Obesity Increases Risk for Pouch-Related Complications Following Restorative Proctocolectomy with Ileal Pouch–Anal anastomosis (IPAA)

Purpose

Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) is the preferred surgical treatment for patients with ulcerative colitis and familial adenomatous polyposis. As obesity is becoming more epidemic in surgical patients, the aim of this study was to investigate if obesity increases complication rates following IPAA.

Methods

This study was conducted as a retrospective review of patients undergoing IPAA between January 1990 and April 2011. Patients were categorized by body mass index (BMI): BMI?<?30 (non-obese) and BMI?≥?30 (obese). Preoperative patient demographics, operative variables, and postoperative complications were recorded through chart review. The primary outcome studied was cumulative complication rate.

Results

A total of 103 non-obese and 75 obese patients were identified who underwent IPAA. Obese patients had an increased rate of overall complications (80 % vs. 64 %, p?=?0.03), primarily accounted for by increased pouch-related complications (61 % vs. 26 %, p?<?0.01). In particular, obese patients had more anastomotic/pouch strictures (27 % vs. 6 %, p?<?0.01), inflammatory pouch complications (17 % vs. 4 %, p?<?0.01) and pouch fistulas (12 % vs. 3 %, p?=?0.03). In a regression model, obesity remained a significant risk factor (odds ratio [OR]?=?2.86, p?=?0.01) for pouch-related complications.

Conclusions

Obesity is associated with an increased risk of overall and pouch-related complications following IPAA. Obese patients should be counseled preoperatively about these risks accordingly.     

Laparoscopic versus conventional ileoanal pouch procedure in patients undergoing elective restorative proctocolectomy (LapConPouch Trial)—a randomized controlled trial

Purpose

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the standard surgical procedure for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). While minimal invasive techniques have been applied increasingly, clear evidence of superiority for laparoscopic pouch procedures is not yet available. The aim of the LapConPouch Trial was to compare the effectiveness of laparoscopic (LAP) versus conventional (CON) ileoanal pouch procedure in patients undergoing elective restorative proctocolectomy.

Methods

The trial was designed as a single-centre, pre-operatively randomized, controlled trial using a two-group parallel superiority design. Eligible for participation were patients scheduled for restorative proctocolectomy either for FAP or for UC. Patients and outcome assessors were blinded to group assignment. The primary endpoint was defined as the amount of blood loss. Statistical analyses were explorative since the trial had to be stopped prematurely.

Results

A total of 42 patients (21 LAP (50.0 %); 21 CON (50.0 %)) were randomized. The trial had to be stopped prematurely due to insufficient patient recruitment. There was no difference in the amount of blood loss between both groups: LAP 261.5?±?195.4 ml, CON 228.1?±?119.5 ml. Secondary endpoints differ in both groups. Laparoscopic surgery was superior regarding the length of skin incision; in contrast, the conventional approach was superior in duration of operation. There were no discrepancies in length of hospital stay, postoperative pain, bowel function, and quality of life between both approaches. The conversion rate from LAP to CON approach was 23.8 %.

Conclusion

There was no difference with respect to blood loss between the LAP and the CON group. The LAP approach is feasible for restorative proctocolectomy, and IPAA seems at least as safe as CON surgery. The most obvious advantage of the minimal invasive technique is the improved cosmesis.     

Adenomas at resection margins do not influence the long-term development of pouch polyps after restorative proctocolectomy for familial adenomatous polyposis

BACKGROUND: The aim of this study was to consider whether adenomas in the resection margins could represent a risk factor for pouch polyps in familial adenomatous polyposis (FAP) patients. METHODS: We reviewed 46 patients treated by restorative proctocolectomy (RPC) for FAP: 9 hand-sewn and 37 stapled ileal pouch-anal anastomosis (IPAA). We analyzed the presence of polyps in the doughnuts from stapled anastomosis and in the resection margins from hand-sewn anastomosis. The presence of polyps in the IPAA was then assessed in 30 patients (6 hand-sewn and 24 stapled IPAA): 4 from the histology of the excised pouch and 26 by endoscopy (range 4 months to 12 years after operation, mean 6 years). RESULTS: Surprisingly, pouch adenomas were found in only 2 of 30 (7%) of patients, 1 of 6 hand-sewn and 1 of 24 stapled anastomosis (P > 0.1), 9 and 11 years, respectively, after operation. However, there were 6 patients with inflammatory (3), fibroepithelial (2), or lymphoid (1) polyps. The risk of pouch adenomas after 8 years was 20% (P < 0.05). Pouch adenomas were found in 1 of 11 patients having adenomas in the margins or in the doughnuts (9%) and in 1 of 19 with no adenomas at the margins (5%; P > 0.1). CONCLUSIONS: Incidence of pouch adenomas was low. There was no correlation between adenomas in the resection margins and the development of pouch adenomas.     

