Adenocarcinoma in the Anal Canal After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis Using a Double Stapling Technique

A case of adenocarcinoma, developed in the anal canal after ileal pouch-anal anastomosis for ulcerative colitis using a double stapling technique, is reported. In this case a T3N0 cecal cancer was found unexpectedly in the colectomy specimen. Two years later, this patient presented with an outlet obstruction of the pouch because of development of an adenocarcinoma of the anal canal. This was treated with an abdominoperineal excision of the pouch and anorectum.     

Pregnancy,Delivery, and Pouch Function After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis

PURPOSE: This study was designed to evaluate the pregnancies, method of delivery, and functional results of females with chronic ulcerative colitis who have an ileal pouch-anal anastomosis. METHODS: A mailed questionnaire was sent to all females with an ileal pouch-anal anastomosis for chronic ulcerative colitis. Information on the pregnancy, method of delivery, and outcome was collected. Those females who had a successful pregnancy and delivery were contacted by telephone to clarify results and determine pouch functional results. Other clinical information was obtained from the Mount Sinai Hospital Inflammatory Bowel Disease database. RESULTS: Thirty-eight subjects had 67 pregnancies. Of these, 29 subjects had 49 deliveries. There were 25 vaginal deliveries and 24 cesarean sections. There were two pouch-related complications during the pregnancies and four pouch-related complications postpartum. All were treated nonoperatively. Stool frequency and day and night incontinence were increased during pregnancy in most subjects, but after delivery, prepregnancy function was restored in 24 (83 percent) of them. Five subjects (17 percent) had some degree of permanent deterioration in pouch function. Of these, three had vaginal deliveries, and two had cesarean sections. Multiple births and birth weight were not found to adversely affect subsequent pouch function. CONCLUSION: Pregnancy is safe in females with ileal pouch-anal anastomosis. Functional results are altered almost exclusively during the third trimester, but pouch function promptly returns to prepregnancy status in most females. A small proportion of females have long-term disturbances in function, but these are not related to the method of delivery. Thus, the method of delivery should be dictated by obstetric considerations.     

Female Infertility After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis

PURPOSE: Although ulcerative colitis commonly affects young females, the impact of ulcerative colitis and its treatment on female fertility have not been well studied. The purpose of this survey was to examine the impact of ulcerative colitis and ileal pouch-anal anastomosis on female reproductive ability.METHODS: Demographic, reproductive history, and disease history information were obtained via a questionnaire mailed to females who had pelvic pouch surgery or nonoperative management for ulcerative colitis. Based on age at diagnosis, age at surgery, and marital status, 153 females who had pelvic pouch surgery and 60 females who had nonoperative management for ulcerative colitis were identified for inclusion. Patients were asked if they attempted to become pregnant, when relative to their diagnosis or surgery, and if they were successful. Married or cohabiting females aged 18 to 44 years who failed to become pregnant during 12 months of unprotected intercourse were defined as infertile.RESULTS: The infertility rate was significantly higher in females who had pelvic pouch surgery compared with females managed nonoperatively (59/153 (38.1 percent) vs. 8/60 (13.3 percent), respectively; P < 0.001). There was no difference in female fertility after diagnosis with ulcerative colitis compared with before diagnosis (odds ratio, 0.68; P = 0.23). In contrast, there was a 98 percent reduction in fertility after pelvic pouch surgery compared with before surgery (odds ratio, 0.021; P < 0.0001). By logistic regression, increasing age was the only factor associated with failure to become pregnant after surgery (odds ratio, 1.136 per additional year of age; P = 0.027).CONCLUSIONS: Females with ulcerative colitis who are managed nonoperatively have normal fertility, which suggests that ulcerative colitis and medical therapy do not decrease female reproductive ability. After pelvic pouch surgery for ulcerative colitis, female fertility is significantly decreased and this problem should be discussed routinely with patients considering this procedure.Read at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.Supported by a grant from the Maternal Research Unit, Sunnybrook and Womens College Health Sciences Centre. Dr. Johnson was supported by the Lew Dunn Scholarship. Dr. Richard was supported by a fellowship from the Crohns and Colitis Foundation of Canada.     

