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

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

Results of ileal J-pouch-anal anastomosis in familial adenomatous polyposis complicated by rectal carcinoma

PURPOSE: Rectal cancer frequently occurs in patients with familial adenomatous polyposis (FAP) and, in some cases, proctocolectomy and ileal pouch-anal anastomosis (IPAA) can be proposed as an alternative to end ileostomy. This study aimed to assess the results of IPAA for familial adenomatous polyposis complicated by rectal carcinoma. PATIENTS AND METHODS: Postoperative morbidity and bowel function following IPAA were assessed in six patients who had a mesorectal excision for rectal cancer. The functional results were compared with those obtained after IPAA in 134 FAP patients without bowel cancer. RESULTS: Carcinomas were located at a mean of 11 cm from the dentate line. There were no postoperative complications. One patient with synchronous hepatic metastases died 6 months after operation and the 5 others were alive without recurrence after a mean follow-up of 29 months. Mean frequency of defecation was 6.5/day (vs. 4.2/day in patients without carcinoma), 86 percent of patients had nocturnal defecation (vs. 50 percent), day and night continence were normal in 66 percent and 33 percent of patients, respectively, compared with 90 percent and 85 percent for IPAA without cancer. Pouch excision was required in one patient for unsatisfactory functional result. CONCLUSION: IPAA can be safely performed for cancer of the upper rectum complicating FAP, but a poor functional outcome related to mesorectal excision has to be expected.     

Effect of small bowel obstruction on functional outcome and quality of life in patients with ileal pouch-anal anastomosis: 10-year follow-up study

Background and Aim: Postoperative abdominal adhesion formation is a troublesome clinical problem and a common cause of intestinal obstruction, chronic pain and infertility. The aim of this study was to evaluate the effect of small bowel obstruction (SBO) on functional outcome and quality of life (QOL) in patients who experienced ileal pouch‐anal anastomosis (IPAA). Methods: A total of 2418 patients who had undergone IPAA were categorized into three groups: group 1 comprised patients who had no SBO episodes until the last follow‐up; group 2 comprised patients who had one or more SBO episodes treated medically; and group 3 comprised patients who had one or more SBO episodes, at least one of which was treated surgically. Functional outcomes and QOL scores for patients in each group were evaluated at 1, 3, 5 and 10 years of follow‐up using multivariate analysis. Results: We found that patients who had SBO episodes which were treated medically were more likely to have a higher number of total bowel movements in a day in the first year of follow‐up compared to patients without postoperative SBO (P = 0.03), and more seepage during the day at 10 years follow‐up compared to patients with no SBO episodes or surgically treated SBO episodes (P = 0.01). The Cleveland Global Quality of Life (CGQL) scores were comparable between the three groups at 1, 3, 5 and 10 years of follow‐up. Conclusion: Medical management of SBO is associated with an increase in two symptoms, but QOL is comparable with surgical management.     

Follow-up after surgical treatment of patients with familial adenomatous polyposis: results in a southern Spanish population]

OBJECTIVE: The study was to assess changes in the rectal mucosa and pouch in a series of patients with familial adenomatous polyposis (FAP) who underwent either subtotal colectomy and ileorectal anastomosis (IRA) or proctocolectomy and ileal pouch-anal anastomosis (IPAA), and to evaluate the suitability of the follow-up interval and postoperative treatment employed to prevent the development of cancer. METHOD: This study involved 28 patients with FAP who underwent IRA (n=20) or IPAA (n=8), and were followed endoscopically over a mean period of 7.47 years. The number and both macroscopic and histological features of polyps before and after surgery, the treatment, and complications were all analyzed. The suitability of the follow-up interval was assessed. RESULTS: None of the 26 patients who complied with follow-up developed rectal cancer. Two patients developed rectal cancer at 21 and 36 months after withdrawing from the protocol. Except in two cases in which surgery was indicated, patients who developed adenomas during follow-up were treated by endoscopic polypectomy. CONCLUSIONS: In our series, the failure to comply with follow-up examinations was associated with cancer development.     