Volvulus of ileal S-pouch: A rare complication of ileal pouch anal anastomoses

INTRODUCTION

Ileal pouch anal anastomosis (IPAA) after total proctocolectomy is a frequently performed surgery for medically refractory ulcerative colitis (UC). Volvulus of the ileal pouch as a complication of IPAA is extremely rare. We present a case of volvulus of S-type ileal pouch.

PRESENTATION OF CASE

A 28 year old male, with history of total proctocolectomy with IPAA for severe UC in 2009 presented with signs of bowel obstruction. Emergency laparotomy was done and a volvulus of the S-type ileal pouch was derotated and pouchpexy done.

DISCUSSION

The IPAA has a wide spectrum of complications, with obstruction of proximal small bowel occurring frequently. Volvulus of the ileal pouch is extremely rare with only 3 reported cases. Early diagnosis and intervention is important to salvage the pouch. Computed tomography (CT) may aid the diagnosis in stable patients.

CONCLUSION

The diagnosis of ileal pouch volvulus although rare, should be kept in mind when dealing with patients complaining of recurrent obstruction following IPAA.     

Prevalence of Adenomas and Carcinomas in the Ileal Pouch After Proctocolectomy in Patients with Familial Adenomatous Polyposis

Purpose  Restorative proctocolectomy has become the most common surgical option for patients with familial adenomatous polyposis (FAP). However, adenomas may develop in the ileal pouch mucosa over time, and even carcinoma in the pouch has been reported. Our aim was to evaluate the prevalence, nature, and etiology of ileal pouch and nonpouch adenomas and carcinoma in patients with FAP. Patients and methods  This was a retrospective study of 31 FAP patients with Kock’s continent ileostomy (Kock; n = 8), ileorectal anastomosis (IRA; n = 7), and ileal pouch–anal anastomosis (IPAA) (n = 16). All patients were followed with a standardized protocol including chromoendoscopy and biopsies of visible polyps in the ileal pouch and nonpouch mucosa. Results  Sixteen of 24 pouch patients (Kock and IPAA) developed adenomas in the ileal pouch mucosa, and all patients with IRA developed adenomas in the rectal mucosa. The prevalence of ileal adenomas was significantly higher in pouch patients than in IRA patients (P = 0.002). Only one patient with Kock showed adenoma in the prepouch area. Two cases of adenocarcinomas and one case of advanced adenoma were found in the ileal pouch mucosa. Conclusion  Our results show a high frequency of adenomas in the ileal pouch mucosa, with evolution into carcinoma in some patients. Regular endoscopic surveillance of the pouch is recommended at a frequency similar to that for the rectal mucosa after IRA in pouch patients with FAP.     

Pre-Colectomy Appendectomy and Risk for Crohn’s Disease in Patients with Ileal Pouch-Anal Anastomosis

Background

A subset of patients with a pre-operative diagnosis of ulcerative colitis can develop Crohn??s disease (CD) of the pouch after restorative proctocolectomy. While appendectomy has been implicated to be associated with an increased risk for CD, its impact on the development of de novo CD of the pouch in patients?? ileal pouch-anal anastomosis (IPAA) has not been studied. The aims of the study were to assess the prevalence of CD of the pouch in patients with pre-colectomy appendectomy and to investigate the impact of appendectomy on the development of de novo CD of the pouch.

Methods

All eligible patients with restorative proctocolectomy and IPAA for IBD who had available information on pre-colectomy appendectomy were studied. Demographic and clinical characteristics were evaluated. Cox regression analysis was performed.

Results

The study included 434 patients (44.9?% male) with a mean age of 45.2?±?14.4?years and follow-up of 4.6?±?2.3?years. Forty patients (9.2?%) had had appendectomy prior to colectomy. Appendectomy was not shown to be associated with CD of the pouch or its phenotypes in both univariable and multivariable analyses. In the Cox model, independent risk factors associated with CD of the pouch were active smoking (hazard ratio [HR]?=?1.58; 95?% confidence interval [CI], 1.03?C2.43) and family history of CD (HR?=?1.82; 95?% CI, 0.99?C3.32).

