Restorative Proctocolectomy for Pediatric Patients with Ulcerative Colitis

Purpose A restorative proctocolectomy has become an elective surgical treatment for patients with ulcerative colitis (UC). In children with UC, however, the role of this procedure has not yet been well evaluated. We investigated the postoperative status of pediatric patients with UC regarding the side effects of steroids, postoperative complications, and growth. Methods The medical records of 15 patients with UC who underwent a restorative proctocolectomy between August 1993 and October 2003 were retrospectively reviewed. Results Their mean age was 12.6 ± 3.4 years (range 5.7–15.7; boys: 9, girls: 6). All patients had total colitis, except for one who had left-sided colitis. The mean cumulative dose of preoperative prednisolone was 6201 ± 7980 mg (mean ± SD). The operative indications were an unsuccessful response to medical treatments in 12 patients (80%) and severe colitis in 3 patients (20%). Surgery was performed in one stage in 6 patients and in two stages in 9 patients. Seven patients (47%) demonstrated growth retardation at the time of operation. Steroid-related complications were seen in 3 cases, i.e., steroid myopathy, glaucoma, and cataracts, respectively. As early postoperative complications, an intestinal obstruction was seen in 2 patients, peritonitis in 1, and pancreatitis in 1. As late complications, anastomotic stenosis was observed in 5 patients, pouchitis in 4, residual proctitis in 3, and anal or proctovaginal fistula in 2. An intestinal obstruction, peristomal pyoderma gangrenosum, and dehydration each was seen in 1 patient. A growth “catch-up” was obtained for all but one patient. All patients became free of corticosteroids. Conclusion A restorative proctocolectomy was found to be an effective treatment alternative even in children with UC when conservative therapy proves to be ineffective.     

Staple-Line Ulcer in the Ileal Reservoir Following Restorative Proctocolectomy

Purpose. Following restorative proctocolectomy, seven cases with staple line ulcer around the pouch anal anastomosis and/or staple line in the ileal pouch were experienced. Their clinical, endoscopical characteristics were analyzed. Methods. The patients noted anal bleeding following restorative proctocolectomy were examined with colonofiberscopy and histological study was conducted. Results. Staple line ulcer was seens in seven cases (2.3%, 7/304). The onset was immediate or within 2 months postoperatively in 5 cases. Bleeding occurred in all the patients and lower abdominal pain, anal pain, increased bowel movements and anal fissure were seen frequently. Ulcers were linear along the staple line and there were no cases complicated by simultaneous pouchitis. Most of the patients responded to treatments with metronidazol, 5-ASA, and topical or oral steroids, although one patient required ligation of bleeding ulcer and two complicated perianal excoriation required ileostomy. Conclusion. Staple line ulcer should be recognized as different complication to pouchitis. Received: February 8, 2001 / Accepted: July 17, 2001     

Functional Outcome After Restorative Proctocolectomy in Pigs: Comparing a Novel Transverse Ileal Pouch to the J-Pouch and Straight Ileoanal Anastomosis

Background  Restorative proctocolectomy followed by an ileoanal J-pouch procedure is the therapy of choice for patients with familial adenomatous polyposis and ulcerative colitis. After low anterior rectal resection, the authors have reported on a novel, less complex pouch configuration, a transverse coloplasty pouch. The aim of the present work was to apply this new design to the ileal pouch construction, to evaluate feasibility, and to measure functional results in comparison with the J-pouch and the straight ileoanal anastomosis using the pig as an animal model. Methods  Twenty-three pigs underwent restorative proctocolectomy followed by reconstruction with straight ileoanal anastomosis (IAA; n = 5), J-pouch (n = 7), and a transverse ileal pouch (TIP; n = 11). Pigs were followed for 6 days postoperatively. Peristaltic function was assessed by manometry proximal to the pouch, in the reservoir, and at the level of the ileoanal anastomosis. Functional outcome was monitored by semiquantitative assessment of the general condition of the animals, postoperative feeding habits, and stool frequency and consistency. A Fourier analysis was performed in order to compare peristalsis in the ileal reservoirs. The reservoir volume was measured in situ by triple contrast computed tomography scan with 3D reconstruction. Results  Seventeen animals survived for 1 week. There was no difference in the general condition or the feeding habits of the groups. A significant number of pigs with the TIP pouch (7/10) had semisolid or formed stools as opposed to liquid stools after J-pouch (6/6) and IAA (4/5; p = 0.01). TIP animals had a lower stool frequency (3.2 ± 1.14 per day) on day 6 after the operation than pigs with J-pouch, 5.33 ± 1,03, and IAA, 4.6 ± 1.82 (p = 0.0036). The in situ volume of the pouches did not differ significantly. The Fourier analysis demonstrated a disruption of peristalsis by the J-pouch and the TIP reconstruction but not after IAA. Conclusion  The function of ileoanal reservoirs after proctocolectomy may result from the disruption of properistaltic waves after pouch formation. The mechanism of peristalsis disruption is independent of the in situ volume of the pouch. This work was funded by Covidien Germany. F. H. Schmitz-Winnenthal and M. Kadmon contributed equally to this work.     