Clinical Features of Ileal Pouch Polyps in Patients with Underlying Ulcerative Colitis

Purpose Polypoid lesions rarely occur in the ileal pouch in ulcerative colitis patients after restorative proctocolectomy. Clinical features, malignant potential, and management of pouch polyps have not been characterized. Methods We identified 23 ulcerative colitis patients with large polyps (size≥1 cm) of the ileal pouch from our 2,512-case ulcerative colitis pouch database. Demographic, clinical, endoscopic, and histologic data were reviewed. The Pouchitis Disease Activity Index symptom score (range, 0–6) was used to quantify patients’ symptoms before and after polypectomy. Results Of the 23 patients, 95.7 percent (22 patients) had pouch endoscopy indicated for the evaluation of symptoms when polyps were detected, and 60.9 percent of patients had the polyps in the pouch, 26.1 percent in the anal transitional zone, and 21.7 percent in the afferent limb. The mean size of pouch polyps was 1.9 cm ± 1 cm. Twenty-one patients (91.3 percent) had concomitant pouchitis, cuffitis, or Crohn’s disease. On histology, 21 patients (91.3 percent) had inflammatory-type polyps, and 2 (8.7 percent) had dysplastic or malignant polyps. In 18 patients who had endoscopic polypectomy with concurrent medical therapy, the prepolypectomy and postpolypectomy mean symptom scores were 3.4 ± 1.7 and 1.1 ± 1.2 points, respectively (P = 0.015). Two patients (8.7 percent) had pouch excision for malignancy or for concomitant chronic refractory pouchitis. Conclusions The majority of patients with large ileal pouch polyps were symptomatic. These polyps were typically detected on the background of pouchitis, cuffitis, or Crohn’s disease. Although the majority of polyps were inflammatory type, polyps in two patients were dysplastic or malignant. Endoscopic polypectomy with concomitant medical therapy seemed to improve patients’ symptom scores. Supported in part by a NIH grant R03 DK 067275 and an American College of Gastroenterology Clinical Research Award (to B.S.). Poster presentation at meeting of the American College of Gastroenterology, Honolulu, Hawaii, October 30 to November 2, 2005. Reprints are not available.     

Atrophy and Neoplastic Transformation of the Ileal Pouch Mucosa in Patients With Ulcerative Colitis and Primary Sclerosing Cholangitis

INTRODUCTION: Patients with ulcerative colitis and primary sclerosing cholangitis have an increased risk of developing carcinoma both in the bile ducts and in the colon. PURPOSE: To investigate whether this patient group also has an increased risk of developing atrophy and neoplasia in the ileal pouch mucosa after construction of a pelvic pouch with an ileoanal anastomosis or a continent Kock ileostomy. METHODS: Flexible video endoscopic examinations of the ileal pouch were performed in 16 patients with ulcerative colitis and primary sclerosing cholangitis and in 16 matched patients with ulcerative colitis without sclerosing cholangitis. Biopsies were sampled from different locations in the pouch for histologic assessment of mucosal atrophy and dysplasia and for flow cytometric DNA analysis assessing chromosomal aberrations. RESULTS: The patients with sclerosing cholangitis developed moderate or severe atrophy in the pouch significantly more often (P < 0.01). Persistent severe mucosal atrophy was revealed in eight patients with sclerosing cholangitis and only in two controls. One patient with sclerosing cholangitis had high-grade dysplasia in multiple locations. Low-grade dysplasia was assessed in three patients with sclerosing cholangitis and in two of the controls. DNA aneuploidy was displayed in three patients, all with sclerosing cholangitis and dysplasia. All patients with neoplastic transformation had a pouch with ileoanal anastomosis and a long pouch duration (> 8 years). CONCLUSION: Patients with ulcerative colitis and primary sclerosing cholangitis with an ileal reservoir are more prone to developing mucosal atrophy in the pouch and seem to have a higher risk of neoplastic transformation in the pouch mucosa than patients with ulcerative colitis without sclerosing cholangitis.     

Mental Disorder and Psychologic Distress in Patients With Ulcerative Colitis After Ileal Pouch-Anal Anastomosis

PURPOSE The aim of this study was to determine if ileal pouch-anal anastomosis in patients with ulcerative colitis is a psychologic burden for patients, the frequency of mental disorders, the amount of psychologic distress, and their possible disease-related determinants. These factors were studied in patients with ulcerative colitis after ileal pouch anal anastomosis and were compared with ulcerative colitis patients without ileal pouch-anal anastomosis and the general German population.METHODS A total of 37 patients with ulcerative colitis after ileal pouch-anal anastomosis (age 46.8 ± 11.8 years; 35 percent female) and 62 patients with ulcerative colitis without ileal pouch-anal anastomosis (age 44.4 ± 13.9 years; 37 percent female) completed the following questionnaires: medical and sociodemographic questionnaire of the German Competence Network Inflammatory Bowel Diseases and the German version of the Hospital Anxiety and Depression Scale. Disease activity was measured in patients with ileal pouch-anal anastomosis by the Pouch Disease Activity Index and in patients without ileal pouch-anal anastomosis by the German Inflammatory Bowel Disease Activity Index. Psychologic distress was assessed by the subscale scores of the Hospital Anxiety and Depression Scale. A probable mental disorder was identified if a patient scored 11 or higher in at least one subscale of the Hospital Anxiety and Depression Scale.RESULTS The frequency of a probable psychiatric disorder in patients with ileal pouch-anal anastomosis (16 percent) and without ileal pouch-anal anastomosis (23 percent) did not differ from that in the general German population (17 percent). Ulcerative colitis patients with or without ileal pouch-anal anastomosis did not differ in the amount of psychologic distress. Ileal pouch-anal anastomosis patients had higher levels of anxiety than the general population (P < 0.01). Regression models of disease-related factors predicting mental disorder and psychologic distress showed no significant results.CONCLUSIONS Ileal pouch-anal anastomosis neither increases nor decreases the frequency of mental disorders or the amount of psychologic distress in ulcerative colitis patients.This investigation is part of the Competence Network IBD, sponsored by the German Ministry of Education and Research (BMBF D 20.00415).Presented in part at the 25th European Conference on Psychosomatic Research, June 23 to 26, 2004, Berlin, Germany.     

