Laparoscopic restorative total proctocolectomy with ileal pouch anal anastomosis for familial adenomatous polyposis

BACKGROUND: Familial adenomatous polyposis is a hereditary disease characterized by the presence of thousands of colonic adenomas, which, if untreated, invariably undergo malignant transformation. Because this disease manifests at a young age, the laparoscopic approach to perform surgery would be desirable due to its cosmetic benefits. We describe our experience with this procedure and review the literature on the topic. METHODS: This is a case series of 15 patients who underwent restorative proctocolectomy with ileo-anal pouch anastomosis for familial adenomatous polyposis between 2000 and 2007. The salient operative steps are described. RESULTS: There were 9 males and 6 females, 32 to 52 years of age, with an average age of 44.8 years. The median body mass index was 21.5 (range, 17 to 28). Rectal cancer was already present in 4 patients at the time of diagnosis. The median operating time was 225 minutes. Mean blood loss was 60 mL, with none of the patients requiring perioperative blood transfusion. None of the surgeries required conversion to the open approach. Bowel function resumed on the second postoperative day in 12 patients and on the third postoperative day in 3 patients. The median hospital stay was 8 days. Postoperatively, there was no mortality and no serious morbidity. CONCLUSION: Laparoscopic restorative proctocolectomy with ileal pouch anal anastomosis is a feasible surgery for familial adenomatous polyposis, and considering its cosmetic benefit, is a desirable option for this group of predominantly young patients.     

Impact of Screening Examinations on Survival in Familial Adenomatous Polyposis

Background: Prophylactic family screening and surgery has improved the outcome of patients with familial adenomatous polyposis (FAP) largely preventing deaths due to colorectal cancer. The present study compared the mortality rates and causes of death of FAP patients diagnosed by symptoms (probands) or by family screening (call-up). Methods: The study comprised all 236 FAP patients registered in the Finnish Polyposis Registry until the end of June 1998. There were 116 probands and 120 call-up patients with a median age of 36.8 and 22.8 at diagnosis and median follow-up times of 6.3 and 9.9 years, respectively. Cumulative crude and relative survival estimates were calculated for each group and the causes of death were determined. Results: The life expectancy was significantly better in the call-up group than in the probands after colectomy (P < 0.001). The survival rates of the call-up group equaled those expected for a comparable group in the general population up to 18 years after colectomy. The main cause ofdeath was colorectal cancer accounting for 54 out of 68 deaths: four in the call-up group (all rectal stump cancer) and 50 in probands. Upper GI-tract cancer caused four deaths (periampullary cancer two, stomach cancer two) and two deaths were due to postoperative pulmonary embolism. Conclusion: The survival of FAP patients is significantly improved by prophylactic screening and surgery. Further improvement may be possible by using restorative proctocolectomy instead of colectomy and ileorectal anastomosis and by regular upper GI-tract endoscopic surveillance.     

Aneuploidy and columnar cuff surveillance after stapled ileal pouch-anal anastomosis in ulcerative colitis

PURPOSE: A stapled pouch-anal anastomosis without mucosectomy is widely used in restorative proctocolectomy. Uncertainty exists about the longer-term outcome of retaining a columnar cuff of epithelium in the anal canal and about the need for surveillance of the columnar cuff. The aim of this article was to assess the ability to obtain biopsies of the columnar cuff, to assess the risk of dysplasia, and to search for the presence of aneuploidy as an early of marker of dysplasia in nondysplastic epithelium. METHOD: A total of 457 biopsy specimens were taken during 203 examinations of 113 patients. All biopsy specimens were stained with hematoxylin and eosin and examined by microscopy. One hundred thirty-two of these biopsy specimens from 67 patients were frozen and analyzed by flow cytometry for aneuploidy. RESULTS: Mean follow-up after pouch formation was 2.5 years, and the time after diagnosis of ulcerative colitis was 10.1 years. Successful columnar cuff biopsies were done on 93 percent of patients. There was no dysplasia. Two biopsy specimens from one patient had aneuploidy. CONCLUSION: To date, neoplastic change in the columnar cuff is rare. A selective policy of surveillance biopsies is recommended that includes patients greater than ten years after the diagnosis of ulcerative colitis and patients with dysplasia or cancer in their proctocolectomy specimen, but long-term follow-up data are needed.Mr. Thompson-Fawcett was funded by the Oxford Radcliffe Colorectal Surgery Research Trust Fund, Oxford Radcliffe NHS Trust, United Kingdom.Presented in part at the European Council of Coloproctology Biennial Meeting, Edinburgh, United Kingdom, June 17 to 19, 1997. Published in abstract form: Thompson-Fawcett M, Warren B, Mortensen N. Surveillance of the columnar cuff after restorative proctocolectomy. Int J Colorectal Dis 1997;12:163.     