Ulcerative colitis and coexisting colorectal cancer: Recurrence rate after restorative proctocolectomy

Background: The association between mucosal ulcerative colitis (MUC) and adenocarcinoma is well established. Methods: Records of patients who had undergone restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) from 1983 through 1992 were examined. Of these, 604 had MUC and 27 (4.3%) had MUC with coexisting cancer. Patients were surveyed annually for recurrent disease. Pouch function and quality of life were evaluated with a questionnaire and physical examination. Results: The duration of disease was longer (p=0.001) in patients with cancer (16.1±8.0 years) than in those without cancer (9.1±7.1 years), although the mean age at diagnosis of MUC was the same. Of the 27 patients, 20 had colon cancer and seven had rectal cancer. Multicentricity was found in seven (25.9%) patients. Using the TNM staging classification, 14 patients (51.8%) had stage 1 cancer, eight (29.6%) had stage 2, four (14.8%) had stage 3, and one (3.8%) had stage 4. The patient with stage 4 cancer died 5 months after surgery and was excluded from the follow-up analysis. During a mean follow-up time of 4.3±2.6 years, cancer recurred in two of the remaining 26 patients (7.7%). In one patient, a local recurrence was found 8 months after surgery, and distant metastases were found in the other patient 35 months after surgery. Both recurrences were in patients with colon cancer. Two of the 26 patients died; one death was related to cancer recurrence (3.8%). Pouch function is good to excellent in all surviving patients. Conclusions: Restorative proctocolectomy for patients with MUC and coexisting colorectal cancer can be performed with a favorable prognosis and function. It is appropriate for curative intent, given that an adequate margin without tumor is obtained.Presented at the 47th Annual Cancer Symposium of The Society of Surgical Oncology, Houston, Texas, March 17–20, 1994.     

Adenocarcinoma Arising Below an Ileoanal Anastomosis After Restorative Proctocolectomy for Ulcerative Colitis: Report of a Case

We report a case of adenocarcinoma developing in remnant rectal mucosa below a hand-sewn ileal pouch–anal anastomosis (IPAA) after restorative proctocolectomy for ulcerative colitis (UC). To our knowledge, this is the first such case to be reported from Japan. A 60-year-old man with a 13-year history of UC underwent proctocolectomy with a hand-sewn IPAA and mucosectomy for anal stenosis and serious tenesmic symptoms. About 7 years later, a follow-up endoscopy showed a flat elevated malignant lesion, 2 cm in diameter, below the ileoanal anastomosis. He was treated by abdominoperineal resection of the pouch and anus with total mesorectal excision. Histopathological examination of the resected specimen confirmed the presence of a well-differentiated adenocarcinoma but there were no metastatic lymph nodes. He recovered uneventfully and remains well without evidence of recurrent disease 2 years and 3 months after his last operation.     

Clinical Outcomes After Restorative Proctocolectomy With Ileal Pouch Anal Anastomosis Using Ultrasonically Activated Scalpel for Ulcerative Colitis

We compared 3 different initial operative procedures performed in patients with ulcerative colitis who underwent an ileal pouch anal anastomosis (IPAA) procedure with a Harmonic Scalpel (HS). We selected 775 patients who underwent a restorative proctocolectomy with a mucosectomy using an HS and hand-sewn IPAA. Ninety-six patients underwent a total colectomy (3-stage procedure) as the initial operation, whereas 258 underwent IPAA without ileostomy (1-stage procedure) and 421 underwent IPAA with ileostomy (2-stage procedure). There were no significant differences regarding early pouch functional rate among the 3 groups. After 5 years with a functioning ileal pouch, the survival rates for the total colectomy, IPAA with ileostomy, and IPAA without ileostomy groups were 100%, 99.3%, and 99.0%, respectively. There was low operative mortality, and acceptable rates of early and late complications in patients with ulcerative colitis who underwent a restorative proctocolectomy and IPAA using an HS.     