一期全结肠直肠切除、回肠储袋肛管吻合术治疗溃疡性结肠炎的安全性及生活质量评估

目的探讨一期全结直肠切除、回肠储袋肛管吻合术（IPAA）治疗溃疡性结肠炎（UC）的安全性和术后生活质量。 方法回顾性分析四川大学华西医院胃肠外科中心2014年1月至2015年12月行一期IPAA治疗的22例UC患者的术中和术后临床资料及生活质量评分,探讨该术式的技术要点、安全性及生活质量。 结果22例患者均成功实施IPAA,共18例患者发生20例次并发症,其中,中-重度并发症（Clavien-Dindo Ⅲ~Ⅳ）2例次：1例发生胸腔积液行胸腔穿刺术,1例因术后肺部感染入ICU治疗,未发生储袋肛管吻合口漏。术后3月及12月时随访患者平均排便次数为（6.75±1.24）次/天和（4.18±1.00）次/天,克利夫兰总体生活质量评价（CGQL）为（0.85±0.08）及（0.92±0.06）。 结论对择期UC患者,采用一期IPAA治疗安全可行,术后患者排便功能及生活质量满意。     

Clinical analysis of eight kindreds of familial adenomatous polyposis

AIM: To study the early diagnosis and management of familial adenomatous polyposis (FAP). METHODS: Eight pedigrees of FAP were collected and their pedigree trees were protracted. Clinical characteristics and treatment outcomes of FAP patients in these kindreds were analysed. RESULTS: A total of 157 members were investigated in eight kindreds and 25 patients with FAP were diagnosed. The ratio of male patients and female patients was 16:9 and the average age at onset was 38 years. Among them, six patients died of cancer with a mortality rate of 28%, and 36% (9/25) FAP patients were diagnosed as synchronous colorectal cancer on the basis of FAP. A proband was diagnosed as synchronous colorectal cancer with liver metastasis and died 11 mo later after partial colectomy and hepatic metastatic lesion biopsy. The other seven probands received total abdominal colectomy and rectal mucosectomy with ileal pouch-anal anastomosis (IPAA), and one of them was diagnosed as synchronous colon cancer on the basis of FAP and was still alive after 7.5 years follow-up. Among the other seven patients with synchronous colorectal cancer on the basis of FAP underwent total abdominal colectomy with ileorectal anastomosis (IRA), one underwent total remnant rectum resection and ileostomy for recurrent carcinoma in the retained rectum 2.5 years later after the IRA and was still alive, while the others all died of recurrence with a median survival time of 4.6 years. Through close follow-up and termly endoscopic surveillance, three FAP patients were detected before presenting symptoms at the age of 18, 20 and 23 years, respectively. Prophylactic IPAA was performed and results were satisfactory after the patients were followed-up for 6, 1, and 8 years, respectively. CONCLUSION: Pedigree investigation, close follow-up and termly endoscopic surveillance are very important for early detection of FAP. Prophylactic IPAA can give satisfactory results to FAP patients.     

Ten-year impact of pancreaticoduodenectomy on bowel function and quality of life of patients with ileal pouch-anal anastomosis for familial adenomatous polyposis

BackgroundPatients with familial adenomatous polyposis (FAP) carry a risk of duodenal adenocarcinoma. These patients, who already have an ileal pouch-anal anastomosis (IPAA), sometimes require pancreaticoduodenectomy (PD). This work aims to evaluate the long-term consequences of the combination of PD + IPAA.MethodsAll patients with IPAA due to FAP who underwent PD from 1991 to 2017 were included (PD + IPAA group). Patients were matched 1:1 according to age, sex, ASA score and presence of colorectal cancer. Fecal continence and quality of life (QoL) were assessed using the Wexner score and the EORTC-QLQ-C30 questionnaire.ResultsThirty-two PD + IPAA patients were matched with thirty-two IPAA-only patients. In each group, the response rate to the questionnaire was 78% (25/32). No differences were noted between PD + IPAA and IPAA-only groups in terms of daytime fecal frequency (6.0 vs 6.0; p = 0.362), Wexner score (3/20 vs 4/20; p = 0.984) and global QoL score (83.3/100 vs 83.3/100; p = 0.401). In the PD + IPAA group, 26% of patients developed diabetes a median period of 10.0 years after PD. The global QoL for these patients was significantly altered (p = 0.011), while daytime fecal frequency was unaffected (p = 0.092) as fecal continence (p = 0.475).ConclusionIn FAP patients with IPAA, PD does not affect bowel function or QoL.     