Conclusions

While this study has shown no association between previous appendectomy and the development of CD of pouch, active smoking was an independent risk factor for development of CD of the pouch.     

Male Gender Is Associated with a High Risk for Chronic Antibiotic-Refractory Pouchitis and Ileal Pouch Anastomotic Sinus

Background and Aims

The impact of gender on the development of chronic ileal pouch disorders following ileal pouch-anal anastomosis (IPAA) has not been evaluated. This study was aimed to assess the association between gender and pouch outcomes.

Methods

Comparisons of long-term pouch outcomes between male and female patients were performed using both univariate and multivariate analyses.

Results

Of all patients enrolled (n?=?1564), 881(56.3 %) were males. Male patients were older at the time of inflammatory bowel disease (IBD) diagnosis and pouch construction. The frequencies of neoplasia as the indication for colectomy and significant comorbidity were higher in males, while fewer male patients had IBD-related extra-intestinal manifestations or concurrent autoimmune disorders. There was no significant difference between the genders in other clinicopathological characteristics. More male patients (n?=?144, 16.3 %) developed chronic antibiotic-refractory pouchitis (CARP) than females (n?=?73, 10.7 %) (P?=?0.001). Seventy-four males (8.4 %) had ileal pouch anastomotic sinus versus 22 female patients (3.2 %) (P?<?0.001). Multivariate logistic regression analyses confirmed the association between male gender and CARP (odds ratio (OR) 1.64, 95 % confidence interval (CI) 1.21–2.24, P?=?0.002) and male gender and ileal pouch anastomotic sinus (OR 2.85, 95 % CI 1.48–5.47, P?=?0.002). After a median follow-up of 9.0 (interquartile range 4.0–14.0) years, pouch failed in a total of 126 patients (8.1 %). No significant difference was identified between male and female patients in pouch failure (P?=?0.61).

Conclusions

Among the pouch patients referred to our subspecialty Pouch Center, male patients were found to have an increased risk for the CARP and ileal pouch sinus. The pathogenic mechanisms of the association warrant further study.

     

Rectal eversion and double-stapled ileal pouch anal anastomosis in familial adenomatous polyposis syndrome

INTRODUCTION

Surgery is the only treatment option for familial adenomatous polyposis (FAP). Aim of surgery in FAP is to minimize colorectal cancer risk without need for permanent stoma. There are especially two operation options; Total colectomy with ileorectal anastomosis (IRA) and total proctocolectomy with ileo-pouch anal anastomosis (IPAA). We report here a patient with FAP who had resection via rectal eversion just over the dentate line under direct visualization and ileoanal-J pouch anastomosis by double-stapler technique.

PRESENTATION OF CASE

A 40 yr. old female patient with FAP underwent surgery. Firstly, colon and the rectum mobilized completely, and then from the 10 cm. proximal to the ileo-caecal valve to the recto-sigmoid junction total colectomy was performed. Rectum was everted by a grasping forceps which was introduced through the anus and then resection was performed by a linear stapler just over the dentate line. A stapled J-shaped ileal reservoir construction followed by intraluminal stapler-facilitated ileoanal anastomosis. Follow up at six months anal sphincter function was found normal.

DISCUSSION

There is only surgical management option for FAP patients up to now. Total colectomy with IRA and restorative proctocolectomy with IPAA is surgical options for FAP patients that avoid the need for a permanent stoma. Anorectal eversion may be used in the surgical treatment of FAP, chronic ulcerative colitis and early stage distal rectal cancer patients.

CONCLUSION

J-pouch ileoanal anastomosis can safely be performed by rectal eversion and double stapler technique in FAP patients.     

A treatment strategy for preventing pouchitis as a postoperative complication of ulcerative colitis: the significance of the management of cuffitis

Purpose

The aim of this study was to examine the risk factors for and to evaluate strategies for preventing pouchitis as a postoperative complication of ulcerative colitis (UC).

Methods

A total of 119 cases of UC in which restorative proctocolectomy with an ileal pouch-anal anastomosis (IPAA) was performed at our institution between 2000 and 2012 was investigated; nine patients in whom it was impossible to close the ileostomy due to an intractable anal fistula or pelvic abscess were excluded.