Technique of laparoscopic-assisted total proctocolectomy and ileal pouch anal anastomosis in children and adolescents: a single center's 8-year experience

Background

Laparoscopic techniques have been applied to restorative proctocolectomy since the early 2000s. We have employed a technique for laparoscopic-assisted total proctocolectomy (TPC) and ileal pouch anal anastomosis (IPAA) for the treatment of children with ulcerative colitis (UC).

Methods

A total of 68 children underwent laparoscopic-assisted TPCs at our institution from June 2003 to February 2011. The patients ranged from 5 to 22 years of age. We progressively modified our surgical approach in positioning, equipment use, and operative technique.

Results

A total of 68 children underwent laparoscopic-assisted TPC within the 8-year time period. Two major complications occurred (2/68 = 3%) consisting of 1 duodenal injury and 1 small bowel injury. There were 6 minor complications (6/68 = 9%), including 5 stoma revisions and 1 port site hernia. There were no superficial wound infections. There were no reported cases of pouch fistulas, anastomotic breakdown, or neurovascular injuries.

Conclusions

Our surgical technique is safe and effective in treating children with UC.     

Proctocolectomy–Ileal Pouch-Anal Anastomosis for Ulcerative Colitis After Liver Transplantation for Primary Sclerosing Cholangitis: A Multi-institutional Analysis

Background  The association between primary sclerosing cholangitis (PSC) and ulcerative colitis (UC) often mandates their contemporaneous management. Orthotopic liver transplantation (OLTX) has emerged as the only curative therapy for PSC, and total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the definitive treatment for refractory UC. The published experience to date describing IPAA after OLTX has been limited; we sought to examine outcomes associated with proctocolectomy-IPAA after OLTX. Materials and Methods  We reviewed our multi-institutional experience performing proctocolectomy-IPAA for UC after OLTX for PSC. Results  Twenty-two patients underwent proctocolectomy-IPAA for UC after OLTX for PSC at four academic medical centers between 1989 and 2006. No perioperative complications or allograft dysfunction were observed. During a median follow-up of 52 months, complications have included transient dehydration (n = 6), chronic pouchitis (n = 2), recurrent PSC (n = 2), small bowel obstruction (n = 2), and pouch-anal anastomotic stricture (n = 1). Median 24-h stool frequency was 5, and fecal continence was reported as satisfactory by all patients. Conclusions  This multi-institutional experience suggests that proctocolectomy-IPAA can be performed safely after OLTX. Management strategies should include optimization of small bowel length during pouch and ileostomy construction, vigorous postoperative hydration, early ileostomy closure, and careful monitoring for pouchitis.     

Better characterization of operation for ulcerative colitis through the National surgical quality improvement program: A 2-year audit of NSQIP-IBD

IntroductionThere is little consensus of quality measurements for restorative proctocolectomy with ileal pouch-anal anastomosis(RPC-IPAA) performed for ulcerative colitis(UC). The National Surgical Quality Improvement Program(NSQIP) cannot accurately classify RPC-IPAA staged approaches. We formed an IBD-surgery registry that added IBD-specific variables to NSQIP to study these staged approaches in greater detail.MethodsWe queried our validated database of IBD surgeries across 11 sites in the US from March 2017 to March 2019, containing general NSQIP and IBD-specific perioperative variables. We classified cases into delayed versus immediate pouch construction and looked for independent predictors of pouch delay and postoperative Clavien-Dindo complication severity.Results430 patients received index surgery or completed pouches. Among completed pouches, 46(28%) and 118(72%) were immediate and delayed pouches, respectively. Significant predictors for delayed pouch surgery included higher UC surgery volume(p = 0.01) and absence of colonic dysplasia(p = 0.04). Delayed pouch formation did not significantly predict complication severity.ConclusionsOur data allows improved classification of complex operations. Curating disease-specific variables allows for better analysis of predictors of delayed versus immediate pouch construction and postoperative complication severity.Short summaryWe applied our previously validated novel NSIP-IBD database for classifying complex, multi-stage surgical approaches for UC to a degree that was not possible prior to our collaborative effort. From this, we describe predictive factors for delayed pouch formation in UC RPC-IPAA with the largest multicenter effort to date.     