Long-term results of ileal pouch-anal anastomosis in Crohn's disease

The unexpected diagnosis of Crohn's disease (CD) after restorative proctocolectomy is a relatively frequent occurrence. We report a retrospective analysis of the long-term development of patients with an ileal pouch-anal anastomosis (IPAA) in whom the definitive anatomopathological diagnosis was CD, and compare their development with that of patients in whom the diagnosis of ulcerative colitis (UC) was confirmed. We reviewed the clinical data of 112 patients with an IPAA. The definitive diagnosis was CD in 12, and UC in the rest. The mean follow-up period was 76 months (range 12 to 192). We analyzed and compared the epidemiologic and clinical data, postoperative complications, functional results, anxiety, and quality of life in the two groups. Postoperative morbidity and the degree of satisfaction were similar in the two groups. The test showed a lower level of anxiety and higher quality of life in patients with CD. Of all the functional parameters studied, only urgency of defecation presented a higher risk in the CD group (HR: 4.13, CI: 1.41-12.04, p = 0.027). Despite the fact that a diagnosis of CD is currently considered a contraindication for an IPAA, some patients with secondary diagnosis of CD have good functional outcome and quality of life after restorative proctocolectomy. Closure of the temporary ileostomy may be justified in these patients.     

Ileoanal-pouch reconstruction does not impair sphincter function or quality of life

BACKGROUND/AIMS: A retrospective trial with regard to continence function and quality of life was conducted in patients who had undergone proctocolectomy and ileo-anal-pouch (IAP) reconstruction for ulcerative colitis (UC) or familial polyposis (FAP), and continence function was compared to patients under conservative treatment for UC. The aim of the study was to evaluate, if proctocolectomy and IAP differed in quality of life and sphincter function from those patients with chronic UC who were not operated on. METHODOLOGY: 50 patients were included in this study: 25 patients had undergone proctocolectomy and ileo-pouch-anal-anastomosis (IPAA) for UC (n=13) or FAP (n=12). The control group included 25 patients under medical treatment for UC (n=25). Anal manometry was performed and quality of life questionnaires were evaluated. RESULTS: No significant differences in maximum basal and squeeze pressure were found. There was a significantly later pouch perception in the patient group (55mL in patients vs. 39mL in controls; p = 0.0054) as well as a significantly greater stool frequency (6 vs. 4 per day; p = 0.0018) and a shorter high pressure zone in the patients' group (25 mm vs. 35 mm; p < 0.0001). Patients demonstrated superior but not significantly better values for Gastrointestinal Quality of Life Score (GLQI) and Activity Index (AI). Furthermore, there was a significant negative correlation between perception values and GLQI (p = 0.014) and AI (p = 0.04) in this group, indicating that the later the perception the worse the Quality of Life and Activity Index. CONCLUSIONS: Proctocolectomy combined with IPAA neither deteriorates anorectal function nor quality of life compared to conservatively treated controls. These data support that prophylactic proctocolectomy in patients who are at high risk for the development of colorectal cancer can be performed at an early stage of the disease.     

Health-related quality of life after ileal J-pouch-anal anastomosis for ulcerative colitis: long-term results.

BACKGROUND: This questionnaire study examined associations between health-related quality of life and long-term follow-up results with J-pouch anal anastomosis for ulcerative colitis. METHODS: A two-part questionnaire was sent to patients treated for ulcerative colitis by handsewn J-pouch-anal anastomosis at our institute in the period 1985-95. The health-related quality of life measurement was based on a RAND SF-36 Finnish version of the questionnaire. Scores were compared with the normal Finnish population. The functional status was analysed with a 34-item questionnaire on pouch function and incontinence. RESULTS: The response rate was 62%. The median follow-up time was 8 years (3 to 13 years). Functional results were acceptable: median number of bowel movements per 24 h was six. Soiling at night occurred in 32%, and inability to differentiate pouch contents in 24% cases. Twenty-four per cent used a pad occasionally, and 9% every day. The functional score and the health-related quality of life score correlated strongly. Poor functional status and a history of chronic pouchitis were associated with lower score. The limiting value after which the score was lower was 10 bowel movements per 24 h in 16%. A compromised anal continence proved to decrease the health-related quality of life as well. CONCLUSIONS: RAND SF-36 scores seem to provide a useful tool to evaluate the health-related quality of life after pelvic pouch operation for ulcerative colitis. Frequent bowel movements, impaired anal continence, and pouchitis are common in long-term follow-up after ileal pouch operation. The scores were, however, comparable to those in the normal population in terms of adaptation to daily life with a pelvic pouch.     