Results

The cumulative risk of developing pouchitis 5 years after IPAA with stoma closure was 31.0 %. Significant relationships with pouchitis were found for the surgical indication (p = 0.0126) and surgical method (p = 0.0214). A significant correlation was found between pouchitis and cuffitis. Pouchitis was significantly more common in the cases with cuffitis than in those without (p = 0.0002). There was also a significantly different cumulative incidence observed between the cases with and without cuffitis (p < 0.0001). In addition, pouchitis had a greater tendency to recur in the cases with cuffitis than in those without (p = 0.2730).

Conclusion

The cumulative incidence rate of pouchitis was 10.6 % at 1 year, 15.1 % at 2 years and 31.0 % at 5 years. Controlling cuffitis is important to prevent pouchitis.     

Risk of Neoplastic Change in Ileal Pouches in Familial Adenomatous Polyposis

Introduction

Neoplastic change in ileal reservoirs after proctocolectomy has been reported in patients with familial adenomatous polyposis. We aim to determine the incidence and progression of neoplastic change in the ileal pouch of familial adenomatous polyposis patients at our institution.

Methods

A retrospective review of all patients who underwent proctocolectomy for familial adenomatous polyposis with construction of an ileal pouch from 1972 to 2007 was performed. Data and status at follow-up were retrieved from the Mayo Clinic Colorectal Surgery Pouch database.

Results

One hundred seventeen patients were identified with a median age of 26, 52 were male. Ileal reservoirs included J-pouch (a?=?104), Kock pouch (n?=?9), S-pouch (n?=?3), and W-pouch (n?=?1). Median follow-up was 125 months. Polyps were biopsied in 33 patients: non-dysplastic polyps (n?=?2), low-grade dysplasia (n?=?30), and adenocarcinoma (n?=?1). No patients had high-grade dysplasia. Median time to development of dysplasia was 149 months. Adenocarcinoma developed in one patient after 284 months. Risk of dysplasia at 10, 20, and 25 years was 17, 45, and 69 %, respectively.

Conclusion

Though there is a high incidence of low-grade dysplasia in the ileal reservoir in familial adenomatous polyposis patients, high-grade dysplasia and cancer occur rarely. Patients with low-grade dysplasia may still necessitate regular follow-up.     

Sexual activity after ileal pouch-anal anastomosis in Japanese patients with ulcerative colitis

Purpose

The aim of this study was to evaluate the sexual activity after restorative proctocolectomy with ileal J-pouch-anal anastomosis (ileoanal anastomosis) in Japanese patients with ulcerative colitis.

Methods

Sixty-one patients who had undergone ileoanal anastomosis and were followed for at least 6 months after surgery were randomly selected. Their quality of life was assessed using the Japanese version of the Inflammatory Bowel Disease Questionnaire. Scores of three or less for the item “Sex life” were predetermined to represent poor sexual activity. The medical staff then asked them the reasons for this using a non-structured interview and open-ended questions.

Results

Overall, 19 patients reported poor sexual activity. There was a significant difference in the scores for “Social functions” other than Sex life between individuals with poor and good sexual activities (21.6 ± 4.6 vs. 24.1 ± 4.2, P = 0.016). Ileoanal anastomosis after the age of 40 (OR 22, P = 0.02) and a total preoperative corticosteroid dose ≥15 g (OR 7.4, P = 0.04) were significant risk factors for poor sexual activity after ileoanal anastomosis.

Conclusion

Our results suggest that ileoanal anastomosis results in relatively poor sexual activity, which was associated with other social functions, older age and a higher dose of corticosteroids administered to Japanese patients with ulcerative colitis.     

Reduced port versus conventional laparoscopic total proctocolectomy and ileal J pouch-anal anastomosis

Background

The feasibility and safety of single-incision laparoscopic total proctocolectomy (TPC) and ileal pouch anal anastomosis (IPAA) were first reported in 2010. To improve accuracy and efficiency while maintaining the cosmetic advantages of single-incision laparoscopic surgery, we have since modified the technique to include the use of a 5-mm instrument placed through the eventual drain site. The aim of this study is to compare reduced port laparoscopic (RPL) IPAA with conventional laparoscopic IPAA with respect to short-term outcomes to assess safety.

