciencias Medicas y Nutrición Salvador Zubirán (INCMNSZ). Methods All the patients in the authors’ institution who underwent a one- or two-stage laparoscopic total proctocolectomy with IPAA between June 2005 and December 2006 were included in the study. All the operations were performed by the same surgeon, who had already completed the learning curve for colorectal laparoscopic procedures. Results For the study, 10 patients underwent a laparoscopic proctocolectomy with IPAA by a single surgeon. Eight of the patients underwent a one-stage procedure, whereas two patients with severe colitis underwent a two-step procedure. All the cases were managed with a diverting loop ileostomy. Six patients underwent a standard double-stapled IPAA anastomosis, and two patients with FAP underwent a mucosectomy with a manual IPAA anastomosis. The mean operative time was 187 min, and the mean blood loss was 46 ml. There were two postoperative complications. One patient presented with an early small bowel obstruction due to an internal hernia, which required reoperation. The other complication was a wound infection. The mean return to oral intake was 1.5 days, and the mean length of hospital stay was 3.4 days. Conclusion Although this was not a comparative study and although sample size imposed limitations, with this preliminary data, we conclude that the laparoscopic approach to UC and FAP at our institution is safe, feasible, and effective. However, to achieve the benefits in postoperative outcome, this procedure should be performed only by experienced laparoscopic surgeons.     

Does an ileoanal pouch offer a better quality of life than a permanent ileostomy for patients with ulcerative colitis?

Although an ileoanal pouch is frequently offered to patients with ulcerative colitis, it is still not clear to what extent this operation offers advantages over a permanent ileostomy. The aim of this study was to determine whether patients with a pouch have less morbidity and a better quality of life than a matched group of patients with a Brooke ileostomy. Nineteen patients (12 males and 7 females, median age 41 years) who had undergone total colectomy and ileoanal pouch formation for ulcerative colitis were individually matched with patients who had had a panproctocolectomy and ileostomy; patients were matched for disease process, sex, age, socioeconomic status, and time since surgery. Quality of life was assessed using the Short-Form 36 version 2 questionnaire, the inflammatory bowel disease questionnaire, and a few additional questions on perception of body image. The scores were compared using the nonparametric Wilcoxon signed-rank test for paired samples. The number and type of postoperative complications, as well as the number of operative stages, were recorded prospectively. Restorative proctocolectomy was associated with a significantly better perception of body image than a permanent stoma, although quality of life in general was similar in both groups. Patients with a pouch had more long-term complications than patients with an ileostomy within the same period of time (52.6% vs. 26.3%). The median number of stages for pouch construction was two, compared to a median of one stage for an ileostomy (P < 0.0001). Because of the high long-term complication rate and the relatively small quality-of-life advantage associated with restorative proctocolectomy, patients need to be counseled thoroughly before agreeing to this operation. Presented at the Millenium Joint Scientific Meetings of the Association of Surgeons of Great Britain and Ireland and the Surgical Research Society, Cardiff, Wales, May 23–26, 2000; and published as an abstract in British Journal of Surgery 2000;87(Suppl 1):47. Supported by an educational grant from ConvaTec Ltd.     

Ileorectal anastomosis for ulcerative colitis

Several options can be considered when medical management of ulcerative colitis fails or if a serious complication develops. One alternative to proctocolectomy with ileostomy or ileoanal pull-through is the ileorectal anastomosis. Its main advantage is preservation of the rectal reservoir without risking injury to the pelvic nerves or and sphincter. It is not indicated when the rectum is severely diseased or stenosed or in the presence of rectal carcinoma. Patients older than 55 to 60 years can expect a good functional result in a relatively short time compared with the prolonged adaptation period associated with pull-through procedures.     

Abdominopreanal proctocolectomy and ileal U-pouch in ulcerative colitis or familial adenomatous polyposis

In some cases of ulcerative colitis and familial adenomatous polyposis, cancerous changes frequently occur on the distal rectum, in which case a restorative proctocolectomy is not recommended because of the limitations of a radical resection. Even if rectal cancer is not confirmed preoperatively, a strong possibility of cancer in the rectum could afford some support for a radical pelvic dissection during the anus-sparing procedure. The author designed a new operative procedure for resolving this problem. It is an abdominopreanal extrasphincteric proctocolectomy with preileal-pouch positioning of the distal ileal segment including the ileocecal sphincter (ileal U-pouch) for the treatment of ulcerative colitis and familial adenomatous polyposis coli (restorative radical proctocolectomy). The author performed this restorative radical proctocolectomy on seven patients over the past 5 years at the Department of Surgery, Pusan National University Hospital, of which four cases were ulcerative colitis and three were familial adenomatous polyposis. The results obtained were as follows: (a) The most common sequela was nocturnal seepage, which lasted for 6 months in 4 patients after the final operation. (b) The mean frequency of defecation was six times per day at 6 months after the final operation. (c) The average amount of stool was about 460 g per day at 6 months after the final operation. Therefore, the ileal U-pouch is considered to be effective in reducing the daily amount of stool. A preanal extrasphincteric approach could be especially useful in the case of a difficult dissection of the anterectal space while also providing an effective dependent drainage of the ileoanal anastomotic space.This paper was presented at the 95th Annual Congress of the Japan Surgical Society in Nagoya, Japan, April 10–12, 1995. The author received a travel grant from the Japan Surgical Society.