Optimizing perioperative Crohn’s disease management: Role of coordinated medical and surgical care

AIM: To investigate rates of re-establishing gastroenterology care, colonoscopy, and/or initiating me-dical therapy after Crohn’s disease(CD) surgery at a tertiary care referral center.METHODS: CD patients having small bowel or ileocolonic resections with a primary anastomosis between 2009-2012 were identified from a tertiary academic referral center. CD-specific features, medications, and surgical outcomes were abstracted from the medical record. The primary outcome measure was compliance rates with medical follow-up within 4 wk of hospital discharge and surveillance colonoscopy within 12 mo of surgery. RESULTS: Eighty-eight patients met study inclusion criteria with 92%(n = 81) of patients returning for surgical follow-up compared to only 41%(n = 36) of patients with documented gastroenterology follow-up within four-weeks of hospital discharge, P < 0.05. Factors associated with more timely postoperative medical follow-up included younger age, longer length of hospitalization, postoperative biologic use and academic center patients. In the study cohort, 75.0% of patients resumed medical therapy within 12 mo, whereas only 53.4% of patients underwent a colonoscopy within 12 mo of surgery.CONCLUSION: Our study highlights the need for coordinated CD multidisciplinary clinics and structured handoffs among providers to improve of quality of care in the postoperative setting.     

Consequences of delayed ileostomy closure after ileal pouch-anal anastomosis

Temporary diverting loop ileostomy is a generally accepted component of the ileal pouch-anal anastomosis (IPAA) procedure. Ileostomy closure is usually performed within two to three months but may be delayed because of disruption of the ileoanal anastomosis, suspected leak from the ileal reservoir, concomitant medical problems, or patient convenience. Of 362 patients undergoing IPAA at The Cleveland Clinic Foundation for inflammatory bowel disease, 10 have had their ileostomy closures delayed for more than six months. Clinical and manometric parameters are examined in these patients and compared with those who had earlier closure. There appears to be no significant difference in the functional outcome of IPAA in these patients in terms of number of bowel movements and degree of continence. Reservoir compliance and maximum tolerated volumes are similar. We conclude that delaying ileostomy closure for more than six months after IPAA has no deleterious effect on pouch function.     

The effect of age on pain, function, and quality of life after total hip and knee arthroplasty

BACKGROUND: As utilization rates for total joint arthroplasty increase, there is a hesitancy to perform this surgery on very old patients. The objective of this prospective study was to compare pain, functional, and health-related quality-of-life outcomes after total hip and total knee arthroplasty in an older patient group (> or =80 years) and a representative younger patient group (55-79 years). METHODS: In an inception community-based cohort within a Canadian health care system, 454 patients who received primary total hip arthroplasty (n = 197) or total knee arthroplasty (n = 257) were evaluated within a month prior to surgery and 6 months postoperatively. Pain, function, and health-related quality of life were evaluated with the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index and the 36-Item Short-Form Health Survey (SF-36). RESULTS: There were no age-related differences in joint pain, function, or quality-of-life measures preoperatively or 6 months postoperatively. Furthermore, after adjusting for potential confounding effects, age was not a significant determinant of pain or function. Although those in the older and younger groups had comparable numbers of comorbid conditions and complications, those in the older group were more likely to be transferred to a rehabilitation facility than younger patients. Regardless of age, patients did not achieve comparable overall physical health when matched with the general population for age and sex. CONCLUSIONS: With increasing life expectancy and elective surgery improving quality of life, age alone is not a factor that affects the outcome of joint arthroplasty and should not be a limiting factor when considering who should receive this surgery.     