Methods

RPL cases were matched to conventional laparoscopy cases for patient age (±5?years), body mass index, gender, diagnosis, type and number of stages of surgical procedure, American Society of Anesthesiologists (ASA) classification, and year of surgery (±3?years). Groups were compared using ?? ² or Fisher exact tests for categorical and Wilcoxon rank-sum test for quantitative data.

Results

Twenty-four RPL patients were case-matched to an equal number of patients who underwent conventional laparoscopic IPAA. Short-term outcomes including postoperative complications, length of hospital stay, and time to first bowel movement were similar between groups. Despite similar diagnosis, previous surgery, and comorbidity, operative blood loss (p?<?0.001) and operating time (p?=?0.02) were lower for the RPL group.

Conclusion

RPL IPAA can be safely performed with short-term outcomes comparable to conventional laparoscopy.     

Restorative proctocolectomy with and without protective ileostomy in a pediatric population

Purpose

This study aim was to review outcomes of pediatric patients after restorative proctocolectomy with or without a protective ileostomy in the treatment of ulcerative colitis and polyposis syndromes.

Methods

All patients who underwent rectal mucosectomy with ileal pouch reservoir and hand-sewn ileal pouch anal anastomosis (IPAA) during 19-year period were reviewed retrospectively.

Results

Eighty-three patients with ulcerative colitis and 7 patients with polyposis syndromes (ages 2.0-21.8 years) were reviewed. Sixty-eight patients underwent IPAA without diverting ileostomy. Fifty-six patients underwent restorative proctocolectomy as single-stage procedures, and 12 had abdominal colectomy and subsequent definitive IPAA without diverting ileostomy. Nineteen patients had IPAA with diverting ileostomy and subsequent closure of ileostomy. Three-stage procedures were performed in 3 cases. An ileal pouch leak or pelvic abscess occurred in 2 patients. Surgical pouch revision for retraction, efferent limb syndrome, prolapse, pouchitis, or perirectal infections occurred in 19 (6/62 J-pouch, 13/28 S-pouch). Fourteen patients (5/22 with diversion, 9/68 without diversion) developed small bowel obstruction. Overall, daytime and nighttime continence was excellent with rare nocturnal evacuations.

Conclusions

Restorative proctocolectomy without protective ileostomy is not associated with an increased morbidity, even in patients with active colitis, and may be appropriate most patients.     

Familial adenomatous polyposis: prevalence of adenomas in the ileal pouch after restorative proctocolectomy

OBJECTIVES: To determine the prevalence of adenomas in ileal pouches from patients with familial adenomatous polyposis (FAP) and to determine whether a correlation exists between the presence of pouch adenomas and duodenal adenomas and the site of the adenomatous polyposis coli gene mutation. SUMMARY BACKGROUND DATA: Restorative proctocolectomy can markedly reduce the risk of colorectal adenocarcinoma in FAP patients. However, adenomas with the potential to progress to adenocarcinoma can develop in the duodenum, ileum, and continent ileostomy after restorative proctocolectomy. More recently, adenomas have been described in the ileal pouch after ileoanal anastomosis. METHODS: Pouch endoscopy was offered to 167 patients with FAP who had undergone restorative proctocolectomy between January 1984 and December 1996. RESULTS: Adenomas were found in 35% of the 85 ileal pouches examined. No invasive carcinomas were noted. The risk of developing one or more adenomas at 5, 10, and 15 years was 7%, 35%, and 75%, respectively. Patients with adenomas were more likely to have duodenal and ampullary adenomas. No correlation was detected between adenoma development and the site of the adenomatous polyposis coli mutation. CONCLUSIONS: Adenomas are frequently found in the ileal pouch of patients after restorative proctocolectomy for FAP. Regular endoscopic surveillance of the pouch is recommended at a frequency similar to that of upper gastrointestinal endoscopy.     

Clinical value of surveillance pouchoscopy in asymptomatic ileal pouch patients with underlying inflammatory bowel disease

Background

There is no consensus on the need for and the interval of surveillance pouchoscopy in asymptomatic ileal pouch patients with underlying ulcerative colitis (UC). The purpose of this study was to evaluate the likelihood of finding dysplasia or incidental ileal pouch disorders in asymptomatic patients undergoing surveillance pouchoscopy.

Methods

This study included all eligible consecutive asymptomatic UC patients undergoing surveillance pouchoscopy to our subspecialty Pouchitis Clinic from 2002 to 2011. Univariable and multivariable analyses were performed.