The Influence of Ileal Pouch-Anal Anastomosis for Ulcerative Colitis on Ileal Glycoprotein Synthesis

Restorative proctocolectomy and ileal pouch-anal anastomosis are frequently associated with the onset of low-grade inflammation, colonic metaplasia, and pouchitis. The influence of intestinal adaptation and inflammatory activity on ileal glycoprotein synthesis (GS) has been assessed. Ileal GS activity in controls (n = 13, 28.9 ± 3.6) was similar to that of patients with ulcerative colitis (n = 18, 26.4 ± 3.6) irrespective of the presence of backwash ileitis (n = 6, 22.0 ± 4.0). Ileoanal pouch construction was not associated with a significant change in ileal GS activity regardless of the presence of low-grade inflammation (n = 19, 25.9 ± 2.2), frank pouchitis (n = 5, 24.4 ± 4.6), or transformation to a colonic type of mucosa (n = 6, 25.4 ± 5.2). The transformation of ileal mucosa from an absorptive to a storage function is associated with characteristic morphologic and inflammatory changes but does not produce a protective response mediated by increased GS.     

Intestinal Mucosa-Associated Microflora in Ulcerative Colitis Patients Before and After Restorative Proctocolectomy with an Ileoanal Pouch

Purpose  This study was designed to identify the mucosa-associated microflora in patients with severe ulcerative colitis before and after restorative proctocolectomy with ileoanal pouch construction in comparison with historic controls. Methods  Ten patients with a diagnosis of ulcerative colitis were evaluated. Mucus was collected during colonoscopy from all segments of the colon and terminal ileum before surgery, and from the ileal pouch two and eight months after ileostomy closure. The prevalence and mean concentration of the mucosa-associated microflora were compared over time and with historic controls. Results   Veillonella sp was the most prevalent bacterium in patients and controls. Klebsiella sp was significantly more prevalent in the ileum of controls, was not found in patients with ulcerative colitis, and after proctocolectomy returned to values found in controls. Some bacteria such as Enterobacter sp, Staphylococcus sp (coag-), Bacteroides sp (npg), Lactobacillus sp, and Veillonella sp had higher mean concentrations in the ileal pouch of patients after surgery than in controls. Conclusion  No bacterium was identified that could be exclusively responsible for the maintenance of the inflammatory process. The mucosa-associated microflora of patients with ulcerative colitis underwent significant changes after proctocolectomy with ileal pouch construction and returned to almost normal values for some bacteria. Presented at the meeting of the International Society of University Colon & Rectal Surgeons, Budapest, Hungary, June 6 to 10, 2004.     

Anal Canal Strictures After Ileal Pouch-Anal Anastomosis

PURPOSE: This study was designed to define the different types of strictures, the factors favoring their occurrence, and their treatment after ileal pouch-anal anastomosis. METHODS: Between January 1981 and June 1996, 1,884 ileal pouch-anal anastomoses were constructed at the Mayo Clinic in Rochester, Minnesota. Data were collected prospectively and included age, gender, type of underlying diseases (chronic ulcerative colitis vs. familial adenomatous polyposis), proctologic antecedents, technique of anastomosis, intraoperative difficulties, and postsurgical complications. Strictures were categorized as nonfibrotic and fibrotic on the basis of the presence or absence of a fibrotic segment at the anal canal anastomosis that was responsible for pouch-outlet obstruction requiring at least one dilation. RESULTS: Strictures occurred in 213 patients (11.2 percent; 11 percent for chronic ulcerative colitis and 12 percent for familial adenomatous polyposis; P = not significant). Strictures were nonfibrotic in 86.4 percent of patients and fibrotic in 13.6 percent. A greater number of strictures were observed after a handsewn anastomosis (12 percent) than after a stapled anastomosis (4 percent; P = 0.03). Intraoperative technical difficulties were associated with 13 percent of all strictures regardless of the type of stricture (fibrotic, 7.5 percent; nonfibrotic, 14 percent; P = 0.4). Postoperative complications such as abscess, fistula, and pouch retraction were found in 13 percent of cases and were primarily associated with fibrotic strictures. Treatment included dilation, which was successful in 95 percent of nonfibrotic strictures but in only 45 percent of fibrotic strictures (P = 0.0001). Surgical treatment was required in 25 strictures (12 percent), including excision of the strictured segment with mucosal advancement flap (5 patients), excision of the pouch with permanent ileostomy (9 patients), or redo pouch (3 patients). With one exception, all excised pouches were associated with other perianastomotic complications, such as abscess, fistula, and pouch retraction. The remaining eight patients had other surgical procedures because of abscess (n = 3), division of an obstructive bridge (n = 2), and débridement and curettage of a fistula (n = 3) with dilation for associated strictures. CONCLUSIONS: Strictures were observed in 11.2 percent of the patients in this study. Nonfibrotic strictures responded well to anal dilation, whereas fibrotic strictures were more commonly associated with intraoperative or postoperative complications, often necessitated surgical therapy to salvage pouch function, and were eventually responsible for pouch failure in nine patients.     