痔特佳胶囊治疗溃疡性结肠炎82例疗效观察

为观察痔特佳胶囊口服治疗溃疡性结肠炎的疗效,总结分析82例溃疡性结肠炎患者的临床资料、治疗方法及临床疗效。结果显示,82例患者均口服痔特佳胶囊2个疗程以上。近期疗效：显效71例,有效8例,无效3例（均为持续型患者）,总有效率为96．3％。结果表明,日服痔特佳胶囊治疗溃疡性结肠炎疗效确切,无毒副作用,服用方便,经济。     

Restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis:A narrative review

Restorative proctocolectomy with ileal pouch-anal anastomosis(RP-IPAA) is the gold standard surgical treatment for ulcerative colitis.However,despite the widespread use of RP-IPAA,many aspects of this treatment still remain controversial,such as the approach(open or laparoscopic),number of stages in the surgery,type of pouch,and construction type(hand-sewn or stapled ileal pouch-anal anastomosis).The present narrative review aims to discuss current evidence on the short-,mid-,and long-term results of each of these technical alternatives as well as their benefits and disadvantages.A review of the MEDLINE,EMBASE,and Ovid databases was performed to identify studies published through March 2016.Few large,randomized,controlled studies have been conducted,which limits the conclusions that can be drawn regarding controversial issues.The available data from retrospective studies suggest that laparoscopic surgery has no clear advantages compared with open surgery and that one-stage RP-IPAA may be indicated in selected cases.Regarding 2- and 3-stage RP-IPAA,patients who underwent these surgeries differed significantly with respect to clinical and laboratory variables,making any comparisons extremely difficult.The long-term results regarding the pouch type show that the W- and J-reservoirs do not differ significantly,although the J pouch is generally preferred by surgeons.Hand-sewn and stapled ileal pouch-anal anastomoses have their own advantages,and there is no clear benefit of one technique over the other.     

回肠末段的病理改变与溃疡性结肠炎相关性研究

为探讨溃疡性结肠炎（UC）与末段回肠炎的相互关系,对68例UC结肠镜检查末段回肠的镜下表现及病理结果进行分析。结果显示,68例中66例发现末段回肠炎症病变占97．1％,其中32例在第1次复诊时发现存在末段回肠炎性改变,另外34例在第2次复诊时出现末段回肠的病理改变;两次复诊时间间隔为10～14个月。结果表明,末段回肠慢性炎症改变是UC在小肠的另一种表现。     

Laparoscopic Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis: A Comparative Observational Study on Long-term Functional Results

Purpose  Long-term results after laparoscopic ileal pouch anal anastomosis (IPAA) have not been thoroughly evaluated. Our study prospectively compares short- and long-term outcomes of laparoscopic and open IPAA. Methods  Between October 2002 and November 2007, 73 laparoscopic and 106 open IPAA patients were enrolled. Patient- and disease-specific characteristics and short- and long-term outcomes were prospectively collected. Results  There were no differences in demographics, treatment, indication, duration of surgery, and diversion between groups. Laparoscopic patients had faster return of flatus (p = 0.008), faster assumption of a liquid diet (p < 0.001), and less blood loss (p = 0.026). While complications were similar, the incidence of incisional hernias was lower in the laparoscopic group (p = 0.011). Mean follow-up was 24.8 months. Average number of bowel movements was 6.8 ± 2.8/day for laparoscopy and 6.3 ± 1.7 for open (p = 0.058). Overall, 68.4% of patients were fully continent at 1 year, up to 83.7% long term without differences between groups. Other indicators of defecatory function and quality of life remain similar overtime. Conclusions  Laparoscopic IPAA confers excellent functional results. Most patients are fully continent and have an average of six bowel movements/day. When present, minor incontinence improves over time. Laparoscopy mirrors the results of open IPAA and is a valuable alternative to open surgery. This study was funded in part by the University of Chicago Cancer Research Foundation (UCCRF) Auxiliary Board Research Support Grant (A.F.). Presented at the American Society of Colon and Rectal Surgeons Tripartite Meeting. Boston. June 9, 2008.     

TRAF4在溃疡性结肠炎中的表达及意义

本研究探讨TRAF4在溃疡性结肠炎（UC）中的表达，进一步了解TRAF4与自身免疫性疾病的关系。将UC患者35例（UC组）和普通肠炎患者15例（对照组）经结肠镜活检，HE、免疫组织化学检测肠黏膜腺上皮及淋巴细胞、浆细胞的TRAF4表达情况．并进行分类比较。结果显示，UC中淋巴细胞、浆细胞核的TRAF4的阳性率明显高于对照组（P〈0．05），UC肠黏膜腺上皮细胞核的TRAF4表达阳性率明显高于对照组（P〈0．05），UC中肠黏膜腺上皮细胞浆的TRAF4表达与对照组无明显差异（P〉0．05）。结果表明，TRAF4在UC中细胞核的表达存在异常，尤其在淋巴细胞、浆细胞核中的表达存在明显异常。     