Results

A total of 138 patients met the inclusion criteria, with 72 (52.2 %) being male. The mean age at pouch construction was 45.4 ± 15.0 years, and the mean interval from ileostomy closure to the inception of first surveillance pouchoscopy was 89.4 ± 78.8 months. One patient was found to have indefinite for dysplasia on pouch body mucosal biopsy (0.7 %), and two patients had non-caseating granulomas, suggesting Crohn’s disease (CD) of the pouch. Of the 138 patients, 69 (50 %) had abnormal endoscopic findings, 102 (73.9 %) had acute and/or chronic inflammation on histology, and 62 (44.9 %) had both abnormal endoscopy and histology. The abnormal endoscopic findings included isolated pouch ulcer (n = 29, 21 %), active pouchitis (n = 31, 22.5 %), inflammatory polyps (n = 10, 7.2 %), strictures at the anastomosis (n = 5, 3.6 %), inlet (n = 10, 7.2 %) or outlet (n = 2, 1.4 %). Thirteen patients (13/17, 76.5 %) with pouch strictures underwent endoscopic balloon dilatation therapy and nine had (9/10, 90 %) endoscopic polypectomy. Multivariable analysis showed that patients with a preoperative diagnosis of CD and concomitant extraintestinal manifestations had a higher risk for abnormal pouch endoscopic findings with odds ratios of 2.552 (95 % confidence interval [CI] 1.108–16.545, p = 0.035) and 4.281 (95 % CI 1.204–5.409, p = 0.014), respectively.

Conclusions

Dysplasia was rare in asymptomatic patients with restorative proctocolectomy who underwent surveillance pouchoscopy in this cross-sectional study. However, “incidental” abnormal endoscopic and/or histologic findings were common, which often needed endoscopic therapeutic intervention.     

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.     

Laparoscopy impacts outcomes favorably following colectomy for ulcerative colitis: a critical analysis of the ACS-NSQIP database

Introduction

The surgical management of ulcerative colitis (UC) often involves complex operations. We investigated the outcome of patients who underwent surgery for UC by analyzing a nationwide database.

Methods

We queried the American College of Surgeons National Surgical Quality Improvement Program database (ACS-NSQIP, 2005–2008) for all UC patients who underwent colectomy. To analyze by operation, groupings included: partial colectomy (PC; n = 265), total abdominal colectomy (TAC; n = 232), total proctocolectomy with ileostomy (TPC-I; n = 134), and total proctocolectomy with ileal pouch-anal anastomosis (IPAA; n = 446) to analyze 30-day outcomes.

Results

From 1,077 patients (mean age, 44 years; 45 % female; 7 % emergent), a laparoscopic approach was used in 29.2 %, with rates increasing 8.5 % each year (18.5 % in 2005 to 41.3 % in 2008, P < 0.001). Complications occurred in 29 %, and laparoscopy was associated with a lower complication rate (21 vs. 32 % open, P < 0.001). On multivariate regression, postoperative complications increased when patients were not functionally independent [odds ratio (OR) = 3.2], had preoperative sepsis (OR = 2.0), or prior percutaneous coronary intervention (OR = 2.8). A laparoscopic approach was associated with a lower complication rate (OR = 0.63). When stratified by specific complications, laparoscopy was associated with lower complications, including superficial surgical site infections (11.4 vs. 6.7 %, P = 0.0011), pneumonia (2.9 vs. 0.6 %, P = 0.023), prolonged mechanical ventilation (3.9 vs. 1.3 %, P = 0.023), need for transfusions postoperatively (1.6 vs. 0 %, P = 0.016), and severe sepsis (2.9 vs. 1.0 %, P = 0.039). Laparoscopy was also was associated with a lower complication rate in TACs (41.7 vs. 18.8 %, P < 0.0001) and IPAA (29.9 vs. 18.2 %, P = 0.005) and had an overall lower mortality rate (0.2 vs. 1.7 %, P = 0.046).

Conclusions

Results from a large nationwide database demonstrate that a laparoscopic approach was utilized in an increasing number of UC patients undergoing colectomy and was associated with lower morbidity and mortality, even in more complex procedures, such as TAC and IPAA.     