Functional and quality-of-life outcomes in patients with rectal cancer after combined modality therapy, intraoperative radiation therapy, and sphincter preservation

PURPOSE: Locally advanced primary and recurrent rectal cancers treated with external beam radiation therapy, intraoperative radiation therapy, and chemotherapy represent a complex group of patients in the setting of extensive pelvic surgery and sphincter preservation. We sought to define functional outcome and quality of life in this subset of patients. METHODS: We retrospectively reviewed our experience with locally advanced primary and recurrent rectal cancer patients who underwent intraoperative radiation therapy with either low anterior resection (n = 12) or coloanal anastomosis (n = 6) between 1991 and 1998. Current functional outcome and quality of life were evaluated by a detailed questionnaire. RESULTS: Median time from operation to assessment was 24 (range, 6-93) months. Using a standardized Sphincter Function Scale, incorporating the number of bowel movements per day and degree of incontinence, patients were graded as poor, fair, good, or excellent function. Of all patients, 56 percent reported unfavorable (poor or fair) function. Of the subset of patients with coloanal anastomosis or very low low anterior resection, 88 percent had unfavorable function as compared with 30 percent with standard low anterior resection. (P = 0.02; Fisher's exact probability test). A quality-of-life satisfaction score based on social, professional, and recreational restrictions demonstrated 56 percent of patients to be dissatisfied with their bowel function. CONCLUSIONS: The majority of patients with advanced rectal cancers who require external beam radiation therapy, extensive pelvic surgery, and intraoperative radiation therapy report unfavorable functional and quality-of-life outcomes after sphincter preservation. In this setting patients being considered for coloanal anastomosis or very low anterior resection may be better served by permanent diversion.     

Sexual and bladder dysfunction after total mesorectal excision for benign diseases

PURPOSE: An evaluation was made of sexual and bladder dysfunction combined with quality of life (QoL) score after a proctocolectomy with total mesorectal excision (TME) for benign diseases. METHODS: An in-depth questionnaire was mailed to all patients (n = 94) who had undergone a proctocolectomy with TME followed by an ileal pouch-anal anastomosis (IPAA) in the period from 1989 through 1994. Seventy-six patients responded (81%) with a mean age of 34 +/- 10.6 years and a mean follow-up of 33 +/- 18.3 months. RESULTS: Sexual activity, satisfaction and libido were preserved better in males than in females. Severe sexual dysfunction was found in two males (permanent retrograde ejaculation) and in one female (complete vaginal dryness). No severe bladder dysfunction was found, although minor dysfunction, such as stress and urge incontinence, occurred frequently. QoL was significantly increased postsurgery. Moreover, no evident correlation was demonstrated between QoL and sexual and bladder dysfunction. CONCLUSION: A relatively low incidence of severe sexual and bladder disorders was found following proctocolectomy with TME and IPAA, whereas minor dysfunction was a relatively common finding. Nevertheless, a significant increase was found in postoperative QoL compared to preoperative QoL.     

Long-term results of ileal pouch-anal anastomosis in patients with Crohn's disease

PURPOSE: Ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for most patients with chronic ulcerative colitis. Crohn's disease is, however, a contraindication. Because distinction between UC and Crohn's disease can be difficult, some patients with Crohn's disease inadvertently undergo IPAA. The aim of this study was to determine the long-term outcome of patients with Crohn's disease who have undergone IPAA. METHODS: A total of 37 patients (20 men) were studied. Each had undergone mucosectomy with handsewn IPAA (J-pouch, n=35; S-pouch, n=1; W-pouch, n=1). Histologic examination of the resected specimen at time of IPAA showed features of ulcerative colitis (n=22), indeterminate colitis (n=9), or Crohn's disease (n=6). The stoma was closed in all patients. RESULTS: A total of 11 of 37 patients developed complex fistulas (pouch-cutaneous (n=6), pouch-vaginal (n=4), or pouch-vesical (n=1). Crohn's disease has recurred in the pouch (n=20), anal canal (n=4), pouch and anal canal (n=10), and elsewhere (n=3). After ten years (range, 3–14), the pouch remains in situ in 20 patients in whom frequency of bowel movement is seven times (3–10)/24 hours,in situ but defunctioned in seven patients, and excised in ten patients (failure rate, 45 percent). CONCLUSIONS: Inadvertent IPAA for Crohn's disease is associated with a high rate of failure (45 percent) but an acceptable long-term functional result if the pouch can be kept in situ.Read at the meeting of the Association of Surgeons of Great Britain and Ireland, Glasgow, United Kingdom, May 22 to 24, 1996.     