通因通用疗法与传统疗法治疗溃疡性结肠炎的对比研究

为探讨中医通因通用疗法治疗慢性溃疡性结肠炎的疗效,将150例慢性溃疡性结肠炎患者按就诊顺序随机分为3组,即治疗组、对照1组和对照2组,每组50例。治疗组采用中医通因通用疗法治疗,即脾胃虚弱、寒湿凝滞型患者口服三物备急丸,脾胃虚弱、湿热内蕴型患者口服大承气汤加味,患者泻后均口服参苓白术散加味以调理脾胃;对照1组予柳氮磺吡啶及结肠炎丸口服;对照2组予锡类散加云南白药保留灌肠。结果显示,治疗组治愈率明显高于对照1组和对照2组（90．0％VS70．0％VS74．0％）,P〈0．01。1个疗程后,治疗组腹痛、腹泻、黏液脓血便及里急后重情况明显减轻,2个疗程后各症状基本消失。经统计学分析,治疗组症状缓解情况明显优于对照1组和对照2组,P〈0．01。结果表明,通因通用疗法比传统疗法治疗溃疡性结肠炎疗效好。     

Morbidity of Loop Ileostomy Closure after Restorative Proctocolectomy for Ulcerative Colitis and Familial Adenomatous Polyposis: a Systematic Review

Background

Temporary loop ileostomy is a routine procedure to reduce the morbidity of restorative proctocolectomy. However, morbidity of ileostomy closure could reduce the benefit of this concept. The objective of this systematic review was to assess the risks of ileostomy closure after restorative proctocolectomy for ulcerative colitis or familial adenomatous polyposis.

Materials and Methods

Publications in English or German language reporting morbidity of ileostomy closure after restorative proctocolectomy were identified by Medline search. Two hundred thirty-two publications were screened, 143 were assessed in full-text, and finally 26 studies (reporting 2146 ileostomy closures) fulfilled the eligibility criteria. Weighted means for overall morbidity and mortality of ileostomy closure, rate of redo operations, anastomotic dehiscence, bowel obstruction, wound infection, and late complications were calculated.

Results

Overall morbidity of ileostomy closure was 16.5 %, there was no mortality. Redo operations for complications were necessary in 3.0 %. Anastomotic dehiscence occurred in 2.0 %. Postoperative bowel obstruction developed in 7.6 %, with 2.9 % of patients requiring laparotomy for this complication. Wound infection rate was 4.0 %. Hernia or bowel obstruction as late complications developed in 1.9 and 9.4 %, respectively.

Conclusion

The considerable morbidity of ileostomy reversal reduces the overall benefit of temporary fecal diversion. However, ileostomy creation is still recommended, as it effectively reduces the risk of pouch-related septic complications.     

健脾理肠汤口服及保留灌肠治疗溃疡性结肠炎48例临床观察

为观察健脾理肠汤口服及保留灌肠治疗溃疡性结肠炎（UC）的临床效果,将96例UC患者随机分为治疗组和对照组,每组各48例。治疗组采用健脾理肠汤口服及保留灌肠治疗,对照组采用柳氮磺吡啶保留灌肠治疗。结果显示,治疗组有效率91．7％,对照组77．1％,两组有显著性差异（P〈0．05）。结果表明,健脾理肠汤口服及保留灌肠治疗UC疗效肯定。     

Anal Function During Pregnancy and Postpartum After Ileal Pouch Anal Anastomosis for Ulcerative Colitis

Purpose Total proctocolectomy and ileal pouch anal anastomosis (IPAA) is now a common procedure for ulcerative colitis (UC). Moreover, it has been reported that fertility is preserved in women who undergo this procedure, many of whom can experience normal delivery.Methods We assessed the perinatal outcomes and changes in anal function in four women, aged from 27 to 35 years, who gave birth after undergoing IPAA for UC. Pregnancies were confirmed 15–111 months after IPAA, three women had full-term pregnancies, and one gave birth after 31 weeks gestation.Results Cephalic delivery with a vacuum extractor was used for one patient, and another underwent cesarean section. The other two patients experienced normal delivery. None of the patients needed artificial insemination and none had any symptoms of intestinal obstruction during their pregnancy. After delivery, two patients suffered a transient increase in bowel frequency and soiling, which gradually resolved.Conclusions Although transient anal dysfunction occurred in the puerperal period, there were no changes in anal function during pregnancy. Therefore, there are no factors directly prohibiting pregnancy and vaginal delivery in women who undergo IPAA for UC.