Emergency total proctocolectomy in an uninsured patient with Familial Adenomatous Polyposis Syndrome and acute lower gastrointestinal hemorrhage in a community hospital: A case report

IntroductionRectal bleeding is the most common symptom of Familial Adenomatous Polyposis (FAP). This case investigates the efficacy of emergency surgery for FAP with total proctocolectomy end ileostomy for recurrent lower gastrointestinal (GI) hemorrhage in an uninsured patient in a 266-bed community hospital. The optimal treatment for FAP with acute lower GI hemorrhage and hemodynamic compromise unresponsive to conservative management is unclear.Presentation of caseA 41-year-old uninsured African American man with no past medical or family history presented to the emergency department with hematochezia lasting three days. A clinical diagnosis of FAP made on colonoscopy with biopsies revealed villous and tubulovillous adenomas without dysplasia. After blood products resuscitation, an emergency total proctocolectomy with end ileostomy was performed. A staged ileal J pouch to anal anastomosis and creation of protective loop ileostomy was performed months later after securing state funding. A final loop ileostomy reversal occurred six weeks later. His self reported quality of life is improved.DiscussionLower GI hemorrhage from FAP unresponsive to blood products may require emergency total proctocolectomy and end ileostomy with a staged ileal J pouch to anal anastomosis, which can be done in a community acute care hospital for an uninsured patient.ConclusionA total proctocolectomy is feasible in the emergency setting in an uninsured patient with lower GI bleeding and FAP. A staged ileal J pouch-anal anastomosis is easier to justify to the hospital compared to a staged completion colectomy with proctectomy. It is essential to monitor the ileo-anal anastomosis with anoscopy.     

Adenocarcinoma after ileoanal anastomosis for familial adenomatous polyposis: Review of risk factors and current surveillance apropos of a case

Restorative proctocolectomy has become the most common surgical option for familial adenomatous polyposis (FAP) patients, based on the premise that it provides good functional results and reduces colorectal cancer risk. But several adenomas may develop in the pouch mucosa over the years, and even cancer at the anastomosis or in the pouch mucosa has been reported rarely. This article aims to describe a case of pouch cancer after restorative proctocolectomy for FAP, reviewing the possible causes of this unfortunate outcome. A 40-year-old man started presenting with fecal blood loss 12 years after restorative proctocolectomy with mucosectomy and hand-sewn anastomosis for FAP. Proctologic examination revealed an elevated mass 3 cm from the anal margin, which biopsy determined to be a mucinous adenocarcinoma.Thepatient underwent pouch excisionand terminal ileostomy. Histologic analysisshowed a 2.2 cm mucinous adenocarcinoma between the ileal and anal mucosa (T2N0Mx) and multiple tubular microadenomas in the ileal pouch. The present case and the data presented here suggest that restorative proctocolectomy is not a "cancer-free" alternative to ileorectal anastomosis, because it does not remove the risk of metachronous intestinal neoplasia. Although the long-term risk of malignancy is not known, lifelong follow-up seems to be necessary after restorative proctocolectomy. Current recommendations for pouch surveillance are presented.     

Decreased levels of mucosal detoxification enzymes in the pouch of patients with familial adenomatous polyposis

BACKGROUND: Adenomas can develop in the pouch after colectomy with ileal pouch-anal anastomosis (IPAA) in patients with familial adenomatous polyposis (FAP). Glutathione S-transferases (GSTs) have a protective role in carcinogenesis. GST activity is much higher in the ileum than in the colon. The present study examined the hypothesis that the protective capacity of GSTs may be lowered as a result of colonic metaplasia of the ileal pouch. METHODS: Levels of GSTs, glutathione and cysteine, and the degree of inflammation and colonic metaplasia were quantified in biopsies from the pouch and afferent loop of 26 patients with FAP. RESULTS: GST enzyme activity, and levels of GST alpha, glutathione and cysteine in the pouch were significantly lower than those in the afferent loop (308 versus 398 nmol per min per mg protein (P<0.001), 4604 versus 5286 ng per mg protein (P=0.010), 27.1 versus 34.8 nmol per mg protein (P=0.023) and 0 versus 4.8 nmol per mg protein (P=0.009) respectively). No correlation was found between inflammation or colonic metaplasia of the pouch and GST enzyme activity in the pouch. CONCLUSION: After IPAA, GST detoxification activity in the pouch is significantly lower than that in the afferent ileal loop, which may promote tumorigenesis.