Anal Transitional Zone Cancer After Restorative Proctocolectomy and Ileoanal Anastomosis in Familial Adenomatous Polyposis

PURPOSE: Restorative proctocolectomy with ileal pouch-anal anastomosis is accepted as the surgical treatment of choice for many patients with familial adenomatous polyposis. The risk of cancer developing in the ileal pouch after this surgery is unknown. Cancer may arise from the ileal pouch after restorative proctocolectomy, but that arising from the anal transitional zone has not been documented in familial adenomatous polyposis. We report two cases of this cancer from the anal transitional zone in patients with familial adenomatous polyposis, with a review of the literature. METHODS: All patients with familial adenomatous polyposis treated with restorative proctocolectomy and ileal pouch-anal anastomosis in The Cleveland Clinic were included in the study. Patients whose surveillance biopsy of the anal transitional zone revealed invasive adenocarcinoma were studied. RESULTS: Among a total of 146 patients with familial adenomatous polyposis who underwent restorative proctocolectomy and ileal pouch-anal anastomosis from 1983 to 2001 in our institution, none developed cancer of the anal transitional zone at up to 18 years of follow-up. However, there were two patients, both of whom underwent surgery elsewhere but who were followed up here, who developed invasive adenocarcinoma of the anal transitional zone. In one of them, cancer was diagnosed three years after a double-stapled ileal pouch-anal anastomosis, whereas in the other, cancer occurred eight years after a straight ileoanal anastomosis with mucosectomy. CONCLUSIONS: Cancer may develop in the anal transitional zone after restorative proctocolectomy with ileal pouch-anal anastomosis for familial adenomatous polyposis. Long-term surveillance of the anal transitional zone needs to be emphasized.     

Factors Associated With Ileal Mucosal Morphology and Inflammation in Patients With Ileal Pouch-Anal Anastomosis for Ulcerative Colitis

PURPOSE: Pouchitis has been associated with abnormal bacterial flora responding to antibiotics. Dietary factors may play a role in modifying the qualitative and quantitative components of the microflora. We evaluated interactions between nutritional factors, fecal and mucosal bacterial flora, and mucosal morphology in patients with a history of pouchitis compared with patients with optimal outcome at least five years after ileal pouch-anal anastomosis for ulcerative colitis. METHODS: Thirty-two patients were enrolled in the study: 11 (7 males; mean age, 49.8 years) with optimal outcome and 21 (11 males; mean age, 47.3 years) with pouchitis history. A seven-day food diary was recorded, endoscopy performed, and biopsies taken from the pouch for histology, mucin staining, and bacterial culture. Fresh fecal samples were quantitatively cultured, and fecal bile acids analyzed by gas-liquid chromatography. RESULTS: No differences existed in mean nutrient intake, composition of fecal bile acids, or microbial tissue biopsy cultures between the groups with and without pouchitis. Those with optimal outcome tended to have more benign disease course of ulcerative colitis than patients with pouchitis. In those patients, fecal concentrations (log10 colony-forming unit/g) of anaerobes and aerobes were significantly higher (P = 0.007). Degree of villous atrophy and colonic metaplasia were both associated with fecal anaerobic flora. Low intake of lactose was associated with sulfomucin predominance. A negative correlation existed between fecal aerobes and dietary lactose consumption. CONCLUSIONS: A higher total load of fecal anaerobic bacterial flora is strongly associated with degree of colonic metaplasia, villous atrophy, and inflammation activity after surgery for ulcerative colitis. An association existed between dietary lactose, fecal bacteria, and pouch morphology. Lactose may have prebiotic properties.