The ileo neo rectal anastomosis: long-term results of surgical innovation in patients after ulcerative colitis and familial adenomatous polyposis

Purpose

Restorative proctocolectomy with ileo neo rectal anastomosis (INRA) combines cure of ulcerative colitis (UC) or familial adenomatous polyposis (FAP) with restoration of intestinal continuity. Evaluation of long-term results was needed to determine if there is a place for INRA in the armamentarium of a surgeon besides the ileal pouch anal anastomosis (IPAA).

Methods

All patients with INRA were included in the analysis. Patient demographics and clinical and follow-up data (morbidity, dietary problems, defecation frequency, fecal continence, anal and neorectal physiology, and neorectal mucosa assessment) were registered prospectively.

Results

Seventy-nine patients were enrolled, and in 58 patients (50 UC, 8 FAP), INRA was successful. In 21 patients, intraoperative conversion to IPAA was needed. In 49 patients with INRA, a functional reservoir was achieved. No pelvic sepsis or bladder or sexual dysfunction occurred. Thirteen patients experienced episodes of reservoir inflammation. Median bowel movements of six (5, 8) with a nocturnal defecation frequency of one were recorded with fecal continence or minor incontinence. Anal manometry and neorectal physiology showed a decrease in resting pressure and an increase in squeeze pressure and maximum tolerated volume. The median follow-up was 8.1 years (6.7, 10.1).

Conclusions

This is an example of a surgical innovation with a theoretical potential to be superior to the current technique. This potential was not confirmed in short- and long-term evaluations. Hence, IPAA is currently the best available alternative to a conventional ileostomy.     

Long-term quality of life after ileal pouch anal restorative proctocolectomy for ulcerative colitis

Restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) has evolved as the surgical procedure of choice for ulcerative colitis (UC). The aim of our study was to evaluate the quality of life (QOL) of UC patients who underwent this procedure over 5 years ago. Thirty-nine UC patients who underwent restorative proctocolectomy with IPAA were interviewed by the validated inflammatory bowel disease questionnaire (IBDQ). Each patient was assigned a score, ranging from 32 to 224, in which the highest score indicates the best QOL. QOL for postoperative patients was good in 15 (38.5 %), regular in 23 (59 %), and bad in 1 (2.6 %) patient. QOL was not significantly influenced by age or gender of the patient. The emotional aspect received the highest score in the IBDQ and for each question that was analyzed separately; most of the patients were pleased and thankful with their lives and this question received the highest score. Long-term QOL was good in UC patients who underwent IPAA. This operation should be considered as the first choice since the patients were stable after long-term follow up.     

Age, functional capacity, and health-related quality of life in patients with heart failure

BACKGROUND: Although heart failure disproportionately affects older persons and is associated with significant physical disability, existing data on physical limitations and health-related quality of life (HRQL) derive largely from studies of younger subjects. We compared the relationship between functional limitation and HRQL between older and younger patients with heart failure. METHODS AND RESULTS: We evaluated 546 outpatients with heart failure enrolled in a multicenter prospective cohort study. At baseline and 6 +/- 2 weeks later, functional status was assessed by New York Heart Association (NYHA) classification and 6-minute walk testing. HRQL was measured with the Kansas City Cardiomyopathy Questionnaire (KCCQ). Comparing older (age >65 years, n = 218) and younger patients (n = 328), we assessed baseline HRQL across strata of functional status. In the 484 patients who completed follow-up (194 older and 290 younger patients), we also assessed the changes in HRQL associated with changes in functional status over time. At baseline, older patients had better HRQL than younger patients (mean KCCQ score 60 +/- 25 versus 54 +/- 28, P = .005) in spite of worse NYHA class (mean 2.54 versus 2.35, P < .001) and lower 6-minute walk distances (824 +/- 378 versus 1064 +/- 371 feet, P < .001). After multivariable adjustment including baseline NYHA class, older age was independently correlated with better HRQL (beta = +7.9 points, P < .001). At follow-up, older patients with a deterioration in NYHA class experienced marked declines in HRQL compared with younger patients (mean HRQL change of -14.4 points versus +0.3 points, respectively, P < .001). Analyses using 6-minute walk distance as the functional measure yielded similar results. CONCLUSIONS: Although older patients with heart failure have relatively good HRQL in spite of significant functional limitations, they are at risk for worsening HRQL with further decline in functional status. These results underscore the importance of treatments aimed at maintaining functional status in older persons with heart failure, including those with significant baseline functional limitations.