补益复方药冲剂抗诱变作用的探讨

采用微核实验技术对两种补益复方药冲剂抑制诱变作用进行了研究。结果表明，这两种冲剂对诱变剂丝裂霉素Ｃ诱发正常人淋巴细胞微核率有明显的抑制作用。两种冲剂在同一剂量下，没有显著性差异。     

A longitudinal study of long-term quality of life after ileal pouch-anal anastomosis

BACKGROUND: There is a lack of longitudinal long-term studies of quality of life (QOL) after surgery with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis, where cohorts of patients are used as their own controls. METHODS: Forty ulcerative colitis patients who had undergone IPAA were prospectively assessed while they had a temporary ileostomy, and at a median of 18 months and 7 years after ileostomy closure. QOL was measured with the Psychosocial Adjustment to Illness Scale and the Well-Being Profile. RESULTS: QOL was good at all three time points and, with some exceptions, did not change significantly between the assessments. There was a high degree of stability in the patients' evaluation of their QOL over time. CONCLUSIONS: QOL was already good when the patients had a temporary ileostomy and generally did neither improve nor deteriorate during 7 years after ileostomy closure. QOL was also quite stable in terms of individual differences.     

Predictors for acute and chronic pouchitis following restorative proctocolectomy for ulcerative colitis

Objective  This study was undertaken to evaluate the cumulative incidence, onset and risk predicting factors for acute and chronic pouchitis. Method  A consecutive series of patients (n = 210), who underwent restorative proctocolectomy (RPC) and had a minimum follow‐up of 12 months was reviewed. The cumulative incidence and onset of pouchitis was determined. Univariate analysis, followed by logistic regression analysis was used to evaluate the association of various demographic, clinical and histopathologic variables with the subsequent development of acute and chronic pouchitis. Results  A total of 198 patients were included. The mean follow‐up was 64 months (range, 12–180). Sixty‐four patients (32%) developed pouchitis, 35 acute and 29 chronic. The first episode of pouchitis occurred within the first year in 70% of cases. The presence of backwash ileitis (OR, 2.6; P = 0.015), primary sclerosing cholangitis (PSC; OR, 2; P = 0.018) and the duration of follow‐up (OR, 1.1; P = 0.043) were associated with a higher incidence of pouchitis. The duration of follow‐up was the only variable associated with acute pouchitis (P = 0.007). The presence of backwash ileitis and PSC were independent risk factors for chronic pouchitis (OR, 5.9; P < 0.001; OR, 2.8; P = 0.001 respectively). Conclusion  Pouchitis is a heterogeneous disease which tends to occur early after restoration of gastrointestinal continuity. Patients with backwash ileitis and/or PSC are at considerable risk of developing chronic pouchitis. The strong association between backwash ileitis, PSC and chronic pouchitis suggests a common link in their pathogenesis.     

Videoproctographic assessment after restorative proctocolectomy

Videoproctography was performed in 40 patients after restorative proctocolectomy to evaluate pouch emptying, anopouch angle, and pelvic floor movement in relationship to functional outcome. Results were compared between the two different pouch designs tested and a control group of 26 patients who had an intact rectum. There was no difference in emptying between the two pouch designs or compared with the control subjects. Emptying did not influence either the frequency of defecation or patient soiling rate. The presence of an anal stricture was associated with poor emptying in each case in the pouch group. Anorectal angle was no different between the different pouch designs or compared with the control group at rest, during pelvic floor contraction, or attempted defecation. A similar finding was obtained with anorectal angle position and movement during pelvic floor contraction and attempted defecation in both pouch design groups and when compared with normal rectum. This study shows that the only factor that is consistently associated with poor pouch emptying is the presence of an anal stricture.Read at the meeting of The American Society of Colon and Rectal Surgeons, Toronto, Canada, June 11 to 16, 1989.     

Restorative qualities of indoor and outdoor exercise settings as predictors of exercise frequency

Positive environmental determinants of exercise frequency remain poorly understood. Knowing that people often value exercise for psychological restoration, we investigated the restorative quality of indoor and outdoor exercise settings as predictors of exercise frequency. We surveyed 319 members of fitness centers in Zurich that offer indoor and outdoor exercise alternatives. Outdoor settings were rated as more restorative. For each type of environment, restorative quality predicted the frequency of exercise in the past 30 days, independent of socio-demographic characteristics, expectations of exercise benefits, and personal barriers. We discuss the results with regard to the provision of exercise settings for urban populations.     

Optimization of sphincter function after the ileoanal reservoir procedure

PURPOSE: Impairment of sphincter function in patients who undergo ileoanal reservoir is usually most severe immediately after ileostomy closure. Therefore, a prospective, randomized trial was undertaken to assess the potential value of preileostomy closure sphincter-strengthening exercises to improve early functional outcome. METHODS: Patients were randomized either to a control group (Group 1) or to undergo a five-week pelvic floor exercise program (Group 2). An incontinence score from 0 to 20 was used to clinically assess the functional results. Anorectal manometric assessment included: highpressure zone length, mean resting pressure, highest resting pressure, mean squeezing pressure, and highest squeezing pressure. The paired t-test was used to compare the functional results preoperatively and at the time of ileostomy closure. This time corresponded to the conclusion of the exercise program or the equivalent time period for the control group. RESULTS: Twenty-six patients who underwent double-stapled ileoanal reservoir between July 1991 and June 1992 were studied. They included 16 males and 10 females with a mean age of 38 (range, 17–69) years. When both evaluations were compared, the mean incontinence score decreased from 0.2 to 2.8 (=2.6) in Group 1 and from 0.2 to 2.0 ( = 1.8) in Group 2 (P=0.07). None of the changes between the preoperative and postoperative clinical and physiologic evaluations were statistically significant (P>0.05). CONCLUSION: Sphincter-strengthening exercises before ileostomy closure did not minimize the transient impairment of functional results.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993.